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Telehealth Poses Documentation Challenges

By Tammy Combs, RN, MSN, CCS, CCDS, CDIP, CNE

According to a recent report from Parks Research, 64% of US broadband households reported using a telehealth service from April 2020 through April 2021. Thirty-four percent of those households reported they used telehealth services as the only option to see a provider during that time. According to a survey from Harris Poll, 35% of those surveyed would consider replacing their primary care provider if the telehealth options featured qualified physicians on demand. Bottom line? Telehealth is something that isn’t going away anytime soon.

With several studies pointing to higher patient satisfaction and lower provider costs, telehealth helps bridge the gaps in provider shortages in a cost-efficient manner. However, new methods of seeing patients brings new challenges in properly documenting telehealth visits and can compromise quality if not done correctly.

Consider the variables. The pandemic brought to light that no two households were alike. Some had access to internet, while others did not. Some patients continued seeking health care, while others put it on hold. Some people continued with their lives as if nothing new was happening, while others locked down only to emerge months later looking to make up for lost time—especially when it came to their health. These variables presented challenges and a variety of situations when it came to connecting with patients virtually.

So, while a key tenet in health care is consistency in services and documentation, telehealth is proving to be anything but consistent, which presents countless hurdles in accurate documentation. A provider can connect with a patient in one of three ways with each presenting several variables. For example, services might be provided through audio only, audio and visual, or electronic communication. Each of these also carries different benefits and challenges. If the connection is audio only, the provider misses the opportunity to have a visual of the patient and relies only on what the patient decides to share over the phone. If there is a visual component, it may help the patient feel a connection with the provider and be more open to sharing additional elements that may need a provider’s attention. Documenting, while done as well as it can be, has its limits, as the provider may miss something that having eyes on the patient would otherwise reveal.

Did the appointment take place in a clinic, a hospital, a skilled nursing facility, or the patient’s home? And how did the provider capture basic health measures, such as blood pressure, heart rate, and other vitals that are typically taken at every appointment? While some patients may be able to check their own vitals and provide height and weight, providers should consider that for many, these health indicators are missed entirely if the telehealth appointment was done with the patient at home. Since these indicators can’t be documented, it leaves a gap in patient history and trend documentation that, if not monitored, can lead to missed problems in the future.

Additional information exchanged in the telehealth visit should include the elements that would have been captured if the appointment had occurred face-to-face in a clinical or doctor’s office setting, especially if the appointment is part of a new patient/provider dynamic. These elements should include medical and family history and symptoms the patient is experiencing. Proper documentation of these factors is key to capturing a broader patient picture that helps in future appointments and determining an accurate course of treatment following the telehealth appointment.

Presenting a diagnosis during a telehealth visit can be challenging for the patient to hear and accept. Furthermore, once a diagnosis has been determined, there are additional hurdles in accurate documentation of the patient’s condition. Since a diagnosis needs to be documented to the highest level of specificity, it can be done only when fully supported by clinical evidence, acuity and severity, type, and complications, among other things. Information regarding the treatment plan, actual time regarding the length of the visit, and services provided during the visit should also be documented to provide a solid foundation for treatment moving forward.

According to a 2021 study by Cleveland Clinic, patient satisfaction from virtual visits with health care providers tends to be comparable to traditional visits conducted in-person. With 82% of patients reporting that their virtual visit was “as good as an in-person visit,” 91% indicated meeting with their provider virtually made it easy to get the care they felt they needed, while 93% found meeting virtually was easy to do. While all these statistics point to a positive telehealth experience for the patient, the entire experience has seemingly countless factors which can adversely affect future visits and have the potential to compromise the patient’s overall health if not documented correctly.

Proper documentation has always required a significant emphasis on provider accuracy. Telehealth adds a new layer of potential complications and learning curves when it comes to communicating with patients through new yet highly accessible provider and health care availability. It is critical that providers consider telehealth variables and accurately document every aspect of a telehealth appointment similarly to how they would if the appointment was in person.

— Tammy Combs, RN, MSN, CCS, CCDS, CDIP, CNE, is practice director for clinical documentation improvement and clinical foundations at AHIMA.