Interoperable Telehealth: Patient Safety Considerations

Pandemic restrictions forced an accelerated adoption of virtual care because telehealth was often the only option for patients to receive healthcare services. As efforts to connect patients and providers through telehealth continue, new delivery challenges have become apparent.

Barriers to telehealth on the patient’s side include lack of internet access or bandwidth sufficient to support digital care, discomfort with technology, and cultural and linguistic challenges. Barriers on the practitioner’s side include unease with digital practice, inability to conduct a hands-on physical assessment, and lack of seamless integration between the telehealth solution and practice information management systems (including the EHR).

Interoperability

Interoperability is defined as the integration of digital health systems. Before the pandemic, most practices using telemedicine employed a single enterprise-wide solution. The pandemic forced healthcare practitioners to pivot swiftly from typical office-based outpatient care to virtual models of care. Regulatory concessions and state emergency orders permitted practices to implement video conferencing solutions that were not previously permitted under strict confidentiality and privacy laws. Ironically, this approach resulted in a patchwork of disparate solutions with no ability to connect to the EHR, billing, or scheduling systems. This situation magnifies the problems associated with the lack of interoperability.

Seamless integration is critical. In addition to audio and video capability, both practitioner and patient should be able to access the patient’s record and download, view, and transmit documents during the visit. An interoperable system can perform multiple functions, including capturing the information collected from monitoring devices, such as blood pressure, oxygen saturation, and blood glucose readings; coordinating visit timing for billing; reporting quality measures, such as technical concerns; and rescheduling visits to the office.

The benefits of an interoperable single-source telehealth solution may include patient relationship management features such as scheduling, a private “waiting room,” and the ability for the practitioner to share screens with the patient while discussing diagnostic results and delivering education.

Most major EHR vendors include an option for telehealth integration. Anecdotally, practitioners report that easy access to the EHR during a telehealth visit facilitates better care and rapport with the patient. In addition, the practitioner can easily create a visit summary and transmit it to the patient with any orders for diagnostic tests or referrals.

Organizations that continue to provide telehealth visits through a system that is not interoperable with the EHR may wish to consider options to address the problem. Practices at this stage of the decision-making process might enlist a consultant or a structured decision-making process, such as the Institute for Healthcare Improvement’s failure modes and effects analysis, to help them consider the risks and benefits of all available options.

Patient Safety Considerations for Interoperable Solutions

It is important that physicians, dentists, and advanced practice clinicians who use telehealth participate in selecting and applying the enterprise telehealth solution and peripheral support technologies. Consider the following:

Care model: Determine what type of telehealth model works best. Patient and practitioner satisfaction are significant contributors to overall patient safety. Many patients like having a telehealth option, and specific demographics, such as young adults, may be more comfortable with a virtual visit. Telehealth is convenient and can save the patient travel time, parking fees, and the need to take time off work. It may also reduce healthcare barriers for rural and inner-city residents, patients with conditions requiring extremely specialized care, those needing to arrange child or elder care, and pregnant women living in areas with few options for maternity care.

Practitioners also have telehealth preferences. Some choose not to participate in telehealth, some may wish to specialize, and some may enjoy a hybrid model providing both types of care. Hybrid models tend to work well for follow-up care in specialties such as cardiology, surgery, and dentistry. Hybrid delivery of prenatal services to pregnant women was very effective during the pandemic. Patient satisfaction was high, and no significant differences were found between traditional perinatal services and hybrid telehealth delivery.¹

Document and image management: An interoperable solution allows a practitioner to share consent forms, visit summaries, and treatment instructions with the patient during the visit. Benefits include real-time opportunities to discuss and confirm patient understanding, improved patient engagement, and increased practitioner satisfaction.

Depending on the type of patient visit, video capture or photography may be helpful. Video and picture files are large and usually stored in an imaging system instead of in the telehealth application or EHR. Practices using imaging (such as teledentistry, pediatrics, and dermatology) will need to consider appropriate image capture and storage solutions that integrate with telehealth and EHR systems.

Third-party capability: It may sometimes be helpful to include additional people from other locations in a visit. Examples include interpreters for the deaf, medical translators, specialists, and guardians. When evaluating telehealth options, look for a solution that permits more than two participant locations.

Telehealth peripherals: Inadequate assessments are a common factor contributing to diagnosis errors and malpractice claims. Ensure that the patient’s condition is suitable for a telehealth visit. When used appropriately, telehealth peripherals (such as remote stethoscopes, otoscopes, and vital sign monitors) improve care and patient safety by increasing the practitioner’s ability to perform an assessment.

Advanced peripherals, also known as remote patient monitoring (RPM) devices, include devices used for fetal monitoring for women with high-risk pregnancies, infants waiting for heart surgery, patients waiting for organ transplants, and patients with chronic diseases. RPM devices allow some patients to remain at home instead of being hospitalized.

Telehealth has been a boon for healthcare in many ways. Well-managed interoperable systems can increase the safety and efficacy of remote services. For additional guidance, see our telehealth resources or contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.