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    Christian Green
    Christian Green, MA

    May 12, 2020. 11 p.m. EST. A patient in Virginia is experiencing severe nausea, abdominal pain and fever. She does not have a family practitioner because she just moved to the area. She considers driving to the ER but thinks twice for fear of the unknown with COVID-19. Instead, she downloads a telehealth app on her cell phone, creates an account and begins to review provider profiles. After a couple minutes of information overload, she decides to simply select the first available provider.

    Thirty seconds later, she is connected to a young physician wearing a black-and-white striped shirt. The physician is sitting in a dark corner. There are metal blinds behind her. She introduces herself, but shortly thereafter her voice is drowned out by the sound of sirens on the street below. Throughout the appointment, the physician spends most of her time looking down at the notes she’s taking. When she does look up, she fixes her gaze on the patient rather than into the camera.

    After they discuss the patient’s symptoms, the physician asks the patient to lie on the floor and press on the area where she is feeling pain. The patient says her pain has been getting worse and she thinks she needs a CT scan or blood test. She simply wants the physician to confirm this.

    This unfortunate scenario illustrates the importance and need for virtual care competency, particularly when it comes to being proficient in webside manner. If providers are new to telehealth, as many were at the beginning of the COVID-19 pandemic, their level of comfort in communicating over videotelephony may have been subpar. As with bedside manner, webside manner does not often come naturally and may require physicians to train for better performance.

    Training on the fly

    Practices that quickly launched virtual care during the early stages of the pandemic often had to cobble together training programs, tutorials and cheat sheets for their providers. They did what they could, but formal training was often in short supply.

    For Adam Pople, CMPE, practice administrator, Steamboat Medical Group & Steamboat Urgent Care, Steamboat Springs, Colo., who served as clinic operations manager for three specialty clinics in Montana in the early months of the pandemic, provider instruction came in the form of group and individual training and dry runs. This was followed by a simulation with a member of the clinical information operations team to ensure providers were comfortable with the virtual platform and could effectively use the EHR during virtual visits.

    Initially, providers were sometimes more focused on the platform than the patient, Pople recalled, because they were still learning the nuances of the platform. “I think that some patients were experiencing so many virtual meetings where people were distracted by emails or web-browsing that if the physician appeared to look away from the camera or look at another screen, there was more concern that the physician was distracted,” said Pople.

    Help comes in many forms

    To improve provider comfort levels, Pople frequently rounded and served as a conduit for information between the physicians and the clinical information operations team. Once the providers became comfortable, Pople said their webside manner became comparable to their in-person bedside manner and, in some cases, surpassed it. 

    Pople’s group also hired a new provider during the pandemic who helped provide peer coaching and new perspectives and tips. “Up until then we were really trying to reach out to anyone on … what was working and what was not,” explained Pople.

    Jason Manley, director of quality and AMR, AllianceHealth Oklahoma, who oversees seven medical groups across the state, took it upon himself to make certain providers were comfortable with the telehealth platform they used. He first scheduled two different training calls with the providers, clinical staff and clinic managers, and helped them create profiles on the platform. During the training calls, he logged in to a computer as a provider, shared his screen and then called into a simulated appointment from his cell phone to log in as a patient. “With that, I walked them step by step through the virtual visit … as they’re going through the workflow of seeing the patient,” he said of the simulation.

    In one instance, he took the entire day to sit with a provider to observe how he was interacting with patients to help define the proper use of a telehealth appointment. “[The doctor] would have the virtual visit, complete that visit and then ask the patient to come into the office,” said Manley of the provider’s approach. “That kind of defeated the purpose of the telehealth visit; I had to coach him about there being certain visits that can be telehealth and certain ones that can’t.” Accordingly, Manley and the provider reviewed situations in which the staff would be able to determine whether a patient should come into the office or whether a telehealth visit would suffice.

    Success does not happen overnight

    Regardless of the amount of virtual care training providers receive, proficiency takes time. As Jocelyn Piccone, MHA, MA, CMPE, program director, Liberty Healthcare Corporation, related, one of her initial steps when training providers in telehealth is to determine their level of understanding with the equipment they will use. “There’s a lot of physicians who are in their 60s and 70s, who are still practicing but probably don’t have as much ease with technology,” she said. 

    Next, she determines whether the provider is comfortable being on screen with a patient. “When you’re treating a patient [via telehealth], there’s more eye contact, most of the time, than there normally could be when you’re sitting in your office and you can look around to other objects,” she maintained.

    She also asserted that providers shouldn’t have any strange visual habits: On a screen the patient mostly sees the provider’s head and vice versa, which exaggerates what each sees. Similarly, full attention should be given to the patient, so it’s important to have a uniform background free from distractions, such as a stack of books, and refrain from using other devices or even Googling something that’s pertinent to the conversation with the patient.

    No matter the amount of time she spends training providers, she feels as though the long-term benefits far outweigh any bumps in the road. “Once you train people on how to do telehealth, and the benefits of it, I think they’re happier because they don’t have to leave their house to have a visit,” she said. “[Patients] don’t have to make arrangements to get there, so I think there should be less no-shows with telehealth.”

    The best virtual care stems from formal training and education

    At the heart of virtual care training is ensuring that practices have comprehensive guidelines and best practices they can rely on to provide the best care.

    One such telehealth training program was developed by the Reimagine New York Commission with assistance from groups that include the Northeast Telehealth Resource Center, Cityblock Health, Stony Brook Medicine and Weill Cornell Medicine. The federally funded program provides a framework for telehealth education for New York-based providers through its e-learning portal, which includes real-time and on-demand training that adheres to state telemedicine guidelines.

    The telehealth training program is one of several being developed throughout the United States, often through the National Consortium of Telehealth Resource Centers, which includes 12 regional and two national centers, including the aforementioned Northeast Telehealth Resource Center.

    In the vanguard: Weill Cornell Medicine

    Long before the pandemic necessitated virtual care training programs, one of the early adopters of telehealth curriculum was Weill Cornell Medicine, which started telemedicine education in 2017 and opened its Center for Virtual Care (CVC) in 2019. When the program was established, nearly every medical student’s training in care competency was geared toward in-person encounters, according to Neel Naik, MD, director of Emergency Medicine Simulation Education. The curriculum is hands-on and individualized, which allows medical students to critique themselves while learning a new medium. (Since the start of the pandemic, Weill Cornell Medicine has also offered this training to providers in medical practices through its remote flipped classroom.)

    When they started the program, Naik and the other Weill Cornell Medicine CVC educators emphasized to their students that the medicine would not change just because they weren’t in the same room as their patients. Once that was made clear, the main concerns that arose were determining best practices for treating patients via videotelephony. Oftentimes, students were self-conscious or worried that they couldn’t hear the patient or vice versa.

    Naik said this opened the door for further discussion about developing curriculum around verbal and nonverbal communication via videotelephony to account for a reduced range of actions a physician could perform virtually. Putting a hand on a patient’s shoulder or offering them a tissue box, for example, don’t translate when provider and patient aren’t in the same room, explained Naik.

    “It started with … camera angles, looking into the camera to make eye contact,” said Naik of how instruction evolved over time. “Then as we broadened the scope of it, when we started having discussions with the students and answering the questions that they had, we were able to build out this entire curriculum, which over the last year has grown and taken off.”

    This has enabled learning to be tailored to the individual, especially because Weill Cornell Medicine stresses instruction through simulation. “The beauty of simulation is that the discussion is built around the questions the learners have,” said Naik. “So the discussions around the simulations have grown, and we’ve been able to modulate the discussion based on the level of the learner. … It’s the discussion, and the questions, and the personal experiences that are brought into the discussion that change with every course.”

    Best practices in webside manner

    Naik stressed that physicians need to regard webside manner in the same fashion as bedside manner — essentially focusing on everything that isn’t the medicine itself. But that’s easier said than done when physicians don’t control the environment, as they typically do during an in-person hospital or office visit. “When the patient walks into a hospital, they’re mentally primed to have a medical encounter,” said Naik. “They see signage, they have a greeter, they register … And you know, the best example of this is, we tell the patient to change into this really flimsy gown and sit on a cold table and they do that without hesitation.”

    The nonverbal communication that may come naturally in person may take more effort in a virtual environment. Naik says it’s the provider’s responsibility to work to establish a connection at the beginning of the telehealth visit, along with an environment that makes the patient feel comfortable, regardless of their location. “If they’re calling from the diner, or from a car, or from their bathtub, which we’ve all had patients call from, we have to figure out a way to optimize that to be conducive to medical care,” said Naik. “That includes making sure there’s privacy … if there are people next to the patient who are off camera, we know who that is.”

    Naik expressed that webside manner should be viewed holistically, which includes training on everything from creating a comfortable environment and verbal and nonverbal communication to empathy, lighting and camera work, and scripting, all of which lay the groundwork for a successful telehealth encounter.

    Ultimately, physicians need to be at ease to ensure patients are, too. “If we can teach them to feel comfortable doing the physical exam over this medium … they’re able to have a lot more confidence in their ability to conduct these visits,” said Naik.

    Another key aspect of training that Weill Cornell Medicine emphasizes is that telehealth visits are a 50/50 proposition between provider and patient. “You really have to work with the patient for the visit to go well,” said Naik. “They know the pharmacies and the drugstores and the laboratory sites around their area better than you do, so you really have to partner with them and make it a two-way street.”

    Simulation can help identify common mistakes

    Weill Cornell Medicine emphasizes simulation in its training, so CVC educators are better able to identify common mistakes medical students and providers make. According to Naik, they record these individuals and review the videos to show them what they may need to work on, including eliminating distractions.

    “A classic example is you have a patient calling in with dizziness,” offered Naik. “And they’re talking to you on this virtual background, and you’re doing this visit from your home office … and you have a ceiling fan going on in the background. To you, that ceiling fan is keeping you cool, but to the patient it’s actually making their symptoms worse.”

    Naik has even observed providers inadvertently sending mixed messages, simply by what patients see on camera. In one example, a provider may be counseling a patient on diabetes: “I’m doing my visit from my kitchen because it’s a flat counter with a table, and I have a cookie jar in the background,” remarked Naik. “Even though I’m saying all the right things, the nonverbal thing that’s communicated with that cookie jar in the background completely takes away from the message that I’m actually trying to instill.”

    Another issue Naik often sees, even with those who have some experience with videotelephony, is lack of eye contact. Medical students and providers frequently focus so much on looking at the camera rather than at the screen that they get self-conscious about it. “It’s making eye contact with purpose,” stated Naik. “So if I’m going to make a point … that’s when I look into the camera, or when the patient is telling me about something.”

    Likewise, Naik pointed out that providers don’t want to make it seem as though they are not paying attention because they are looking at another screen or jotting down notes. If this is likely during an appointment, Naik said it’s important for the provider to explain at the beginning of the call that he or she may be reviewing the patient’s chart or other vital information.

    Having an opening script, including confirming name and birthdate, obtaining verbal consent and even confirming where a patient is calling from, is crucial, Naik believes, in avoiding any legal issues. But it’s also imperative to establish a level of comfort with the patient. For example, “It could even be something like a transgender patient calling in, and I inadvertently use a pronoun that they don’t identify with,” said Naik. “Just that initial aspect of it can shut down the entire visit; if they don’t like the way the visit is going or they don’t feel comfortable, they hang up and leave.”

    Training modules

    Although simulation may be the most important aspect of virtual care competency training at Weill Cornell Medicine in developing good webside manner, it’s part of a larger training module based on a general approach to the virtual physical exam. It includes instruction on legal and regulatory aspects of telemedicine; lighting, framing, and staging; hardware requirements; and safety protocols. As a result, medical students and providers have the same level of knowledge when they begin the simulation sessions.

    “With the simulations, they are allowed to apply that knowledge that they now have,” said Naik. “In our discussions, we still highlight some of those things, maybe take a deeper dive into some of those topics based on what the students want to talk about.”

    With the eCornell Module, Weill Cornell Medicine’s online flipped classroom course, much of the instruction is similar to its in-person experiential learning module and is taught by four principal CVC educators who have practiced telemedicine for five to six years. “There’s a course component to it with assignments, role playing, and there’s some self-directed simulation that’s built into that to create an interactive learning environment that’s more conducive to learning some of these tools and putting them into practice,” said Naik of the online module.

    As Naik noted, Weill Cornell Medicine has conducted in-house training for some medical practices. In addition to the basics of telemedicine, the CVC educators tailor their training sessions to address the difficulties practices face with virtual care. “I think a lot of the faculty … get a ton out of that aspect of it,” said Naik. “Because they’re able to personalize it to the practice, whether that’s a primary care practice, a surgical practice or an ER practice.”

    Training a diverse set of providers who have had a variety of experience in virtual care has helped improve the program. “It’s the questions and the personal experiences that are brought into the discussion that change with every course,” said Naik of integrating these experiences into what they teach. “It really addresses the needs of the individual learner … and it has evolved with time, as we’ve known more and different technologies are out there and different wearables, and a different level of acceptance of telemedicine over the last year.”

    As virtual care continues to evolve, so too will the need to continuously improve competency so that patients receive the same quality care they would receive in person.

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    Learn more

    • The National Consortium of Telehealth Resource Centers (NCTRC) — This collaborative of 12 regional and two national Telehealth Resource Centers is funded by the Department of Health & Human Resources and Health Resources & Services Administration and has numerous articles, case studies, toolkits and webinars in such areas as telehealth basics, telehealth and COVID-19, and technology and broadband.
    • Weill Cornell Medicine Center for Virtual Care — Provides virtual care training, including modality-specific decision-making, remote patient examination skills and webside manner, as well as instruction in medicolegal and technical standards.
    Christian Green

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