An Interprofessional Online Immersion Experience in Response to COVID-19

During the COVID-19 pandemic, telehealth became a critical player in assuring that Americans received high-quality immediate health care while continuing to maintain a social distance. Telehealth quickly became the new normal in health care delivery. Providers who were previously reluctant to use telehealth began incorporating telehealth visits into their practices, replacing the traditional model of in-person care. These changes were precipitated by the many telehealth waivers enacted on March 17, 2020, by the Centers for Medicare & Medicaid Services (CMS). These waivers removed many of the regulations CMS had previously placed on telehealth that restricted its use. The waivers were applied nationally and were made retroactive to March 1, 2020. Examples of the waivers included an expansion of allowable treatment locations reimbursed for telehealth, an expansion of telehealth modality reimbursement, a relaxation of interstate licensure guidelines, prescribing via telehealth, relaxation of Health Insurance Portability and Accountability Act (HIPAA) guidelines, and expansion of providers who could be reimbursed for telehealth services (CMS, 2020b). As a result, there was an immediate increase in telehealth use. Results of this movement toward telehealth suggested that care was now accessible to individuals with limited access to physical services, including some rural Americans, disabled, and elderly patients who were unable to travel. Telehealth decreased providers’ overhead costs while also affording them additional time. The need for valuable personal protective equipment (PPE) was also decreased as a result of virtual visits in lieu of in-person visits (Agency for Healthcare Research and Quality, 2020). After decades of imperceptible progress in telehealth, in-person care was replaced with virtual visits to promote social distancing and a decrease in limited PPE.

This rapid move toward telehealth was not without complications. As a result of the COVID-19 pandemic, providers often found themselves using telehealth without any training resulting in awkward and, at times, frustrating encounters. Most providers were confused with the new CMS waivers, lack of guidelines, and knowledge regarding available resources for assistance. Changes to the new policies and regulations happened daily, sometimes several times in a day. Many outpatient clinics and facilities found themselves unprepared for telehealth visits. Even the most experienced telehealth providers, telehealth coders, and telehealth program directors were left confused and questioning the new guidelines. Telehealth billing codes were updated; HIPAA restrictions were lifted; smartphone video chat and personal phone use was now acceptable for patient encounters; providers could practice across state lines; and telephone “visits” were reimbursable (CMS, 2020a). During this rapid transition in care, patients were unsure of what to expect or how to connect with their providers. There were early concerns by providers as to whether this new approach to health care could be effective and financially beneficial (American Medical Association, 2020).

Prior to the COVID-19 pandemic, the primary barrier to telehealth adoption was a lack of academic training (Mozer et al. 2015). Emerging literature had highlighted the importance of incorporating telehealth into health care curriculums (Jonas et al., 2019; Rutledge et al., 2017). Despite the interest in telehealth education, little research had been conducted on the learner outcomes as a result of structured telehealth training programs. Edirippulige and Armfield (2017) conducted a review of the literature related to education and training of current and future providers. Of the nine articles reviewed, five described short continuing education programs and four described formal university courses. The educational content included topics related to defining telehealth and related terminology, clinical applications, evidence for clinical practice, telehealth design and implementation, technology, legal issues, and national strategies. Modalities included in the described courses included theory, didactic, and hands-on practical skill development. Courses were designed for knowledge, some provided exposure either with simulated laboratory experiences and some in the clinical setting, and few evaluated students’ confidence in providing care via telehealth technologies. These programs were often provided in university courses and through both public and private professional organizations.

As the COVID-19 pandemic ravaged the world, strategies for attending to the educational and clinical needs of current and future health care professionals became paramount. Higher education institutions were challenged to pivot in-person courses and clinical experiences to online platforms in an unprecedented time frame. Experiential training such as in-person simulation and team-based training needed to be abandoned. Prior to the pandemic, telehealth was still considered a novel approach and not a standard of care by most providers and health professional faculty. The National Organization of Nurse Practitioner Faculty (2018) was one of the only organizations that had developed a white paper on preparing students for telehealth delivery. This gap in academic knowledge created both a problem and an opportunity for training programs that suddenly recognized the unique and valuable role that telehealth played in the pandemic.

By late March and early April 2020, most universities made the decision to halt all in-person education. Faculty were challenged to quickly transition traditional educational experiences into online platforms. Health care programs were struggling to identify strategies that would allow their students to participate in clinical encounters through telehealth to obtain needed clinical hours. Telehealth was suddenly the one approach to health care that had potential for addressing both students’ educational requirements and the patient’s clinical needs. However, even with the realization, educational programs were at a loss on how to adjust their curriculum to embrace telehealth.

This article provides an overview of a nurse-led educational program that was transitioned to a totally online program that educated an interprofessional team of students to use telehealth to address health care during the COVID-19 crisis and beyond. The specific aims of the program were to (a) offer the interprofessional experience through a totally online format, (b) prepare the students to embrace telehealth as a modality for providing care in situations such as the COVID-19 pandemic, and (c) to develop future telehealth users and/or champions.

New Model: The Four Ps of Telehealth

This rapid transition into telehealth shed light on many of the gaps in both telehealth education and telehealth delivery. It became evident that four steps were needed for a telehealth program to optimize its effectiveness and efficiency. These steps, coined by the primary author as the four Ps of telehealth, included planning, preparing, providing, and performance evaluation and are presented in Figure 1.

The four Ps of telehealth: planning, preparing, providing, and performance evaluation.

Figure 1.

The four Ps of telehealth: planning, preparing, providing, and performance evaluation.

The planning phase represents the process that must be undertaken prior to the development of a telehealth delivery program. It is the phase during which decisions are made regarding the details of the telehealth program to be provided. This includes (a) identifying the population/health care issues that will be addressed, (b) selecting the telehealth equipment that will be used, (c) researching legal and regulatory issues that may affect the delivery, (d) understanding reimbursement, and (e) identifying the providers.

The preparing phase pertains to setting up the telehealth program after the decisions regarding its implementation (planning phase) have been made. This consists of (a) protocol development (e.g., work flow, handling emergencies at distant sites, contacting patients, follow up); (b) consenting process; (c) purchasing, setting up, and testing equipment; (d) training in delivering telehealth (e.g., telehealth etiquette, videoconferencing physical assessments, use of peripherals); and (e) making sure everything is in order to deliver the telehealth session.

The providing phase is the actual delivery of the telehealth encounter.

The final phase is the performance evaluation phase. This phase includes evaluating the impact of the telehealth. It is critical that all telehealth programs measure patient outcomes, provider and patient satisfaction, and access and money saved. Two organizations have developed metrics for measuring telehealth outcomes nationally. The National Quality Forum (2017) developed a framework for measuring telehealth outcomes in 2017. As a response to the COVID-19 pandemic, the multicenter collaborative pediatric research network SPROUT developed the Telehealth Evaluation and Measurement (STEM) Framework (SPROUT, 2020). Data obtained on telehealth programs can be used for refinement and as a tool for lobbying within organizations, as well as statewide and national use of telehealth.

The four Ps of telehealth model was used as the framework for the educational program presented in this article. The section on performance evaluation was not included since actual telehealth was not offered. Programs in the future may want to incorporate a component on the telehealth metrics.

Method

For the past 7 years, the graduate nursing program at a state-funded university located in the southeastern United States has provided a 2-week interprofessional/telehealth educational immersion experience for students from 10 different professions and four different universities (Haney et al., 2018). Telehealth and interprofessional education were combined in the experience due to the belief by the faculty that due to the shortage of providers from other professions in these remote areas, many advanced practice nurses in rural and underserved areas need telehealth to interact interprofessionally. More than 2,200 interprofessional health care students have participated in the program since its inception. Health care professional students in this program have included medicine, advanced practice nursing (nurse practitioners and clinical nurse specialists), physical therapy, athletic training, speech and language pathologist, clinical counseling, pharmacy, dental hygiene, and social work. These learners completed online modules and then an interprofessional immersion experience on campus where they worked collaboratively with students from the varying professions. One of the most unique experiences offered during the on-campus day was the opportunity to have hands-on experiences with the telehealth equipment. The final week of the experience involved the development of a website by each interprofessional team.

As a result of COVID-19 and the closure of the university, the faculty converted the interprofessional program to a totally online curriculum, adapted the modules and hands-on experiences, and changed the assignments to address the COVID-19 pandemic. A pretest–posttest study design was used to determine the impact the program had on the learners. The evaluation of the program was approved by the university institutional review board. The primary focus was to prepare the students to address the COVID-19 pandemic and the future of health care by increasing their knowledge, exposure, and confidence to utilize telehealth to deliver care and work interprofessionally. Students completed pre- and postassessments that were embedded into the online learning site used for the program. The 53-item survey addressed demographic information, previous telehealth experience, knowledge of telehealth etiquette, and their confidence in preparing for and providing telehealth.

Telehealth Program

The telehealth immersion experience was provided in three phases through a totally online format that was provided using the online learning site. The three phases included (a) team orientation and learning modules, (b) video review, and (c) presentation of a group proposal for the implementation of a telehealth program.

Phase I

Phase I occurred over the first week of the program. Students, having been assigned to teams of five to six individuals from varying professions, participated in group discussions to become acquainted with each other and develop an understanding of each other’s role in health care. They were then expected to review three online modules that were geared toward telehealth and interprofessional collaboration: (a) introductions to telehealth, (b) interprofessional practice, collaboration, and communication, and (c) changes to health care/telehealth resulting from the COVID-19 epidemic. The modules included narrated presentations and selected readings. These self-paced modules were developed by interprofessional faculty members and each took 30 to 60 minutes to complete. The content from the modules was used by the student groups to develop the telehealth proposal that they were to present at the end of the 2-week program. The Introduction to Telehealth module provided the students with a general overview of telehealth including its definition, how it is used, and the various types of telehealth modalities (e.g., videoconferencing, store-and-forward, mHealth, and remote patient monitoring). The module on Interprofessional Practice and Collaboration stressed the Interprofessional Education Competencies (Interprofessional Education Collaborative, 2016) and the role of telehealth in interprofessional collaboration. Specific focus was on the unique skills needed to communicate and collaborate interprofessionally using telehealth modalities. The model on Changes to Healthcare/Telehealth Resulting from the COVID-19 Epidemic focused on Medicare and Medicaid telehealth waivers due to the COVID-19 pandemic. It was critical that students understood both pre–COVID-19 and post–COVID-19 telehealth regulations at the federal and state level.

Phase II

During phase II, the students were provided with videos to review. This was done in lieu of the on-campus hands-on telehealth experience. The first group of videos focused on different telehealth delivery models and the equipment used. For example, students were able to watch videos that demonstrated the use of a smartphone and smartphone peripherals to provide care (e.g., ophthalmic examination, ultrasound, 12-lead electrocardiogram, pulse oximetry); a drone to deliver supplies for cardiopulmonary resuscitation; a telemedicine cart with peripherals; videoconferencing capabilities and the transfer of images used for stroke care by connecting a rural emergency department with a neurologist; and remote patient monitoring used to manage a patient with chronic disease at home.

A second set of five videos were used to demonstrate poor, good, and excellent telehealth delivery based on telehealth etiquette. Guidelines were provided to help the learner understand the role that telehealth etiquette plays on the success of a telehealth program. Specific emphasis was on auditory and visual disruptions, HIPAA, and effective communication and body language via telehealth.

Phase III

In phase III, the interprofessional teams developed a presentation on their assigned telehealth device from those presented in the videos. Presentations addressed current events related to COVID-19; changes in health care delivery, policy, and reimbursement because of COVID-19; and how the assigned telehealth technology can be used or adapted to meet health care needs of certain populations or practice settings under circumstances of social distance or quarantine. They were instructed to develop the presentation in a manner that would convince those observing the presentation that the telehealth program they were delivering should be adopted and implemented in a clinical site. Group work during this second week of the rotation occurred through technology using cell phones, email, virtual meeting platforms, and online file sharing and synchronization as learners lived in different geographic regions across the state and nation. At the end of week two, the interprofessional groups delivered their presentation via a virtual meeting platform to two other interprofessional teams and interprofessional faculty members. This was the only synchronous component of the learning experience. The synchronous nature of the presentations allowed the interprofessional team members to learn from and with each other, faculty to provide feedback, and all participants to engage in discussion related to interprofessional collaboration, telehealth, and COVID-19.

Results

The sample of learners consisted of 67 students from seven different professions, including advanced practice nursing (nurse practitioner and clinical nurse specialists), athletic training, clinical counseling, dental hygiene, medicine, social work, and pharmacy. Table 1 provides an overview of the students’ demographic data. The largest group of students was the medical students due to the size of their fourth-year class. The students were divided into 12 interprofessional groups, with five to six students representing different professions in each group. To balance the representation of the medical students, they were assigned to groups based on the specialty tracks they had matched for their residencies. This allowed for each group to have a diverse group of medical students representing different specialties. Most of the students (71.2%) were in the 22- to 34-years age range, and more than half were female (58.5%). Two thirds were from suburban areas with only 9.3% being from the rural areas. A predominance of the students was considered White (60.4%).

Demographic Data of the Sample

Table 1:

Demographic Data of the Sample

Assessments

Three researcher-developed tools using 5-point Likert scales (1 = strongly disagree to 5 = strongly agree) were used to assess the impact of the program. These included the Confidence in Planning for Telehealth Scale, the Telehealth Etiquette Knowledge Scale, and the Confidence in Providing Telehealth Scale. The three scales were completed at the beginning of the program and again at the end. In addition to the scales, the students responded to open-ended questions regarding the impact of the program.

The Confidence in Planning for Telehealth Scale consisted of 13 items. Total scores ranged from 13 to 65, with higher scores indicating greater confidence in planning for a telehealth program. Example of questions included, “I am confident I can select appropriate technology to use in my practice setting,” “I am confident I can determine when Telehealth is applicable and when it is not,” and “I am confident I can appropriately follow the reimbursement guidelines for telehealth.” The scale was tested for internal consistency using Cronbach’s alpha and scored .93.

The Telehealth Etiquette Knowledge Scale was previously developed by the researchers and has been used in prior studies to assess students’ knowledge of telehealth etiquette. This 10-item scale had total scores ranging from 10 to 50, with higher scores indicating greater understanding of telehealth etiquette. Examples of questions include “My clothing choices (color and design) matter when conducting telehealth” and “It is important that a telehealth visit resemble a face-to-face visit (beginning, middle, and end of the appointment).” The alpha level for this scale has ranged from .82 to .86 (n = 407).

The Confidence in Providing Telehealth Scale consisted of 12 items. Total scores ranged from 12 to 60, with higher scores suggesting a greater level of confidence in providing telehealth. This include items such as “I am confident I can correctly perform a psychosocial assessment of a patient I meet in a videoconference,” “I am confident I can create a rapport with a patient I meet in a videoconference,” and “I am confident I can create a treatment plan in collaboration with a patient I treat via telehealth.” This scale was tested for internal consistency and found to have an alpha level of .91.

Data Analysis

Descriptive statistics were used to analyze data and explain student outcomes. The paired t test was used to detect and measure differences in the pre- and postprogram results related to the three study variables: planning for a telehealth program, preparing for telehealth delivery/telehealth etiquette, and providing telehealth. The independent t test was used to assess difference in the study variables based on student characteristics.

Significant improvements in scores occurred on all the scales following the administration of the online telehealth program (Table 2). This suggests that the program was instrumental in improving the students’ confidence in planning for a telehealth program and then providing the program. The score on the Telehealth Etiquette Knowledge scale increased significantly after the program suggesting that the students gained knowledge related to telehealth etiquette.

Pretest–Posttest (t Test) of Telehealth Etiquette, Telehealth Planning, and Telehealth Delivery

Table 2:

Pretest–Posttest (t Test) of Telehealth Etiquette, Telehealth Planning, and Telehealth Delivery

Differences were also assessed as they related to characteristics of the learners. The independent t test was used to assess differences based on gender and professional status (medical doctor [MD] versus non-MD; Table 3). There were no differences in any of the variables related to gender. However, it was found that the MD students had significantly lower preprogram scores on the Telehealth Etiquette Knowledge scale than the non-MD students (p = .019, t = 2.426). Following the program, the MD students improved in their telehealth etiquette knowledge and were aligned with the other providers. There were no significant differences from preprogram to postprogram between the MD and non-MD groups related to planning for or providing telehealth; however, all groups did improve as reflected by higher scores on the relevant scales.

Differences in Telehealth Etiquette, Planning, and Provision of Telehealth Based on Professions

Table 3:

Differences in Telehealth Etiquette, Planning, and Provision of Telehealth Based on Professions

Since the number of advanced practice nurses (APNs) in the group was small (n = 10), difference testing was not conducted for them separately. They were included in the non-MD group for the difference testing. The scores for the APNs are listed on Table 3 separately to demonstrate how they scored in each category on an average. The APNs improved in all categories following the program and were the highest of all groups in Telehealth Etiquette Knowledge following the program.

Qualitative Outcomes

Students were asked to respond to open-ended questions at the completion of the program. The comments were overwhelmingly positive and included statements such as:

  • I could not have experienced this class at a better time than during the COVID-19 crisis. It is with the class and crisis that I have seen and learned the amazing benefits associated with telehealth.
  • This experience has helped open my eyes to how telehealth could be a wonderful tool.
  • I think that telehealth will be an important role in my future practice. It will allow me to have flexibility to see clients when and where they need to be seen. I think that it is important to implement telehealth when possible after learning all the benefits that it holds.
  • This was a wonderful experience! I had a great time learning from my peers who are in different health care disciplines, particularly as I was able to gain multiple perspectives on telehealth experiences, views on current regulatory changes in the COVID pandemic, and discuss their views on efficacy and the long-term benefits of telehealth use. I think telehealth and the recent COVID public health crisis also opens up a variety of opportunities for interprofessional education in the future as well as for health care students and am excited to see where this goes! Thank you again for a great learning experience!
  • It was an eye-opening experience that allowed me to see the benefits of telehealth that I had skepticism about prior to this.
  • I really appreciated the way this course was so specifically tailored to the current COVID-19 situation. The faculty could have left it the way it was before this pandemic began. But instead they adapted it to current events that are not only affecting us but are also excellently applicable to the topic of telehealth. They recognized an invaluable learning opportunity and worked hard and quickly to make it happen.
  • I never really thought of telehealth prior to starting this program, but during my clinicals and with this experience, it seems more providers are utilizing this service. I enjoy technology and could see myself utilizing telehealth visits in my future practice.
  • I see telehealth impacting my future practice in that the use of telehealth is only going to continue and grow. I imagine that for some individuals, telehealth services are more convenient and beneficial, so for those individuals they may choose to continue telehealth services versus face-to-face visits following the conclusion of the current pandemic.

The open-ended comments reflected an appreciation for the telehealth rotation being provided at this crucial time, an acceptance of the role of telehealth in the future, and an increased understanding and awareness of the impact of telehealth. Many students expressed that they had not been receptive to telehealth in the past but now had their “eyes opened.” These examples of student feedback also demonstrate their appreciation for the rapid response of the faculty to tailoring the program to the current pandemic and the high value they place on relevant, engaging learning experiences that prepare them for current and future practice.

Conclusion

In previous iterations of this program, students were introduced to telehealth via a hybrid teaching format (both online and in person). Students were generally receptive to the idea of using telehealth; however, there was often skepticism as to its application as they moved forward into their respective practices. Transitioning the content to telehealth’s use during the COVID-19 pandemic resonated with students. It was an application to which all students could relate. In the past, some felt that telehealth would not apply to them. Now, by tying the program to the challenges of providing health care wrought by the pandemic crisis, students saw and experienced a real-time need and application for telehealth.

The results of this project suggest that telehealth education can be successfully implemented using an online format. The online program prevented students from gaining hands-on experience with the devices but did allow for videos to be shared on how each form of technology could be used in different settings and the proper etiquette that should be used. As a result, students actually had more time and opportunity to see the applications, allowing them to witness the full breadth of telehealth. Student groups worked collaboratively to develop their presentations: meeting to plan, dividing up responsibilities, and practicing presentations all in an online format. This collaborative model further demonstrated an effective learning experience that exposed students to different roles of professions and how they applied to telehealth.

In the health care teaching and learning environment, it is imperative for programs to stay current by looking for and seizing opportunities to strengthen the learning of students by making the content relevant to the current state of health care delivery. The program presented in this article accomplished that objective by framing the learning objectives to telehealth focused on the COVID-19 pandemic. It provided the opportunity for students to fully immerse themselves as individual learners and in a collaborative team environment. As a result, students embraced telehealth and voiced appreciation for the current focus. The realism of the program was relevant and underscored the importance of telehealth.

As telehealth has moved to the frontline of care, it has become evident that there are more factors to consider than just using the equipment. By using the telehealth model based on the four Ps of telehealth, the content provided during the educational program represented the reality of developing and implementing a telehealth program. Students not only learned about telehealth delivery, they also learned how rules, regulations, and reimbursement had previously served as limiting factors to telehealth delivery and, due to COVID-19 waivers, were now serving as facilitating factors. The results of this study suggest that the program was successful in improving the confidence that students experienced regarding the planning and provision of telehealth. Findings also supported the program as being instrumental in improving the knowledge the students had regarding telehealth etiquette, a component of the preparing phase. The model focusing on the four Ps of telehealth provided a blueprint that can be followed to ensure that future telehealth programs incorporate the components needed to develop and implement successful and comprehensive telehealth educational programs.

The experience was a powerful learning opportunity for faculty and students. Faculty learned how a program that was previously hybrid in delivery nature could be successfully implemented and offered completely online. In fact, it demonstrated that the program’s impact could be as effective or even more so than its previous iteration. As health care providers and educators, the importance of staying abreast of the changing health care environment is touted to optimize patient outcomes. This program served as a model for students, educators, and providers in truly staying abreast and embracing the changing health care environment.

References

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Demographic Data of the Sample

Variable n %
Age, years
  ⩽21 1 1.5
  22–34 47 71.2
  35–44 6 9.1
Gender
  Male 22 41.5
  Female 31 58.5
Racial or ethnic identity
  Hispanic 3 5.7
  Asian 10 18.9
  Black/African American 4 7.5
  White 32 60.4
  Two or more 6 7.5
Home of record
  Rural 5 9.3
  Urban 13 24.1
  Suburban 36 66.7
Profession
  Advanced practice nurses 10 14.7
  Mental health 10 14.7
  Athletic training 4 5.9
  Medicine 32 47.1
  Pharmacy 5 7.4
  Dental hygiene 1 1.5
  Social work 7 10.3

Pretest–Posttest (t Test) of Telehealth Etiquette, Telehealth Planning, and Telehealth Delivery

Variable Pretest Posttest p Value


M SD M SD
Planning 50.78 7.73 57.16 6.91 .000
Preparing/telehealth etiquette 44.05 4.06 46.30 3.53 .000
Providing 47.84 6.61 52.70 5.63 .000

Differences in Telehealth Etiquette, Planning, and Provision of Telehealth Based on Professions

Characteristic Telehealth Etiquette Planning/Preparing Providing



M SD p Value (t) M SD p Value (t) M SD p Value (t)
Profession, pretest .019 (2.426) .376 (0.894) .672 (0.426)
  Non-MD 45.40 3.25 51.79 6.16 48.25 5.97
  MD 42.81 4.38 49.88 8.92 47.44 7.29
  APN 44.81 3.49 54.83 8.13 49.50 7.77
Profession, posttest .184 (1.363) .746 (0.327) .991 (0.011)
  Non-MD 46.95 3.19 57.19 7.03 52.45 5.04
  MD 45.36 3.52 56.36 7.62 52.43 6.05
  APN 47.00 2.29 56.17 4.54 52.33 3.93

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