Selected Podcast
Telehealth: What Does the Risk Manager Need to Know to Minimize Risk
Health care risk management is a very diverse field and when you meet one risk manager, you meet one risk manager. One size does not fit all. This podcast series will look to discuss risks inherent to a variety of areas in health care. This podcast, the ninth in the series, will look at telehealth and risks that are inherent to this delivery care model.
Featuring:
Judy has extensive experience working for both physician and hospital medical malpractice insurance carriers, both in claims and risk management. She began her insurance career in the 1980s with PMSLIC in Pennsylvania and PICO in Ohio. Prior to joining Coverys, Judy spent 10 years with OHA Insurance Solutions, Inc. (OHAIS), where she developed the risk management program, managed the department, and worked closely with insured clients. Prior to joining OHAIS, Judy spent 14 years at OHIC Insurance Company as a Senior Risk Management Specialist and Claims Supervisor.
Judy contributes to risk management publications and speaks frequently on risk and patient safety-related topics. Judy has spoken for the Ohio Hospital Association, the Ohio Society of Healthcare Risk Managers, Indiana Society for Healthcare Risk Management, Hospital Insurance Forum, Medical Professional Liability Association and American Society for Healthcare Risk Managers.
Judy holds a B.S. degree in medical science from Alderson-Broaddus College, is a Certified Professional in Healthcare Risk Management, and is a Fellow of the American Society of Healthcare Risk Management. She is past President of the Indiana Society for Healthcare Risk Management (ISHRM), past President of the Ohio Society of Healthcare Risk Managers (OSHRM) and is a board member for the Ohio Patient Safety Institute (OPSI). Judy is a committee chair for the American Society for Healthcare Risk Managers (ASHRM) and the Hospital Insurance Forum. She is also a member of the Ohio Hospital Association, the Ohio Society of Healthcare Risk Managers, the Indiana Society for Healthcare Risk Management, the American Society of Healthcare Risk Managers, the American Academy of Physician Assistants, and the Hospital Insurance Forum.
Dr. Jennifer Kozaily has been overseeing quality, patient safety, accreditation and risk management programs at different leadership levels. Her current main responsibilities include the coordination and oversight of quality improvement and risk management activities according to the accreditation standards, JCI and Department of Health, Abu Dhabi, UAE.
Dr. Kozaily received her Doctor of Pharmacy from the Lebanese American University (LAU), Lebanon. She then completed a PGY-1 Pharmacy Residency at Florida Hospital in Orlando, FL, USA and then worked as the Emergency Medicine Pharmacist and the Medication Safety Officer at Florida Hospital, she received the Adventist Health System Pharmacy Quality Award for the implementation of pharmacy services in Emergency Department.
She has been involved in several patient safety and risk management trainings and workshops at both institutional and national levels.
Dr. Kozaily is a Certified Professional in Health Care Risk Management (CPHRM)and Patient Safety (CPPS), and she has recently received her Master of Laws (LLM) in Medical Law & Ethics at the University of Edinburgh in 2021. She is an active member of the American Society for Healthcare Risk Management (ASHRM) and serves on ASHRM Committees including the Journal Editorial Review Board and Chapter Leadership Task Force.
Judy Klein, PA, CPHRM, FA SHRM | Jennifer Kozaily, PharmD, LLM, CPHRM, CPPS
Judy Klein has over 30 years of experience as a physician assistant, risk manager and working in professional liability insurance. Judy has clinical experience as a physician assistant, practicing in both hospitals and physician offices. Judy has also worked as a hospital risk manager.Judy has extensive experience working for both physician and hospital medical malpractice insurance carriers, both in claims and risk management. She began her insurance career in the 1980s with PMSLIC in Pennsylvania and PICO in Ohio. Prior to joining Coverys, Judy spent 10 years with OHA Insurance Solutions, Inc. (OHAIS), where she developed the risk management program, managed the department, and worked closely with insured clients. Prior to joining OHAIS, Judy spent 14 years at OHIC Insurance Company as a Senior Risk Management Specialist and Claims Supervisor.
Judy contributes to risk management publications and speaks frequently on risk and patient safety-related topics. Judy has spoken for the Ohio Hospital Association, the Ohio Society of Healthcare Risk Managers, Indiana Society for Healthcare Risk Management, Hospital Insurance Forum, Medical Professional Liability Association and American Society for Healthcare Risk Managers.
Judy holds a B.S. degree in medical science from Alderson-Broaddus College, is a Certified Professional in Healthcare Risk Management, and is a Fellow of the American Society of Healthcare Risk Management. She is past President of the Indiana Society for Healthcare Risk Management (ISHRM), past President of the Ohio Society of Healthcare Risk Managers (OSHRM) and is a board member for the Ohio Patient Safety Institute (OPSI). Judy is a committee chair for the American Society for Healthcare Risk Managers (ASHRM) and the Hospital Insurance Forum. She is also a member of the Ohio Hospital Association, the Ohio Society of Healthcare Risk Managers, the Indiana Society for Healthcare Risk Management, the American Society of Healthcare Risk Managers, the American Academy of Physician Assistants, and the Hospital Insurance Forum.
Dr. Jennifer Kozaily has been overseeing quality, patient safety, accreditation and risk management programs at different leadership levels. Her current main responsibilities include the coordination and oversight of quality improvement and risk management activities according to the accreditation standards, JCI and Department of Health, Abu Dhabi, UAE.
Dr. Kozaily received her Doctor of Pharmacy from the Lebanese American University (LAU), Lebanon. She then completed a PGY-1 Pharmacy Residency at Florida Hospital in Orlando, FL, USA and then worked as the Emergency Medicine Pharmacist and the Medication Safety Officer at Florida Hospital, she received the Adventist Health System Pharmacy Quality Award for the implementation of pharmacy services in Emergency Department.
She has been involved in several patient safety and risk management trainings and workshops at both institutional and national levels.
Dr. Kozaily is a Certified Professional in Health Care Risk Management (CPHRM)and Patient Safety (CPPS), and she has recently received her Master of Laws (LLM) in Medical Law & Ethics at the University of Edinburgh in 2021. She is an active member of the American Society for Healthcare Risk Management (ASHRM) and serves on ASHRM Committees including the Journal Editorial Review Board and Chapter Leadership Task Force.
Transcription:
Bill Klaproth (host): Welcome to the ASHRM Podcast made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted health care through enterprise risk management. You can visit ASHRM that's ashrm.org/membership to learn more and to become an ashram member. I'm Bill Klaproth, so when it comes to tele-health, what does the risk manager need to know to minimize risk? Well, let's find out with Dr. Jennifer. Kozaily, her main responsibilities include the coordination and oversight of quality improvement and risk management activities. According to the accreditation standards, JCI and Department of Health in Abu Dhabi. And Judy Klein. She is a BD lead, a PA and risk manager. And also she is in risk management and analytics for Covaris. Jennifer and Judy, thank you so much for your time. We appreciate it. Jennifer, let me start with you. How do we measure the success of the tele-health program?
Jennifer Kozaily: So like any program or project that we want to implement in the healthcare setting, it is important to measure the success and the performance of the telehealth program in order to secure its future and to determine the next steps. On a clinical aspect, whether we want to scale the program to expand benefits to more patients, conditions, specialties, or on a financial aspect to justify the continued costs and fundings implicated with the program. So now how do we measure the success of the program?
First, every organization has to set its own enterprise objectives and goals that they want to achieve through the telehealth program, both short term and long term, and then accordingly develop an evaluation and routine performance monitoring plan. That includes the key performance indicators or KPIs with defined targets. There is definitely no one size fits all approach to telehealth when it comes to KPIs, like any other area of patient care. And the choice of KPIs depend on the goals and objectives set and types of services provided.
However, there are some standard KPIs that can be used to measure success, and these indicators cover the different organizational domains. Such as operational clinical outcomes, patient safety, human capital, financial technologies, strategic reputation, and legal. Now I'm gonna go over some examples of those KPIs under each domain, let's start with the clinical outcome indicators. For example, we want to have improved health outcomes and the targets are specific to each disease that we are treating.
We want to have improvement in the compliance with treatment as a result of access, convenience, and continuity of care through telemedicine. We want to have reduction in ER, visits and readmission rates as for the operational, outcomes. We want to have improved access to care and specialists. And this is very helpful when you talk about behavioral health psychiatry, dermatology, tele sitter, whenever you want multiple patients to monitor against falls, suicide risks. And that helps a lot with the nursing shortage that we have under the financial indicators.
You want to have improved patient reach and we measure that by increased number of patient enrolled in tele-health. We want to have reduced cost, cost per case cost due to be admission. Under strategic reputational, we focus on the patient experience. Under strategic reputation. We focus on patient experience perspective. We want to have improvement in patient satisfaction. And we can measure that through the patient experience surveys that we are gonna be tailoring based on the telemedicine services that we are providing.
Under human capital domain, we have to improve the provider satisfaction indicators, and this is provided due to continuity of care and efficiency of care delivery due to telemedicine. And under technology. We want to make sure we don't have complaints due to, lack of connectivity, wifi, and, even the telemedicine monitors that we are using to monitor the blood pressure and the vital signs.
Bill Klaproth (host): So then what are the strategies that providers in healthcare organizations can take to optimize the use of telehealth to deliver safe and effective care to patients?
Jennifer Kozaily: So there are some strategies that providers and healthcare organizations can take into account to optimize the use of telehealth in order to deliver a safe and effective care to patient. First as discussed earlier in my previous question, we need to make sure that we set up the telehealth system for success by setting goals and establishing key performance indicators. And to use the data from those indicators and other feedback on telehealth experience to continue to see monitor and make improvements. Second, we need to make sure that we are effectively using the clinical services via tele-health.
And we do that by developing protocols and workflows for virtual care. And reducing the variation between specialties and service lines by training providers to provide a standardized high quality care experience for patients. The third strategy that we can use is to ensure appropriate training of staff on telehealth workflows. This is done by creating a series of life educational support and online education modules, and also to identify a staff super user who can provide support and training to the other, remaining staff and healthcare providers.
These trainings have to cover topics such as, equipment technology, training, the use of EMR, informed consent ethics using telemedicine privacy, as well as we need to make sure that you are training our patients on how to use telemedicine. Last and not least, we need to make sure that we are continuously monitoring the technology we are using. We have to make sure that, we ask our vendors for ways they can provide support pre and post implementation. For example, the training that they support, the tech support, the workflow, design collaboration, data analysis, cyber security, and project management as well.
And we also need to make sure that the vendor can provide easy access to data so we can use it for monitoring purposes as I've discussed, using the KPI. And also we need to make sure that we are ensuring that our organization has secure platform that supports HIPAA concerns. And we need to all the time monitor this as well when it comes to our, telemedicine.
Bill Klaproth (host): Well, thank you for that, Jennifer and Judy, can you articulate a few of the main benefits of telehealth?
Judy Klein: A couple of words come to mind when looking at the benefits of tele-health, convenient, efficient, and access. For those who have access to technology and, are comfortable using it, telemedicine really provides an extremely convenient and an efficient way to deliver healthcare. think about it. Patients no longer have to drive to a doctor's. They no longer have potentially long wait times or be exposed to potentially sick patients in a waiting room. And it significantly benefits patients who otherwise might not be motivated to want to go into an office to see healthcare provider.
Consumerism or meeting the demands and expectations of you and I as customers is really driving demand for this convenient way, to get care. We live by our our smartphones, our digital devices, and that includes patients of all ages. So one example that comes to mind is I think of my father-in-law, it's been very beneficial for him because, as he gets up in age, he's had difficulty ambulating and hearing too. And so he can use the technology in his own home, by his own computer, and even adjust the volume to be able to hear better, to meet his needs.
And then his adult children who, you know, ordinarily would not be able to accompany him, for an in person visit, can remotely call into that visit too. And it also helps, the providers they can get, a better understanding of that patient's home environment. Access, also comes to mind telehealth can improve access to, specialists, and address provider shortages, especially in regions of the country who are lacking specialists or care providers. And then I think also when you pair a virtual care with remote patient monitoring or wearable devices, following patients virtually can be used as a means to, better engage your patients, drive down hospital, readmissions. drive down cost and ultimately improve patient outcomes.
It can be a real game changer for patients who are stable, but need monitoring of chronic conditions like diabetes, heart disease to make sure that they're following their treatment plan. They're taking their medications. So, consider, a type two diabetic patient with uncontrolled blood sugars. Who's been prescribed a continuous glucose monitoring or a CGM wearable device, with data inputs that, remotely get relayed to the physician, the patient can now easily track their blood glucose, adjust their diet, their activity accordingly and prevent wide variations.
So, this really helps incentivize, patients makes them more account. and it can also lead to reducing the number of in person, visits that that patient has to have.
Bill Klaproth (host): Right. There certainly are a lot. Benefits and what you listed convenience. That's huge improved access. And being able to follow patients virtually are all really big benefits of telehealth. But Judy then what are the challenges when a patient is not in the same room as the provider and what can be done to address those challenges?
Judy Klein: That's a really good point and great question Bill. You know, although telemedicine does have benefits, it does have limitations. So, some types of visits just are not gonna work virtually. So put simply, the issues come down to, connection and conditions being assessed. So, some visits require that hands on approach. For example, certain presentations like chest pain, shortness of breath, confusion, blood in the stool, a broken bone, require that patient to be seen in person, due to the need to conduct an exam or, listen to a patient's labored breathing.
And patients may not have the equipment needed for the provider to be able to listen to that patient, remotely. It might not be readily apparent as to what those conditions are based on the patient's presenting complaint. So, it cannot change the way some care must be delivered, and it can lead to providers missing, physical and even nonphysical issues that are more readily identified in person. So a subtle whe will the patients, breathing in the exam room or a slight hand tremmor. an unsteady gait while the patient's entering the exam room.
These signs and symptoms can be easier for a practitioner, to miss during a virtual visit, and missing that critical information may result in an adverse outcome for patients that can ultimately lead, to a lawsuit or a claim, such as misdiagnosis, an incorrect diagnosis, or an inadequate assessment, or testing procedures. And then there are, some things like drawing blood or, x-rays, where the patient needs to be face to face or come in person. And then I think another huge challenge can be connection. So, some visits require a social connection.
For example, if your patient's new to your practice, seeing that patient in person helps establish rapport. We also need to consider the technical, connection. So, not everyone is, tech savvy and is comfortable using technology. Not everyone has strong, reliable internet connection or access to a computer. And without all of those things, the virtual visit is really a non-starter. There are language barriers that can impact connecting, with patients virtually too. So offering, language interpreter services is just as important in a virtual visit as an in person visit.
And, one of the ways that that can be done is to enable, VRI or video remote interpreting. Through a telemedicine platform that allows access to, medically qualified interpreters that are especially trained to be able to be remote interpreters.
Bill Klaproth (host): Right. Yeah, that all makes sense. So, Judy, if I can put you on the spot here, can you share with us, five things that, providers and risk managers, should know to best care for patients who are not physically in front of a provider?
Judy Klein: Sure. So, five things that, I think are, really key for providers and risk managers to best care for patients who aren't physically in front of you would be, documenting, clearly and concisely, just like you would in an in-person visit, having that documentation in your, electronic medical record and portal, including, all details of the visit, a working diagnosis based on your clinical assessment history, physical exam, documenting any patient education or instructions provided your diagnostic conclusions, your treatment plan, any lab or test results reviewed and discussed.
And what the next steps are and follow up for that patient, because we often see that, we've been seeing that in some of the claims at our company where that follow up piece is missing in virtual visits. And then, I think a second key takeaway is don't leave, understanding to chance. So, a good way to do that is, implementing teach back strategies. So where the patient relays, the information you shared back to you, so that you assure they understand, and recognizing language barriers, and always, leaving an encounter by asking the patient, is there anything else they would like to know?
Or is there anything that they don't understand? Because without that level of communication, providers can miss that a patient might, not understanding because perhaps they have some personal circumstance or situation going on that is gonna impede their ability to adhere to their care plan or treatment plan, that you need them to. And then I think, another key point is follow up. I mentioned, we're seeing that, in some of our claims, lacking, so adopting a system for following up with patients to ensure that they don't have additional questions and the care plan is proceeding as you intend as the provider.
And ensuring that electronic communications are sent through encrypted applications and documented in the medical record. Next I think, it's important to ask yourself is tele-health right for this patient? Because not all patients are appropriate candidates, for virtual visits or remote patient monitoring. So you really need to start by identifying those conditions that, you can, monitor remotely. Some common conditions include, minor issues where a physical exam is not necessary, reviewing tests, labs, or imaging results, counseling services work really well.
Specialist referrals, medication questions, adjustments, or refill. Discussing a treatment plan and chronic disease management is working really well, in the virtual care, environment. And then ensuring that your patients have the right technology. I talked about a strong internet connection. It's essential to engage in a virtual visit. And, if organizations or, providers are using remote patient monitoring for patients, ensuring that those patients know how to use that how to maintain it, how to troubleshoot their device. When and where to transmit the data and how, and when the healthcare team is gonna look at it.
Manage alerts or monitoring thresholds for clinical interventions. And then, being sure to obtain, informed consent for virtual care visits using the technology and thoroughly documenting that in the medical record. And then I think another key takeaway is to, ask is telehealth right for your practice. do you have the infrastructure in place to, support it, to ensure secure and reliable data transmissions? For example, if you're remotely managing patients with congestive heart failure. Your infrastructure will need to support connection with things like wireless scales and blood pressure cuffs, and your staff will need to monitor and respond to that incoming data or to alerts.
And then lastly, privacy and security risks, providers also need to take steps to safeguard patient information, ensuring that, they're complying with FDA guidelines. For example, if they're using remote patient monitor, And properly encrypting data transmissions to abide by HIPAA or the Health Insurance Portability and Accountability Act.
Bill Klaproth (host): Thank you. Judy, that was really informative. So let me wrap up by each asking you the same question and Jennifer, let me, start with you. So what key risk management best practices and considerations need to be addressed before implementing a telemedicine program and what lessons or takeaways have we learned from rolling out a telemedicine program during the pandemic?
Jennifer Kozaily: So basically we need to make sure that we have a plan before implementing the telemedicine. We have a well detailed plan with checklist that go over, what to do and what are the best things to manage technology and what are the gaps that we have in our organization and how to make sure that we are covering those gaps before implementing the telemedicine program. We have to also make sure that we have, a proactive risk assessment done before implementation of the program.
And that proactive risk assessment has to be covering all the, domains of the enterprise risk management to make sure that we're tackling all the gaps and all the risks before, ensuring that we are implementing the program. If we're having the program in place. so from that perspective, we need to have the risk assessment being done and we need to also have a solid, program plan checklist before implementing the program.
Bill Klaproth (host): Right. And then Judy, same question for you. What key risk management, best practices and considerations need to be addressed? And what are the lessons or takeaways from starting telemedicine in the middle of a pandemic?
Judy Klein: Jennifer raised some really great, points, from where I sit working for, a malpractice insurance company, we get a lot of calls and I think, some of the things to think about are, making sure, one understands state laws and licensure requirements. Because the patient might not be in the same state as the provider offering or conducting that virtual visit. So that means that licensure requirements of multiple states may be relevant. And in addition to State licensure requirements, practitioners must also comply with applicable state and federal laws regarding telemedicine.
So it's really important, to, consult with legal counsel, because state and federal telemedicine laws and licensing requirements really do vary and they continue to evolve. And many of the special exceptions made during the pandemic through waivers are now. I also think, it's really, really important, to connect to Jennifer's point, to be prepared by training staff. Telemedicine, isn't just this occasional camera visit with a patient, it really means, training staff and new workflows, roles and responsibilities, using the technology, troubleshooting and knowing how to conduct yourself during a camera visit.
It's a lot different than, an in person. And then also educating patients and preparing them, ahead of time too. it's really key before, that first visit, whether that's done by a staff member, contacting that patient before the visit or the practice using a video or other platform to educating that patient. Preparing that patient in advance allows the provider then to focus on the clinical conversation, the history, the physical, so that they're not distracted by performing, technology related, functions. And then I also think it's important to keep in mind. and what we've learned is, virtual visits do have limitations.
So see patients in person when you need to, if you need to have them come in to get a complete picture of that condition, to make a diagnosis, make sure you see that patient in person because nothing can replace laying your hands on the patient. So having a process and plan in place for when and how to escalate a virtual visit to a face to face visit is key. And then documenting and informed consent. just as important as in an in person visit, documenting all verbal audio, visual written communication in that record and making sure that you're meeting the medical legal standards of care.
Verbal and written informed consent to disclose information about the telemedicine system, potential risks and benefits of telemedicine, equipment and technology limitations, and both the providers and the patient's responsibilities as part of that virtual visit. Many states do require providers to obtain informed consent from. Before that virtual visit begins. So, providers should, consult with an attorney, to assure any state's specific informed consent requirements. And then, also assessing whether documentation of virtual visits and informed consent integrates with your electronic health record to make sure that all those pieces and parts that are part of the virtual visit.
Perhaps a photograph that the patient sends to you in addition to, the clinical medical record, they all, get filtered to the same place that is that patient's medical record. And then lastly, but very importantly, In virtual care visits is privacy and security. Since telemedicine uses technology, it can make organizations and providers vulnerable, to malware attacks and hacks. So keeping that private healthcare information protected is paramount. Security management, must incorporate things like firewalls to ensure privacy protections are in place. And, providers and organizations need to adhere to. State and federal privacy laws and evaluate their cyber security risk. And that might mean, needing to consult with an outside expert or professional as necessary.
Bill Klaproth (host): Yeah, there's a lot there. you both have provided us with a wealth of information. Thank you for, all of this, great information that you shared with us today we really appreciate this. Jennifer and Judy, thank you again for your time.
Jennifer Kozaily: Thank you.
Judy Klein: Thanks Bill.
Bill Klaproth (host): And once again, this Jennifer Kozaily. Sally and Judy Klein. To join us as a member of ASHRM, go to ashrmforum.org/membership, and the ASHRM Podcast was made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management.You can visit ashrmforum.org/membership.To learn more and to become an ASHRM member, and if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. I'm Bill Klaproth, thanks for listening.
Bill Klaproth (host): Welcome to the ASHRM Podcast made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted health care through enterprise risk management. You can visit ASHRM that's ashrm.org/membership to learn more and to become an ashram member. I'm Bill Klaproth, so when it comes to tele-health, what does the risk manager need to know to minimize risk? Well, let's find out with Dr. Jennifer. Kozaily, her main responsibilities include the coordination and oversight of quality improvement and risk management activities. According to the accreditation standards, JCI and Department of Health in Abu Dhabi. And Judy Klein. She is a BD lead, a PA and risk manager. And also she is in risk management and analytics for Covaris. Jennifer and Judy, thank you so much for your time. We appreciate it. Jennifer, let me start with you. How do we measure the success of the tele-health program?
Jennifer Kozaily: So like any program or project that we want to implement in the healthcare setting, it is important to measure the success and the performance of the telehealth program in order to secure its future and to determine the next steps. On a clinical aspect, whether we want to scale the program to expand benefits to more patients, conditions, specialties, or on a financial aspect to justify the continued costs and fundings implicated with the program. So now how do we measure the success of the program?
First, every organization has to set its own enterprise objectives and goals that they want to achieve through the telehealth program, both short term and long term, and then accordingly develop an evaluation and routine performance monitoring plan. That includes the key performance indicators or KPIs with defined targets. There is definitely no one size fits all approach to telehealth when it comes to KPIs, like any other area of patient care. And the choice of KPIs depend on the goals and objectives set and types of services provided.
However, there are some standard KPIs that can be used to measure success, and these indicators cover the different organizational domains. Such as operational clinical outcomes, patient safety, human capital, financial technologies, strategic reputation, and legal. Now I'm gonna go over some examples of those KPIs under each domain, let's start with the clinical outcome indicators. For example, we want to have improved health outcomes and the targets are specific to each disease that we are treating.
We want to have improvement in the compliance with treatment as a result of access, convenience, and continuity of care through telemedicine. We want to have reduction in ER, visits and readmission rates as for the operational, outcomes. We want to have improved access to care and specialists. And this is very helpful when you talk about behavioral health psychiatry, dermatology, tele sitter, whenever you want multiple patients to monitor against falls, suicide risks. And that helps a lot with the nursing shortage that we have under the financial indicators.
You want to have improved patient reach and we measure that by increased number of patient enrolled in tele-health. We want to have reduced cost, cost per case cost due to be admission. Under strategic reputational, we focus on the patient experience. Under strategic reputation. We focus on patient experience perspective. We want to have improvement in patient satisfaction. And we can measure that through the patient experience surveys that we are gonna be tailoring based on the telemedicine services that we are providing.
Under human capital domain, we have to improve the provider satisfaction indicators, and this is provided due to continuity of care and efficiency of care delivery due to telemedicine. And under technology. We want to make sure we don't have complaints due to, lack of connectivity, wifi, and, even the telemedicine monitors that we are using to monitor the blood pressure and the vital signs.
Bill Klaproth (host): So then what are the strategies that providers in healthcare organizations can take to optimize the use of telehealth to deliver safe and effective care to patients?
Jennifer Kozaily: So there are some strategies that providers and healthcare organizations can take into account to optimize the use of telehealth in order to deliver a safe and effective care to patient. First as discussed earlier in my previous question, we need to make sure that we set up the telehealth system for success by setting goals and establishing key performance indicators. And to use the data from those indicators and other feedback on telehealth experience to continue to see monitor and make improvements. Second, we need to make sure that we are effectively using the clinical services via tele-health.
And we do that by developing protocols and workflows for virtual care. And reducing the variation between specialties and service lines by training providers to provide a standardized high quality care experience for patients. The third strategy that we can use is to ensure appropriate training of staff on telehealth workflows. This is done by creating a series of life educational support and online education modules, and also to identify a staff super user who can provide support and training to the other, remaining staff and healthcare providers.
These trainings have to cover topics such as, equipment technology, training, the use of EMR, informed consent ethics using telemedicine privacy, as well as we need to make sure that you are training our patients on how to use telemedicine. Last and not least, we need to make sure that we are continuously monitoring the technology we are using. We have to make sure that, we ask our vendors for ways they can provide support pre and post implementation. For example, the training that they support, the tech support, the workflow, design collaboration, data analysis, cyber security, and project management as well.
And we also need to make sure that the vendor can provide easy access to data so we can use it for monitoring purposes as I've discussed, using the KPI. And also we need to make sure that we are ensuring that our organization has secure platform that supports HIPAA concerns. And we need to all the time monitor this as well when it comes to our, telemedicine.
Bill Klaproth (host): Well, thank you for that, Jennifer and Judy, can you articulate a few of the main benefits of telehealth?
Judy Klein: A couple of words come to mind when looking at the benefits of tele-health, convenient, efficient, and access. For those who have access to technology and, are comfortable using it, telemedicine really provides an extremely convenient and an efficient way to deliver healthcare. think about it. Patients no longer have to drive to a doctor's. They no longer have potentially long wait times or be exposed to potentially sick patients in a waiting room. And it significantly benefits patients who otherwise might not be motivated to want to go into an office to see healthcare provider.
Consumerism or meeting the demands and expectations of you and I as customers is really driving demand for this convenient way, to get care. We live by our our smartphones, our digital devices, and that includes patients of all ages. So one example that comes to mind is I think of my father-in-law, it's been very beneficial for him because, as he gets up in age, he's had difficulty ambulating and hearing too. And so he can use the technology in his own home, by his own computer, and even adjust the volume to be able to hear better, to meet his needs.
And then his adult children who, you know, ordinarily would not be able to accompany him, for an in person visit, can remotely call into that visit too. And it also helps, the providers they can get, a better understanding of that patient's home environment. Access, also comes to mind telehealth can improve access to, specialists, and address provider shortages, especially in regions of the country who are lacking specialists or care providers. And then I think also when you pair a virtual care with remote patient monitoring or wearable devices, following patients virtually can be used as a means to, better engage your patients, drive down hospital, readmissions. drive down cost and ultimately improve patient outcomes.
It can be a real game changer for patients who are stable, but need monitoring of chronic conditions like diabetes, heart disease to make sure that they're following their treatment plan. They're taking their medications. So, consider, a type two diabetic patient with uncontrolled blood sugars. Who's been prescribed a continuous glucose monitoring or a CGM wearable device, with data inputs that, remotely get relayed to the physician, the patient can now easily track their blood glucose, adjust their diet, their activity accordingly and prevent wide variations.
So, this really helps incentivize, patients makes them more account. and it can also lead to reducing the number of in person, visits that that patient has to have.
Bill Klaproth (host): Right. There certainly are a lot. Benefits and what you listed convenience. That's huge improved access. And being able to follow patients virtually are all really big benefits of telehealth. But Judy then what are the challenges when a patient is not in the same room as the provider and what can be done to address those challenges?
Judy Klein: That's a really good point and great question Bill. You know, although telemedicine does have benefits, it does have limitations. So, some types of visits just are not gonna work virtually. So put simply, the issues come down to, connection and conditions being assessed. So, some visits require that hands on approach. For example, certain presentations like chest pain, shortness of breath, confusion, blood in the stool, a broken bone, require that patient to be seen in person, due to the need to conduct an exam or, listen to a patient's labored breathing.
And patients may not have the equipment needed for the provider to be able to listen to that patient, remotely. It might not be readily apparent as to what those conditions are based on the patient's presenting complaint. So, it cannot change the way some care must be delivered, and it can lead to providers missing, physical and even nonphysical issues that are more readily identified in person. So a subtle whe will the patients, breathing in the exam room or a slight hand tremmor. an unsteady gait while the patient's entering the exam room.
These signs and symptoms can be easier for a practitioner, to miss during a virtual visit, and missing that critical information may result in an adverse outcome for patients that can ultimately lead, to a lawsuit or a claim, such as misdiagnosis, an incorrect diagnosis, or an inadequate assessment, or testing procedures. And then there are, some things like drawing blood or, x-rays, where the patient needs to be face to face or come in person. And then I think another huge challenge can be connection. So, some visits require a social connection.
For example, if your patient's new to your practice, seeing that patient in person helps establish rapport. We also need to consider the technical, connection. So, not everyone is, tech savvy and is comfortable using technology. Not everyone has strong, reliable internet connection or access to a computer. And without all of those things, the virtual visit is really a non-starter. There are language barriers that can impact connecting, with patients virtually too. So offering, language interpreter services is just as important in a virtual visit as an in person visit.
And, one of the ways that that can be done is to enable, VRI or video remote interpreting. Through a telemedicine platform that allows access to, medically qualified interpreters that are especially trained to be able to be remote interpreters.
Bill Klaproth (host): Right. Yeah, that all makes sense. So, Judy, if I can put you on the spot here, can you share with us, five things that, providers and risk managers, should know to best care for patients who are not physically in front of a provider?
Judy Klein: Sure. So, five things that, I think are, really key for providers and risk managers to best care for patients who aren't physically in front of you would be, documenting, clearly and concisely, just like you would in an in-person visit, having that documentation in your, electronic medical record and portal, including, all details of the visit, a working diagnosis based on your clinical assessment history, physical exam, documenting any patient education or instructions provided your diagnostic conclusions, your treatment plan, any lab or test results reviewed and discussed.
And what the next steps are and follow up for that patient, because we often see that, we've been seeing that in some of the claims at our company where that follow up piece is missing in virtual visits. And then, I think a second key takeaway is don't leave, understanding to chance. So, a good way to do that is, implementing teach back strategies. So where the patient relays, the information you shared back to you, so that you assure they understand, and recognizing language barriers, and always, leaving an encounter by asking the patient, is there anything else they would like to know?
Or is there anything that they don't understand? Because without that level of communication, providers can miss that a patient might, not understanding because perhaps they have some personal circumstance or situation going on that is gonna impede their ability to adhere to their care plan or treatment plan, that you need them to. And then I think, another key point is follow up. I mentioned, we're seeing that, in some of our claims, lacking, so adopting a system for following up with patients to ensure that they don't have additional questions and the care plan is proceeding as you intend as the provider.
And ensuring that electronic communications are sent through encrypted applications and documented in the medical record. Next I think, it's important to ask yourself is tele-health right for this patient? Because not all patients are appropriate candidates, for virtual visits or remote patient monitoring. So you really need to start by identifying those conditions that, you can, monitor remotely. Some common conditions include, minor issues where a physical exam is not necessary, reviewing tests, labs, or imaging results, counseling services work really well.
Specialist referrals, medication questions, adjustments, or refill. Discussing a treatment plan and chronic disease management is working really well, in the virtual care, environment. And then ensuring that your patients have the right technology. I talked about a strong internet connection. It's essential to engage in a virtual visit. And, if organizations or, providers are using remote patient monitoring for patients, ensuring that those patients know how to use that how to maintain it, how to troubleshoot their device. When and where to transmit the data and how, and when the healthcare team is gonna look at it.
Manage alerts or monitoring thresholds for clinical interventions. And then, being sure to obtain, informed consent for virtual care visits using the technology and thoroughly documenting that in the medical record. And then I think another key takeaway is to, ask is telehealth right for your practice. do you have the infrastructure in place to, support it, to ensure secure and reliable data transmissions? For example, if you're remotely managing patients with congestive heart failure. Your infrastructure will need to support connection with things like wireless scales and blood pressure cuffs, and your staff will need to monitor and respond to that incoming data or to alerts.
And then lastly, privacy and security risks, providers also need to take steps to safeguard patient information, ensuring that, they're complying with FDA guidelines. For example, if they're using remote patient monitor, And properly encrypting data transmissions to abide by HIPAA or the Health Insurance Portability and Accountability Act.
Bill Klaproth (host): Thank you. Judy, that was really informative. So let me wrap up by each asking you the same question and Jennifer, let me, start with you. So what key risk management best practices and considerations need to be addressed before implementing a telemedicine program and what lessons or takeaways have we learned from rolling out a telemedicine program during the pandemic?
Jennifer Kozaily: So basically we need to make sure that we have a plan before implementing the telemedicine. We have a well detailed plan with checklist that go over, what to do and what are the best things to manage technology and what are the gaps that we have in our organization and how to make sure that we are covering those gaps before implementing the telemedicine program. We have to also make sure that we have, a proactive risk assessment done before implementation of the program.
And that proactive risk assessment has to be covering all the, domains of the enterprise risk management to make sure that we're tackling all the gaps and all the risks before, ensuring that we are implementing the program. If we're having the program in place. so from that perspective, we need to have the risk assessment being done and we need to also have a solid, program plan checklist before implementing the program.
Bill Klaproth (host): Right. And then Judy, same question for you. What key risk management, best practices and considerations need to be addressed? And what are the lessons or takeaways from starting telemedicine in the middle of a pandemic?
Judy Klein: Jennifer raised some really great, points, from where I sit working for, a malpractice insurance company, we get a lot of calls and I think, some of the things to think about are, making sure, one understands state laws and licensure requirements. Because the patient might not be in the same state as the provider offering or conducting that virtual visit. So that means that licensure requirements of multiple states may be relevant. And in addition to State licensure requirements, practitioners must also comply with applicable state and federal laws regarding telemedicine.
So it's really important, to, consult with legal counsel, because state and federal telemedicine laws and licensing requirements really do vary and they continue to evolve. And many of the special exceptions made during the pandemic through waivers are now. I also think, it's really, really important, to connect to Jennifer's point, to be prepared by training staff. Telemedicine, isn't just this occasional camera visit with a patient, it really means, training staff and new workflows, roles and responsibilities, using the technology, troubleshooting and knowing how to conduct yourself during a camera visit.
It's a lot different than, an in person. And then also educating patients and preparing them, ahead of time too. it's really key before, that first visit, whether that's done by a staff member, contacting that patient before the visit or the practice using a video or other platform to educating that patient. Preparing that patient in advance allows the provider then to focus on the clinical conversation, the history, the physical, so that they're not distracted by performing, technology related, functions. And then I also think it's important to keep in mind. and what we've learned is, virtual visits do have limitations.
So see patients in person when you need to, if you need to have them come in to get a complete picture of that condition, to make a diagnosis, make sure you see that patient in person because nothing can replace laying your hands on the patient. So having a process and plan in place for when and how to escalate a virtual visit to a face to face visit is key. And then documenting and informed consent. just as important as in an in person visit, documenting all verbal audio, visual written communication in that record and making sure that you're meeting the medical legal standards of care.
Verbal and written informed consent to disclose information about the telemedicine system, potential risks and benefits of telemedicine, equipment and technology limitations, and both the providers and the patient's responsibilities as part of that virtual visit. Many states do require providers to obtain informed consent from. Before that virtual visit begins. So, providers should, consult with an attorney, to assure any state's specific informed consent requirements. And then, also assessing whether documentation of virtual visits and informed consent integrates with your electronic health record to make sure that all those pieces and parts that are part of the virtual visit.
Perhaps a photograph that the patient sends to you in addition to, the clinical medical record, they all, get filtered to the same place that is that patient's medical record. And then lastly, but very importantly, In virtual care visits is privacy and security. Since telemedicine uses technology, it can make organizations and providers vulnerable, to malware attacks and hacks. So keeping that private healthcare information protected is paramount. Security management, must incorporate things like firewalls to ensure privacy protections are in place. And, providers and organizations need to adhere to. State and federal privacy laws and evaluate their cyber security risk. And that might mean, needing to consult with an outside expert or professional as necessary.
Bill Klaproth (host): Yeah, there's a lot there. you both have provided us with a wealth of information. Thank you for, all of this, great information that you shared with us today we really appreciate this. Jennifer and Judy, thank you again for your time.
Jennifer Kozaily: Thank you.
Judy Klein: Thanks Bill.
Bill Klaproth (host): And once again, this Jennifer Kozaily. Sally and Judy Klein. To join us as a member of ASHRM, go to ashrmforum.org/membership, and the ASHRM Podcast was made possible by the American Society for Healthcare Risk Management to support efforts to advance safe and trusted healthcare through enterprise risk management.You can visit ashrmforum.org/membership.To learn more and to become an ASHRM member, and if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. I'm Bill Klaproth, thanks for listening.