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. 

The COVID-19 pandemic caused many in-person healthcare appointments to be cancelled and most clinical experiences for students in the healthcare fields were disrupted. Providers struggled to determine how to meet with their patients and schools had to figure out new ways to train and assess their students. Telehealth was the answer they found. 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 uses trained standardized patients to assess the student’s skills. When the telehealth 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, including 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 telehealth residents had more factors to contend with than the in-person residents and may not have known what all of these factors were, as they had no training in telehealth.  The competencies that needed the most work included technical factors, including improvements to video, audio, and lighting (Lawrence et al., 2020).  Communicating the expectations and limitations of the system were encountered, as were interrupted conversations due to internet service limitations (Lawrence et al., 2020).  In order to overcome this difficulty, many telehealth residents responded by talking much more than listening in comparison to their in-person peers—this even included talking over the patients, which occasionally made them feel marginalized (Lawrence et al., 2020).  Experienced providers must have encountered similar experiences in switching over to telehealth visits without any training in the systems or experience with the methods.  In the case of the residents, they were given feedback by both the “patient” and the instructor, and new courses will be adding these topics to their list of competencies to cover.

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.