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Telemedicine for HCPs: Lessons Learned From a Mental Health Professional

David Cosio, PhD, ABPP, a behavioral pain specialist, has been using telecare for almost two decades. Here, he shares what providers new to the practice can expect. Plus, a few strategies, from troubleshooting technology to circumventing costs.

Since the arrival of COVID-19 into the United States, clinicians across the country have had to reconsider how to use telemedicine as not only an option - but as a primary means - of healthcare. Behavioral medicine clinicians have been using telecare for some time, partly to address the current shortage of mental health professionals in the US, and because research has found that virtual mental health counseling is at least as effective, if not more, than traditional face-to-face sessions.

While telemedicine was still in its infancy, mental health professionals were among the first adopters of this practice—including myself. I was introduced to telemedicine at the start of the new millennium during my graduate career at Ohio University while working in an HIV/AIDS research laboratory. Telecare proved to be such a great tool to reach such an audience, that I used it as the topic of my dissertation, A Telephone-Delivered, Motivational Interviewing Intervention to Reduce Risky Sexual Behavior in HIV-Infected Rural Persons: A Pilot Randomized Clinical Trial.1

I have also used videoconferencing for groups and pain education programming throughout my career as a psychologist at the US Department of Veterans Affairs (VA), which has been leading the way in telehealth innovation to ensure that veterans can access high-quality care.2 There are several lessons I have learned about telecare throughout the years, including its positive and negative effects.

This article dives into both sides of telemedicine and offers some practical guidance for providers who may be moving beyond face-to-face consultation for the first time and are  seeking effective ways to deliver essential virtual care.

Telemedicine technology for chronic pain consultation has been found to be feasible, cost-saving, and satisfactory to patients and pain physicians. (Image: iStock)

Take Advantage of Telemedicine’s Potential

Research has shown that there are several positive effects of using telecare for remote patient monitoring, including improved mortality and quality of life and reduced hospital admissions. These effects apply across a range of chronic conditions, from cardiovascular and respiratory disease, to psychotherapy as part of behavioral medicine.3

There are few studies, however, on the application of telemedicine to chronic pain patients. A study by Peng and colleagues was the first pilot project to determine that telemedicine technology for chronic pain consultation was feasible, cost-saving, and satisfactory to patients and pain physicians.4 There is also research to show that using telemedicine for pain education programming provides no significant difference between face-to-face and telecare interventions on patients’ stage of readiness to adopt a self-management approach, their experience of pain, or their depressed mood.2

Both providers and patients, therefore, have the opportunity to experience numerous benefits to virtual care. For instance, telemedicine:

  • provides ease and convenience to users who may simply need a computer, webcam, and broadband internet access to provide care via video platform messaging/apps
  • establishes a potentially cost-effective way to reach patients who have difficulty accessing services (vast geographic distances, limited transportation, and physical disabilities preclude many patients who suffer from pain from traveling to face-to-face appointments)
  • circumvents the costs and inconveniences associated with geographic distances between practitioners and patients, costs associated with travel and lodging, and imposes less of a physical strain on the patient’s health
  • increases compliance with visits - when using telecare, patients are less likely to miss appointments since they can meet from their location. The industry average for missed appointments is approximately 30 to 40%. However, with telemedicine, the average no-show rate has been shown to drop down to about 3.5%.5

Despite some providers reporting some loss of the interpersonal benefits of face-to-face consultations (see more below), telecare, in my view, offers an effective alternative, especially during a time where stay-at-home orders are implemented.

Be Aware of Telemedicine’s Downside

Providers using telemedicine for the first time, or on a more regular basis, will soon realize how much work is required behind the scenes. A great deal of logistics come along with the use of telecare, starting with what technology to use.

Tech Know-How

Virtual care can be provided using several types of technology, including the telephone, videoconferencing, and video platform messaging/apps (eg, Facetime, Zoom, WebEx, WhatsApp, Google Duo, and Viber). It is important to be knowledgeable – and test out -- the equipment and technologies you plan to use.

Personally, for videoconferencing, I might use a 42-inch plasma television connected to Tandberg Codec C40’s. The Tandberg Codec C40 provides all the power required to transform any room to a 1080 HD video multimedia presentation.6 The codec is a device, either hardware or software based, that encodes analog video/audio signals to digital video/audio, and vice versa. Use of PowerPoint or other information can be displayed as needed when using the technology in groups or during programming.

Providers may also need to maintain communication and troubleshoot with a telehealth technician who is credentialed and privileged. A telehealth technician provides technical support for providers to ensure clinical efficiency and effectiveness during a telecare visit, such as ensuring there is adequate technology infrastructure, bandwidth, technical troubleshooting, and support. Such a relationship may require a telehealth service agreement, which defines the responsibilities and procedures involved in establishing and operating a telehealth clinic.

Before-and-After Paperwork

The provider takes on several roles when using telemedicine. They are not only responsible for the consultation itself, but they may also need to coordinate the appointments, especially with any pandemic-related limitations in staff. This additional work includes promoting telemedicine services so that patients know what’s available; contacting and scheduling patients; completing patient encounters; and transferring materials to patients when needed.

Legalities

Clinicians  need to be aware of their state’s policies regarding telemedicine, as well as, any internal rules in their place of employment. Also important to find out is how (and when) you will receive reimbursement for services you provide via telecare.

One of the tricky things about telecare is that each state has different policies and requirements for how telemedicine should be practiced. This may require the provider to do a little research on what their state medical board requires. Second, clinicians need to do a bit of research into third-party payer guidelines for telemedicine if they want to bill through a patient’s insurance. For example, Medicare expanded telemedicine coverage for seven mental health services in 2015. Since then, many insurance companies and telemedicine providers have followed suit by encouraging telecare for mental health.

The clinical documentation of the event is very important as with any medical visit, intervention, or encounter. Telecare visits need to be documented and notes should include all pertinent information. Workload can be captured using encounter data and clinic designation. The creation of encounter forms, progress notes, and consult templates to telecare visits are also essential. To ensure the provider and their facility receives accurate workload and to evaluate the economic and other impacts of the telecare programs, sources such as a data warehouse and virtual care modality report can be used to verify accurate workload credit.7

A final but important consideration should be whether the provider’s malpractice coverage covers them for telemedicine services. While virtual care can tax the skills of even the most experienced providers, it is necessary and perhaps even desirable for several reasons.8

Engage in Best Practices and Etiquette

To gain the most out of what telemedicine has to offer and to remain effective as a “virtual provider,” clinicians can engage in a few best practices before, during, and after a patient visit.9  Here are a few tips I’ve learned along the way.

Verbal Check-ins

When using telephone technology, one practical adaptation that can be made is to increase the use of verbal check-ins during a meeting. For example, if a patient is silent for several seconds, the provider might ask “How do you feel about what I just said?” or “Is there something you are thinking about right now?”

Verbal check-ins can be used to better engage patients in the meeting and ensure they are not distracted by persons or events in their environment.

Troubleshooting and Support

When videoconferencing or using video platform messaging/apps, it is the responsibility of the provider (and/or the clinical technician if applicable) to check the room where you will be “broadcasting from” to ensure the seating arrangement and lighting allow you to be properly viewed by your patient.

Make sure all audio/video and media (PowerPoints, audio, and video clips) are fully functioning, and troubleshoot the equipment or platform at least 30 to 45 minutes ahead of the scheduled appointment. To avoid having technical difficulties and to ensure success of the telecare meeting, it is important to build close relationships with the support staff (such as room schedulers and biomedical electronic services if conducted from a facility). These relationships are often overlooked and are actually necessary for a telemedicine encounter to be effective.

On-Camera Cues

Conducting a successful videoconference either through technical equipment or video platform messaging/apps also requires a certain level of etiquette. Whether it’s your first time conducting a telemedicine visit or you use it regularly, be sure to abide by the following (see also, infographic above):

  1. Be dressed appropriately and conduct the meeting in a professional-looking space (eg, your home office, not your bedroom) and introduce yourself (even if the patient already knows you).
  2. Ensure your microphone remains muted until the videoconference starts or until someone in the meeting wants to speak (if using it for groups or programs) .
  3. Be ready to assist your patient(s) in adjusting their screens, volume, and environment to guarantee a successful meeting.
  4. Initiate the meeting punctually. A patient’s experience sitting in a virtual waiting room (many apps allow you to enable these), versus a real waiting room, is quite different. In a virtual setting, if the meeting does not begin on time—or within a few minutes—then the patient is likely to think something is wrong technically and leave the meeting, making reconnecting more difficult and time-consuming. If you do use a virtual waiting room, make sure your patient knows what to expect.
  5. Look into the camera when speaking.
  6. Speak in a normal tone and slow your speaking pace slightly to accommodate split-second delays when transmitting over long distances.
  7. Avoid noisy background activities (eg, tapping a pen or whispered side conversations, phone or computer notifications) which can affect the clarity of the transmission.
  8. Allow 5 to 10 minutes before the end of the meeting to answer any patient questions
  9. Take time to review important items and confirm the next appointment date and time.
  10. At the conclusion of the meeting, you may wish to inquire about your patient’s experience with the virtual session.

Conclusion

Due to the stay-at-home or self-quarantine response to COVID-19, the practice of visiting doctors and therapists via telecare, rather than face-to-face, has witnessed an increase in demand. Telecare visits are quickly replacing the bulk of in-office doctor’s appointments for a range of services, from routine checkups to chronic pain management. This article is meant to offer support to providers who are interested in caring for their pain patients using telemedicine during the COVID-19 epidemic and beyond. These skills may be useful for providers as they learn to cope with the dramatic shift to virtual care that will likely continue well into the future.

 

PPM's COVID and Pain Management Resource Center (updated regularly)

Last updated on: August 3, 2020
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