Expert Consensus: Telehealth Skills for Health Care Professionals

Abstract

Background:

The COVID-19 pandemic has driven most clinicians, from those practicing in small independent practices to those in large system, to adopt virtual care. However, individuals and organizations may lack the experience and skills that would be considered fundamental prerequisites to adopting telehealth in less urgent times. What are those skills? Before the pandemic, the Association of American Medical Colleges (AAMC) convened national experts to identify and articulate a consensus set of critical telehealth skills for clinicians.

Methods:

Through a structured review of the literature, followed by several rounds of review and refinement by committee and community members via a modified Delphi process, the committee came to consensus on a set of skills required by clinicians to provide quality care via telehealth.

Conclusion:

The consensus set of telehealth skills presented in this paper, developed by the AAMC and national experts, can serve providers and health systems seeking to ensure that clinicians are prepared to meet the demand for care delivered via telehealth now and in the future.

Introduction

The COVID-19 pandemic has driven the dramatic growth of health care delivery through telehealth. Many systems shifted, at least temporarily, from sporadic and isolated use of telehealth to delivering a majority of services via telehealth.¹ Both small practices and large institutions have pivoted their in-person care model to virtual care without a roadmap for such a disruptive and rapid transition.

In this context, there is a risk that individuals and organizations may be deploying telehealth without the experience or knowledge that would be considered essential for implementation of such broad changes in less urgent times.² There is further risk that some professionals may not fully embrace telehealth, or that they may do so without the necessary awareness of standards and best practices for care delivery via telehealth. Finally, there is risk that when traditional services ramp back up, telehealth services put in place in the absence of pre-COVID-19 restrictions will either disappear or continue without taking into account temporary allowances, thus compromising privacy, security, and other aspects of care delivery. Compounding these risks is a lack of consensus regarding the set of skills needed by clinicians to deliver telehealth.

Understanding that clinicians needed a roadmap to develop the skills necessary to deliver high-quality care via telehealth, the Association of American Medical Colleges (AAMC) convened a group of experts to articulate a set of skills for clincians using telehealth. This skill set was intended to establish the foundation for telehealth competencies across the spectrum of training and practice.

Due to the COVID-19 pandemic and the related demand for virtual care delivery, the telehealth skills framework developed by AAMC and the expert committee is being published to assist health care systems and institutions as they rapidly transition policies, training, procedures, and workforce to a new care delivery model that is likely to become part of a new normal in health care.

Methods

We conducted a modified Delphi process in six rounds, consistent with the method described by Hsu and Sandford.³ In November 2018, the AAMC convened an 11-member committee of telehealth leaders (see Table 1 for subject matter experts). In advance, a review of the existing peer-reviewed literature on telehealth training for physicians was conducted using PubMed and Scopus, with the guidance of research librarians. For increased relevance, the review was limited to the previous 5 years in PubMed and the previous 10 years in Scopus. Google searches were used to identify relevant gray literature. The search resulted in 57 articles that were reviewed by coauthors (S.L.K. and S.A.S.), who identified 11 relevant articles^{4

–14} for which an annotated bibliography was created and shared with the committee. Inclusion criteria included a focus on training of physicians in the United States.

Table 1.

Subject Matter Experts

AAMC telehealth advisory committee overview:
• 4 former and current presidents of the American Telemedicine Association
• 2 senior federal officials
• 2 members of the American Medical Association's Digital Payment Advisory Group
• 2 authors of a telehealth textbook
• More than 600 publications across the committee
NAME	TITLE	INSTITUTION
Neil Evans, MD	Chief Officer, Office of Connected Care	Veterans Health Administration
Kevin Galpin, MD	Executive Director, Telehealth Services	Veterans Health Administration
Kristi Henderson, DNP	SVP, Telehealth & Innovation	Optum Health
Andrea Borondy Kitts, MS, MPH	Lung Cancer and Patient Advocate, Consultant Patient Outreach & Research Specialist	Lahey Hospital & Medical Center
Elizabeth Krupinski, PhD	Professor & Vice Chair for Research, Department of Radiology & Imaging Services	Emory University
Joseph C. Kvedar, MD	Senior Advisor, Virtual Care Professor of Dermatology	Mass General Brigham Harvard Medical School
Chen-Tan “CT” Lin, MD	Chief Medical Information Officer	UCHealth - Colorado
Curtis Lowery, MD	Director, Institute for Digital Health and Innovation	University of Arkansas
James P. Marcin, MD, MPH	Director, Center for Health and Technology Professor, Pediatric Critical Care	UC Davis Children's Hospital—UC Davis Health
Karen Rheuban, MD	Medical Director, Office of Telemedicine	University of Virginia
Neal Sikka, MD	Chief, Innovative Practice and Telemedicine Section, Professor of Emergency Medicine	George Washington University Medical Faculty Associates

In the initial round, the committee met to review the annotated bibliography and to compile a draft set of telehealth domains and skills. In the second round, the proposed domains were grouped and assigned to small teams for review. Teams developed domain definitions and drafted telehealth skills for each domain. The third round comprised a series of monthly committee webinars, reviewing one to three domains per webinar. A fourth round of edits was submitted by committee members after individual review. In the fifth round, drafted domains and skills were presented to external stakeholders for review. The feedback was shared with the committee for the sixth round of edits.

The final round focused on ensuring consensus across the committee for all domains and skills therein. Once consensus was reached, committee members reviewed the penultimate draft and incorporated minor edits for clarity. The final set of skills is presented below.

Consensus Telehealth Domains and Skills

Domain 1: Using Telehealth: Patient and Practice Readiness and Impact

Understanding when and why to use telehealth, as well as assessing patient readiness, practice readiness, and technology choices

Skills:

1. Describe the objectives for offering a telehealth service to patients.

2. Explain the differences between delivering in-person versus telehealth care, including the risks, benefits, and appropriate use(s) for each telehealth modality and when to initiate or transition a telehealth encounter to a different telehealth modality or in-person care.

3. Identify resources that provide information about current and emerging technologies needed to implement high-quality telehealth.

4. Prepare the full health care team, including health care professionals and supporting staff, to engage patients via telehealth, and develop clear team roles and responsibilities to deliver a successful telehealth encounter.

5. Identify the fiscal impacts of telehealth care delivery on the health system, the provider, and the patient.

Domain 2: Remote Clinical Evaluation and Care

Obtaining and managing clinical information remotely via telehealth to ensure appropriate high-quality care

Skills:

1. Acquire adequate information from a patient during a telehealth encounter to support achieving the desired goals of the encounter.

2. Demonstrate how to conduct a remote physical examination. Describe the physical findings that can and cannot be obtained via remote care, and how to collaborate with a telepresenter and the patient to acquire findings.

3. Incorporate a patient's observed personal environment into the evaluation and leverage it to augment the clinical assessment, treatment plan, and therapeutic relationship.

4. Incorporate patient-generated data into a clinical assessment and treatment plan, while understanding data limitations and documentation requirements.

5. Utilize appropriate telehealth documentation based on modality, health care institution, and practice.

Domain 3: Communication Using Telehealth

Exchanging information effectively between patients, families, caregivers, and health care team members using telehealth modalities with the goal of effective knowledge transfer and understanding.

Skills:

1. When delivering care via telehealth, create rapport, build relationships, and work effectively with

• patients, families, and caregivers;

• referring and collaborating health care providers; and

• remote telehealth support staff (e.g., medical and other health care professionals who are facilitating a remote physical examination).

2. Create a culture of trust and inclusion among remote care teams to achieve safe and coordinated care for patients.

3. Communicate expectations and potential limitations of a telehealth encounter to patients, families, and caregivers.

4. Instruct patients on the appropriate use of relevant telehealth technologies and guide them through basic troubleshooting as necessary.

5. Identify, and communicate to the patient, the locally available resources needed to support their care when recommendations are being made from a distance.

6. Specifically, for asynchronous communication, be able to

• demonstrate clarity and empathy to create a connection in the absence of in-person care; and

• effectively communicate with patients and health care team members, by including the appropriate level of detail, technical and layperson language, and follow-up instructions to ensure understanding of the clinical information and associated recommendations.

Domain 4: Professionalism

Habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, and values in daily telehealth practice for the benefit of the individual and community being served

Skills:

1. Demonstrate professionalism, respect for the individual, and etiquette in asynchronous and synchronous communications:

• Use appropriate salutations, closings, and tone in telehealth exchanges.

• Prepare appropriately for telehealth sessions (e.g., check equipment in advance, wear professional attire).

• Create an environment conducive to a clinical interaction (e.g., assure adequate lighting, minimize glare and distractions, establish a clean, quiet, and private space, avoid interruptions).

NOTE: Also refer to Skill 6 under “Communication Using Telehealth” domain.

2. Demonstrate good “web-side manner” (e.g., body language, eye contact, nonverbal cues).

Domain 5: Information Technology

The basic information technology (IT) skills necessary for clinicians to reliably deliver telehealth services

Skills:

1. Identify the technology needed at the distant and originating sites for the intended service, including an understanding of contingency plans related to technology failures.

2. Recognize the range of available technology capabilities and limitations, including patient-owned devices, and the impact they have on telehealth care.

3. Prepare to use, troubleshoot, and optimize technology for delivering telehealth care.

Domain 6: Privacy and Legal

Understanding the federal, state, local, facility, and practice standards to deliver and bill for telehealth services, while minimizing health care professional and patient risk

Skills:

1. Identify telehealth-specific risks and liabilities for patients, health care professionals, and health care systems, and explain how to mitigate them.

2. Complete telehealth visits in a manner that establishes patient identity, preserves patient privacy, and ensures patient confidentiality.

3. Explain to patients how privacy and security are maintained during telehealth care (e.g., encounters will not be recorded without patient consent).

4. Use local resources and expertise (e.g., colleagues in information technology, compliance, risk management) to ensure compliance with policy, regulations, and legislation related to use of telehealth technologies.

5. Understand current federal and state policies and requirements surrounding telehealth reimbursement.

Domain 7: Ethics

Prioritizing patient interests to preserve and enhance the provider/patient relationship.

Skills:

1. Explain the patient's right to decline care by telehealth in place of in-person care.

2. Discuss potential conflicts of interest and biases with the patient when recommending therapeutic and/or diagnostic modalities.

3. Apply ethical principles, including autonomy, justice, beneficence, and nonmaleficence, to telehealth care.

Domain 8: Patient Safety

Mindful of the strengths and limitations of each telehealth modality, understanding how to maximize patient safety when providing care using telehealth.

Skills:

1. Understand and explain risks to patient safety that are introduced by specific telehealth modalities, when care is provided across distance and/or time.

2. Understand and be prepared to switch telehealth modalities and/or escalate to in-person care based on the clinical scenario.

3. Prepare to respond to behavioral and medical emergencies during telehealth exchanges with both accompanied and unaccompanied patients.

4. Analyze early warning metrics and use effective processes to track and manage remote patient monitoring data.

5. Understand limitations in reliability and validity of remote patient data (e.g., home blood pressure, weight), and determine when confirmation is needed before use in evaluation, diagnosis, and treatment.

Domain 9: Access and Equity

An understanding of telehealth delivery that promotes equitable access, addresses and mitigates cultural biases, and accounts for nonhealth-related community needs and limitations.

Skills:

1. Assess patients' needs, preferences, and potential cultural, social, and linguistic barriers when considering telehealth.

2. Evaluate personal biases and their implications when considering telehealth.

3. Evaluate how technology can mitigate and/or exacerbate health inequity and socioeconomic gaps in access to care.

Discussion

When leveraged effectively, telehealth can increase accessibility by bringing care to the patient, expand capacity by matching clinical supply and demand across communities and regions, improve quality by monitoring and engaging with patients, and enhance patient experience through greater convenience and access.

In the context of the COVID-19 pandemic, telehealth has been critical to patient and provider safety. Telehealth has served to triage potential COVID patients to appropriate services, enhance and support critical care and emergency care, monitor patients in quarantine, conserve personal protective equipment, and maintain routine services while respecting social distancing. These will continue to be important considerations for the foreseeable future.

The dramatic increases in telehealth adoption and utilization during the pandemic underscore a need to ensure that clinicians establish skills required to deliver care via telehealth. Health care systems need to develop the policy, training, and procedures to support the transition of their workforce and assure sustained delivery of comprehensive services through telehealth. Likewise, the future workforce needs to become adept at delivering care virtually, through both training and experiential learning, guided by current evidence.

Providing a set of nationally vetted telehealth skills is important for health care systems, practices, providers, training programs, and medical education. It is hoped that these skills will serve as the foundation for policy, training, and procedure decisions in support of a broad and sustainable telehealth implementation. These skills are intended as best practice recommendations.The skills are not intended to establish a legal standard of care, but instead to guide provider and health system leaders toward appropriate policies and training opportunities that support high-quality care when delivered via telehealth.

The AAMC, through the continued work of its telehealth advisory committee and additional medical education leaders, will translate this set of skills into competencies specific to medical students, residents, and practicing physicians. Collectively, the medical training, credentialing, and quality communities must work together to benchmark the current and future health care workforce against the skills enumerated here, as we all transition to new models of delivering care together.

Footnotes

Authors' Contributions

All authors contributed to the concept and design as well as writing, review, and revision of the article.

Acknowledgments

The authors acknowledge the ongoing collaboration of Lisa Howley, PhD, MEd, Kamilah Weems, MS, and Adrien Barrios in working with the Advisory Committee, and all outside reviewers for their feedback on earlier drafts of the skills. AAMC telehealth advisory committee members: Neil Evans, MD, Chief Officer, Office of Connected Care, Veterans Health Administration; Kevin Galpin, MD, Executive Director, Telehealth Services, Veterans Health Administration; Kristi Henderson, DNP, Innovation & Telehealth, Optum at United Health Group; Andrea Borondy Kitts, MS, MPH, Patient Outreach and Research Specialist, Lahey Hospital and Medical Center; Elizabeth Krupinski, PhD, Professor and Vice Chair for Research, Department of Radiology and Imaging Sciences, Emory University; Joseph C. Kvedar, MD, Senior Advisor of Virtual Care, Mass General Brigham, and Professor of Dermatology, Harvard Medical School; Chen-Tan “CT” Lin, MD, Chief Medical Information Officer, UCHealth—Colorado; Curtis Lowery, MD, Director, Institute for Digital Health, University of Arkansas; James P. Marcin, MD, MPH, Director Center for Health and Technology, Professor, Pediatric Critical Care, UC Davis Children's Hospital—UC Davis Health; Karen Rheuban, MD, Medical Director, Office of Telemedicine, Professor of Pediatrics, University of Virginia; Neal Sikka, MD, Chief of the Innovative Practice & Telemedicine Section, Professor of Emergency Medicine, GW Medical Faculty Associates.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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