Background:  The practice of medicine using technology to deliver care at a distance is called telemedicine (1).  Its usage and popularity are increasing (1). While a variety of telemedicine platforms are available for seriously ill patients who are homebound, functionally limited, or geographically distant (e.g. telephone calls, emails), a real-time videoconferencing platform (a.k.a. “video visit”) offers unique interactive benefits and/or may even be required for specific regulatory reasons. In this Fast Fact, telemedicine will refer to real-time videoconferencing between patients and clinicians (2).  See Fast Facts #76 and 77 for more information on specific types of telephone encounters. Since there is limited evidence to guide telemedicine practices, this Fast Fact primarily assimilates expert opinion.

Telemedicine Visit Set-Up:  

• Work with your institution to identify a HIPAA-compliant and reliable telemedicine platform.  The user-friendliness of your platform alongside you and your patient’s environments can impact the quality of communication by telemedicine. Use a high-quality webcam and microphone on a laptop, desktop computer, or tablet (avoid smartphones) and ensure a stable internet connection (2).
• Consider patient characteristics (e.g. technological savviness, preferred language, hearing issues, cognitive impairment) and the tasks you hope to accomplish to determine if a telemedicine visit is appropriate before scheduling a telemedicine encounter.
• Identify a designated person (e.g. nursing or medical assistant) to do preparation and teaching about the technology prior to make the clinical appointment more efficient. This should include information about the length and purpose of the visit, the technology being utilized, verification of the patient’s internet capacity, and a back-up plan (e.g. telephone call) if things fail.
• For visits with multiple team members, decide if you should sit side-by-side on one screen (sharing one camera) or on separate screens from different computers or locations.  Although it may require greater technical sophistication, utilizing separate screens allows each clinician to position his or herself in front of a camera. This can make it easier for the patient, family, and IDT members to appreciate all participants’ non-verbal cues.  
• Use a technology-checklist to confirm your equipment is working properly and to minimize technological complications before your visit begins (2).  
• Confirm all participants are well-lit, visible on the screen, and can hear each other well (3).  When needed, the clinician should assume the role of the clinic visit “film director”.  For example, if a caregiver is not viewable on the screen, ask for camera adjustments so everyone is in view.
• Orient your patient to where you and any collaborating clinicians are sitting.  Assure the patient you are in a private, confidential space and inquire if they are in a physical location where they feel comfortable sharing medical information with you.
• Ask the patient to introduce who is in the room with them.

Verbal communication during the visit: While most recommended serious illness communication practices apply to telemedicine visits, the following bullet points offer unique telemedicine considerations:

• Talk slower than in-person by embracing pauses in conversation; this can prevent participants from talking over each other (4).
• Explicitly request the patient’s permission before discussing a sensitive or difficult topic. Observe verbal and non-verbal responses to gauge whether it is safe to proceed with the conversation (5).
• If you are having difficulty hearing or understanding your patient, ask directly for clarification: “What you’re saying is really important to me. Can you repeat what you said?”
• Since your facial expressions can be more difficult to interpret and light touch is not possible, clinicians will need to prioritize empathetic statements so they can respond to patient emotions appropriately: “I can’t imagine how difficult this has been for you(6).”
• Closing telemedicine visits can feel abrupt or awkward. Utilize a warning shot: “We have about 10 minutes left.  What might be most helpful to discuss as we finish up our appointment today?”

Non-verbal communication during the visit:

• Good eye-contact is key since the quality of your attention is more evident by video than in-person. Frequently observe your facial expressions and estimate your gaze with your camera positioned slightly above eye-level (7).  
• Avoid typing when discussing sensitive or important topics (8). If you need to look something up on your computer or the patient’s medical chart, explain what you are doing to avoid appearing distracted or disinterested. 
• Maximize the patient on your computer screen to give yourself the best chance of appreciating their body language and subtle facial expressions.
• When utilizing body language to convey empathy, make sure it is visible on the patient’s screen.

After the visit:

• When seeing a patient with other team members, confirm the patient has exited the telemedicine platform before debriefing.
• Consider sending a written summary of the visit through secure email or your electronic medical record to your patient with key recommendations.
• When conducting serial telemedicine visits, create a small habit or routine (e.g. stepping away from your computer to take a few deep breaths or a quick stretch) between visits to minimize fatigue and prepare yourself to communicate effectively with your next patient. (9)

References

1. Webster P. Virtual health care in the era of COVID-19. Lancet Lond Engl. 2020;395(10231):1180-1181. doi:10.1016/S0140-6736(20)30818-7
2. Calton BA, Rabow MW, Branagan L, et al. Top Ten Tips Palliative Care Clinicians Should Know About Telepalliative Care. J Palliat Med. 2019;22(8):981-985. doi:10.1089/jpm.2019.0278
3. Calton B, Abedini N, Fratkin M. Telemedicine in the Time of Coronavirus. J Pain Symptom Manage. Published online March 31, 2020. doi:10.1016/j.jpainsymman.2020.03.019
4. Chua IS, Jackson V, Kamdar M. Webside Manner during the COVID-19 Pandemic: Maintaining Human Connection during Virtual Visits. J Palliat Med. Published online June 11, 2020. doi:10.1089/jpm.2020.0298
5. Flint L, Kotwal A. The New Normal: Key Considerations for Effective Serious Illness Communication Over Video or Telephone During the Coronavirus Disease 2019 (COVID-19) Pandemic. Ann Intern Med. Published online May 14, 2020. doi:10.7326/M20-1982
6. Cooley, Laura. Fostering Human Connection in the Covid-19 Virtual Health Care Realm. NEJM Catal. 2020.  Available at https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0166.  Published May 20, 2020. Accessed June 23, 2020.
7. Ben-Arieh D, Charness N, Duckett K, et al.  A Concise Guide for Telemedicine Practitioners: Human Factors Quick Guide Eye Contact.  Available at https://cdn2.hubspot.net/hubfs/5096139/Eye-Contact-Quick-Guide.final.pdf.  Published February 2016.  Accessed June 30, 2020.
8. The Academy of Communication in Healthcare. COVID 19 Telehealth: Relationship-Centered Communication Skills. Available at: https://www.achonline.org/Portals/36/COVID-19%20Resources/Covid-19%20telehealth%20FINAL.pdf.  Accessed June 20, 2020.
9. Zulman DM, Haverfield MC, Shaw JG, et al. Practices to Foster Physician Presence and Connection With Patients in the Clinical Encounter. JAMA. 2020;323(1):70-81. doi:10.1001/jama.2019.19003

Authors’ Affiliations: University of California, San Francisco

Conflicts of Interest:  None

Version History:  originally edited by Sean Marks MD; first electronically published in September 2020