Abstract: 

Telehealth competency based education has become increasingly important along with the digital shift of society. The demand for telehealth has seen a great increase over the course of the last year during the COVID-19 pandemic. Healthcare professionals, many of whom were not technology natives, were forced to adapt to this new way of providing care via digital platforms. In order to ensure that providers have proper telehealth competencies, an evaluation was conducted of the current policies and practices in place for telehealth education. Some of the topics included in this evaluation include Competency Based Education (CBE), Nursing Telehealth Entrustable Professional Activities (NT-EPAs), cultural competencies, testing and skills assessments. This analysis provided future implications for the adaptation of continued telehealth education. 

Introduction

The field of telehealth has experienced a large increase in demand as a response to technical growth, health care disparities, and the COVID-19 pandemic. Continued training and education is essential for clinicians to remain on the cutting edge of technology while providing the best care. In order to ensure that proper telehealth etiquette and practice is being observed we must evaluate training practices already in place for telehealth and determine what additional practices may need to be adopted. Establishing proper telehealth competencies and determining what additional practices may need to be adopted will make for a smoother transition into a digital healthcare system. The digitalization of our society has created demand for technological intervention in the field of healthcare. As new technologies emerge it can be difficult to keep up. Doctors, nurses, technicians, and other providers are tasked with maintaining quality of care whilst adapting their practice to the ever-evolving field of technology. New means of providing care via videoconferencing, remote patient monitoring, mobile health apps, etc., require a level of competency in order to be effective. Competency can be defined as, “a measurable human capability required for effective performance,” (Hilty et al., 2018). Telehealth competencies involve many overlapping skills, attitudes, and knowledge (van Houwelingen et al., 2016) needed for regular provision of care as well as competencies specific to the use of technology in healthcare. Telehealth providers must be competent in the areas of technology, clinical evaluation, cultural diversity, ethics, legality, and patient privacy. This begs the question; how do providers remain competent in telehealth as technology and society continue to progress? Continued education and training on the competencies of telehealth are essential for clinicians to remain on the cutting-edge of technology while providing the best care.
 

 

Telehealth has the ability to improve access to care, lower healthcare costs, empower patients, and improve continuity of care but without competent providers, it will fail to make any headway in these areas. Entrustable professional activities (EPAs) are, “tasks or responsibilities to be entrusted to the unsupervised execution by a trainee once he or she has attained sufficient specific competence,” (van Houwelingen et al., 2016) a Delphi-study involving a survey of nurses, practitioners, technicians, etc., defined 14 nursing telehealth entrustable professional activities (NT-EPAs) from which 52 competencies important for telehealth were derived. Of these 14 NT-EPAs some of the most recurring were coaching skills, the ability to combine clinical experience with telehealth, communication skills, clinical knowledge, ethical awareness, and a supportive attitude. Many of these are also required for regular nursing in a face-to-face setting. However, new challenges are presented when assisting patients through a screen or digitally. For example, telehealth providers must build a relationship with their clients through a screen making communication skills critical. They also need to be able to teach the client how to use the technology and support them if there are any issues, and therefore need to be competent with the technology themselves. All clinical knowledge is still applicable in a telehealth setting with the added need for assessment and response to triage without the patient physically present. In order for these NT-EPAs to be executed, 52 competencies were identified, 32 of which have emerged as necessary for telehealth. These 32 competencies were further divided into 15 knowledge competencies, 9 attitude competencies, and 28 skill competencies (van Houwelingen et al., 2016). The telehealth attitude competencies identified include support and patient empowerment, patience, ethical awareness, and awareness of legal and safety concerns when using telehealth devices (see below Table 2: Nursing telehealth entrustable professional activities). Telehealth skill and knowledge competencies include communication, coaching, and analytical skills, ability to use clinical experience and telehealth technology in conjunction to make decisions, monitoring symptoms and functioning through videoconferencing, and skills for lifelong learning as technology progresses (van Houwelingen et al., 2016). Telehealth intervention is no small task for providers, competencies in many areas are necessary to maximize quality of care. 

One of the goals of telehealth is to provide quality and accessible care to rural and diverse populations. With this goal comes the need for cultural competency. This includes knowledge about race, ethnicity, religion, sexuality, geography, socioeconomic status, age, etc., of course these are skills necessary for providing quality care in any facet but become even more necessary in the quest to reach under-served populations through telehealth. Different levels of technological education are inevitable, the provider needs to be able to teach about the technologies they are using in a culturally sensitive way. Even still, providers may be met with skepticism or distrust of technology or the medical establishment, requiring cultural competence and patience on their part. Language barriers and translation accessibility are another example of ways in which providers must adapt their care plan to fit for each individual (Hilty, et al., 2020).  To avoid disparities in telehealth clinicians, need to be culturally competent, all of which includes providing care regardless of barriers or differences in culture, language, sexuality, etc., Furthermore, it is the duty of the health education system to teach doctors, nurses, and other providers tools for cultural competence. 

 

 

The digitalization of our society has created demand for technological intervention in the field of healthcare. As new technologies emerge it can be difficult to keep up. Doctors, nurses, technicians, and other providers are tasked with maintaining quality of care whilst adapting their practice to the ever-evolving field of technology. New means of providing care via videoconferencing, remote patient monitoring, mobile health apps, etc., require a level of competency in order to be effective. Competency can be defined as, “a measurable human capability required for effective performance,” (Hilty et al., 2018). Telehealth competencies involve many overlapping skills, attitudes, and knowledge (van Houwelingen et al., 2016) needed for regular provision of care as well as competencies specific to the use of technology in healthcare. Telehealth providers must be competent in the areas of technology, clinical evaluation, cultural diversity, ethics, legality, and patient privacy. This begs the question; how do providers remain competent in telehealth as technology and society continue to progress? Continued education and training on the competencies of telehealth are essential for clinicians to remain on the cutting-edge of technology while providing the best care.

Telehealth has the ability to improve access to care, lower healthcare costs, empower patients, and improve continuity of care but without competent providers, it will fail to make any headway in these areas. Entrustable professional activities (EPAs) are, “tasks or responsibilities to be entrusted to the unsupervised execution by a trainee once he or she has attained sufficient specific competence,” (van Houwelingen et al., 2016) a Delphi-study involving a survey of nurses, practitioners, technicians, etc., defined 14 nursing telehealth entrustable professional activities (NT-EPAs) from which 52 competencies important for telehealth were derived. Of these 14 NT-EPAs some of the most reoccurring were coaching skills, the ability to combine clinical experience with telehealth, communication skills, clinical knowledge, ethical awareness, and a supportive attitude. Many of these are also required for regular nursing in a face-to-face setting. However, new challenges are presented when assisting patients through a screen or digitally. For example, telehealth providers must build a relationship with their clients through a screen making communication skills critical. They also need to be able to teach the client how to use the technology and support them if there are any issues, and therefore need to be competent with the technology themselves. All clinical knowledge is still applicable in a telehealth setting with the added need for assessment and response to triage without the patient physically present. In order for these NT-EPAs to be executed, 52 competencies were identified, 32 of which have emerged as necessary for telehealth. These 32 competencies were further divided into 15 knowledge competencies, 9 attitude competencies, and 28 skill competencies (van Houwelingen et al., 2016). The telehealth attitude competencies identified include support and patient empowerment, patience, ethical awareness, and awareness of legal and safety concerns when using telehealth devices. Telehealth skill and knowledge competencies include communication, coaching, and analytical skills, ability to use clinical experience and telehealth technology in conjunction to make decisions, monitoring symptoms and functioning through videoconferencing, and skills for lifelong learning as technology progresses (van Houwelingen et al., 2016). Telehealth intervention is no small task for providers, competencies in many areas are necessary to maximize quality of care.

 

One of the goals of telehealth is to provide quality and accessible care to rural and diverse populations. With this goal comes the need for cultural competency. This includes knowledge about race, ethnicity, religion, sexuality, geography, socioeconomic status, age, etc., of course these are skills necessary for providing quality care in any facet but become even more necessary in the quest to reach under-served populations through telehealth. Different levels of technological education are inevitable, the provider needs to be able to teach about the technologies they are using in a culturally sensitive way. Even still, providers may be met with skepticism or distrust of technology or the medical establishment, requiring cultural competence and patience on their part. Language barriers and translation accessibility are another example of ways in which providers must adapt their care plan to fit for each individual (Hilty, et al., 2020). To avoid disparities in telehealth clinicians, need to be culturally competent, all of which includes providing care regardless of barriers or differences in culture, language, sexuality, etc., Furthermore, it is the duty of the health education system to teach doctors, nurses, and other providers tools for cultural competence.

 

Since Telehealth is a new and emerging field, innovations are being made at a rapid pace to meet this new demand. However, if the healthcare system does not keep up with the new advancements, telehealth will quickly be left in the stone age. Telehealth calls for Competency Based Education (CBE) and continued learning for providers and educators. In order for providers to stay up to date, the health education system must require that they learn about new advancements as they emerge and use CBE to test their knowledge. Aspects of CBE include assessments, reviews, training, certifications and ongoing practice (Hilty et al., 2018). Institutions implementing new telehealth initiatives should encourage their providers to be life-time learners in the field of telehealth. This may include developing training programs, holding information sessions, and seminars, or requiring that telehealth providers be recertified in certain disciplines periodically. This way, providers can remain competent in telehealth and stay up to date on innovations.

 

An issue that arises is that the health education system cannot keep up with the innovations of telehealth. Those educating new clinicians may no longer be in the field, and therefore may have out-dated knowledge they are passing on. This trickle-down effect does not make for telehealth competent providers. University of Wisconsin’s (UW) nursing school saw this issue and created a model for educating nursing faculty on technology and telehealth and began implementing telehealth into their curriculum. Telehealth competencies that were implemented were telenursing activities, health informatics, terminology, privacy, commercial and experimental telehealth strategies, and ethical, legal and social concerns around telehealth. UW held faculty educational conferences on these topics where they also introduced and demonstrated telehealth devices. In order to add telehealth education into the nursing curriculum assignments were designed which followed telenursing competencies from the American Nurses Association. These competencies included communication, assessment, consultation skills, evaluation, documentation, and understanding policies surrounding telehealth (Gallagher-Lepak et al., 2009). The University of Wisconsin’s nursing school and its professionals saw that telehealth was emerging in their field and decided that in order to help the healthcare system as a whole they needed to produce health professionals that are competent in telehealth. Not only did UW establish a set of competencies for their students but they also recognized the need for continuing to educate their faculty. Educational conferences such as those established at UW should be available for all health educators and healthcare workers in order to maintain telehealth competency.

 

During 2020, the COVID-19 pandemic caused the limitation of many in-person healthcare appointments and the cancellation of most clinical experiences for students in the healthcare fields. Businesses were left struggling to determine how to meet with their patients and schools were left trying to figure out how to train and assess their students. Both turned to telehealth. Due to the pandemic, a number of primary care residents at New York University completed their annual Primary Care Comprehensive Objective Structured Clinical Examination (OSCE) via telehealth (Lawrence et al., 2020). This exam involves the use of trained standardized patients to assess the student’s skills. When these students—who had not been trained in telehealth but were notified that their OSCE would be completed using telehealth—were compared to a group of students who had in-person OSCE, a number of similarities in competencies were discovered. Faculty discovered that residents in both mediums were able to obtain medical, surgical, and social health history and to conduct mental health screenings very successfully (Lawrence et al., 2020). The residents conducting telehealth visits had more factors to contend with than the in-person residents and may not have known what all of these factors were. The competencies that needed the most work included technical factors, including improvements to video, audio, and lighting (Lawrence et al., 2020). A lack of communication regarding the expectations and limitations of the system were also encountered, as were issues with conversations being interrupted due to internet service limitations (Lawrence et al., 2020). This led to residents doing much more talking than listening compared to their in-person counterparts, including talking over the patients, which occasionally made them feel marginalized (Lawrence et al., 2020). The experience was what some providers experienced in switching over to telehealth visits without any training in the systems or experience with the methods. In this case, residents were given feedback by both the “patient” and the instructor, and new courses will add these topics to their list of competencies to cover.

 

Additionally, telehealth providers need to be competent in the legal aspects of the field. Provider access to health information and the HIPAA rights of patients are major concerns for telemedicine (Jin et al., 2020). Another factor is the ability of providers to work across state lines to provide care. Patients who live close to state lines may cross the border to receive care. Providers who work close to state boundaries may be unable to conduct telehealth visits with these patients due to state licensure regulations (Jin et al., 2020). These aspects of legal competence are extremely important and yet easy to overlook in a telehealth visit where the patient could be anywhere. Additionally, providers need to be competent in maintaining patient safety during a telehealth visit. Providers must make sure that they positively identify the patient (Jin et al., 2020). Providers also need to make sure that they have an emergency contact for the patient, in addition to the patient’s phone number and physical location in case the visit becomes emergent (Jin et al., 2020).

 

In the future, telehealth will comprise a much larger percentage of provider visits. Telehealth provides a number of solutions to patient problems with a focus on providing easier access, expanding coverage, reducing costs of healthcare and travel, and improving care. Along with this increase in virtual healthcare will come the need for other supporting fields and competencies in these areas, too. Computers play a key role in the field, so information technology, software engineers, and others who are literate in the health fields will be vital to create the new platforms that will help solve problems with integrating information, protecting patient privacy, and creating better platforms to conduct visits (Thomas et al., 2020). Improving software literacy and the ability to teach others how to use the software will also be necessary to the success of telemedicine (Thomas et al., 2020). Furthermore, people who are experienced in telehealth will need to help reform how providers are compensated for telehealth visits to more accurately reflect their time, effort, and expenses (Thomas et al., 2020).

 

 

 

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