|Competencies||Differences between bedside practice and virtual care||Helpful resources for curriculum development|
|Domain I: Digital communication and webside manner||Optimal visualization, body language, and speech||
Communication speed—reduced for clear enunciation to ensure clarity over online platforms.|
Colloquial speech—avoided to differentiate between professional encounter and lifestyle video communication such as FaceTime®
Body motion and gestures—minimized and made in full view of camera. Motions should be slowed to avoid blurring or poor visualization over video.
Background, lighting, and framing are essential components of a virtual encounter which differ from traditional encounters.
Dress—solid clothes with a neutral background project optimally in a virtual setting.
Camera—located in a fixed position with clinician’s head and shoulders centered. Clinicians look at the camera rather than screen to maintain “eye contact.”
Media training groups such as Media Training Worldwide: https://www.tjwalker.com|
Conferences offer simulation based training for clinicians: https://www.virtualhealthcarenyc.com
The American Telemedicine Association offers courses and webinars: http://learn.americantelemed.org/diweb/start
Coordinator training modules: http://www.caltrc.org/knowledge-center/training/
|Graphic-assisted communication||Imaging and diagnostic findings—conveyed to patients using a screen share methodology|
Understand—be familiar with virtual health platforms|
Troubleshoot—from both patient and clinician perspective
|Systems vary by vendor. Require in-servicing and helpline access. Varies by provider (hospital, medical group, insurance company, employer).|
|Domain II: Scope and standards of care||Licensing||State-specific licensing requirements—limitations on patient location and physician licensing built into each program.||
Telemedicine licensing requirements: http://www.fsmb.org/siteassets/advocacy/key-issues/telemedicine_policies_by_state.pdf|
Cross-state licensing: https://www.ama-assn.org/practice-management/digital/cross-state-licensing-process-now-live-8-states
|Billing and insurance||
Coverage for virtual visits—varies by locale and insurance carrier.|
Medicare policy ongoing evolution. Requires regular updating.
CMS Telemedicine services: https://www.cms.gov/medicare/medicare-general-information/telehealth/telehealth-codes.html|
Reimbursement Laws: https://www.cchpca.org/telehealth-policy/current-state-laws-and-reimbursement-policies
|HIPAA compliance||Privacy—communicate with patient about the privacy of their location. Physician telemedicine visits should be conducted from appropriate space with the necessary privacy.|
|Prescribing||Legal limits of e-prescribing—for both controlled and uncontrolled substances over virtual platforms.|
|Virtual care pathways||
Appropriate follow-up—provide summation, instruction for treatment and follow-up (including home care or ambulatory diagnostic services), and precautions.|
Emergent response—virtual visits may require activation of emergency services. Knowledge of patient location and ability to deploy EMS.
Record patient address during intake.|
Maintain list of emergency and urgent care centers in area serviced by telemedicine program.
Telemedicine applications course: https://telemedicine.arizona.edu/training.cfm
|Domain III: Virtual clinical interactions||Environmental assessment||Safety, cleanliness, activities of daily living—environment provides additional information beyond traditional patient encounter|
|Virtual physical exam||
Remote exam techniques—physician-guided or caregiver-assisted patient examinations used to assist in diagnostic accuracy. Alternatively, additional on-site providers (EMS, nursing) may assist if present.|
Remote monitoring devices—use of home blood pressure cuffs, smart watches, and glucometers for data gathering
|To date, little research exists on these techniques. Evidence remains largely anecdotal and experience based including telemedicine physical exam techniques (http://www.telemedmag.com/article/telemedicine-physical-better-think/) and physician-guided patient self-examination case report (https://www.liebertpub.com/doi/full/10.1089/tmj.2018.0115).|
|Group interactions||Management of group interactions—focus on family and group dynamics. Ensure HIPPA compliance in advance. Establish goals in advance with care management team. Observe experienced virtual health practitioner|