Shannon H Houser1, Cathy A Flite2, Susan L Foster3, Thomas J Hunt4, Angela Morey5, Miland N Palmer6, Jennifer Peterson7, Roberta Darnez Pope8, Linda Sorensen9. 1. Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, USA. 2. Department of Health Services Administration & Policy, Temple University, Philadelphia, PA, USA. 3. Privacy Compliance Educator, HIPAA Privacy Office, Washington University, School of Medicine, St. Louis, MO, USA. 4. Health Informatics Department, School of Health Professions, Rutgers University, New Brunswick, NJ, USA. 5. College of Health Sciences & Professions, Interdisciplinary Healthcare, University of North Georgia, Dahlonega, GA, USA. 6. Health Administrative Services, Weber State University, Ogden, UT, USA. 7. Department of Health Sciences, Health Informatics and Management Program, Illinois State University, Normal, IL, USA. 8. Health Information Management Program, Western Kentucky University, 1906 College Heights Blvd., Academic Complex, Bowling Green, KY, USA. 9. Health Information Management & Allied Health Departments, College of Health Professions, AHIMA Approved ICD-10-CM/PCS Trainer, Davenport University, Grand Rapids, MI, USA.
Abstract
BACKGROUND: During the COVID-19 pandemic, the use of telehealth for patient visits grew rapidly and served an important role as a valuable and necessary resource. Although clinical documentation is critical for telehealth patient visits, there is limited information about how healthcare facilities manage telehealth patient visit documentation, technology used for telehealth visits, and challenges encountered with telehealth patient visit documentation. This study aimed to assess the use of telehealth during the pandemic, the quality of clinical documentation in telehealth practice and to identify challenges and issues encountered with telehealth patient visits in order to develop a strategy for best practices for telehealth documentation and data management. METHODS: Data were collected for this cross-sectional study in January-February 2021 via a self-designed survey of administrators/managers from physicians' offices and mental health facilities. Survey questions included four categories: health organization demographic information; telehealth visits; clinical documentation for telehealth visit; and challenges and barriers related to telehealth documentation technology use. RESULTS: Of 76 respondents, more than half (62%) of the healthcare facilities started using telehealth for patient visits within one year of the onset of the COVID-19 pandemic, with 94% of respondents indicating an increased use of telehealth for patient visits since the pandemic. The most common types of telehealth patient care provided during the pandemic included pediatrics, primary care, cardiology, and women's health. The most consistent data documentation of telehealth visits included: date of service, patient identification number, communication methods, patient informed consent, diagnosis and impression, evaluation results, and recommendations. The telehealth visit data was most commonly used for patient care and clinical practice, billing and reimbursement, quality improvement and patient satisfaction, and administrative planning. The top barriers to telehealth use by the healthcare professionals included patient challenges with telehealth services, such as inequities in quality of technology, lack of patient understanding, and lack of patient satisfaction; this was followed by frustration with constant updates of telehealth guidelines and procedures, understanding required telehealth documentation for reimbursement purposes, payer denial for telehealth visits, and legal and risk issues. CONCLUSIONS: Findings from this study can assist government entities, policymakers, and healthcare organizations in developing and advocating best practices in telehealth usage and clinical documentation improvement strategies. 2022 mHealth. All rights reserved.
BACKGROUND: During the COVID-19 pandemic, the use of telehealth for patient visits grew rapidly and served an important role as a valuable and necessary resource. Although clinical documentation is critical for telehealth patient visits, there is limited information about how healthcare facilities manage telehealth patient visit documentation, technology used for telehealth visits, and challenges encountered with telehealth patient visit documentation. This study aimed to assess the use of telehealth during the pandemic, the quality of clinical documentation in telehealth practice and to identify challenges and issues encountered with telehealth patient visits in order to develop a strategy for best practices for telehealth documentation and data management. METHODS: Data were collected for this cross-sectional study in January-February 2021 via a self-designed survey of administrators/managers from physicians' offices and mental health facilities. Survey questions included four categories: health organization demographic information; telehealth visits; clinical documentation for telehealth visit; and challenges and barriers related to telehealth documentation technology use. RESULTS: Of 76 respondents, more than half (62%) of the healthcare facilities started using telehealth for patient visits within one year of the onset of the COVID-19 pandemic, with 94% of respondents indicating an increased use of telehealth for patient visits since the pandemic. The most common types of telehealth patient care provided during the pandemic included pediatrics, primary care, cardiology, and women's health. The most consistent data documentation of telehealth visits included: date of service, patient identification number, communication methods, patient informed consent, diagnosis and impression, evaluation results, and recommendations. The telehealth visit data was most commonly used for patient care and clinical practice, billing and reimbursement, quality improvement and patient satisfaction, and administrative planning. The top barriers to telehealth use by the healthcare professionals included patient challenges with telehealth services, such as inequities in quality of technology, lack of patient understanding, and lack of patient satisfaction; this was followed by frustration with constant updates of telehealth guidelines and procedures, understanding required telehealth documentation for reimbursement purposes, payer denial for telehealth visits, and legal and risk issues. CONCLUSIONS: Findings from this study can assist government entities, policymakers, and healthcare organizations in developing and advocating best practices in telehealth usage and clinical documentation improvement strategies. 2022 mHealth. All rights reserved.
Entities:
Keywords:
Telehealth; data documentation; health information and technology
Authors: Whitney R Smith; Anthony J Atala; Ryan P Terlecki; Erin E Kelly; Catherine A Matthews Journal: J Am Coll Surg Date: 2020-04-30 Impact factor: 6.113
Authors: Jedrek Wosik; Marat Fudim; Blake Cameron; Ziad F Gellad; Alex Cho; Donna Phinney; Simon Curtis; Matthew Roman; Eric G Poon; Jeffrey Ferranti; Jason N Katz; James Tcheng Journal: J Am Med Inform Assoc Date: 2020-06-01 Impact factor: 4.497