Synchronous Telemedicine Visits
Many virtual platforms and some electronic medical records can send electronic links (often customizable) for the patient and provider to connect to the virtual encounter. Links may be autogenerated at the time of scheduling, often embedded in emails or one-way texts sent to the patient and/or provider. For patient and provider convenience, links may also be sent on the day of the visit at, or prior to, the time of check-in. Support staff (clerical staff, medical assistant, or nurse) may be able to log in to the virtual platform first, for a “face-to-face” check-in in preparation for the visit with the provider. During this virtual rooming, the support staff may
- Confirm patient location.
- Ensure consent for virtual visit was obtained within the past year or consent the patient at the time of the visit.
- Complete other portions of the usual check-in process, such as questionnaires, etc.
If virtual rooming is not available in the platform used, then staff (medical assistant, nurse, or clerical staff, as appropriate) may call patients the day of the visit to:
- Verify time of visit.
- Instruct patient/caregiver on use of the virtual technology. Many providers’ offices have found it beneficial to perform a “test run” on how to log into the platform in advance of the visit.
- Complete intake/questionnaires.
- Confirm if consent was obtained at the time of scheduling. If not, it may need to be obtained by the provider at the start of the virtual encounter.
What do I do if the platform is malfunctioning or if connection to the virtual platform is unsuccessful?
- In addition to the primary virtual platform, have at least one alternate (back-up) HIPAA-compliant virtual platform in place that can be utilized for such cases.
- If the patient or provider is unsuccessful at connecting through synchronous telemedicine modalities:
- The visit may be performed as an audio-only telephone visit; however, be aware that this may not be billed at the same level as a telemedicine visit.
- The visit may need to be re-scheduled as a traditional in-person, face-to-face (F2F) office visit.
What should I do if the patient shows up for the telemedicine visit in an inappropriate place (e.g., bathroom, driving)?
To ensure appropriateness of the visit:
- Personnel performing the virtual rooming should prepare the patient for the provider, including verifying the appropriateness of patient locale at the time of the visit.
- If the patient appears to be seated behind the steering wheel of a car, the visit should be halted until the patient is parked at a safe location before continuing.
- If the patient is unable to comply with appropriate measures, the visit should be terminated and rescheduled.
- Schedulers should verify state of residence and where the patient plans to be at the time of the visit. These out-of-state regulations should be shared with patients at the time of scheduling.
- Patient location should be verified during a virtual check-in. If the patient is in a state that requires out-of-state providers to have a medical license for that state, and the out-of-state provider does not have the needed state medical license, the visit should be rescheduled.
- If state regulations do not allow for cross-state testing, partnerships with local providers may be needed for sleep testing, i.e., home sleep apnea tests (HSATs). Some states require that the sleep doctor reading the HSAT needs to be licensed in the state where the HSAT will be done.
What should I do if only the caregiver/proxy presents without the patient, or the child is not present for a pediatric appointment?
This scenario is more commonly encountered in the center-to-home (C2H) or out-of-center (OOC) models. Caregivers may presume that the patient’s presence is not necessary, especially if the appointment is scheduled for a time when the patient is not co-located with the parent/caregiver/proxy, such as when a child is at school. Remember that virtual visits should mirror traditional F2F office visits. In traditional F2F office visits, patients are required to be physically present, and traditional office visits are not conducted if the patient is not present.
- Schedulers should confirm that the patient will be available for the appointment at the time of scheduling with the parent or caregiver.
- Support staff may call patients/caregivers the morning of the visit, or call the hour before the visit, to ensure that the patient and caregiver will both be present for the meeting.
- If the patient is still not present for the visit, the provider may either reschedule the visit or, in the case of a follow-up visit, consider billing for time coordinating care. Providers may also be able to bill for the visit, without the pediatric patient present, if the patient has already established care in the clinic or if the caregiver/proxy present at the visit has legal guardianship or power of attorney to make medical decisions. Providers should consult payers for appropriate coding in these cases.
Options for monitoring PAP compliance via telemedicine visit:
- Download the data from the portal and load into the chart prior to the visit.
- Arrange with the DME provider to download the data and provide to the clinic prior to the visit.
- Access the device portal and review the data during the visit.
- Mail SD card to the patient prior to, or after, the visit and have the patient return the card to be downloaded and evaluated.
- Have the patient access their internet app and read the data to the provider.
- Have the patient read usage data from the PAP device LCD screen to the provider during the visit.
How do I send questionnaires, surveys, sleep-specific tools (e.g., sleep diaries, sleep logs) to patients and get results back?
Validated sleep tools and questionnaires and post-visit surveys are frequently used to augment the clinical evaluation and management of sleep disorders and to maintain quality. These can be easily adopted into telemedicine models.
Pre-visit tools/questionnaires may be sent to, and received from, patients prior to the visit via:
- Postal service/mail
- Electronic communication via encrypted e-mail or patient portal
- Electronically downloaded from the sleep center website, patient portal, or electronic medical record (EMR) then uploaded back to the site.
- Electronically completed directly into patient platform or patient facing EMR.
Post-visit surveys may also be completed in the same manner. In addition, some surveys may also be conducted through phone apps. It is important to ensure HIPAA compliance with all protected health information (PHI), and all electronic communications should be encrypted.
During in-person visits, I can collect health information, such as weight, blood pressure, and oxygen saturation readings on the day of the visit. How can I collect this information for telemedicine visits?
Patient health information typically collected during a traditional office visit can still be evaluated during a telemedicine visit. Rather than being measured in the clinic, you can have the patient collect and transmit the information to you. Methods for collecting data include:
Self-measurement: Verbally ask the patient to take readings at home or collect through an outside source such as a local pharmacy (e.g., BP) or from a recent prior doctor’s visit. Document if the provider observed the collection of data or if historical (per patient report). Information may include:
- Neck circumference
- Pulse rate
- Blood pressure
Medical devices: Patients can be sent, or they can purchase, measurement devices that can be utilized in the home, including:
- Blood pressure
- Hemoglobin level
Smart devices: Some phone apps allow for collection of EKGs and some blood pressure devices have Bluetooth capabilities to connect to apps on smartphones for data collection. Smart watches may collect heart rate, rhythm, and oxygen levels.
A successful visit ends by sharing important information with the patient, be it verbally or written. Handouts on good sleep habits or specific sleep disorders, exit instructions on clinic processes or sleep study procedures, or even just clinic contact information are commonly dispensed to patients at the time of check-out from a traditional office visit. These can be provided to patients after telemedicine visits utilizing the methods outlined in question 7 (ie, through mail/e-mail, or electronically through web portals or virtual platforms), and may take the form of:
- Paper handouts, CDs/ DVDs/Flash drives with pre-recorded information from the sleep center
- Pre-recorded videos on the sleep center website
- Links to videos on publicly available sites (e.g., YouTube, Vimeo)
- Links to educational resources on sleep specific professional websites (e.g., AASM Patient Information; sleepeducation.org)
These links may also be pasted into the after-visit summary sent electronically or via the postal service.
- Ask if an interpreter is needed at the time of scheduling and document the patient’s primary language if an interpreter is needed. You may want to allow more time for the visit in the case an interpreter is needed.
- Schedule the interpreter service for the time of visit, in advance if possible. If you are using a new interpretation service, you may want to meet with the interpreter prior to the patient visit to set expectations etc. Ideal
- Have the interpreter join the visit at the virtual check-in and document the identity of the interpreter (name of interpreter service or interpreter, name, and relationship of family member if a family member is used as interpreter, etc.).
- Some methods of communication with patients using an interpreter:
- 3-way virtual visit (if virtual platform allows for participants from 3 or more separate sites to join simultaneously)
- 3-way phone call
- Combination of 1 and 2 above (patient and provider on video + interpreter on phone)
- If virtual platform does not allow for more than 2 participants simultaneously, use an additional device (e.g., tablet) linked with the interpreter and held up to the virtual visit (to include interpreter through the tablet)
- At times, the interpreter may need to initiate the phone call/virtual visit and add healthcare provider to the call once the patient/patient’s caregiver has been reached.
- Live interpreter service, phone, or third-party application device at the clinic.
- If a household member is used as an interpreter, they may be physically available at the patient location.
- Special considerations for the hearing or speech impaired3
- For patients who are hearing impaired or have difficulty with speech and communicate through sign language (ASL), high speed audio-video communication (not audio-only) with the interpreter will be necessary for both the patient and provider to communicate.
- Video captioning (CART—communication access real time translation) is an alternative if ASL interpretation is not available. In this method, a qualified captioner (or even voice-to-text automation) provide captions on the screen during the visit.
- Ideally, interpreters should be on the same screen or platform for direct, real-time interpretation, but remote interpreting or captioning may be performed on a separate screen or device as above.
- If 2-way, interactive video communication is not an option, telecommunication relay services (TRS) through phone or internet may be used. Examples of these can be found in the AASM Telemedicine Implementation Guide2.
1Jacobs EA, Lauderdale DS, Meltzer D, Shorey JM, Levinson W, Thisted RA. Impact of interpreter services on delivery of health care to limited-English-proficient patients. J Gen Intern Med. 2001;16(7):468-474. doi: 10.1046/j.1525-1497.2001.016007468.x
2Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727–754. doi: 10.1111/j.1475-6773.2006.00629.x
3National Association of the Deaf – NAD
It is good practice to document the address/location of the patient during virtual check-in, not only to verify compliance with state regulations, but also to deliver emergency services if needed.
- If e-911 is available through the virtual platform, activate e-911 with the address of patient and nature of emergency.
- If e-911 is not available through the virtual platform, call 911 if the patient is local and provide the location of patient along with nature of emergency. If the patient is not local, obtain and call the 10-digit phone number for law enforcement in the community where assistance is needed.
How do I perform telemedicine visits with fellows and residents? Are there specific issues or problems that need to be overcome when using telemedicine with trainees?
Workflows that are used for in-person visits with trainees and allied health professionals can be adapted for virtual visits. Please see Case 12 in Telemedicine Implementation Guide 2 for more details. A common workflow in the traditional office visit model is to have the trainee see the patient first, then leave the room to discuss the case with the attending. After case discussion, the trainee rejoins the room along with the attending. This process may be reproduced through the telemedicine platform:
- For clinical visits: Make sure that the telemedicine platform allows for multiple people to be in the virtual room at the same time. If not, the Attending may need to have their discussions with the patient and trainee separately.
- For sleep study review: Sleep studies can be reviewed virtually with multiple trainees if the platform allows for sharing screens. If screens cannot be shared, then the trainee can review the study themselves and the Attending review the study separately, followed by discussion with the trainee.
- It is important to stay abreast of changes in supervision of trainees through telemedicine after the current public health emergency ends.