During the assessment, the provider may ask the patient or a family member to perform certain maneuvers that the practitioner would typically perform in the clinic setting. For example, a 28-year-old man contacted his primary care provider complaining of abdominal pain. After obtaining his HPI and self-reported elevated temperature and pulse rate, the provider asked him to lie down on a flat surface and use the heel of his right hand and to slowly depress the right lower quadrant of his abdomen. He was then instructed to release his hand quickly. After complaining of pain with this maneuver, he was asked to stand up straight and jump. When both maneuvers elicited pain in the right mid to lower abdomen, he was promptly referred to the local emergency department where he was diagnosed with appendicitis.
Step 4: Diagnosis and Treatment
The next steps of the telehealth visit are to determine the diagnosis and establish the treatment plan. It is important to ensure the patient understands the treatment plan and instructions. Screen sharing is an excellent tool to review laboratory results with patients and provide visuals for patient education. Additionally, the provider can send patient education instructions through a patient portal in the electronic health record.
Devices for Patient Assessment
It is essential to understand the safety and accuracy of software applications utilized on mobile devices for diagnosing and managing health conditions and the role of the Food and Drug Administration (FDA) in regulating digital health. In the fourth quarter of 2020, 51,476 health apps were available.6 To assure the public’s safety, the FDA has identified software applications and devices that require FDA approval through the Digital Health Innovation Action Plan.7 Software applications and devices utilized by patients to manage their disease condition and promote health, without offering management recommendations, are not required to have FDA approval. However, software and devices designed to diagnose, treat, cure, mitigate, or prevent disease or other conditions are considered Software as a Medical Device (SaMD)and require FDA approval.8 For example, use of FaceTime on a mobile device to visualize a lesion does not constitute a medical device. However, utilizing an app on a mobile device that analyzes the lesion using a mathematical algorithm for a risk assessment does require FDA approval.
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Step 5: Documentation
Basic documentation for a telehealth visit resembles an in-person clinic visit. Additional information should include when the telehealth visit started and ended, the specific modality utilized (videoconferencing or voice only), a statement that the patient agreed on the delivery modality, and the modality served as an effective and safe means of care delivery. Document the location of the patient and the provider as well as the roles of any other person(s) participating in the telehealth visit. Coding and billing exceed this article’s scope, but billing codes for telehealth services are available at https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.
One can only predict that additional technology and resources will further promote high-quality patient assessments within the home rather than the clinic setting.
Susan Calloway, PhD, FNP-BC, PMHNP-BC, FAANP, is a professor and director of the Psychiatric Mental Health Nurse Practitioner Program (PMHNP) at Texas Tech University Health Science Center (TTUHSC) in Lubbock, TX. She has practiced as an FNP and PMHNP in rural and urban areas and has been an NP educator for 25 years. She developed one of the first graduate-level telehealth courses for NP students in the country and serves on the telehealth resource groups for the National Organization of Nurse Practitioner Faculties (NONPF) and American Association of Nurse Practitioners (AANP).
Joanna Guenther, PhD, FNP-BC, CNE, is an associate professor in the Family Nurse Practitioner program at TTUHSC. She has practiced as an FNP for 25 years and as an educator for 15 years. She has helped develop and promote telehealth visits at her clinical practice site.
Emily Merrill, PhD, APRN, FNP BC, CNE, FAANP, is a professor and associate dean for Graduate APRN programs at TTUHSC School of Nursing and holds the CH Foundation Endowed Professorship in APRN Studies. She has practiced as an FNP in primary care for 25 years and has supported the integration of telehealth education for APRNs across the curriculum.
References
1. U.S. Department of Health and Human Services. Notification of enforcement discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. Updated January 20, 2021. Accessed May 19, 2021. https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html
2. Staartjes VE, Beusekamp F, Schröder ML. Can objective functional impairment in lumbar degenerative disease be reliably assessed at home using the five-repetition sit-to-stand test? A prospective study. Eur Spine J. 2019;28(4):665-673. doi:10.1007/s00586-019-05897-3
3. Sprowls GR, Brown JC, Robin BN. The shoulder telehealth assessment tool in transition to distance orthopedics. Arthrosc Tech. 2020;9(11):e1673-e1681. doi:10.1016/j.eats.2020.07.008
4. Jayawardena ADL, Mankarious LA, Keamy DG Jr, Cohen MS. Pediatric, family-centered, “at-home” otologic physical examination in the COVID-19 era. Otolaryngol Head Neck Surg. 2020;163(5):1061-1063. doi:10.1177/0194599820934776
5. Bove R, Bevan C, Crabtree E, et al. Toward a low-cost, in-home, telemedicine-enabled assessment of disability in multiple sclerosis. Mult Scler. 2019;25(11):1526-1534. doi:10.1177/1352458518793527
6. Statista. Number of mHealth apps available in the Apple App Store from 1st quarter 2015 to 4th quarter 2020. May 11, 2021. Accessed May 19, 2021. https://www.statista.com/statistics/779910/health-apps-available-ios-worldwide/
7. U.S. Food and Drug Administration. Digital Health Center of Excellence. Updated March 24, 2021. Accessed May 19, 2021. https://www.fda.gov/medical-devices/digital-health/
8. U.S. Food and Drug Administration. Software as a Medical Device (SAMD): clinical evaluation guidance for industry and food and drug administration staff. December 8, 2017. Accessed May 19, 2021. https://www.fda.gov/media/100714/download
