Telemedicine and Team-Based CareImprove Patient Care and Team Engagement by Using Team-Based Care in Telemedicine

What policy changes have been made to facilitate virtual visits during the COVID-19 public health emergency (PHE)?

The Centers for Medicare & Medicaid Services (CMS) has made the following accommodations during the COVID-19 PHE:

• Medicare will pay the same rates for telehealth services as they do for in-person visits for all diagnoses throughout the PHE

• Patients all over the country are eligible for telehealth services during the PHE, not just those in rural areas

• Patients can be in their home, or any other setting, to receive telehealth services

• Patients do not need to have an existing relationship with the physician who is providing telehealth assistance

• Physicians are allowed to waive or reduce costs for telehealth visits

• Physicians may furnish telehealth services outside their state of enrollment; however, they must still adhere to state licensure laws and regulations

• As a temporary waiver, physicians can bill for “audio-only” (telephone) visits as telehealth encounters

During the PHE, some states have temporarily waived licensure requirements, created temporary licenses, or created registration systems for physicians licensed in one state to provide care for patients in a different state. Many of these measures were established through executive order or temporary regulations. As such, requirements vary by state and have different dates of expiration.

Note that waivers and exceptions made by state and federal agencies, through gubernatorial executive order, and by private payers relating to the national PHE are limited in duration unless further action is taken by those policymakers and payers to make them permanent. It is important to seek the advice of qualified advisors, including legal counsel, to help you understand these important issues before making decisions that will extend beyond the term of the current PHE.

What if the patient does not have access to video technology?

Technology limitations can be a significant issue for patients who may not have broadband access, do not own a device with video capability, or are uncomfortable with video technology.⁷ In these cases, telephone visits can be quite useful in allowing access to medical care for this segment of the patient population. Extending the current temporary CMS waiver that allows for “audio-only” visits to be paid as telehealth encounters is being actively discussed, but there is no assurance that it will extend beyond the current PHE.

What virtual platforms can we use for video visits?

EHR-integrated platforms often require patients to be signed up for the patient portal. There are certainly advantages to this type of system, but it may also be a barrier for some patients. Publicly available video chat apps may also be an option, during and potentially after the PHE, depending on their security features, and these platforms continue to be actively developed. Whatever system you use, make the process as simple as possible for patients while ensuring patient information will remain private and secure.

Where should we perform the virtual visit?

The flexibility of virtual visits during the PHE is an advantage. The visit can be done in an exam room, a clinician office, or a physician's home. The ability for physicians to perform virtual visits from home is useful for quarantine requirements following a COVID exposure or during recovery, for creating virtual “clinic space” when distancing requirements limit use of actual clinic space, or simply for convenience and work–life balance.

Should virtual visits be scheduled anytime during the day, or should they be scheduled during dedicated time slots?

If the volume of virtual visits is relatively low, you can schedule them at whatever appointment times are open. However, as virtual visits become more common, it can be helpful to group these visits into specific time periods. This can improve efficiency, as you and your team can focus on virtual visits without having to do face-to-face visits in between. This increases the likelihood that you can start each video visit on time. The “Practice Pearls” in STEP 5 describe the experiences of other practices who have seen success with virtual visits.

What type of training can help team members perform these enhanced roles?

Education on enhanced team-based roles is not part of the usual medical assistant or LPN curriculum. Most systems need to develop additional training for their team members. Documentation training, population health training, medication reviews, and expanded EHR training (order entry, health maintenance review, appointment scheduling) can be very useful. Standardized documentation templates can make their work in documentation support more streamlined.

Do we need to hire more MAs, LPNs, or other support team members to allow for team-based EHR support?

In traditional team-based care models, increasing staffing support for clinicians allows for robust in-room support, and in turn, increases team engagement and clinician satisfaction, and is financially sustainable.¹ However, many team-based care principles can be utilized even if there are staffing challenges. For example, enhanced virtual rooming, including care gap closure, medication review, refill pending, and setting up and starting documentation templates can all be done the same as face-to-face visits.

For synchronous visits, how do patients react to having another person in the virtual “room” during the visit?

We have found that if the physician explains that there will be a medical assistant present whose role is to ensure accurate documentation, order entry, and follow-up so the physician can remain focused on the patient, most patients accept and welcome the additional medical professional helping with their visit. Many patients even see it as an opportunity to have another advocate for their health care and develop close relationships with the assistant over time.

The introductory explanation is especially important for patients who are new to the team care process or are new to telemedicine. It may also be reassuring to let patients know that it is no problem if they want to be alone with their physician. In addition, if the physician or assistant senses that the patient is uncomfortable—such as during certain sensitive parts of the visit—the assistant may leave the virtual room.

Who should initiate the virtual visit and how can EHR support (documentation, order entry, scheduling) be provided during the visit by team members?

It is preferable that team members initiate the visit, which allows them to perform virtual rooming. If the physician and team are co-located in the same office area, the team member can initiate the visit on a smartphone, tablet, desktop computer, or laptop, then hand off the visit to the clinician. They can then provide real-time EHR support on their computer while the co-located clinician connects with the patient on their device. Safety precautions such as physical distancing and mask wearing will be necessary as long as there is concern regarding infectious disease spread.

What is the role of the support team in telephone visits?

It is ideal if the support team members can initiate the visit, then hand off the visit to the clinician. As with video visits, it is helpful if they can stay in the room to provide EHR support during the visit. This allows the clinician to focus on the patient, without distraction, and allows for increased efficiency. The clinician can leave the visit once the plan is set, and the team member can then enter or pend necessary orders, schedule the follow up visit if needed, and reinforce the plan with the patient.

What is ideal to get done during virtual rooming by your support team members?

It is most efficient if your support team rooms patients the same for virtual visits as for face-to-face visits. Virtual rooming includes updating history, medication review and refill pending, agenda setting, care gap closure, and setting up the documentation template. Verifying the history is easier if the patient is logged in through the patient portal and confirms their history and medications and answers the questionnaires. Team members can also ask patients to check their own vitals at home, including blood pressure, heart rate, and weight.

If the support team is unable to provide real-time support during the virtual visit, what can be done to enhance the efficiency of this visit?

In addition to completing the entire rooming process, the team member can set up the documentation template, and start documenting the History of Present Illness. In addition, if they know the clinician's routines, the clinical assistant might anticipate and pend orders for the clinicians. They can also schedule the next routine follow-up appointment for the patient during the rooming process.

What strategies can be used to ensure continual improvement in new processes?

It can be helpful to have whiteboards available so any team member can write down questions or ideas for improvement. Ideally, these should be addressed daily. Regular care team meetings are invaluable to reviewing the processes and workflows and getting ideas for refinement and ongoing improvement. Frequent check-ins like this help keep team members engaged. Be willing to adjust your approach to best serve the team, and ultimately, your patients.