Abstract
Background
The practice of medicine using technology to deliver care at a distance is called telemedicine. 1 Its usage and popularity are increasing. 1 Although a variety of telemedicine platforms are available for seriously ill patients who are homebound, functionally limited, or geographically distant (e.g., telephone calls and e-mails), a real-time videoconferencing platform (a.k.a. “video visit”) offers unique interactive benefits and/or may even be required for specific regulatory reasons. In this Fast Fact, telemedicine will refer to real-time videoconferencing between patients and clinicians. 2 See Fast Facts #76 and 77 for more information on specific types of telephone encounters. Since there is limited evidence to guide telemedicine practices, this Fast Fact primarily assimilates expert opinion.
Telemedicine Visit Setup
Work with your institution to identify a HIPAA-compliant and reliable telemedicine platform. The user-friendliness of your platform alongside you and your patient's environments can impact the quality of communication by telemedicine. Use a high-quality webcam and microphone on a laptop, desktop computer, or tablet (avoid smartphones) and ensure a stable Internet connection. 2
Consider patient characteristics (e.g., technological savviness, preferred language, hearing issues, and cognitive impairment) and the tasks you hope to accomplish to determine if a telemedicine visit is appropriate before scheduling a telemedicine encounter.
Identify a designated person (e.g., nursing or medical assistant) to do preparation and teaching about the technology beforehand to make the clinical appointment more efficient. This should include information about the length and purpose of the visit, the technology being utilized, verification of the patient's Internet capacity, and a backup plan (e.g., telephone call) if technology fails.
For visits with multiple team members, decide if you should sit side by side on one screen (sharing one camera) or on separate screens from different computers or locations. Although it may require greater technical sophistication, utilizing separate screens allows each clinician to position him or herself in front of a camera. This can make it easier for the patient, family, and IDT members to appreciate all participants' nonverbal cues.
Use a technology-checklist to confirm your equipment is working properly and to minimize technological complications before your visit begins. 2
Confirm all participants are well lit, visible on the screen, and can hear each other well. 3 When needed, the clinician should assume the role of the clinic visit “film director.” For example, if a caregiver is not viewable on the screen, ask for camera adjustments so everyone is in view.
Orient your patient to where you and any collaborating clinicians are sitting. Assure the patient you are in a private confidential space.
Ask the patient to introduce who is in the room with them and inquire if they are in a physical location where they feel comfortable sharing medical information with you.
Verbal Communication during the Visit
While most recommended serious illness communication practices apply to telemedicine visits, the following bullet points offer unique considerations:
Talk slower than in-person by embracing conversation pauses; this can prevent participants from talking over each other.
4
Explicitly request the patient's permission before discussing a sensitive or difficult topic. Observe verbal and nonverbal responses to gauge whether it is safe to proceed with the conversation.
5
If you are having difficulty hearing or understanding your patient, ask directly for clarification: “What you're saying is really important to me. Can you repeat what you said?” Since your facial expressions can be more difficult to interpret and light touch is not possible, clinicians should prioritize empathetic statements so they can respond to patient emotions appropriately: “I can't imagine how difficult this has been for you”.
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Closing telemedicine visits can feel abrupt or awkward. Utilize a warning shot: “We have about 10 minutes left. What might be most helpful to discuss as we finish up our appointment today?”
Nonverbal Communication during the Visit
Good eye contact is key since the quality of your attention is more evident by video than in-person. Frequently observe your facial expressions and estimate your gaze with your camera positioned slightly above eye level. 7
Avoid typing when discussing sensitive or important topics. 8 If you need to look something up on your computer, explain what you are doing to avoid appearing distracted or disinterested.
Maximize the patient on your computer screen to give yourself the best chance of appreciating their body language and subtle facial expressions.
When utilizing body language to convey empathy, make sure it is visible on the patient's screen.
After the Visit
When seeing a patient with other team members, confirm the patient has exited the telemedicine platform before debriefing.
Consider sending a written summary of the visit through secure e-mail or your electronic medical record to your patient with key recommendations.
When conducting serial telemedicine visits, create a small habit or routine (e.g., stepping away from your computer to take a few deep breaths or a quick stretch) between visits to minimize fatigue and prepare yourself to communicate effectively with your next patient. 9