Preparing Health Professions Students for Telehealth

by Madeline Wolters, PharmD, PGY1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery VA Medical Center

Telehealth is a rapidly growing modality for delivering health care services.  It can improve access to care, enhance quality and frequency of visits, and reduce costs.¹ Telehealth can be administered in many ways but the most common are video conferencing, telephonic communication, and remote patient monitoring.² The World Health Organization defines telehealth as:

The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.¹

As a pharmacist who trained in Mississippi, I did receive some instruction regarding the delivery of teleservices since access to transportation and the geographic availability of providers are common barriers in rural areas. However, with the arrival of the COVID-19 pandemic, we have seen traditional healthcare delivery restructured, moving away from face-to-face visits to telehealth services.

Technology and virtual services are here to stay, so we must provide instruction to students of all health professions about telehealth.  Here are the key elements that should be addressed in the core curriculum:³

1. Professionalism in a virtual age
2. Appropriate use of mobile health information and technology
3. Communication skills in online environments

In my own experience as a pharmacy student, I was taught these skills through a series of lectures, training courses, professional assemblies, and practice-based experiences. There are countless ways to present and teach about telehealth to fit the needs of learners. Because health professionals must earn and maintain the trust of the people we serve, as practitioners and educators, it is our responsibility to uphold professionalism and teach those principles to the next generation. It is also important to remember that what may seem obvious to an “old pro” might not be intuitive for a novice learner.

Most health profession programs begin with instruction that is primarily classroom-based.  Early in the curriculum is the ideal time to introduce the concepts of professionalism, appropriate use of technology and patient information, and the foundations of successful communication. As learners progress and enter into the experiential or clinical portion of their education, these concepts can be expanded and reinforced through hands-on experiences and practice. In an interview on how telehealth is transforming healthcare during the COVID-19 pandemic, Dr. Richard Van Eck of the University of North Dakota School of Medicine and Health Sciences stressed the importance of putting learners in simulated and realistic environments to truly understand telehealth.⁴ He stated,” you can do all the didactics you want, but until you're in the midst of doing it [telehealth], you don't really understand what's involved”.⁴

The American Medical Association released a “Telehealth Visit Etiquette Checklist” which provides valuable tips that can be applied to all patient care interactions.⁵ A telehealth visit should mimic an in-person appointment as close as possible. If the patient will be using video-capable technology during an encounter, the student should be aware to dress in the same level of professional attire, including a white coat, if applicable.⁵ Just as a practitioner would prepare an exam room, the student should prepare their virtual environment.⁵ The necessary technology should be accessible, the electronic health record (EHR) should be open, and the background scenery and lighting should be appropriate for the encounter. For telephone calls, make sure the student is either using a telephone owned by the healthcare facility or an application that scrambles or protects the student’s personal phone number. The teaching institution should be able to provide any space and equipment that the learner should need.

Learners should also be taught how to appropriately use and share health information and technology. The patient’s confidentiality should be ensured by managing the appointment in a private space and following HIPAA (Health Insurance Portability and Accountability Act) requirements. It is also important to teach what health information may or may not be sent through non-secure platforms like email or text messages. If written patient information is to be shared with other providers, students need to be taught how to encrypt emails or navigate messaging through the EHR. The student should know who to contact if he or she feels the patient’s privacy may have been breached. Additionally, students need to know how and when they are permitted to use personal and institutional issued technology. Specific policies may vary from site to site, but ultimately a student should be taught a general guide to appropriate technology use.

Lastly, communication is at the center of all patient interactions. From the very beginning, students should be taught how to engage in motivational interviewing, deliver patient education, and manage patient exams. However, adjustments may be needed when using a virtual platform. Dr. Van Eck noted that many students inexperienced with telehealth report that they have difficulty understanding what the patient is saying and they are not able to read body language.  Also, patients are more likely to say things like “Who are you?”⁴ It may be helpful to run through example scenarios to boost a student’s confidence with operating the technology and practicing how to interact with a patient. Since you are not in control of the patient’s environment, students should be taught strategies to redirect the patient’s attention. For example, if the TV is loud in the background, the student should have the practice and self-assurance to say, “I would like us to have the best visit possible. Would you be able to turn the TV off for now?²” The importance of speaking clearly and deliberately is heightened during a telehealth encounter. Students may need to make frequent pauses to allow for transmission delays.⁵ During video-capable visits, students must be taught how to maintain eye contact and use non-verbal cues as much as possible.⁵ For telephone calls, students need to learn how to introduce the encounter and explain why they are calling the patient. Since hearing will be the only sensory mechanism, students will need to learn how to use inflection with their voice and implement continuous confirmation with empathetic language.⁵ As with all patient encounters, students must know to verbalize and clarify the next steps and patient care plan. The "teach-back method" is still helpful to confirm a patient's understanding.

A recently published systematic review examined the integration of telehealth topics in health professions curricula.¹ The review noted that telehealth concepts are multifaceted and can be overwhelming for students without foundational knowledge and guided experiences.¹ However, instruction provided to students using different modalities (online delivery, clinical experiences, simulations, and face-to-face instruction) all improved student satisfaction and self-confidence with telehealth encounters.¹ Ultimately, multiple exposures to these concepts throughout the curriculum are essential for the next generation of health care works to become competent and confident using telehealth technologies.¹ As telehealth becomes commonplace, telehealth experiences must become a required component of every curriculum.

References

1. Chike-Harris KE, Durham C, Logan A, et al. Integration of Telehealth Education Into the Health Care Provider Curriculum: A Review. Telemedicine and E-Health [Internet], Published online April 3, 2020. https://doi.org/10.1089/tmj.2019.0261
2. Telehealth. American Pharmacists Association. Accessed February 05, 2021.
3. Aungst TD. Integrating mHealth and Mobile Technology Education Into the Pharmacy Curriculum. Am J Pharm Educ 2014;78: Article 78119.
4. Educators discuss integrating telehealth in student curriculum. American Medical Association, January 2021. Accessed February 12, 2021.
5. Telehealth Visit Etiquette Checklist. American Medical Association. April 2020.  Accessed Feb 15, 2020.

Benefits and Concerns with Educational Handovers

by Elizabeth Sykes, PharmD, PGY1 Pharmacy Practice Resident, Baptist Memorial Hospital-North Mississippi

Most health professional are familiar with hand-off or handover reports which occur at the beginning and end of a shift, when a patient is transferred from one unit to another, or when there is a change in a patient’s condition.  Handovers occur between nurse to nurse, nurse to physician, nurse to a pharmacist, and even from pharmacist to pharmacist.  These handovers occur within and across all disciplines so that patients receive the most appropriate care.  Handovers are very important for patient safety and continuity of care.  It has been shown that poor or inaccurate handovers may lead to delayed and inappropriate treatment, medical errors, and inaccurate assessments and diagnoses.  Perhaps an educational handover between teachers and educational programs can have similar benefits?

An educational handover, the sharing of appropriate learner performance information between teachers and preceptors to support the learner’s ongoing training and development, is a potentially valuable way to support learning over time.¹ In this way, feedback about performance problems can be made based on multiple, longitudinal observations.¹  Benefits of educational handovers may include improved learning through more tailored feedback and support, improvements in a supervisor’s ability to assess learners related to specific competencies, increased assessor accountability, and improved patient safety through the early identification of weak or problematic behaviors.² 

However, not everyone agrees that educational handovers are useful, valuable, or appropriate.  Despite the potential benefits of an educational handover, there are some concerns associated with it.  Informing future teachers or preceptors about potential performance problems may introduce bias into the assessment process and it may lead instructors to treat some learners differently or label them. This could then lead to both the learner and the assessor acting in ways and viewing the learner’s performance through a lens that lines up with prior assessments. In addition, an educational handover may violate a learner’s right to confidentiality and privacy.²

A study performed at McGill University examined the potential bias from an educational handover on workplace-based assessment scores in medical education.  When given handover reports mentioning weaknesses, the hypothesis was that supervisors would provide lower assessment scores and more negative comments than those who did not receive learner reports.  This was a mixed-methods randomized, controlled, experimental study.  All participants viewed two videos of a simulated resident-patient encounter and then assessed the residents’ performance using the mini-Clinical Evaluation Exercise (mini-CEX).  The two videos viewed them in the same order.    The participants were randomized into three groups that differed based on the educational handover condition: no education handover report (control group), educational handover report indicating weaknesses in medical expertise, and educational handover report showing weaknesses in communication.  Participants had to complete a questionnaire that included questions about basic demographic variables (age, gender), clinical and educational variables (specialty, years of experience supervising, years of experience assessing), and mindset.  An analysis of variance was used to compare mean scores, percentages of negative comments, comments focusing on medical expertise, and comments focusing on communication across experimental groups.³

Seventy-two supervisors completed the study with 21 participants in the control group, 21 in the educational handover group indicating weakness in medical expertise, and 30 participants in the group receiving the educational handover indicating communication weaknesses.  No differences were detected in demographic characteristics, rater experience, or mindset across the three groups.  There was no effect of the handover report on assessment scores (F(2, 69) = 0.31, P = 0.74) or percentage of negative comments (F(2, 60) = 0.33, P = 0.72).  However, the participants who received a report indicating communication weakness generated a higher percentage of comments about communication skills than the control group (63% vs. 50%), P = 0.03).³ 

	Control Group (no handover report) n = 21	Medical Expertise Weakness Group n = 21	Communication Weakness Group n = 30
Mean score for Video 1	5.6 (4.9-6.2)	5 (4.2-5.8)	4.9 (4.5-5.4)
Mean score for Video 2	4.8 (4.2-5.4)	5 (4.4-5.6)	4.9 (4.4-5.5)
Mean score for both videos	5.2 (4.6-5.7)	5 (4.4-5.6)	4.9 (4.5-5.3)

This study suggests that an educational handover can lead to more targeted feedback without influencing scores.  Further studies are needed to examine the influence of reports of various performance levels, areas of weakness, and learner behaviors.³ 

Competency-based medical education (CBME) is becoming the cornerstone of medical education programs.  But the transition from undergraduate medical education to graduate medical education is not a smooth process.  It has been suggested that an educational handover at the end of medical school might help with this transition and would help students become more prepared to care of patients.  The Medical Student Performance Evaluation (MSPE) is submitted in early October each year, and there is very little information provided about the final year of medical school.  In April 2018, the American Medical Association’s Accelerating Change in Medical Education consortium developed five recommendations for developing an educational handover that would be provided to residency programs at the end of medical school.  The 5 recommendations are: (1) The purpose of the educational handover is to provide performance data to guide continued improvement in the learner’s ability and performance, (2) the process used to create an education handover should be philosophically and practically aligned with the learner’s continuous improvement, (3) the educational handover should be learner-driven with a focus on individualized learning plans that are co-produced by the learner and his/her coach or advisor, (4) the transfer of information within an educational handover should be done in a standardized format, and (5) together, medical schools and residency programs must invest inadequate infrastructure to support learner improvement.

Despite these recommendations, there are still challenges with educational handovers between educational programs.  Medical schools would have to develop a curriculum for educational handovers that focuses on assessing individuals' performance.  These should include authentic workplace-based assessments coupled with a formative feedback process.  The Family Educational Rights and Privacy Act (FERPA) regulations apply to educational handovers.  Even though medical school graduates transfer from one educational setting to another, FERPA protects the privacy of learners in both contexts.  Thus, any educational handover will need to comply with FERPA.  Medical schools would need to develop a standardized process to support meaningful communication.  Lastly, creating an educational handover should support a successful transition.  Gathering assessments and adjusting each trainee’s experience during the first few months of a residency would be challenging.  But to be truly effective, the content of the educational handover should be used to implement learner-specific curricular modifications.⁵

Health profession educational programs should have some form of handover, but many of them don’t, or they may lack the appropriate framework.⁴  I believe educational handovers would help prepare learners (students and residents) for the next step in their career.  It can provide future preceptors and employers with information about the learners’ past performance and how they should tailor experiences to help address potential weaknesses.  Educational handovers may lead to some bias, but I believe with appropriate training, preceptors and residency program directors can learn to appropriately use this information to address learner needs. 

References 

1. Guidelines for Educational Handover in Competence by Design. Royal College Committee on Specialty Education: 2018 May 
2. (Gumuchian ST, Pal NE, Young M, Danoff D, Plotnick LH, Cummings BA, et al. Learner handover: Perspectives and recommendations from the front-line. Perspect Med Educ. 2020;9:294-301. 
3. Dory V, Danoff D, Plotnick LH, Cummings BA, Gomez-Garibello C, Pal NE, et al. Does Education Handover Influence Subsequent Assessment? Acad Med. 2021;96:118-125.
4. Gordon M, Hill E, Stojan JN, Daniel M. Educational Interventions to Improve Handover in Health Care:  An Updated Systematic Review. Acad Med. 2018;93(8):1234-1244. 
5. Morgan HK, Mejicano GC, Skochelak S, Lomis K, Hawkins R, Tunkel AR, et al. A Responsible Educational Handover: Improving Communication to Improve Learning. Acad Med. 2020;95:194-199.