During the COVID-19 pandemic, primary care practices that had not previously considered telehealth viable were pushed to reconsider it to stay solvent. The pandemic fueled a rapid increase in telehealth to a peak of more than 50% of visits,¹ which has now settled into slightly more than 10%.^2–3 Yet even in this post-pandemic era, telehealth has tremendous potential to strengthen the basic provision of care in small and large practices.

This article describes the benefits of — and workflows for — integrating telehealth into the primary care workday, including tips for conducting effective physical exams via telehealth.

BENEFITS OF TELEHEALTH IN PRIMARY CARE

While telehealth-only offerings have grown in recent years, both for general services (e.g., Teladoc or Zocdoc) and for specific conditions (e.g., acne, testosterone, and fertility online sites), integrating telehealth into the primary care clinic improves continuity and access. We have found that telehealth offers a number of practical benefits, including the following:

It reduces cancellations and no-shows. Telehealth allows for ease of access and communication between clinicians and patients, which often keeps patients from canceling or not showing up for appointments despite other demands on their time. Transportation issues are a common reason for last-minute cancellations and we can often salvage these visits by converting them to telehealth.

It improves chronic disease follow-up. Telehealth makes it easier for patients to follow up on their chronic conditions because they can do it from any location — at home, out of town, or at work on their break or lunch hour.

It improves communication about abnormal results. Telehealth allows us to reach patients quickly to personally discuss unexpected abnormal labs or imaging findings and proceed with next steps,⁴ such as further testing or referrals. We often fit in these telehealth visits as other appointment cancellations arise.

It prevents the spread of contagious illness while improving care for affected patients. Telehealth is valuable for managing potentially contagious patients, such as tuberculosis contacts or those with acute upper respiratory infections. We used to see a high rate of cancellations for routine follow-up visits because patients also developed an acute illness, but with telehealth we can see these patients for their chronic condition follow-up plus the illness that is preventing them from leaving home.

It improves hospital follow-up. Telehealth increases our ability to conduct Medicare transitional care management (TCM) visits and other immediate hospital discharge follow-ups. Patients who are debilitated from a long hospital admission or recovering from surgery may have difficulty coming into the office for a TCM visit due to limited mobility or other issues and are ideal candidates for a telehealth visit. Using telehealth, we have been able to see these patients in the context of their homes and see them sooner after extended hospitalizations. As a result, we are catching more medication dosing issues or other errors than ever before, and catching them earlier with greater clinical impact and improved outcomes.

It prevents emergency department (ED) visits. For example, when worried parents call our office, we can quickly work in a telehealth visit and walk the parents through the signs and symptoms they should be looking for in their child (difficulty breathing, pallor, etc.). This simple check-in often reassures them and prevents the unnecessary ED visit that would have occurred if we had not conducted a telehealth appointment.

It aids shared decision making. Telehealth works well for extended counseling in response to a patient message that requires a nuanced or complex answer. It's also easily reimbursable, whereas some payers may not reimburse clinicians for responding to portal messages (see the FPM blog post “Getting paid for online digital E/M services”). For example, if a patient messages or calls our office because a mammography center is requesting a breast MRI after a basic risk screen, we may wish to discuss the pros and cons instead of just ordering the study.⁵ Quickly working in a brief telehealth visit for this conversation can be effective. Contraception counseling, genetic testing counseling, sexually transmitted infection prevention, HIV pre-exposure prophylaxis counseling, and travel consultations are all examples of the potential for patient-driven telehealth. We have found that our patients appreciate being given a choice of visit options, particularly for potentially sensitive topics.

It helps us address social determinants of health. Our understanding of our patients' social determinants of healthhas improved considerably since offering telehealth because we now have more visibility into issues such as the degree of social isolation and the home environment. Telehealth also helps alleviate transportation challenges for many of our patients.

WORKFLOWS FOR INTEGRATED TELEHEALTH

Telehealth is most successful with a strong team approach that supports the following workflows. (See "An effective telehealth examination.")

1. Normalizing telehealth visits. When patients establish care with our practice, we begin orienting them to the telehealth concept. Ahead of telehealth visits, the front-desk staff takes time to obtain consent for telehealth interactions, explain the process, and help patients test devices. Taking time up front to ensure patients have telehealth access allows for seamless transitions from in-person to telehealth visits. Although we have a high proportion of patients who speak Spanish and are farmworkers, we were able to bring almost our entire patient population into video visits over the course of the pandemic, and we maintained a telehealth rate of more than 85% of visits for many months. Early on, relaxed telehealth rules allowed us to use platforms that even our older, non-English-speaking patients use to talk to their extended family, such as FaceTime, WhatsApp, and Skype. Confidence gained from using these common tools generated greater patient readiness to switch to a conventional HIPAA-compliant platform, which we are now using. We've found that as patients age, telehealth acceptance actually increases because family members are more involved in scheduling and supporting visits, often using the caregiver's device. We postulate that our elderly patients are now receiving better, more immediate care without delays for this reason. The number of patients who have only a landline and live in such isolation that they must do audio-only visits has dropped to under a dozen in our practice. Although we do not have a strong patient portal, we are still able to successfully utilize telehealth, demonstrating that significant technological infrastructure is not a requirement.

2. Scheduling telehealth visits. Our overall approach is not to add telehealth visits on top of clinicians' already overburdened schedules but to make more effective use of their schedules by minimizing downtime related to cancellations, no-shows, etc., and turning that time into reimbursable telehealth visits. While we maintain protected time slots for same-day sick visits throughout the day for every clinician, we can also triage these patients into immediate, brief telehealth visits if they prefer. Most often, we can successfully manage same-day problems with a focused video encounter, but sometimes we use a mix of in-person and telehealth interactions depending on the patient's situation. For example, if we find that a telehealth patient needs a subsequent focused exam in person, such as an ear check for a sick child, we can quickly work them in because the bulk of the visit has already occurred virtually. Similarly, we may instruct a telehealth patient to stop by our office later in the day for a COVID, strep, or other on-site test, which staff can handle without affecting the physician's schedule. We also have patients with suspected urinary tract infection drop off a urine sample early in the day for a urinalysis, in preparation for a telehealth visit later in the day. Some of our clinicians accept overflow urgent visits at the end of their day, and because we schedule charting time for the last 30–45 minutes of the day, an additional sick visit or two rarely leads to a prolonged workday. For last-minute cancellations of in-person visits, we can often persuade those patients to do a telehealth visit during their same time slot, or at least by the end of the day. This allows us to keep the visit, without adding to future workloads and impacting future schedules. Our patient population consists primarily of working-class families, with many patients employed in trade or agriculture jobs that have changing work sites and schedules, typically leading to a higher-than-average no-show rate. Telehealth has helped us manage these scheduling challenges.

3. Gathering patient data for the visit. The history portion of the visit generally does not change significantly with telehealth. Our medical assistants begin by establishing contact with the patient and obtaining vital signs, mostly patient self-reported data. Most patients have a thermometer and bathroom scale, and we recommend that patients with certain conditions (e.g., hypertension) obtain blood pressure (BP) monitoring devices. Alternatively, some patients have come into our office before work for a quick BP check, and then participated in a telehealth visit with a clinician later in the day. Our medical assistants also obtain any needed screening instruments, such as depression or anxiety screening, earlier in the day. These interactions may be verbal or through portal, texting, or other modalities.

4. Conducting the remote physical exam. Training in remote physical exams, including a clinician-directed patient self-exam, is key to clinician and patient confidence in telehealth visits. The clinician should not always be a “talking head” during the visit, but rather guide the patient to obtain the most thorough and appropriate examination possible. To ensure our clinicians could confidently perform aspects of physical exams via telehealth, they obtained training through the Thomas Jefferson University self-paced course “Telemedicine: Conducting an Effective Physical Exam.” Additionally, we have used video resources to learn specific examination skills. (See “Telehealth training resources for clinicians.”)

With guidance, natural or bright indoor lighting, and a basic smartphone, remote patients can assist in elucidating an astonishing number of physical exam findings. Examples in our practice include diagnoses of acute appendicitis and strep throat. We can also effectively rule out the need for certain physical exam elements by observing patient behavior, such as ruling out the need to look at an eardrum if a child has no fever, is smiling, and is not in pain when the patient or parent gently tugs on the earlobe. Talking through and explaining such findings increases patient understanding and reassurance. Overall, we assess patient appearance as we would with any visit, and we listen for shortness of breath and look at the upper chest as the patient speaks. If needed, we can request appropriate visualization such as having the patient unbutton the top few buttons to the level of the sternal notch in order to assess breathing. A pharyngeal exam in good lighting yields a surprisingly high-resolution view to detect pharyngeal exudates. We don't hesitate to ask our patients to improve the lighting in their setting, such as moving to a window. We can demonstrate joint movements to assess the patient's range of motion for neck, elbow, knee, etc. Sometimes we request an assistant (e.g., a patient's family member) to hold the phone camera so we can evaluate gait, tremor, a rash on the patient's back, etc., or to perform an abdominal exam. When clinicians realize all of this can be accomplished via telehealth, the quality of the encounter increases.

Having a comfortable computer setup is essential for effective telehealth exams, but each of our clinicians have different styles and have autonomy to choose what works best for them. Some use a split screen, with the EHR displayed on one side and the patient's video on the other side; others use a freestanding iPad or tablet for the patient's video and view the EHR on their main computer screen; and one of our physicians prefers to use just her cell phone for the video portion, proving that high-resolution screens are not central to good communication through telehealth. If poor connectivity leads to loss of video during a telehealth visit, we simply turn off the camera and switch to an audio-only visit. Our ability to pivot quickly helps us stay on track and fully conclude the visit, preventing patient frustration or confusion.

After the visit, our practice can send and receive items such as work-excuse slips, lab results, and other relevant materials via text or portal, along with other follow-up communication.

CLINICAL VIGNETTE

A 22-year-old female patient calls her family physician's office at 4:30 p.m. as the physician is seeing the last scheduled patient of the day. The patient is complaining of abdominal pain and says she has returned from the ED, is still in pain, and is not sure what to do. Given the time constraints and inability to get her into the office before it closes, the physician requests a telehealth visit with her. A medical assistant asks the patient for her temperature and weight, and records the patient history in the EHR. The patient describes no bowel movement that day, no fevers or chills, and a diffuse abdominal pain. The physician joins the video visit and notes that the patient appears to be tired and in mild to moderate discomfort, and her facial expression seems drawn. Her color is good, and she appears to have no difficulty breathing. The physician obtains verbal permission for the patient's sister to assist with the exam. The patient is positioned on her couch, and the sister is instructed to hold the camera to allow the physician to see the patients' face and abdomen. The physician explains a palpation technique, and the sister assists in completing a methodical exam, which clearly shows localization to the right lower quadrant of the abdomen. Changing position elicits more pain. The patient is advised to return to the ED immediately, where she is later found to have a ruptured appendix.

TELEHEALTH COVERAGE

Many of the COVID-related telehealth flexibilities were extended for Medicare through the end of 2024. However, Medicare coverage and private payer coverage will continue to evolve. We recommend practices appoint a staff member to routinely look at the latest coverage advisories from state and national organizations and carefully monitor for any plan-specific drops in reimbursement for telehealth services.

A vital tool for understanding your state's current telehealth policies for private payers, Medicaid, and federally qualified health centers is the Center for Connected Health Policy.

For Medicare, the following resources may helpful:

• Medicare telehealth policies that remain in effect (for now),

• Services currently payable under the Medicare Physician Fee Schedule when furnished via tele-health.

SUPPORTING HIGH-QUALITY PRIMARY CARE

Telehealth can be a powerful support to the provision of high-quality primary care. Continuing to incorporate it into daily primary care workflows is feasible and highly desirable in a busy clinic context. While staffing shortages and overburdened schedules are a current reality, effective and thoughtful telehealth implementation can help alleviate these challenges. However, practices must continue to support front-desk staff, who are key to promoting telehealth and testing devices so patients understand the benefits. As the health care system moves toward improved support for primary care with advanced payments for care quality, practices will want to make full use of all the modalities available and advocate for telehealth services that are integrated into continuous and relationship-oriented primary care.