Table 2 Telemedicine work system challenges identified in nursing homes

Tools

1. Telemedicine platform used by consulting health system sends encounter invite to resident rather than NH staff

• NHs couldn't access resident's email or electronic patient portal to obtain visit links for telemedicine encounter

• Many consulting providers lacked access to NH EHR

2. Internet connectivity issues

3. Lack of EHR interoperability between NH & health system

Tasks

1. Difficulty scheduling telemedicine encounters

• NHs often lacked access to a centralized scheduling system/process

• Providers and/or their clinic staff had to make multiple attempts to contact resident’s nurse in order to schedule a telemedicine appointment

• Multiple NH staff had the ability to schedule resident appointments resulting in residents being double-booked (e.g., physical therapy session and telemedicine encounter)

2. Training staff on new technology

3. NH staff had to learn how to navigate different telemedicine platforms

4. High information exchange demand from provider

• Many providers, even those with NH EHR access, preferred to receive information verbally from the NH staff

• NH staff often required staff to provide the same information to the provider’s clinic staff prepping the encounter and again to the provider at the beginning of the encounter

People

1. Telemedicine encounters are less effective for residents with auditory, visual, and/or cognitive impairments

2. Telemedicine encounters were less effective when facilitated by a non- clinical staff member

• Limited availability of clinical staff prompted facilities to use non-clinical staff to facilitate telemedicine encounters

• Non-clinical staff unable to provide same level of information exchange as clinical staff and were unable to perform critical aspects of the physical exam

3. Telemedicine results in a loss of personal connection

4. Some residents prefer face-to-face visits

Organization

1.Telemedicine services increased NH staff workload

• Telemedicine created new tasks (e.g., prepping, facilitating) that were simply added on top of other resident care responsibilities

2. Access to appropriate types and/or amounts of equipment to conduct telemedicine encounters effectively

• Facilities often lacked access to the most effective equipment for conducting telemedicine encounters

• Facilities lacked the financial resources to purchase needed equipment

• Equipment used for other purposes was often repurposed for telemedicine encounters

3. Challenges with coordinating resident, staff, and provider schedules

• Telemedicine encounters benefited most from having a clinical staff member present, but these individuals often had competing responsibilities

• Provider clinics often requested encounter times that conflicted with critical facility meetings (e.g., morning standup) and resident care activities (e.g., physical therapy)

4. Limited IT support

• Nursing home staff were often hindered by a lack of support from internal or corporate information technology staff especially as it related to the limited access to the telemedicine software

5. Billing Issues

• NHs could only submit reimbursement for successfully implemented telemedicine visits that were conducted by video. Encounters where providers directly called the resident or who converted from a video to telephone modality precluded submission of an origination charge

• Perception that some providers used telemedicine as a billing opportunity

Internal Environment

1. Resident rooms were not ideal for conducting telemedicine encounters

• NH staff felt that the physical aspects of the resident’s room including the absence of furniture to support equipment positioning to allow the provider to see the patient along with poor lighting and the small screen size combined to impact the quality of the telemedicine encounter

External Environment

1. Each Healthcare system utilized a different platform

• Since each health care system utilized a different telehealth platform, the impact on NH staff was significant because they had to learn different scheduling systems, different telemedicine platforms, and to understand the preferred clinic telemedicine visit preparation requirements

2. Uncertain regulatory environment

• NHs were initially uncertain about HIPAA and privacy requirements surrounding telemedicine and whether their facilities were covered