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.