Executive Session: Improving telemedicine by training effective “medical virtualists”

As many physicians have seen fewer patients in person and expanded telehealth services amid the COVID-19 pandemic, many doctors and patients have expressed concern that the level of care may not be equal to the traditional office visit, potentially affecting the physician-patient relationship.

At the same time, some healthcare leaders describe the problems with telemedicine as growing pains that can be overcome with training and increased familiarity with the technology.

Michael Nochomovitz, MD, chief clinical partnerships officer, Devoted Health, New York, and Rahul Sharma, MD, MBA, FACEP, professor and chairman, Department of Emergency Medicine, NewYork-Presbyterian Weill Cornell Medicine, New York, have been at the forefront of this concept of training “medical virtualists” with a specific skill set to effectively deliver telemedicine.

For Dr. Sharma and the NYP Weill Cornell Medicine team, their telehealth journey began in 2016 with an emergency department-based program. “When we first launched it, I think a lot of people thought we were crazy, thinking that we could actually do telemedicine in the emergency department,” Sharma said. “But it's been quite successful.” So successful, in fact, that NYP Weill Cornell Medicine has received several national awards in recent years for its telehealth services.

Virtualist competencies: The importance of “webside manner”

When the Journal of the American Medical Association published Nochomovitz and Sharma's first article on medical virtualists,¹ telehealth existed but was not yet mainstream. After the dramatic expansion of telehealth in the past eight months, the need for physicians and other clinical team members to train for effective virtual care delivery is clearer and more pressing than ever.

“It only takes a few seconds for a virtual care visit to go poorly,” Sharma said, whose team established a training center in 2019 for physicians, residents, fellows, physician assistants (PAs), nurse practitioners (NPs), care managers, medical students and more. That training emphasizes soft skills required for conducting virtual visits with a camera, or “webside manner.”

“We learn a lot about bedside manner in our training as medical students, nurses and residents, but very little on webside manner, which is equally as important,” Sharma said. “We would never put a medical student, a nursing student or any healthcare provider in front of a patient and do a visit without giving them the right skill set. … So why is it okay to do that with telemedicine?” Sharma noted.

During the COVID-19 pandemic, Sharma’s team has trained hundreds of providers within the organization and at other practices. The concept of specifically training physicians and other clinicians has caught on in other organizations: For example, nursing students at the University of Houston shadow nurses on virtual visits as part of their training.²

In a 2019 article,³ Nochomovitz, Sharma and their co-authors outlined three domains of core competencies for virtual healthcare:

1. Digital communication and webside manner, in which visualization, body language and speech are optimized
2. Scope and standards of care, addressing the legal and regulatory aspects of care delivery via telemedicine, such as legal limits of e-prescribing, HIPAA compliance and virtual care pathways
3. Virtual clinical interactions, which includes environmental assessment, group interactions and how to conduct virtual physical examinations of patients and use remote monitoring devices.

• Click here for a full list of NYP’s numerous publications on telehealth innovations.

While many medical practices rapidly expanded telemedicine in 2020, not all of them did so with best practices developed for optimal care delivery, including elements of presentation. “It’s not just about getting on FaceTime,” Sharma said. “Presentation matters so much. Are you wearing a white coat? What is your framing? Are people able to see you? How’s the lighting? Are you looking at the patient? These are aspects that we feel that people needed to be taught.”

Some key tips for providers in optimizing their digital communication and webside manner include:

• Reduce communication speed to ensure clarity over online platforms.
• Minimize body motion and gestures to avoid blurring or poor visualization over video.
• Stage the environment with an appropriate background and good lighting.
• Wear solid colors with a neutral background.
• Position the camera to frame the clinician’s head and shoulders.
• Look at the camera rather than screen to maintain “eye contact” with the patient.
• Use screen-sharing technology to convey imaging and diagnostic findings.

Education for physicians and patients

Reaching optimal levels of care delivery and outcomes via telemedicine is not limited to physician and care team education, Nochomovitz and Sharma stressed. “It is equally as important that we make this easy for our patients,” Sharma said. “Patients don't want to download multiple applications. … We have to make it easy. We have to make sure that it's also available in multiple languages.”

Preparing patients for a virtual visit is one of the most important aspects of virtual care. “You should have certain guidelines and key tips that patients should read” before a visit, Sharma added. In NYP’s Health Matters,⁴ Sharma detailed some of the more crucial items for patients to know before a visit:

• Make sure the technology is working, especially the internet connection, camera and volume on your smartphone or computer.
• Prepare as for an in-person visit. Have a list of questions, medications, and be prepared to answer questions about your symptoms.
• Use a private space where you feel comfortable and others cannot hear your information. Set up your phone or computer so you are visible on the screen and if your doctor needs to see your whole body, not just your face.
• Be ready to check your vitals using a thermometer or wearable technology that measures your heart rate (e.g., a smartwatch).
• Expect a possible physical exam, such as opening your mouth and shining a light on the back of your throat, showing a rash, or showing your breathing pattern to see if you are in respiratory distress.
• Set up in a well-lit room and have a flashlight available if the doctor needs a better view.
• Be willing to accept some limitations of not having an in-person visit.

Expectations rise as the market for virtualists matures

Nochomovitz asserted that it’s too narrow to think of telehealth as being a small part of any clinician’s work; as organizations such as Cleveland Clinic demonstrate,⁵ there is now a market for virtualists who only provide telehealth services. “This is now becoming a career choice,” Nochomovitz said, “and those people will require special training.”

To manage the COVID-19 crisis in New York City — which at one point was overwhelmed by calls to emergency responders — Sharma said that telemedicine carts placed in isolation rooms for patients with COVID-19-like symptoms enabled communication with doctors, nurses, care managers and others during “one of the most isolating times” for those patients.

New care delivery models also will require an understanding of the finer points of telemedicine. Sharma points to telestroke programs as having great impact on outcomes in neurological improvement, as well as the promise of community paratelemedicine, in which paramedics go to patients’ homes, allowing environmental assessment and checks on medication adherence to help reduce ED admissions and improve quality of care. Nochomovitz cited the ability to do post-operative physical therapy visits virtually daily as a vast improvement over having a patient visit a facility for that care.

As practices continue to recover from volume and revenue declines during the pandemic, Nochomovitz suggested that telemedicine for addressing chronic care management is a “boundless area” to improve on, as one of the country’s largest issues in terms of cost and utilization.

But with this proliferation of use cases for telehealth will come new, higher standards. “Patient expectations for virtual care will change,” Sharma said. “As patients are getting comfortable, providers are getting comfortable, I expect that the expectations of the actual visit are going to be elevated and that's why we have to make sure that the providers that are doing the telemedicine visits are prepared.”

That preparation will entail staying on top of regulatory and billing updates as telemedicine becomes more of a value-based platform, Sharma said. “We will have to show that telemedicine is providing high-quality care that’s effective.” Nochomovitz added that effective telehealth services hold potential to reduce unnecessary visits to facilities, which will require physicians to refine their decision-making as they deliver care remotely.

While Nochomovitz believes telemedicine will continue to grow, enabling its full potential will depend on ensuring patients have access to smartphones, tablet devices and broadband/mobile connections that support virtual visits.

“We’re at the beginning of the telehealth tsunami, which will be good for healthcare delivery across the world,” Nochomovitz said. “And we’re excited to see where this goes in the future.”

Notes

1. Nochomovitz M, Sharma R. “Is It Time for a New Medical Specialty? The Medical Virtualist.” JAMA. 2018;319(5):437–438. doi:10.1001/jama.2017.17094.
2. Minemyer P. “How COVID-19 is shaking up medical education — for good.” Fierce Healthcare. Aug. 14, 2020. Available from: bit.ly/3j1jf9u.
3. Sharma R, Nachum S, Davidson KW, Nochomovitz M. “It’s not just FaceTime: core competencies for the Medical Virtualist.” Int J Emerg Med. 2019 Mar 12;12(1):8. doi: 10.1186/s12245-019-0226-y. PMID: 31179921.
4. NewYork-Presbyterian. “How to Have a Better Virtual Healthcare Visit.” Health Matters. Available from: bit.ly/3l2Q5bN.
5. Nochomovitz M, Sharma R. “The Medical Virtualist Comes Of Age With COVID-19.” Physician Leaders. May 4, 2020. Available from: bit.ly/2Ynaf6x.

Additional resources

• “Is It Time for a New Medical Specialty?: The Medical Virtualist” (JAMA)
• “It’s not just FaceTime: Core competencies for the Medical Virtualist” (IJEM)
• “The Medical Virtualist Comes Of Age With COVID-19” (Physician Leaders)
• Weill Cornell Medicine Virtual Care Center
• MGMA COVID-19 Recovery Center
• MGMA Podcasts