Telehealth and

Virtual Care
Robert M. Vineet Shruti John D. Abraham

Opportunities Wachter, MD
Professor and
Arora, MD, MAPP
Herbert T. Abelson
Chandra, MD
Assistant Professor
Halamka, MD, MS
President, Mayo
Verghese, MD, MACP
Professor and Linda
Chair of the Tenured Professor of Emergency Clinic Platform
and Challenges in
R. Meier and Joan
Department of of Medicine, Medicine, F. Lane Provostial
Medicine, UCSF University of Thomas Jefferson Professor, Vice Chair

Graduate Medical Chicago University for the Theory and

Practice of Medicine,
the School of Medicine
Education at Stanford University

Red Paper
A McGraw Hill Red Paper
Telehealth and Virtual Care
Opportunities and Challenges in Graduate Medical Education

Executive Summary
The COVID-19 global pandemic propelled telehealth to the forefront of clinical care. How will graduate
medical education evolve to prepare clinicians for the “new normal” of telehealth and virtual medicine?

To address these and other topics, McGraw Hill Professional sponsored an exclusive telehealth roundtable
hosted by Dr. Robert Wachter, Professor and Chair of the Department of Medicine at the University of
California, San Francisco (UCSF). The event featured a panel of prominent medical educators and experts on
the vanguard of telemedicine, including:

Vineet Arora, MD, MAPP, Herbert T. Abelson Tenured Professor of Medicine at the University of Chicago

Shruti Chandra, MD, Assistant Professor of Emergency Medicine at Thomas Jefferson University

John D. Halamka, MD, MS, President of the Mayo Clinic Platform

Abraham Verghese, MD, MACP, Professor and Linda R. Meier and Joan F. Lane Provostial Professor and
Vice Chair for the Theory and Practice of Medicine at the School of Medicine at Stanford University

A valuable resource for GME program directors, coordinators, faculty, and librarians, this red paper explores
the topics discussed in the roundtable, providing additional context and references. Coverage includes:

⊲⊲ How the COVID-19 global pandemic impacted GME programs

⊲⊲ Changes in telehealth regulations

⊲⊲ Barriers to telehealth

⊲⊲ Challenges and opportunities

⊲⊲ Key telehealth skills for medical students and residents

⊲⊲ How GME leaders and institutions can adapt to an evolving clinical care environment

⊲⊲ The future of telehealth

accessmedicine.com
Surge in Telehealth Visits Impacts GME Programs
Telehealth has been used modestly for decades in clinical and medical education settings.1
However, adoption of telehealth services notably accelerated once COVID-19 became a global
pandemic. The acceleration stemmed from requests for the public to stay home and limit
exposure to others; the need for healthcare facilities to limit exposure to their clinical staff;
the relaxation of many regulatory policies around virtual care; and improved payments for
telehealth visits.

“There are very few things good things about pandemics, but one of them…is that they often spur
innovation,” said Dr. Wachter during the roundtable. “In the case of COVID-19, probably the main
digital innovation has been telehealth. In some ways, it’s not an innovation because it’s been around
for a while, but it certainly has had a very slow adoption curve until the last year.”

“At UCSF…we saw our use of telehealth skyrocket. We’ve all seen those curves going from 1% or 2% of
visits to 70%. That’s what happened for us. …[Telehealth] is clearly now going to be an enduring part of
the medical healthcare landscape,” said Dr. Wachter.

GME programs have not traditionally incorporated telehealth and virtual care into their formal curricula
or informal learning experiences. The acceleration of telehealth in 2020 presents new challenges for
GME programs as well as new educational and clinical opportunities.

Strategic educational planning and dedicated

time are necessary to create a program on which Telehealth is clearly
to build a solid foundation of telehealth and
virtual care knowledge for clinicians, including
going to be an enduring
those in GME programs. Faculty development part of the medical
training for telehealth and virtual care are key
elements of a formal education plan that would
healthcare landscape.
help new programs succeed. —Dr. Robert Wachter
Relaxed Telehealth Regulations and Payment Policies Aim to
Accommodate Patient Demand
Telehealth has experienced many regulatory and payment-related limitations since its inception.
However, in early 2020, the flood of requests for these services during the pandemic caused
government agencies to relax certain virtual visit policies and to offer more general payments.
Below are a few of the key changes that had an impact on GME programs.

Patient-centered care

©2021 McGraw-Hill accessmedicine.com

 Regulatory Changes in Telehealth that Impact GME 2-5

Primary Care Exception

⊲⊲ Residents can bill for all levels of service; E/M billing code restrictions have been lifted.

⊲⊲ There is no requirement to document a history and physical exam.

⊲⊲ All levels of primary care E/M services may be provided by a resident through interactive
video or audio technology, under the direct supervision of the teaching physician.

Supervision Changes
⊲⊲ Direct supervision: The supervising physician is concurrently monitoring the resident-patient
virtual visit via audio or video.

⊲⊲ Indirect supervision: The attending physician is immediately available during the virtual visit,
if needed.

⊲⊲ Oversight: The supervising physician is available immediately following the virtual visit, should
a meeting with the resident be required.

HIPAA Enforcement Discretion

The Office of Civil Rights (OCR) will not impose penalties for noncompliance with Health
Insurance Portability and Accountability Act (HIPAA) regulatory requirements.

Barriers to Telehealth

Patient Inequities

While many regulatory and payment barriers to virtual care have been lifted (at least for the time being),
other barriers to these services still exist, including lack of access to reliable broadband connections. Equity
and access to care are critical considerations when planning virtual patient care. Limited research has
been conducted to specifically examine how sociodemographic factors affect in-person versus telephone
versus video visits during the pandemic. This type of research is essential as it highlights healthcare delivery
differences and disparities that may impact access to quality care for certain populations.

©2021 McGraw-Hill accessmedicine.com

One such study was conducted at the University of Chicago (UChicago) Medicine, which looked at
outpatient visit types (in-person versus virtual, and telephone versus video visits), according to patient
sociodemographics for the initial 11 weeks of the COVID-19 pandemic.6

Video virtual visits comprised the majority of outpatient clinical encounters during the study period.
There were notable sociodemographic differences between visits conducted in-person versus virtual,
and video versus telephone. Populations with decreased access to wi-fi and smart devices, and who
had limited knowledge about the digital environment were less likely to complete their outpatient visits
using video conferencing. Studies have shown that patients whose virtual visits used video instead of
telephone-only report higher satisfaction.

These findings are concerning, as the use of video visits may contribute to more inequalities between
patient populations. This divide could be exacerbated if telephone visits are no longer reimbursed, or if
there is a disproportionate reimbursement between telephone and video visits following the pandemic.

Clinician Barriers

During the roundtable, Dr. Vineet Arora described how UChicago Medicine surveyed 200 medicine
and pediatric faculty members about the process of seeing patients through video virtual visits. The
results showed that clinicians also experience barriers to video visits, including:

⊲⊲ Challenges with technology access

⊲⊲ Inadequate knowledge about technology

⊲⊲ More time to conduct visits

⊲⊲ General reluctance to adopt

Guidelines Needed for In-Person Versus Virtual Care

Guidance needs to be established for clinicians to understand when it is best to see a patient in
person versus virtually. The mechanics of how to conduct a physical exam virtually are unfamiliar
to many practitioners. Some are unaware of the sophisticated equipment available to support
virtual physical exams, such as electronic stethoscopes, video otoscopes, dermatoscopes,
intraoral scopes, and retinal imaging systems. Some patients wear fitness trackers that can monitor
a variety of body functions, including heart rate, blood pressure, blood oxygen levels, sleep
patterns, and EKG. These readings can be shared with clinicians via health applications or through
electronic health messaging systems.

©2021 McGraw-Hill accessmedicine.com

Challenges of Telehealth

Diagnostic Error

Research shows that clinicians diagnosing patients via virtual care often order more tests to collect
objective data than they would if seeing the same patient in a clinic.8 Some conditions are difficult
to diagnose via video because they present with subtle physical abnormalities that can be easily
missed on the screen, such as mild clubbing or changes in capillary refill.

Fragmented Care

Poor communication with the patient and other providers caring for the patient is a risk with any
type of clinical encounter, but perhaps more so with telehealth. This breakdown in communication
may lead to fragmentation, which may create gaps in care, lead to excessive use of care, cause
unnecessary or redundant care, or lead to medication error.8

Patient Rapport

The computer screen may inhibit the development of a trusting relationship with the provider for
some patients. This could become a major issue for patients with chronic or complex disease who
require frequent follow-up but may feel uncomfortable if a trusting patient-provider relationship
is not cultivated. “Webside manner” encompasses a set of key attributes with which providers
conducting telehealth visits must become comfortable, including, on-camera appearance, proper
eye contact, lighting, empathy, and the experience as a whole.9

Benefits of Telehealth

Research has shown that telehealth improves patient self-management and outcomes, decreases
healthcare costs, and increases continuity of care.10

Improved Access

Clinician shortages exist worldwide leaving many without healthcare services. Telehealth enables
people to receive medical attention even when there are no available providers in an area.
Diagnostic Error

©2021 McGraw-Hill accessmedicine.com

 Patient Preference

Convenience is one of the primary reasons patients often prefer virtual over in-person visits.
Telehealth eliminates the need to commute to the clinic or take time away from work. During the
early days of the COVID-19 pandemic, many patients were able to meet their healthcare needs
safely through virtual care. Even as the pandemic begins to resolve, those who are vulnerable or
caring for vulnerable loved ones may choose to continue with telehealth visits to decrease the
threat of contracting the virus.8

Improved Chronic Disease Management

Patients with chronic disease conditions such as heart failure may be easily managed through
telehealth services, which reduces hospital stays or keeps them out of the hospital entirely,
decreases time spent away from work for appointments, decreases travel time, and results in
lower healthcare costs to the patient and healthcare system.

Quality Outcomes

Much research has been conducted in intensive care units (ICUs) over the last decade to examine
patient outcomes using telehealth in the ICU.11 These programs have improved patient safety
through the use of off-site critical care providers and standardization of care processes, which has
had the added benefit of lowering costs to patients and the healthcare system.

Behavioral health is another sector of medicine in which telehealth has proven to be an effective
alternative to in-person patient care. Studies have consistently shown improved symptom
management, higher quality of life, and decreased costs in mental health patients receiving care
virtually.12 These results include a large population with a variety of mental health diagnoses.

Meaningful Opportunities

Ambulatory Care

There are many challenges to resolve in order to seamlessly deliver telehealth services, but there
are also unexpected opportunities that allow a deeper understanding of the patient’s life.

©2021 McGraw-Hill accessmedicine.com

As Dr. Abraham Verghese noted in the roundtable, a We all need more
virtual visit may reveal more about a patient’s living
circumstances than could be gleaned during an in-person formal education on
visit. For example, the patient may be living in a confined how to (practice
space or they may have poor or no wi-fi connection.
Perhaps a significant other who typically does not telemedicine) well.
accompany a patient to the clinic may be able to support —Dr. Abraham
their loved one during a virtual appointment from home.
Verghese
Telehealth visits provide an “extraordinary glimpse...into
the patient’s real world (which can be) far richer than
anything I’m seeing in the social history or the family history,” said Dr. Verghese. “We all need
more formal education on how to (practice telemedicine) well,” he added.

These unique discoveries allow for a different type of dialogue between the physician and patient
than would normally occur in a clinic office.

Inpatient Care

The inpatient setting has used telehealth services successfully to care for complex patients for
many years. Providers inside or outside the hospital monitor the patient’s clinical condition and
manage their care remotely.8

Telehealth Education Competencies

Recent events have highlighted the need for a We must think of

formal telehealth training program in GME, but how
does this body of new information fit into the already equipping our graduates
crowded curriculum? Some suggest that it should be to be well trained as
incorporated into the daily workflow now, until a more
formalized approach is available. a workforce ready
“The COVID-19 pandemic really accelerated the to deliver virtual care.
adoption of virtual care. …The rapid uptake and daily —Dr. Shruti Chandra
clinical care did not permit for a foundational design
of logistics, workflow, education competencies, and
assessments in the training environment for most

©2021 McGraw-Hill accessmedicine.com

programs.” said Dr. Shruti Chandra during the roundtable. “For any new modality to succeed,
training and education is key. …We must think of equipping our graduates to be well trained as a
workforce ready to deliver virtual care,” she added.

Dr. Chandra was part of the telehealth advisory committee established by the Association of
American Medical Colleges (AAMC). Through this committee, the AAMC has developed core
competencies for telehealth to guide virtual care delivery using six domains, and they have
included milestones within each domain for recent medical school graduates entering residency.
The following summary is based on the pre-publication version of the AAMC’s new cross-
continuum competencies in telehealth.13

Patient Safety and Appropriate Use of Telehealth

Clinicians will understand when and why to use telehealth, as well as assess patient readiness,
patient safety, practice readiness, and end user readiness.

Data Collection and Assessment via Telehealth

Clinicians will obtain and manage clinical information via telehealth to ensure appropriate
high-quality care.

Communication via Telehealth

Specific to telehealth, clinicians will effectively communicate with patients, families, caregivers,
and healthcare team members using telehealth modalities. They will also integrate both
the transmission and receipt of information with the goal of effective knowledge transfer,
professionalism, and understanding within a therapeutic relationship.

Ethical Practices and Legal Requirements for Telehealth

Clinicians will understand the federal, state, and local facility practice requirements to meet the
minimal standards to deliver healthcare via telehealth. Clinicians will maintain patient privacy while
minimizing risk to the clinician and patient during telehealth encounters, while putting the patient
interest first and preserving or enhancing the doctor-patient relationship.

©2021 McGraw-Hill accessmedicine.com

 Technology for Telehealth

Clinicians will have basic knowledge of technology needed for the delivery of high-quality
telehealth services.

Access and Equity in Telehealth

Clinicians will have an understanding of telehealth delivery that addresses and mitigates cultural
biases as well as physician bias for or against telehealth, accounts for physical and mental
disabilities, and non-health related individual and community needs and limitations to promote
equitable access to care.

We need to integrate
[telehealth] better
into all aspects
of the clinical learning
environment.
—Dr. Vineet Arora

©2021 McGraw-Hill accessmedicine.com

 In the virtual roundtable, Dr. Arora presented the following TELEMEDS tips
created by UChicago Medicine colleagues Drs. Alkuireshi and Lee.

Test It Out First

Prior to the visit, practice using your video visit platform. Check audio and video. Test mute and screen
share. Practice splitting the screen to allow you to see your patient and the EHR at the same time.

Evaluate Your Schedule

Identify patients that should not have video visits. Proactively anticipate needs for the visit
(outside records, translation services, etc.).

Lay Out an Agenda

Contextualize your visit agenda by reviewing your patient’s internal history (last note, labs, etc.).
Note any outstanding orders of preventative health needs that should be addressed.

Establish Visit Rules

Introduce yourself, team members, and verify your patient. Determine a technical back-up plan.
Identify your patient’s goals for the visit and balance those with your agenda items.

Modify Your Speech

Vary tone and inflection. Speak slowly to allow for buffering and lag. Pause for questions often.
Check for understanding

Encourage Patient Engagement

Look for opportunities to educate patients using screen share—demonstrate websites,
review EHR information. Engage patients in note writing when appropriate and jointly create an
after-visit summary to reinforce the plan.

Demonstrate Positive Non-verbal Communication

Maintain good eye contact. Smile or express concern when appropriate. Signal active listening
by nodding or shaking your head.

Summarize Next Steps

Be specific about when and how to follow up. Encourage patient portal use to review their
after-visit summary and chart updates for reference. Elicit direct patient feedback.

©2021 McGraw-Hill accessmedicine.com

Next-level Telehealth: Caring for Patients with Serious and Complex Diagnoses

When thinking of the most suitable patients for virtual care, the serious and complex patient is
probably not front-of-mind. However, caring for such patients is possible with the right technical
equipment, trained healthcare staff, and infrastructure.

Mayo Clinic Platform is a large digital initiative led by John Halamka, M.D., MS. Its purpose is to deliver
quality healthcare through digital and artificial intelligence (AI) capabilities to people throughout the world.14

“It’s about seeing more patients in more geographies and ensuring we don’t worsen the digital
divide,” said Dr. Halamka during the roundtable.

According to Dr. Halamka, it is necessary to understand the journey patients have taken in the
past to advise future patient journeys. As part of their digital initiative, Mayo Clinic has taken 154
years of deidentified patient data and used an AI factory to identify patterns that can be used to
formulate new knowledge based on that data. Residents, faculty, researchers, and fellows are
using this data to create the tools and technologies that will assist patients in the future.

The AI factory has produced “30 algorithms that help us better diagnose patients based
on patterns of disease,” said Dr. Halamka. “As more and more care is going to be delivered
at a distance, understanding patterns of disease and being able to interpret the objective,
the subjective, and the telemetry and create for our clinicians delivering virtual care a set of
probabilities of disease is increasingly important,” he added.

Mayo Clinic now has a home hospital platform where providers care for patients with serious and
complex healthcare needs entirely from a distance. They outfit the patient’s home with cellular
technology so there is no dependence on reliable internet or technology literacy. Mayo Clinic
provides the monitoring tools, including electronic
wearables and devices that stay in the home.
These devices provide telemetry readings, vital We will need a whole
new cadre of caregivers
signs, and other pertinent data to inform clinicians
of their status. Care is managed and adjusted
based on these findings. able to deliver care at a
There have been approximately 350 patients distance and deliver
discharged from this program so far. Patient satisfaction
scores have been excellent, and safety and quality
care in a home setting.
metrics are equivalent to those of onsite care.15 —Dr. John Halamka

©2021 McGraw-Hill accessmedicine.com

 Healthcare Jobs of the Future

Virtual healthcare is going to require a new caliber of clinician – sometimes called a “virtualist” – who will have
the knowledge and skills of a hospitalist but will deliver comprehensive care to patients entirely from a distance.
Community paramedics or other non-physician providers will be needed to provide supply-chain support to
persons in non-traditional settings. AI enablement training will also be necessary.16 “We will need a whole new
cadre of caregivers able to deliver care at a distance and deliver care in a home setting,” said Dr. Halamka

Conclusion and Recommendations

Telehealth and virtual care are here to stay and will likely increase
even as the COVID-19 global pandemic subsides. Graduate
medical education will need to evolve to prepare tomorrow’s The locus of
clinicians for the “new normal” of telehealth and virtual medicine.
the training has
Reflecting on the future of medical care, Dr. Wachter commented, to change.
“The patients we see both in the hospital and the ambulatory
world will be a highly selected group of people who really need to —Dr. Robert Wachter
come in...(for) something we can only do in person. ...The locus
of the training has to change.”

Some recommendations gleaned from the roundtable event, Telehealth and Virtual Care Opportunities and
Challenges in Graduate Medical Education, include:

⊲⊲ Find ways to integrate telehealth education into GME training now, as opportunities arise.

⊲⊲ Create a formalized telehealth and virtual care training program for GME programs based on
the AAMC telehealth competencies.

⊲⊲ Establish guidance for physical examinations—when is an in-person visit preferred over a virtual one?

⊲⊲ Advocate to make permanent current policies that allow virtual visit reimbursement.

⊲⊲ Close the digital divide by advocating for widespread broadband access.

⊲⊲ Advocate to permanently implement current policies regarding residents, telehealth, and supervision.

⊲⊲ Develop new professional roles and training that will result in providers who solely function in virtual care
and support staff who provide virtual patient assistance.

©2021 McGraw-Hill accessmedicine.com

 AccessMedicine is an acclaimed online medical resource that provides a complete
spectrum of trusted, continuously updated content in a variety of formats—compiled from
the best minds in medicine.
AccessMedicine delivers:

⊲⊲ The latest editions of 130+ texts covering all medical specialties

⊲⊲ 1,000+ interactive cases covering clinical medicine and basic science

⊲⊲ 1,000+ multimedia resources: procedure, diagnostic test, physical exam, patient

communication, and lecture videos

⊲⊲ 11,000+ self-assessment Q&As to master clinical and basic sciences

AccessMedicine provides a variety of resources to support telehealth education.

Click here to request a free institutional trial of AccessMedicine.

©2021 McGraw-Hill accessmedicine.com

References
1. Nesbitt TS, Katz-Bell J. History of Telehealth. In: Rheuban K, Krupinski EA. eds. Understanding Telehealth. McGraw-Hill;
Accessed March 04, 2021. https://accessmedicine.mhmedical.com/content.aspx?bookid=2217&sectionid=187794434

2. “Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19.” CMS.gov. Centers for Medicare & Medicaid Services,
January 28, 2021. https://www.cms.gov/files/document/covid-19-physicians-and-clinicians.pdf.

3. Nasca, Thomas J. “ACGME Response to the Coronavirus (COVID-19).” ACGME, March 18, 2020. https://acgme.org/Newsroom/
Newsroom-Details/ArticleID/10111/ACGME-Response-to-the-Coronavirus-COVID-19.

4. Common Program Requirements (Residency).” ACGME. Accessed March 10, 2021. https://www.acgme.org/Portals/0/
PFAssets/ProgramRequirements/CPRResidency2020.pdf.

5. Secretary, HHS Office of the, and Office for Civil Rights (OCR). “Notification of Enforcement Discretion for Telehealth.” HHS.
gov. US Department of Health and Human Services, January 20, 2021. https://www.hhs.gov/hipaa/for-professionals/special-
topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html.

6. Gilson SF, Umscheid CA, Laiteerapong N, Ossey G, Nunes KJ, Shah SD Growth of Ambulatory Virtual Visits and Differential Use
by Patient Sociodemographics at One Urban Academic Medical Center During the COVID-19 Pandemic: Retrospective Analysis
JMIR Med Inform 2020;8(12):e24544
doi: 10.2196/24544

7. Kemp MT, Liesman DR, Williams AM, et al. Surgery Provider Perceptions on Telehealth Visits During the COVID-19 Pandemic:
Room for Improvement [published online ahead of print, 2020 Nov 13]. J Surg Res. 2020;260:300-306. doi:10.1016/j.
jss.2020.11.034

8. Romanick-Schmiedl, S., Raghu, G. Telemedicine — maintaining quality during times of transition. Nat Rev Dis Primers 6, 45
(2020).https://doi.org/10.1038/s41572-020-0185-x)

9. Smith, Timothy M. “To Succeed with Telehealth, Know Your ‘Webside Manner.’” American Medical Association,
September 28, 2020. https://www.ama-assn.org/practice-management/digital/succeed-telehealth-know-your-webside-
manner#:~:text=Just%20as%20bedside%20manner%20encompasses,the%20totality%20of%20the%20encounter.

10. Agboola, Stephen. “Telemedicine and Patient Safety.” PSNet, September 1, 2016. https://psnet.ahrq.gov/perspective/
telemedicine-and-patient-safety.

11. Clin Chest Med. 2015 Sep;36(3):401-7. doi: 10.1016/j.ccm.2015.05.004. Epub 2015 Jun 27. DOI: 10.1016/j.ccm.2015.05.004

12. Bashshur RL, Shannon GW, Bashshur N, Yellowlees PM. The Empirical Evidence for Telemedicine Interventions in Mental
Disorders. Telemed J E Health. 2016;22(2):87-113. doi:10.1089/tmj.2015.0206

13. AAMC Telehealth Competencies. AAMC. Accessed March 5, 2021. https://www.aamc.org/system/files/2020-09/hca-

telehealthcollection-telehealth-competencies.pdf.

14. “At the Edge of Possible.” Mayo Clinic. Mayo Foundation for Medical Education and Research, June 2020. https://
mayomagazine.mayoclinic.org/2020/06/at-the-edge-of-possible/.

15. HealthLeaders. “John Halamka, MD, Launches Mayo Clinic’s ‘Digital Data Business’.” HealthLeaders Media. Accessed March
5, 2021. https://www.healthleadersmedia.com/innovation/john-halamka-md-launches-mayo-clinics-digital-data-business.

16. Oran, Daniel P, and Eric J Topol. “The Rise of the Virtualist.” The Lancet, July 6, 2019. https://doi.org/https://doi.org/10.1016/
S0140-6736(19)31498-9.

©2021 McGraw-Hill accessmedicine.com