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.įindings 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. 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 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 most common types of telehealth patient care provided during the pandemic included pediatrics, primary care, cardiology, and women's health. 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. 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. 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.ĭata 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. 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. 9 Health Information Management & Allied Health Departments, College of Health Professions, AHIMA Approved ICD-10-CM/PCS Trainer, Davenport University, Grand Rapids, MI, USA.ĭuring the COVID-19 pandemic, the use of telehealth for patient visits grew rapidly and served an important role as a valuable and necessary resource.

8 Health Information Management Program, Western Kentucky University, 1906 College Heights Blvd., Academic Complex, Bowling Green, KY, USA.7 Department of Health Sciences, Health Informatics and Management Program, Illinois State University, Normal, IL, USA.6 Health Administrative Services, Weber State University, Ogden, UT, USA.5 College of Health Sciences & Professions, Interdisciplinary Healthcare, University of North Georgia, Dahlonega, GA, USA.4 Health Informatics Department, School of Health Professions, Rutgers University, New Brunswick, NJ, USA.

3 Privacy Compliance Educator, HIPAA Privacy Office, Washington University, School of Medicine, St.2 Department of Health Services Administration & Policy, Temple University, Philadelphia, PA, USA.

1 Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, USA.

M.e.a.t. clinical documentation