A physician shares his best tips for a successful telehealth practice

Ophthalmology might not be the first specialty that comes to mind when envisioning a telehealth practice, but Dr. Rahul Bhola, medical director of ophthalmology at CHOC Children’s, has seamlessly integrated the service in his practice, completing more than 900 telehealth visits since March.

In this Q & A, Dr. Bhola outlines his team’s success in transitioning to telehealth, and shares best practices that physicians in a variety of specialties can put into practice: 

What does an ophthalmology telehealth appointment look like?

A synchronous (live audio-video) CHOC ophthalmology telehealth appointment is divided into four components. I call them the four C’s: contact, connect, consult and care.

  1. Contact
    Our front desk reaches out to the family to confirm contact information. We send a Zoom link to the families, along with information about how to connect to Zoom and download the visual acuity app to check vision before the appointment. 
  2. Connect
    As the appointment day approaches, our technician connects with the family to discuss any technical issues that should be resolved prior to the physician consultation. The technician also goes over the at-home visual acuity check and evaluates basic medical history. 
  3. Consult
    On the actual day of the appointment, the physician connects with the families on Zoom to go over the pertinent history and visual acuity, and performs a focused examination including an external and ocular motility exam. If needed, pictures and videos from the family are requested for further evaluation. This enables us to diagnose a majority of anterior segment ocular issues as well as visual acuity concerns like amblyopia, refractive errors and ocular motility disorders.
  4. Care
    We discuss the treatment care plan and review any medical issues or concerns the patient is experiencing. Throughout this process, we can fulfill their needs ranging from prescription refills for medication or broken glasses without them having to step outside the comfort of their home.

Our office will then schedule a follow-up visit depending on the medical necessity.

Dr. Rahul Bhola offers his best tips for telehealth practices
Dr. Rahul Bhola, medical director of ophthalmology at CHOC , has completed more than 900 telehealth visits since March.

How do your patients and families feel about telehealth?

While some physicians may have been wary of telehealth care, I was pleasantly surprised that patients love telehealth.

Telehealth helped our patients and families feel secure, supported and assured that there would be no interruption in the patient’s care plan during COVID-19.  Our families are so grateful that during this time of emergency, their physician was able to connect with them to address any urgent issues and follow them in clinic on a need-to basis.

Due to the positive response we have received from our families, we will continue to offer telehealth visits for our families, when appropriate.

 Does telehealth compromise quality of care?

Not at all. Providers are often able to spend more time with patients during a telehealth visit. Children are more comfortable in their home setting and you can engage more with them and spend more time on-screen with them.

If we felt the urgency to see our patients face-to-face after the initial exam, we schedule in-person appointments.

What makes your telehealth visits successful?

The expression “Necessity is the mother of invention” really is true when it comes to telehealth.  Telemedicine has been around for a while, but it took a pandemic to make it universal and successful. As soon as the stay-at-home orders were announced we knew we had to connect with our patients to prevent any disruption of their care. Our team was not afraid of change and we realized the urgency to adapt to the circumstances right away to provide uninterrupted care to our patients and their families. We reallocated our resources to maximize our outreach; our goal was to connect with each and every patient scheduled to be seen in the clinic.

What advice and tips do you have for other providers to do telehealth successfully?

Being open minded, adaptable to the changing circumstances and embracing technology were a few things that helped us during this unprecedented time. We created a vigorous team of both technical and non-technical staff in a short span of time to enable successful initiation of a robust tele-ophthalmology program. The key was strategizing dynamically in this constantly changing environment and having frequent huddles with the team to address any issues.

Very quickly we realized that telehealth was amazing to address the four-part aim of healthcare: access, cost-effectiveness, patient satisfaction and physician satisfaction.

There will be nuances for specific specialties. In our case the American Academy of Ophthalmology right away provided resources and tools to help us initiate an effective synchronous telehealth portal.

Technological innovations like visual acuity apps and the ocular motility app were phenomenal tools developed to assist effective consultations.

Find other resources to grow your telehealth practice.

6 telehealth tips for providers

For many providers, the COVID-19 pandemic has accelerated the use of telehealth to serve patients and families. With that, this may be a developing skill set for many physicians and advanced practice professionals. Here are a few tips to ensure a successful video visit:

Determine if the patient is a good telehealth candidate

It’s up to each clinician to gather enough information to make appropriate medical decisions. Refer the patient to in-person care if you determine a video exam is not adequate to provide high-quality medical decision-making.

Here are some things to consider:

  • Is the patient in a private location? Do not provide telehealth services when a patient or parent is driving or in a public location.
  • Does the patient or family have access to the internet and a computer or mobile device?
  • Do you have a medical license for the state in which the patient lives? Restrictions during COVID-19 have been waived but this may change.
  • Is the patient and family able to help with the physical exam, testing and vital signs, if necessary? For example, do they have a thermometer and scale? Are they able to count respirations?

Prep your virtual exam room

Take a few steps to prepare your environment for an optimal video experience:

  • Check for clutter and any personal health information visible in the camera frame. Consider activating the virtual background if necessary.
  • Check your self-view and make any needed lighting adjustments so your face can be seen clearly.
  • Be aware of the position of your devices. If you’re using two screens, ensure they are positioned optimally so you can look back to the patient frequently when documenting.
  • Shut your door, if possible, and hang a sign indicating a video session is in progress.
  • Once the visit begins, be mindful that any typing from charting or notetaking will likely be picked up by the microphone.

Perform some housekeeping

Once the session begins, you’ll need to start with a few housekeeping matters:

  • Verify you are with the correct patient and family by using two patient identifiers such as full name and date of birth.
  • Obtain consent for the telehealth visit from the patient and parent.
  • Explain to the patient and family that the video visit is not recorded, meets HIPAA requirements, and cannot be posted or forwarded.

Ensure comfort and privacy

For both the provider and patient, this visit will certainly “feel” different than a typical encounter. Acknowledge that to the family and then take some steps to increase comfort:

  • Your usual techniques to connect with families can translate well on video. For example, help your patient warm up by asking them to show you their favorite toy or book.
  • To help the family feel more comfortable – particularly if the exam will require clothing to be removed – ask non-essential staff and family members to leave the respective rooms.
  • If others are in the room, introduce everyone in the location. Ask the family to do so as well for anyone who is in the room but off camera and in the microphone’s range.

Double down on communication

Communication is always important – but doubly so during a video exam. Be engaging and encourage cooperation from the patient and parent throughout the exam:

  • Be comfortable giving the patient and family direction to improve the experience. This could mean asking them to adjust lights; move closer or farther from the camera; remove objects obstructing your view; or speak more loudly.
  • Let the patient and family know they may hear you typing but this is because you want to accurately document the visit.
  • Make eye contact with your camera, not the patient’s eyes.
  • Do not cover your camera or mute your microphone; this could make the patient and family feel you’re not giving them your full attention.

Ask for assistance from the patient and family

In the absence of physical proximity, you might need the patient and family to help you perform exam maneuvers:

  • Direct them to remove clothing, as necessary, and remember to tell them when it is OK to put on their clothing again.
  • Tell them how to palpate to localize pain.
  • Explain how to perform range of motion maneuvers.
  • Describe the landmarks you use in clinic to find the right location for an exam component, such as ribs or the pelvic bone.
  • Watch carefully and ask them to repeat anything that appears questionable.
  • Verbalize what you think you are seeing, allowing the patient and their parent to clarify as needed.

Find more resources for telehealth services.