Technical Best Practices for Professional Telehealth Patient Experiences during COVID-19 Pandemic

Dr. Lauren Doyle Strauss prepares for a telehealth visit using her iPhone

The Centers for Medicare & Medicaid Services (CMS) broadened access to Medicare telehealth services during the COVID-19 outbreak so beneficiaries can get a wider range of services from their doctors and other clinicians without traveling to a health care facility. On March 6, 2020, Medicare began temporarily paying clinicians to furnish beneficiary telehealth services residing across the entire country. At this critical point it is important to ensure patients follow CDC guidance including practicing social distancing to reduce the risk of COVID-19 transmission. This change will help prevent vulnerable patients from unnecessarily entering a health care facility when clinicians can meet their needs remotely.

Prior to the COVID-19 pandemic telehealth was limited to only certain services. “In this quickly changing environment many clinicians across the country have started telehealth visits for the first time with little training in how best to use this technology,” shares Dr. Lauren Doyle Strauss, assistant professor in pediatric neurology and headache specialist at Wake Forest School of Medicine. It is important for the patient and provider experiences to have the best video and audio quality possible. In an effort to better equip health care providers for an increase in telehealth visits during the COVID-19 pandemic, Dr. Vail Fucci, a professional photographer with a Ph.D. in Bioethics, has compiled the following list of suggestions for technical best practices for telehealth visits. It is broken down into best practices for providers and best practices for telehealth patients.

TELEHEALTH BEST PRACTICES FOR PROVIDERS

Signal Strength and Bandwidth: Pixelation, smearing, image pulsing, and loss of video can occur during telehealth sessions if you do not have a good internet connection. When possible pick a location for your telehealth session that is close to your WiFi router, you want the strongest signal possible. Turn off all unnecessary electronic devices that wirelessly connect to your network. This will make the most bandwidth accessible during your telehealth session. If you do not have WiFi at your location and are using a cellular network, go to a room that gives you the most bars for the strongest wireless signal. Standing near a window can help.

Lighting: Proper lighting makes a huge difference in how you look on the screen to the patient. Unless you are taking the call from a desktop computer you likely have a choice as to where you are going to be sitting or standing. Ideally you want to have a window in front of you or at your side, NOT behind you. Here’s why. If you have a bright light behind you and no bright light in front of you, viewers will see you just as a silhouette, with little to no detail in your face like in the image below on the left. This is because the camera on your computer or phone is automatically trying balance the two extremes in lighting. By just rotating so that the window was on the right instead of behind me resulted in vastly better lighting, see image on right.

If you can’t avoid an intensely bright light behind you, there are some solutions. You can place a large object in front of the window to block the light. This can be as simple as drawing the curtains or blinds closed. The easiest and most flattering solution is to place a light in front of you so that you are better illuminated. The ideal light source is natural light from a window. Look at the difference in how clear my face is in the image below on the right where the curtains were opened in front of me compared to the one with the curtains drawn shut.

If window light isn’t available try a ring light. Many even come with cell phone holders on their stands and are less than $50 on Amazon.

The next best thing is a lamp. Lamps provide side lighting which is much more flattering than overhead lighting. Lighting from below should be avoided as it tends to give a ghoulish or monsterous appearance to the subject.

Background Matters: Once you have your location nailed down look behind you and see what is there. Is it a mess? Is there anything distracting? Is there anything embarrassing? Look at the preview window of what your camera sees. Everything will be on display. Patients will understand that you are likely taking the call from home but what they see will have a huge impact on their experience. Think of what is in your office at work normally that visually helps your patients to have confidence in you: books related to the field, diplomas, and a clean and well organized examination room. You won’t have access to all these items at home but you can do some little things that will go a long way. Do a quick cleanup of the area to get rid of anything you wouldn’t want your patient seeing. Straighten up pillows. Cover clutter that may be too big to be moved out of the background with large blankets.

Remove personal photos from the walls. If you have any diplomas or certificates at home put them up on the walls behind you if possible. If you have a bookshelf at home full of books related to your field try sitting in front of it for your sessions. The environment you place yourself in will have a big impact on your patient.

Dress For Success: During this outbreak most of us are at home in our athleisure wear, but for your telehealth sessions you should be dressed and styled exactly (or as close as possible) as you would be in the office. Remember patients and their insurance companies are being billed as if this was an office visit. Anything you can do to make it feel more like a regular office visit and less like a chat on FaceTime or WhatsApp with your patients’ friends and loved ones is something you should try. If you normally see your patients while wearing a white coat, put it on for the telehealth session. If you don’t have your coat at your disposal a crisp white dress shirt could be worn instead to give a similar feel. If you typically wear business casual or scrubs, solid colors for shirts are best. Stay away from patterns, they are too distracting. Check your teeth to make sure there is nothing leftover from lunch. Style your hair the same way you normally would for office visits. When possible, do not wear a mask or N95 respirator during the telehealth session. With regards to makeup, mascara and lipstick will help give your face definition on the two dimensional screen.

Choose A Good Angle: We tend to feel at the mercy of the camera when it comes to what angle we are being viewed from, some make us look great while others make us look horrible. Luckily you actually have a great deal of control you can exercise when it comes to camera angle for telehealth sessions. The best is when the camera is about eye-level or slightly above eye level. It is the most flattering and mimics normal conversations we typically have in person. The absolute worst is when the camera is angled from below (see the image below on the left). It makes everyone look like they have a double chin. This is usually what happens when using a laptop or we have our phones on our desks or in our laps. To avoid this effect put some books underneath the laptop, tablet, or phone to raise it a bit.

The camera can also be too high. For large desktops the camera is often set very high up. This makes it seem like your viewers are looking down on you. In this situation it is best to raise your chair up if possible. If you can’t do that, sit on some pillows to raise you up higher.

Don’t Handhold The Camera: We are all used to holding our phones in our hands, so it is only natural to do exactly that during a telehealth session. The problem with that is it results in a shaky video. You are much better off placing your phone propped up on a steady surface. If you don’t have a device on the back of your phone or iPad to facilitate this, try a stand or just put a heavy object, like a can of soup, behind it that the device can safely rest against. This will make the viewing experience so much better for your patient.

Mirror The Orientation of the Patient’s Screen: If you are using a tablet like an iPad or a smart phone like an iPhone, the orientation you hold the phone in will impact how the patient sees you. For example if they are viewing you on a phone or have their iPad in portrait orientation and you have your phone in landscape orientation they will see you as a skinny bar in the middle of their screen flanked by black bars on the top and bottom, and you will see them as a long skinny bar in the middle flanked by black bars on the right and left. While most of us like to look thinner on screen, this is not the look you are going for. This just means you are smaller on a screen that is already probably small and hard to view. In general it is best to mirror your patient’s device orientation because this will make you as large as possible on the screen and will eliminate black bars they would see otherwise.

Appropriate Distance From The Camera: This is important for both how you look and how you sound on the video. Often times people move in very close to their device because they can’t hear what is being said well. As a consequence of this your face is then much closer to the camera which makes it look huge and distorted, which is totally unflattering.

As an added bonus you are now way too close to the microphone and so the patient on the other end is hearing you much too loud and your voice may be distorted as well. So you are much better off turning up the volume on your device before your telehealth session begins so you can properly hear them without getting nose close to it. If that isn’t possible try a set of headphones or earbuds.

Be far enough back that people can see you from your upper waist to just above your head. Don’t leave tons of room above your head so that viewers on a small phone screen aren’t left having a lovely view of your wall or ceiling and your head left only the size of a dime.

If you go too far back from the camera you will be tiny in the frame and the microphone on your device may not pick up your audio at all.

Audio: To get the best quality audio for your patients try to find a location that is quiet, not right next to an AC unit, fan, or heater, and away from any background noises that the microphone might pick up. A room with a door that can be locked is ideal so as to prevent mid-session intrusions by children and anyone else there with you. It may be helpful to make a sign for your door to let other family members know when sessions are going on so they will know not disturb you.

Place yourself about an arms-length away from the camera. This is likely the sweet spot for the built in microphone. If you are typing up your notes during the telehealth session try to move the keyboard away from the microphone as the sound of you tapping the keys may be very loud for your patient.

Keep Your Focus On Your Viewer(s): A telehealth visit is totally different from a telephone visit. Unless you shut off your video feed, or cover the webcam with something like a post-it, your patient on the other side can see and hear everything you are doing. So make sure you keep your attention on your viewer(s). They will notice if you are checking your email, or doing something else instead of looking at them. Be polite and give them the attention they deserve. It is ok to pause the video recording to do something as long as you tell the patient you are doing so.

Make sure everyone who is speaking during the session is within your view on the screen. If the camera is in a fixed location you can ask the patient and the other person to back up from the camera until you can see them both on the screen. This will allow you to pick up on non-verbal communication.

Color Concerns: The cameras in computers, webcams, tablets, and smartphones all try to reproduce accurate color representations of their subjects through auto white balance algorithms. Different types of light produce different color casts. Daylight produces true to life colors. Objects in shade have a blue cast. Objects in incandescent or “soft white” LED light have a warmer orange cast. Fluorescent lights give a green color cast. These different color casts can have ramifications for telehealth when assessing color specific diagnostics such as pallor, mole coloration, and rash appearances. In situations such as these have the patient turn off any forms of artificial light that they can (i.e. lamps and overhead lighting). The patient should then move as close to a window as possible if it is still during daylight hours. If this is not possible the patient can hold a piece of white paper next to themselves. This can help to achieve a more accurate auto white balance and can serve as a reference point for the clinician. If the white paper appears to have a color cast the clinician can assume that a similar color cast on the patient is due to the lighting on the patient and not due to an underlying condition (i.e. if the white paper looked yellow then a concern for jaundice based on the appearance of a yellow cast to the skin/sclera may be unfounded).

Specialty Specific Considerations: Different medical specialties have different technical requirements for telehealth sessions. Some sessions will require demonstrations of a large range of movement. In that case the patient will need a large amount of space that has been cleared off so that they can have the camera further away from them during these portions of the examination. Patients should be made aware of these requirements in advance. Other telehealth sessions will require close up views of the patient such as looking at pupil size, rash appearance, and mole characteristcs. The closer the camera is held to the patient the less light they get as the phone or tablet starts to block the light. Clinicians can request in advance that patients have a flashlight on hand to provide additional light if necessary.

A second set of hands can also be extremely helpful. If the patient has a family member or caretaker who can hold the phone or tablet they can switch the view from forward facing to rear facing so that they can use the rear facing camera (which produces a higher quality image, and may even have a zoom feature) instead of the front facing wide-angle “selfie” camera to capture the necessary views of the patient for the clinician.

Practice Beforehand: Before ever doing a formal telehealth session with a patient, practice with a colleague and a friend who is not a medical professional. Start with a colleague and do a mock exam with them. Have them note if there is anything they would suggest you change. After that do another mock exam with your friend that is not a medical professional. Work on guiding them into the proper location that allows for the best lighting of the patient. These practice sessions will make a huge difference in how well your first telehealth sessions go with real patients.

Be Patient With Your Patients: The COVID-19 pandemic has been very stressful. Having to see their health care provider over a screen instead of face-to-face in the office like they are used to may be very off-putting to patients. As a provider, do your level best to keep your bedside manner as calm as possible. Following directions over a telehealth screen can be very difficult for a patient. You may need to repeat instructions multiple times or ask a patient or caretaker to do something in many different ways before you actually get the patient into the position you need. Acknowledge any technical difficulty they might be having. You will likely have to act as both tech support and health care provider at first. With practice and your guidance, your patients will learn what they need to do to get you the information you require to treat them effectively.

TELEHEALTH BEST PRACTICES FOR PATIENTS

Prior to a telehealth session the patient or caretaker should be provided with some instructions for the session that will allow the provider to see and hear the patient better. These best practices are similar to those listed above for providers but they should be written out in simple terms. Sample language that could be used is provided below:

  • When possible pick a location for your telehealth session that is close to your WiFi router so that you get the strongest signal possible.
  • Turn off all other unnecessary electronic devices that wirelessly connect to your WiFi network so you get a strong signal.
  • If you don’t have WiFi at your location and are using a cellular network, go to a room that gives you the most bars for the strongest wireless signal. Standing near a window can help.
  • During the session avoid, when possible, having a window directly behind you. A bright light behind you will make it hard for the provider to see you clearly on the screen.
  • During the telehealth session try to sit in a spot with a window in front of you or at your side. If a window isn’t available, a lamp or overhead lights can also be used to give you better light.
  • Have a flashlight available in case the provider needs to look at part of you (skin, throat, eyes, etc.) in better detail up close.
  • If possible do not hold the phone or tablet with your hands. Handholding the device will make the video very shaky. If you do not have a stand for your device, lean the device against a heavy object (i.e. a can of soup) and angle the device so it has a good view of you.
  • Do not place the device in a location where it is likely to fall.
  • The provider may need you to have the device placed higher up for a portion of the exam. You may do this by placing the device safely on a stack of books.
  • Turn the volume on your device up before the telehealth session begins so that you can hear the provider well.
  • If anyone in addition to the patient is helping with the examination or speaking to the provider they should be within the view of the camera. To accomplish this the camera may need to be placed further than an arm’s length away from the patient and the other person who needs to be on screen.
  • If the provider has asked you to have on specific clothing for the telehealth session (i.e. short sleeves) please change into the clothes before the telehealth session begins.
  • During the examination the provider may ask you to use the camera on the back of your phone or tablet instead of the “selfie” camera on the front of the screen. The camera on the back can sometimes be used to zoom in on something. To access the camera on the back look for a button that looks similar to this.

Author Bio: Vail Fucci has a Ph.D. in Bioethics from Case Western Reserve University School of Medicine, a Masters in Bioethics from University of Pennsylvania School of Medicine, and a Bachelors of Applied Science in Bioengineering from University of Pennsylvania School of Engineering and Applied Sciences. Dr. Fucci worked in Washington, DC, in PhRMA’s scientific and regulatory affairs department as a liaison between the FDA and member companies from 2006-2010, with a focus on issues concerning generic biologic drug safety, small molecule drug development, vaccine schedules, and transmission of bovine spongiform encephalopathy through animal derived products. In 2010 she changed careers to follow her life-long passion for photography. Dr. Fucci now runs her own company, Vail Fucci Photography, and teaches photography.  She is the author of the book, How to Get Off the Green Auto Setting: A Practical Guide To DSLR Photography for Beginners.

This blog post was written specifically for telehealth sessions. For information on how to look and sound your best during video conference calls check out this blog post. These basic principles can be used with any video conferencing platform, such as Zoom, WhatsApp, FaceTime, Google Hangouts, and WebEx.

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How To Look and Sound Your Best on a Video Conference Call in 5 Minutes or Less

So in 5 minutes you are about to have your very first video conference call since COVID-19 hit the scene. You have been forced to communicate with others via a screen instead of in person due to required social distancing. How can you ensure this will go off without a hitch and that you will look professional like the image on the right and not the poorly lit mess on the left? Follow these tips that can easily be done in 5 minutes or less and you will look and sound great! (A post specific to Telehealth and the COVID-19 Pandemic is available here).

Signal Strength and Bandwidth: Pixelation, smearing, image pulsing, and loss of video can occur during video conferencing sessions if you do not have a good internet connection. When possible pick a location for your video conference that is close to your WiFi router, you want the strongest signal possible. Turn off all unnecessary electronic devices that wirelessly connect to your network. This will make the most bandwidth accessible during your session. If you do not have WiFi at your location and are using a cellular network, go to a room that gives you the most bars for the strongest wireless signal. Standing near a window can help.

Location, Location, Location: Unless you are taking the call from a desktop computer you likely have a choice as to where you are going to be sitting. Ideally you want to have a window in front of you, NOT behind you. Here’s why. If you have a bright light behind you and no bright light in front of you, viewers will see you just as a silhouette, with little to no detail in your face like in the image below on the left. This is because the camera on your computer or phone is automatically trying to give a balanced exposure. To a computer a balanced exposure is about middle gray when you put everything it sees on camera in grayscale. So if your background is super bright and you are very dark, to the computer that is a great exposure, the scene averages out to middle gray, but those viewing you on the other end can barely view you at all!

By just rotating so that the window was on my right instead of behind me I got vastly better lighting. If you can’t avoid a super bright light behind you, there are some solutions. You can place a large object in front of the window to block the light. This can be as simple as drawing the curtains or blinds closed. The easiest and most flattering solution is to place a light in front of you so that you are better illuminated. The ideal light source is natural light from a window, but if that isn’t available try a lamp. Lamps provide side lighting which is much more flattering than overhead lighting. Look at the difference in how clear my face is in the image below on the right where the curtains were opened in front of me compared to the one with the curtains are drawn shut.

Once you have your location nailed down look behind you and see what is there. Is it a mess? Is there anything distracting? Is there anything embarrassing? Look at the preview window of what your camera sees. Everything will be on display. Do a quick cleanup of the area to get rid of anything you wouldn’t want the people on the other end of the video call seeing.

Dress For Success: Most of the day you can get away with working from home in your jammies, but that just won’t cut it for a business call. Go ahead and take 30 seconds to change into a collared shirt and brush your hair. Solid colors for shirts are best. Stay away from patterns, they are too distracting. Check your teeth to make sure there is nothing leftover from lunch. Ladies, a little bit of makeup will go a long way. Mascara and lipstick will help give your face definition on the screen.

Choose A Good Angle: We tend to feel at the mercy of the camera when it comes to what angle we are being viewed from, some make us look great while others make us look horrible. Luckily you actually have a great deal of control you can exercise when it comes to camera angle for video conferencing. The best is when the camera is about eye-level or slightly above eye level. It is the most flattering and mimics normal conversations we typically have in person. The absolute worst is when the camera is angled from below (see the image below on the left). It makes everyone look like they have a double chin. This is usually what happens when using a laptop or we have our phones on our desks or in our laps. To avoid this effect put some books underneath the laptop or phone to raise it a bit. The camera can also be too high. For large desktops the camera is often set very high up. This makes it seem like your viewers are looking down on you. In this situation it is best to raise your chair up if possible. If you can’t do that, sit on some pillows to raise you up higher.

Don’t Handhold The Camera: We are all used to holding our phones in our hands, so it is only natural to do exactly that during a video call. The problem with that is it results in a shaky video. You are much better off placing your phone propped up on a steady surface. If you don’t have a device on the back of your phone or iPad like a pop socket or stand to facilitate this easily just put a heavy object, like a can of soup, behind it that it can rest against. This will make the viewing experience so much better!

Mirror The Orientation of the Viewer: If you are using a tablet like an iPad or a smart phone like an iPhone the orientation you hold the phone in will impact how the viewer on the other end sees you. For example if they are viewing you on a computer or have their iPad in landscape orientation and you have your phone in standard portrait orientation they will see you as a tall skinny bar in the middle of their screen flanked by black bars on the right and left, and you will see them as a long skinny bar in the middle flanked by black bars on the top and bottom. While most of us like to look skinny, this is not the skinny we are going for. This just means we are smaller on a screen that is already probably small and hard to view. In general it is best to mirror your viewer’s orientation because this will make you as large as possible on the screen and will eliminate black bars they would see otherwise.

Appropriate Distance From The Camera: This is important for both how you look and how you sound on the video. Often times people move in very close to their device because they can’t hear what is being said well. As a consequence of this your face is then much closer to the camera which makes it look huge and distorted, which is totally unflattering.

As an added bonus you are now way too close to the microphone and so the people on the other end are hearing you much too loud and your voice may be distorted as well. So you are much better off turning up the volume on your device so you can properly hear them without getting nose close to it. If that isn’t possible try a set of headphones or earbuds. Be far enough back that people can see you from your upper waist to just above your head. Don’t leave tons of room above your head so that viewers on a small screen aren’t left having a lovely view of your wall or ceiling and your head left only the size of a dime. If you go too far back from the camera you will be tiny in the frame and the microphone on your device may not pick up your audio at all. To get the best quality audio for your viewers try to find a location that is quiet, not right next to a fan, away from any background noises that the microphone might pick up.

Keep Your Focus On Your Viewer: Video conferencing is totally different from teleconferencing. Unless you shut off your video feed, or cover the webcam with something like a post-it, your viewer on the other side can see and hear everything you are doing. So make sure you keep your attention on your viewer. They will notice if you are checking your email, or doing something else instead of looking at them. Be polite and give them the attention they deserve.

That’s it! Now you are ready to be a video conferencing pro. These basic principles can be used with any video conferencing platform, such as Zoom, WhatsApp, FaceTime, Google Hangouts, and WebEx. Wishing you all the best!

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Ethically, what should we do now that Novel Coronavirus is here in the United States?

Most of my clients don’t realize that I have a Ph.D. in bioethics from Case Western Reserve University and an undergraduate degree in bioengineering from University of Pennsylvania. Prior to being a photographer I worked at PhRMA in Washington DC in the Scientific and Regulatory affairs department. I worked as a liaison between the pharmaceutical companies and the FDA on small molecule drugs, biologic drugs, and vaccines. Over 10 years ago I left the field for a vastly more enjoyable career in photography, but there are times when I feel I have an obligation to bring out my bioethics skillsets. Now is one of those times. People have been asking me what SHOULD we do, ethically, in light of COVID-19. You might ask, why is this an ethical decision? It is an ethical decision because the actions we take can have a very large impact on those who are at the greatest risk for dying from COVID-19, the elderly and those with pre-existing conditions. Additionally stopping the spread is critical to not overwhelming our healthcare system. So how can you play your part? Here are my suggestions.

  • If you are allowed to WORK FROM HOME, DO IT!
  • If you are able to keep your children at home, do it.
  • If you are older (50+) or have any health problems, STAY HOME! You are the population most at risk and the population that is most critical that should self-isolate. The more people who end up in the hospital the worse the situation becomes for everyone. If you are in this vulnerable population do not take care of younger children that are in contact with other people that are not staying at home. They can be carriers of the virus without showing any noticeable symptoms and still get you sick.
  • If you can’t stay home due to work restrictions, try to practice social distancing as much as possible and wash your hands many times a day. If anyone around you is coughing, do your best to stay away from them. 6 feet or more is recommended.
  • If public assistance is not made available to bring food and supplies to those who are more vulnerable to COVID-19, see what you can do about bringing food to them by leaving it on their doorstep for them.
  • Ideally schools and daycares would be kept open on a limited basis so that those who cannot stay home with their children, like health care workers and grocery workers, have a safe place to bring their children. If this is not possible hospitals or the government need to set up places for children to stay so that their parents can do their critical jobs. Schools that can provide classes online should do so.
  • Limit grocery store trips when you can. Go to the grocery store for larger trips, not just for a few things here or there every day. Grocery delivery is an option some places. The less we are in lines together the better.
  • If you are staying at home you can bring your children outside, like your own backyard, or large open areas, but avoid having them meet with other children and families. This defeats the purpose of self-isolation in homes.And of course, WASH YOUR HANDS! Practicing good hand hygiene is the most important thing you can do to help prevent the spread of this outside of social distancing. The virus can live for days on metal and plastic surfaces so things like door knobs and elevator buttons can be viral vectors and be sources of the virus. If washing your hands isn’t possible you can use hand sanitizer that is 60% or more alcohol as a stop gap until you can get to a sink and wash your hands.
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