PREPARING FOR TELECONSULTATION:

GUIDANCE FOR FILIPINO CLINICIANS AND THEIR PATIENTS

Teleconsultation refers to consultation done through telecommunications, with the purpose being
diagnosis or treatment of a patient with the sites being remote from patient or physician. (Deldar,
2016; Van Dyk, 2014). This document is third in the series of telemedicine guidance documents
prepared by the faculty, alumni and graduate students of the University of the Philippines Medical
Informatics Unit. It follows Teleconsultation: Guidance for Filipino Clinicians and Telemedicine:
Guidance for Filipino Physicians.

This guidance is for:

● Filipino patients who are unfamiliar with the teleconsultation process,

● Filipino physicians who desire to help their patients prepare for a teleconsultation; and
● Medical specialty organizations supporting their members in transitioning to telemedicine

Review of relevant literature was done to answer the following questions:

● How can physicians help patients prepare for the teleconsultation?

Choose which patients will benefit from a teleconsultation. Inform the patients of the
hardware, software, internet connection and room/environment requirements. Discuss if
the patient will be accompanied during the teleconsultation and if certain maneuvers for
physical examination need to be done. Orient the patient of the process flow before, during
and after the teleconsultation.

● How can physicians ensure that teleconsultations empower patients and support self-
management?
Healthcare organizations may create implementation groups to assist healthcare
professionals as part of a digital technology strategy. Teleconsultation with the following
may also help: two-way communication, analysis of patient-generated health data, tailored
education and individualized feedback. Individualized health coaching and telemonitoring
were shown to be of help in management and improvement of some chronic diseases.
Multiple touchpoints during implementation can maximize the impact of telehealth.

● How can patients be advised about the limits of teleconsultation?

Patient concerns on technology are usually rooted in lack of familiarity and uncertainty of
using technology correctly. These may be addressed by proper explanation and
demonstration. Discuss the issue of recording the teleconsultation with patients as doing
so without consent can harm the physician-patient relationship. Patients may feel that
teleconsultation is inferior as it lacks physical human interaction. Promoting a natural
environment may help improve patient perception on teleconsultation. Explaining the
intrinsic limitations of telemedicine may also properly set the expectations of the patient.

Document Version: 8 May 2020 | 1 of 18

AUTHORS:

Iris Thiele Isip Tan, MD, MSc Michael Fong, MD

Chief, UP Medical Informatics Unit MS Informatics Student
UP College of Medicine UP College of Medicine

Lisa Traboco, MD Millicent Tan-Ong, MD, MSc

MS Informatics Student MS Health Informatics Alumna
UP College of Medicine UP College of Medicine

Angelito Magno, MD Angelica Guzman MD

MS Informatics Student MS Health Informatics student,
UP College of Medicine UP College of Medicine

Justine Megan Yu, MD Jan Michael Herber RN

MS Health Informatics student MS Health Informatics student,
UP College of Medicine UP College of Medicine

Roy Dahildahil, RMT Neil Roy Rosales, RN

MS Informatics Student MS Health Informatics student
UP College of Medicine UP College of Medicine

For questions and comments, please contact Dr. Isip Tan at icisiptan@up.edu.ph or send to
bit.ly/miutelemedfeedback
Date released: 8 May 2020

Document Version: 8 May 2020 | 2 of 18

How can physicians help patients prepare for the teleconsultation?

Choose carefully which patients will benefit from a teleconsultation. Inform the patients of the
hardware, software, internet connection and room/environment requirements. Discuss if the
patient will be accompanied during the teleconsultation and if certain maneuvers for physical
examination need to be done. Orient the patient of the process flow before, during and after the
teleconsultation.

1. Which patients will benefit from telemedicine?

As previously discussed in Teleconsultation: Guidance for Filipino Clinicians, it is the physicians

who decide which patients can benefit from telemedicine, as long as the standard of care
delivered is reasonable within the limitations of that service as determined by the clinical context,
objectives, and availability of objectives (National Telemedicine Guidelines of Singapore, 2015;
Chaet, 2017). In a scoping review on the use of patient-facing teleconsultations in the UK National
Health Service (O’Cathail et al, 2020), most of the patients reported high levels of satisfaction with
this service, except in one small randomized controlled trial where satisfaction suffered due to
poor audio and image quality. Despite this however, O’Cathail et al cautioned that the data may
not be reflective of teleconsultation in real life which may be more inconvenient; and that most
patients still prefer the option of a face-to-face consultation as the gold standard. While
teleconsultations may be more convenient especially during this CoVID-19 pandemic, physicians
should be mindful about the tradeoffs from the patients’ viewpoint such as invasion of privacy at
home, limitations in the physical examination and possible awkwardness in the virtual interaction.

Luz (2019) has called for preserving humanism while using telemedicine to improve medical care.
He believes that telemedicine will not fully replace traditional care and that the first visit should be
in person. The anamnesis, and physical examination is indispensable for the diagnosis and
referral or a case. He also advocates for regular in-person re-evaluations. He then enumerates
the following circumstances where telemedicine may be useful:

● To reassess or monitor known patients. Such as when to adjust or check for medications
adherence, or answer simple questions
● To share information on additional tests, especially when these are normal. The patient
does not have to go back to the office just to know that everything is normal.
● To avoid unnecessary hospital visits, such as to get results of simple tests, in which case
medical advice can be given at a distance, saving time and discomfort in addition to
reducing costs.
● To advise on the choice of specialists for specific cases.
● To reduce hospitalization time - such as when monitoring patients after discharge.
● To facilitate or redirect overwhelmed public healthcare in cases where there is a long
waiting for a consultation.
● To help patients in remote regions where there are no access to healthcare resources;
such patients can receive general guidance as in cases of diarrhea, fractures, childbirth,
trauma and other ordinary situations.

Miller and Derse (2002) also add that new patient-physician relationships online pose more
significant risks that must be evaluated in relation to communication, quality, and outcomes. Given
the role that nonverbal communication appears to play in conveying empathy, some situations

Document Version: 8 May 2020 | 3 of 18

may seem ill suited to online medical practice. However, this in-person requirement for new visits
has been waived during national health emergencies such as the COVID-19 pandemic. (Centers
for Medicare & Medicaid Services, 2020; American Academy of Neurology, 2020). In these
situations, Chaet (2017) supports that it may not be feasible to receive care in person. When the
limited options for a patient are to receive care that may be less than ideal via telemedicine or not
to receive care at all, telemedicine services can be deemed appropriate even though the
physician, patient, or their surrogate, would prefer that marginally superior care be provided in
person. With a temporary waiving of in-person consult for new visits in favor of allowing new
patient teleconsults, more flexibility in healthcare response to the pandemic can be achieved.

2. What are the hardware, software and internet connection requirements for patients?

When the patient is at home, office, or school, the patient would be needing their own mobile
devices (with or without camera), landline and/or laptops. If the mode of consultation is video, a
landline or cellular phone should still be available in case of disconnection. Patients should be
advised to make sure their devices have adequate charge or can be easily plugged to a power
source. (Greenhalgh, 2020; Cleveland Clinic Digital Telehealth Playbook, 2020) Speakers or
microphones may need to be placed closer to elderly patients for easy adjustment. (Krupinski,
2014)

The patient should also confirm through their physician or hospital of choice on what
software/platform will be used. Different platforms may have different set up steps. (Greenhalgh,
2020) Thus, physicians should develop (or source from the platform vendor) a wide variety of
patients educational materials to set up. Different patients will have different learning styles. (AMA
Telehealth Playbook, 2020)

In order to attain clear audio and video for the teleconsultation, it is recommended that a minimum
bandwidth speed of at least 2Mbps be used. This would allow for a resolution of HD720p and a
frame rate of 30fps. In a setting where internet connection will be shared concurrently by many
users, page 13 of Telemedicine for Health Professionals provides a table of recommended
minimum bandwidths per number of users utilizing the same internet source.

For both Greenhalgh (2020) and Akerman (2020), it could also be helpful to do a demo visit 24
hours prior to the actual teleconsultation. Patients may be also advised to restart their devices
before the scheduled visit. This will ensure that the visit can go smoothly. Background processes
that could be running or utilizing cameras or microphones can slow devices. Institutions who
provide patient portals should consider creating an IT care team for sessions with patients who
need IT assistance. (AMA Telehealth Playbook, 2020)

3. What are the room or environment requirements for patients?

Krupinski (2014) considers that most patient sites will be outside of the clinical environment
(home, school, office). Thus, it may not always be possible to change wall colors or buy new
lighting so easily. But it is possible to advise patients to optimize their environment by selecting a
private room that avoids competing sounds from family members, TV or radio. Background clutter
should also be minimized. Carpeting can decrease echo. (Major, 2005) The table must not be
wobbly or shaking. (Krupinski, 2014; Rheuban, 2018)

Document Version: 8 May 2020 | 4 of 18

When acquiring digital photos, the light sources should be as close as possible to while light, and
fluorescent day-light or full spectrum bulbs should be used instead of incandescent. For example,
part of the consultation may include instructing the patient to read the labels on the medication or
describe the color of the pills. It is thus imperative that they can see clearly to understand it.
(Krupinski, 2014) Older patients take longer to adjust to changes in eye levels (ATA, 2017).

4. Who can accompany the patient during teleconsultation?

Aside from meeting with a lone patient, the teleconsultation may instead proceed with a patient
companion or caregiver. The Medical Council of India, 2020, defines “patient companion” or
“caregiver” as either a family member or an individual authorized by the patient to represent him
or herself. Caregivers may be involved in two settings: 1) the patient is present with the caregiver
or 2) the caregiver is consulting on behalf of the patient. In the former setting, family members or
caregivers may be asked to learn how to use monitoring devices at home, which can influence
the healthcare provider’s decision making (Chaet, 2017). In the latter setting, the caregiver may
represent the patient if the patient is a minor or if the patient is incapacitated either mentally (ie
the patient is suffering from a mental disorder) or physically. Alternatively, the caregiver may also
consult on behalf of the patient if there was prior formal authorization or verified document
establishing relationship with the patient and/or the patient has provided explicit consent by
verifying the caregiver in a previous in-person consult. (Medical Council of India, 2020).

In Telemedicine facilities in the institution or communities, a patient may be accompanied by a

trained telepresenter which may be a physician or another healthcare professional. (American
Telemedicine Association, Glossary, AAN Telemedicine Implementation Guide, 2020) This can
be a form of telecollaboration (National Telemedicine Guidelines of Singapore, 2015) and will be
addressed in another document.

5. Are there maneuvers that the patient has to do since the doctor cannot physically
examine the patient?

Patients must be informed that there are limitations to a physical examination done during
teleconsultation such as palpation and auscultation (Weinstein et al., 2018). Assessment devices
such as blood pressure cuffs or digital stethoscopes would not always be available. To further
help in The Virtual Physical Examination found in page 5 of the Teleconsultation: Guidance for
Filipino Clinicians, certain maneuvers can be done and additional instructions can be given by the
physician to come up with a comprehensive examination using telemedicine. As Sir William Osler
has once reminded us; let us not forget our most keen diagnostic tool: a thorough patient history
(Showalter, 2020).

As stated previously, adequate lighting should be ensured at the start of the examination (ATA,
2017). A patient’s companion or family member can also be asked to help. Depending on the
chief complaint and medical history of the patient, the physician will assess and will then focus
further on examining the organ system/s involved.

Document Version: 8 May 2020 | 5 of 18

Table 1. Patient Maneuvers
Organ System Additional examination/s on the patient or special
maneuver/s

Constitutional Use of electronic communications that collect and send

information to foster remote patient monitoring e.g. vital signs
or blood glucose levels1

Eyes Eye chart tools to evaluate visual acuity2

Use of flashlight to evaluate reactivity3

Ears, Nose, Mouth, Throat Inspection of the external appearance of the ears, nose, (for
scars, lesions), color of the lips, mouth, mucosa, symmetry of
tracheal position. The patient can also be instructed to palpate
sinuses or ears, and do range of movement of the neck (flexion
anterior, posterior and lateral)7
Oral Cancer Self-Exam4

Respiratory Assessment of respiratory effort, such as use of intercostal

muscles, pursed lip breathing, sentence completion. Audible
wheezing can also be present. 7
COPD Assessment Test questionnaires1

Cardiovascular The presence of edema can be observed. Capillary refill may

also be instructed to able patients.7
Wearable technology can measure heart-rate variability (HRV)
and daily weight monitoring for heart failure patients1

Gastrointestinal Recruit family members/companion to do abdominal

examination, assess for tenderness and localize the pain3

Genitourinary Testicular self-examination5

Skin Camera angle perpendicular to skin lesions, use autofocus and

several views, show entire anatomic unit if a lesion is present,
use tape or press back to show skin changes in hairy areas,
and measurement tools as appropriate6

Musculoskeletal Redness, warmth, swelling can be observed or documented by

the patient. Household items with known weight can be made
available within reach to use for strength evaluation. The
physician can ask the patient to move their joints 3 by making

Document Version: 8 May 2020 | 6 of 18

 them copy range of motion movements. Walking gait, standing
station & posture can also be assessed.7

Neurological Standardized examinations can be administered

Range of motion1

Psychological Physical exam are generally limited1

Hematologic, Lymphatic, Mobility and firmness of lumps and bumps 1

Immunologic

Adapted from the following:

1. Ansary, A. M., Martinez, J. N., & Scott, J. D. (2019). The virtual physical exam in the 21st century. Journal of Telemedicine and
Telecare. https://doi.org/10.1177/1357633X19878330
2. Yeung, W. K., Dawes, P., et al. (2019). eHealth tools for the self-testing of visual acuity: a scoping review. Npj Digital Medicine,
2(1). https://doi.org/10.1038/s41746-019-0154-5
3. Joshi A & Hollander J. Why the Telemedicine Physical is Better Than You Think. Telemedicine Magazine. March 9, 2017
4. American Association of Oral and Maxillofacial Surgeons. Oral Cancer Self-Exam.
https://www.aaoms.org/docs/media/oral_cancer/oral_cancer_self_exam.pdf
5. Rovito, M. J., Manjelievskaia, J., Leone, J. E., Lutz, M., Cavayero, C. T., & Perlman, D. (2018). Recommendations for
Treating Males: An Ethical Rationale for the Inclusion of Testicular Self-Examination (TSE) in a Standard of Care. American
Journal of Men’s Health, 12(3), 539–545. https://doi.org/10.1177/1557988315620468
6. McKoy, K., Norton, S., & Lappan, C. (2012). Quick guide to store-forward teledermatology for referring providers. American
Telemedicine Association, (April), 3. Retrieved from https://accessderm.aad.org/img/ATA_Telederm_Guidelines.pdf
7. Showalter, G. (2020, March 30). Telehealth Physical Exam. Loengard, A., Findley, J. (Eds.). https://caravanhealth.com/

6. What is the process flow for patients in a teleconsultation?

It is imperative that the patient is oriented on what needs to be done before, during and after a
teleconsultation. A checklist is provided in Appendix A.

A. Before the Teleconsultation

1. Schedule a teleconsultation with his/her physician.

Book a teleconsultation with a physician at a particular time and date convenient to both
patient and physician. The patient should have no other activities during the
teleconsultation. In scheduling a teleconsultation, the patient must inform the physician
regarding his/her limitations (poor internet connection, no available hardware and
software), so the physician may look for alternative solutions for his/her concerns (look for
nearby hospital/clinic with telemedicine facility). Payment method should also be
determined when the teleconsultation is scheduled.

2. Read and sign informed consent

The patient must read carefully the informed consent (page 16 of Teleconsultation:
Guidance for Filipino Clinicians) that will be sent to him/her prior to the teleconsultation.
He/she must also know that teleconsultation has several limitations being a remote
consultation. He/she must sign the informed consent and send it to his/her physician.

Document Version: 8 May 2020 | 7 of 18

 3. Prepare for the teleconsultation

Like any usual consultation, the physician will ask for the patient’s history and preparation
on the part of the patient is important for a successful history taking. The patient must be
able to identify the chief complaint requiring such teleconsultation and the signs and
symptoms that may be related to it. These information may be written down in a paper
before the actual teleconsultation. The patient may also do some research on his or her
signs and symptoms for possible differential diagnosis that may be discussed during the
teleconsultation. In this way, he or she can formulate questions in advance that can be
asked and clarified during the teleconsultation. In addition, by doing advance reading on
the patient’s chief complaint, he/she can also do an advanced physical examination that
might be relevant to his/her condition. If there are important documents like laboratory and
imaging results, these can be sent to the physician ahead of time. Prepare the technical
set up and room for teleconsultation. It should be done in a private environment to avoid
sensitive patient information being heard or seen by other people. It should also be done
in a well-lit location, which is important during physical examination. Check if internet
connection, audio and video are all good and working. Also, the patient should still wear
appropriate attire as if he/she is going to a normal consultation.

B. During Teleconsultation

4. Come on time

Patients should come to the teleconsultation before the scheduled time because it may
take time to set-up and to connect.

5. Full cooperation and Active participation during history taking and physical
examination

Patient must identify him/herself to the physician at the start of teleconsultation. History
taking and remote physical examination is usually facilitated by the physician but it
requires full cooperation of the patient to prevent delay and prolonged teleconsultation
sessions. As mentioned above, an intelligent patient prepares for the history taking and
physical examination. Patient must be truthful and direct in giving information. It is
important to follow every instruction during physical examination.

6. Make notes and ask questions

Patient must take notes on the information shared during teleconsultation, so as not to
forget important details. Ask questions or clarifications if something is not clear. At the end
of teleconsultation, ask the physician for a recap of diagnosis, and management plan and
what to do next.

C. After consultation

7. Give feedbacks and evaluation

Feedbacks can be given during or after the teleconsultation sessions. It is important that
the patient has an open communication with the physician and should not be afraid to give
feedback. Also, the patient must also evaluate the process and system of teleconsultation
used, whether it is appropriate for him/her or not.

Document Version: 8 May 2020 | 8 of 18

 Figure 1. Teleconsultation Process Flow from the Patient’s Perspective

Adapted from:
1. John Sharp.A Patient’s Guide to Telemedicine: What to Do When Your Doctor Calls or Video-Chats with You. March
25,2020. https://www.himss.org/news/patients-guide-telemedicine.
2. Telehealth Support: Provider to Patient Visits. American Academy of Pediatrics. https://www.aap.org/en-
us/professional-resources/practicetransformation/telehealth/Pages/Provider-to-Patient-Visits.aspx.

D. Patient Feedback

Patients (and caregivers) should be encouraged to provide feedback. So that future telemedicine
encounters can be refined and improved. (National Telemedicine Guidelines of Singapore, 2015)

As previously mentioned in the second chapter of the Telemedicine Guidance Document -

Teleconsultation for Filipino Clinicians, eliciting patient feedback may help assess patient
satisfaction and help evaluate the service in order to achieve the best possible outcome. The
importance of maintaining key quality indicators for patient satisfaction should be upheld
regardless on how care is delivered (Kruse et al., 2017).

A sample patient evaluation feedback can be seen at the Appendix D (page 21) of
Teleconsultation: Guidance for Filipino Clinicians. However, a more comprehensive framework,
which is the Telemedicine Service Encounter Quality Model - Patient Perspective, has been
developed based on direct observation, focus groups and survey as well as multi-perspective
interpretation. Aside from the model, the study has elicited specific attributes which appears to be

Document Version: 8 May 2020 | 9 of 18

critical in a telemedicine encounter by the patients (LeRouge, 2014). These critical attributes are
defined by having a mean score of at least 3.5. The model as well as the highest 10 scoring mean
attributes are synthesized into one image below.

Figure 2. Telemedicine Service Encounter Quality Model - Patient Perspective

How can physicians ensure that teleconsultations empower patients and support self-
management?

Healthcare organizations may create implementation groups to assist healthcare professionals

as part of a digital technology strategy. Telemedicine consultation with the following components
may also help: two-way communication, analysis of patient-generated health data, tailored
education and individualized feedback. Individualized health coaching and telemonitoring were
shown to be of help in management and improvement of some chronic diseases. Multiple
touchpoints during implementation can maximize the impact of telehealth.

Amidst the CoVID-19 pandemic, teleconsultation is one way to continue access to care. Now
more than ever, physicians need to support patients in the self-management of their conditions.
Teleconsultations will likely be part of the new normal In the post-pandemic scenario. The AMA
Telehealth Playbook (2020) emphasized that a teleconsultation visit can only truly be successful
when patients are empowered to use them.

O’Cathail (2020) suggests that healthcare organizations should begin to consider a digital
technology strategy and create implementation groups to assist healthcare professionals in
integrating technologically associated care into their routine practice. As with any introduction of
new technology, they should be reassessed regularly with feedback from key stakeholders. The
AMA Telehealth Playbook (2020) echoes this sentiment, by recommending that the value of

Document Version: 8 May 2020 | 10 of 18

teleconsultation should be repeated at multiple points in time to drive patient awareness and
continued interest.

Some telemedicine studies have shown a positive impact on a patient's health behaviors. In a
systematic review of reviews evaluating technology-enabled diabetes self-management
education and support, intervention with following components were most effective: two-way
communication, analysis of patient-generated health data, tailored education and individualized
feedback. These components should be present in a teleconsultation (Greenwood, 2017).

In the systematic review and meta-analysis by So and Chung, (2018) they found that telemedicine
consultations promoted diabetes self-management by patients as manifested by lower glycated
hemoglobin and lower 2-hour postprandial blood glucose. Patients were satisfied in that they
saved time and saved money for travel. In Kelley et al. telemonitoring of chronic kidney disease
patients with tailored text messages of diet-coaching were encouraging patients to self-manage
their diet. (Kelly et al., 2019) A 12-week weight management intervention via telehealth
significantly reduced weight of cardiac patients compared to a control group as measured by BMI
and weight change. (Shumer & Nokoff, 2017) A study on rheumatoid arthritis patients who utilized
a telemonitoring web patient portal with questionnaires achieved faster disease remission and
higher disease remission rate. It is important to note that in this study, patients were previously
trained with the use of the website. (Salaffi et al., 2016) In the meta-analysis of Inglis and
colleagues, they found a reduction in mortality among heart failure patients who underwent
telemonitoring. (Inglis et. al., 2015) Telephone-based, individualized health coaching was also
seen to be cost-effective to conventional management of chronic diseases. The incremental cost-
effectiveness ratio (ICER 20,000 euros per QALY) was greatest in type 2 diabetes patients,
modest in cardiac patients (ICER 40,278 euros per QALY) and negative in heart failure patients.
(Oksman et. al., 2017)

However, there are still inconsistencies in the available studies. Brief telephone intervention was
noted to be not significant in reducing the depression of symptomatic lung cancer patients and
their caregivers. (Lakhani, 2019) A year-long telemonitoring through coaching of self-monitoring
of weight, blood glucose, blood pressure and daily steps compared to conventional management
failed to show improvement in quality of life in cardiac and diabetic patients. (Karhula et al., 2015)

Strategically engaging the patient in multiple touchpoints during implementation can maximize the
impact of telehealth. Patients must have a clear expectation for the appointment to ensure
repeated use and long term success. What to expect, general reminders, tips, FAQs should be
incorporated into practice marketing, communications, or featuring education materials in patient
portals, newsletters, email and SMS are some suggestions from the AMA Telehealth Playbook
(2020).

How can physicians address patients’ expectations of the teleconsultation?

Patient concerns on technology are usually rooted in lack of familiarity and uncertainty of using
technology correctly. These may be addressed by proper explanation and demonstration.
Discuss the issue of recording the teleconsultation with patients as doing so without consent
can harm the physician-patient relationship. Patients may feel that teleconsultation is inferior as
it lacks physical human interaction. Promoting a natural environment may help improve patient

Document Version: 8 May 2020 | 11 of 18

perception on teleconsultation. Explaining the intrinsic limitations of telemedicine may also
properly set the expectations of the patient.

1. Concerns about technology

A study by Lee, et al (2018) explored perspectives of patients on the use of telehealth in the
management of type 2 diabetes. Majority of the interviewed participants were receptive of
telehealth as they see technology as part of the modern world. Some of them, however, expressed
some concerns related to their lack of familiarity with the technology and uncertainty in using the
equipment correctly. It is important to note that these concerns were immediately resolved after
explanation and demonstration were provided. There is no doubt that the equipment and devices
may be daunting. It is essential, that participants must not be scared off, and that skills required
can be taught. (Hjelm, 2005) As mentioned in the previous questions, an IT care team can prove
to be helpful for some (AMA Telehealth Playbook, 2020)

Recent advances in technology have allowed the ease of recording devices.(Rodriguez, 2015)
However, when an encounter is recorded without consent, the integrity of the trust relationship
between patient and physician is harmed. (Rodriguez, 2015; Elwyn, 2017) Section 13 of the Data
Privacy Act reminds us that in Sensitive Personal Information and Privileged information, “all
parties to the exchange have given their consent prior to processing”. While the HB 8378 amends
the RA 4200 (Anti Wiretapping Law) that it would be “unlawful for any person, not being
authorized by all party to any oral, wire, radio, digital or electronic private communication to tap
(any wire or cable, or by using any other device or arrangement, to secretly overhear) intercept,
or record such communication (or spoken word by using a device commonly known as a
dictaphone or dictagraph or walkie-talkie or tape recorder or however otherwise described) with
the use of any electronic, mechanical, digital or analog phone system or similar devices”. While
technology may dramatically change healthcare delivery, a strong physician to patient relationship
must be maintained independently. (Kruse, 2017)

2. Concerns that teleconsultation is somehow inferior

Some patients may feel that they are receiving a substandard level of care due to the impersonal
nature of telehealth as it lacks physical human interaction (O’Connor, et al, 2016). This sense of
depersonalization was also mentioned by Hjelm (2005), as our perceptions on what is seen by
the monitors are influenced by watching TV. With this, we refer the readers to pages 14 of
Telemedicine for Health Professionals Guidance & page 9 of Teleconsultation Guidance for
Filipino Clinicians, on the suggestions on how to project a natural environment and how to
achieve a high quality teleconsultation. (Krupinski, 2014; Gonzales, 2017, Cleveland Clinic Digital
Health Playbook, 2020).

Moreover, because teleconsultation relies heavily on visual observation, this limits physicians
from performing their assessment completely. Patients with movement disorders, for example,
are difficult to assess especially in terms of postural instability and rigidity. Neurological
examinations were particularly difficult to perform. (Hanson, et al, 2019). These limitations also
need to be communicated to patients prior to even considering a teleconsultation. Some
institutions or communities may consider creating a Telemedicine Facility where there can be a
proxy examiner or a Telepresenter. This will be further discussed in another document.

Document Version: 8 May 2020 | 12 of 18

Appendix – Checklist for Telemedicine Patients

PATIENT PREPARATION SHEET

• Healthcare providers can customize the information to reflect the services offered, and make this sheet available at checkout and/or in
your patient portal

Who are the patients this service is for?

• Eligibility criteria or list of telemedicine appropriate situations depending on the physician / hospital

What is the Telemedicine service being offered?

• The patient can discuss with the physician regarding his/her limitations (poor internet connection, no available hardware and software),
so the physician may look for alternative solutions for his/her concerns (look for nearby hospital/clinic with telemedicine facility).

Before During After

Action • Schedule a teleconsultation with your • You may be reminded again about privacy • You may be asked to
physician at an agreed time and date. There and confidentiality laws, including fill out a patient
should be no other activities during the cybersecurity as is written in the consent feedback form to help
teleconsultation. form. your doctor improve
• Remote physical examination will need the telehealth service.
your full cooperation. If you have a
companion, they can assist you and your
healthcare provider

Environment • Identify a private and quiet place to set up with • Close unnecessary programs and
& Equipment adequate lighting. Inform your family or notifications on your devices as these
roommates about the scheduled might take up bandwidth and affect quality
teleconsultation (Health Insurance, 2020; of the call or disrupt the session
Gordon, 2020) (University of South California, 2020)
• Depending on the mode of teleconsultation • In case of disconnection during video
agreed upon, you will need a desktop or consultations, your physician may call or
laptop, a tablet, a smartphone with camera or message you to continue the consult.
a telephone. Make sure they are fully charged, • Have pen and paper or note-taking
or plug them in to avoid power disruptions. devices where you can take down notes
Check your video camera, speaker volume during the actual consultation
and that the microphone picks up your voice
clearly.

Document Version: 8 May 2020 | 13 of 18

 • Learn about the platform or software you and
your health care provider agreed on using.
Test ahead of the visit, download or install any
updates needed. (Iafolla, 2020), (University of
South California, 2020).
• Check your internet speed. Refer to
Telemedicine: Guidance for the Filipino
Physicians Page 13 for the recommended
internet speed
• If available, have nearby any medical devices
your doctor has recommended, such as
thermometer, bathroom scale, home blood
pressure monitor, and/or glucometer.

Documents • Digital or printed copy of informed consent to • You may be asked to verify your identity • A summary of the visit
conduct the teleconsultation may have been by showing a government issued ID or may be sent to you
sent to you ahead of the visit. An example can other documents.
be found at (Teleconsultation: Guidance for
Filipino Clinicians - Page 16)
• Prepare all available medical records i.e.
physician orders, laboratory results, previous
prescriptions, over-the counter medications. If
prescriptions for the medication are not
available, empty medicine bottles or blister
packs containing the generic name of the
medication would suffice.

Self- • Keep a record of your symptoms, when it • Write down your doctor’s • Ask about the follow-
Empowerment occurred, what seems to trigger or aggravate recommendations or treatment plan. If up care and next
them and what alleviates them (Gordon, 2020) there are medications, take note of the scheduled
• Make a list of any chronic conditions you have, directions on how to take any of the appointment (Flesher,
a list of medications, vitamins and herbal medication. 2020) (Gordon, 2020)
supplements you are on. • Ask questions or clarifications if
• List down questions to ask during the something is not clear. Some information
consultation. For example: may have been missed due to signal
• What is the diagnosis? interference (Greenhalgh, 2020)
• Are there medications I need to take? • Before end the consultation, you can also
• Are there medications I should not take? ask your doctor if you can repeat your
Or activities or food to avoid?

Document Version: 8 May 2020 | 14 of 18

 notes for to allow them to correct any
misunderstanding

Adapted From:
• American Medical Association, Telehealth Playbook, 2020
• American Academy of Pediatrics. Telehealth Support: Provider to Patient Visits. Accessed 5 May 2020. https://www.aap.org/en-us/professional-
resources/practicetransformation/telehealth/Pages/Provider-to-Patient-Visits.aspx
• Fleischer, J (2020). How to Prepare for a Telehealth Appointment. Brain & Life. Accessed 6 May 2020 (https://www.brainandlife.org/the-magazine/online-exclusives/how-to-
prepare-for-a-telehealth-appointment/)
• Gordon, M. How To Get The Most Out Of Your Virtual Medical Appointment. National Public Radio. Accessed 7 May 2020. https://www.npr.org/sections/health-
shots/2020/04/15/828084250/how-to-get-the-most-out-of-your-virtual-medical-appointment.
• Greenhalgh, T., Koh, G., & Car, J. (2020). Covid-19: a remote assessment in primary care. BMJ (Clinical research ed.), 368, m1182. https://doi.org/10.1136/bmj.m1182
• Greenhalgh, T et al; Video Consultation: Information for GPs; IRIHS research group, University of Oxford 2020, Accessed 17 Apr 2020
• Health Insurance. 7 Steps To Prepare For Your First Telemedicine Appointment. Accessed 5 May 2020. https://www.healthinsurance.com/learning-center/article/steps-to-
prepare-for-your-first-telemedicine-visit
• Iafolla, T. 15 Physician Tips for a Better Telemedicine Visit. eVisit.com. Accessed 7 May 2020 (https://blog.evisit.com/15-physician-tips-better-telemedicine-visit)
• John Sharp. (2020) .A Patient’s Guide to Telemedicine: What to Do When Your Doctor Calls or Video-Chats with You. Accessed 5 May 2020.
https://www.himss.org/news/patients-guide-telemedicine.
• University of South Carolina. Five tips to prepare for your first telemedicine visit. Accessed 7 May 2020 https://hscnews.usc.edu/five-tips-to-prepare-for-your-first-
telemedicine-visit

Document Version: 8 May 2020 | 15 of 18

 REFERENCES:
1. A Patient’s Guide to Telemedicine: What to Do When Your Doctor Calls or Video-Chats
with You. (2020, March 25). Retrieved April 30, 2020, from
https://www.himss.org/news/patients-guide-telemedicine
2. Akerman, S (2020) A primer for those new to the world of Telemedicine. KevinMD.com
Accessed 5 May 2020 (https://www.kevinmd.com/blog/2020/03/a-primer-for-those-new-
to-the-world-of-telemedicine.html)
3. American Medical Association; Telehealth Implementation Playbook; March 2020.
Accessed 20 Apr 20
4. American Academy of Neurology. Telemedicine and COVID-19 Implementation Guide.
10 April 2020. (Accessed 06 May 2020). https://www.aan.com/siteassets/home-
page/tools-and-resources/practicing-neurologist--administrators/telemedicine-and-
remote-care/20-telemedicine-and-covid19-v103.pdf
5. American Telemedicine Association. Let There be Light. A Quick Guide To Telemedicine
Lighting. (2017) Accessed 2 May 2020 (https://www.americantelemed.org/resources/let-
there-be-light-a-quick-guide-to-telemedicine-lighting/)
6. American Telemedicine Association. Telemedicine Glossary. Accessed 5 May 2020
(https://thesource.americantelemed.org/resources/telemedicine-glossary)
7. Centers for Medicare and Medicaid Services. Physicians and Other Clinicians: CMS
Flexibilities to Fight COVID-19. 29 April 2020. (Accessed 06 May 2020).
https://www.cms.gov/files/document/covid-19-physicians-and-practitioners.pdf
8. Chaet, D., Clearfield, R., Sabin, J. E., Skimming, K., & Council on Ethical and Judicial
Affairs American Medical Association (2017). Ethical practice in Telehealth and
Telemedicine. Journal of general internal medicine, 32(10), 1136–1140.
https://doi.org/10.1007/s11606-017-4082-2
9. Cleveland Clinic; Cleveland Clinic COVID-19 Response: Digital Health Playbook; April
13, 2020 (Accessed 20, April 2020 at: https://my.clevelandclinic.org)
10. Doshi, A. et. al (2020) Keep Calm and Log On: Telemedicine for COVID-19 Pandemic
Response. Published online first DOI: 10.12788/jhm.3419
11. Gordon, M. How To Get The Most Out Of Your Virtual Medical Appointment. National
Public Radio. Accessed 7 May 2020. https://www.npr.org/sections/health-
shots/2020/04/15/828084250/how-to-get-the-most-out-of-your-virtual-medical-
appointment.
12. Greenhalgh, T., Koh, G., & Car, J. (2020). Covid-19: a remote assessment in primary
care. BMJ (Clinical research ed.), 368, m1182. https://doi.org/10.1136/bmj.m1182
13. Greenhalgh, T et al; Video Consultation: Information for GPs; IRIHS research group,
University of Oxford 2020, Accessed 17 Apr 2020
14. Greenwood, D. A., Gee, P. M., Fatkin, K. J., & Peeples, M. (2017). A Systematic Review
of Reviews Evaluating Technology-Enabled Diabetes Self-Management Education and
Support. Journal of diabetes science and technology, 11(5), 1015–1027.
https://doi.org/10.1177/1932296817713506
15. Elwyn, G., Barr, P. J., & Castaldo, M. (2017). Can Patients Make Recordings of Medical
Encounters?: What Does the Law Say?. JAMA, 318(6), 513–514.
https://doi.org/10.1001/jama.2017.7511
16. Hjelm, NM. (2005) Benefits and drawbacks of Telemedicine. Journal of Telemedicine
and Telecare 11(2):60-70. DOI: 10.1258/1357633053499886
17. Hanson, R.E., Truesdell, M., Stebbins, G.T., Weathers, A.L. and Goetz, C.G. (2019),
Telemedicine vs Office Visits in a Movement Disorders Clinic: Comparative Satisfaction
of Physicians and Patients. Movement Disorders Clinical Practice, 6: 65-69.
doi:10.1002/mdc3.12703

Document Version: 8 May 2020 | 16 of 18

18. Health Insurance. 7 Steps To Prepare For Your First Telemedicine Appointment.
Accessed 5 May 2020. https://www.healthinsurance.com/learning-center/article/steps-to-
prepare-for-your-first-telemedicine-visit
19. House Bill No. 8378. An Act to Prohibit and Penalize Wire Tapping and other Related
Violations of the Privacy of Communication. Seventeenth Congress. Third Regular
Session (2018)
20. Inglis, S. C., Clark, R. A., Dierckx, R., Prieto-Merino, D., & Cleland, J. G. F. (2015).
Structured telephone support or non-invasive telemonitoring for patients with heart
failure. Cochrane Database of Systematic Reviews, 2015(10).
https://doi.org/10.1002/14651858.CD007228.pub3
21. Karhula, T., Vuorinen, A. L., Rääpysjärvi, K., Pakanen, M., Itkonen, P., Tepponen, M., …
Saranummi, N. (2015). Telemonitoring and mobile phone-based health coaching among
finnish diabetic and heart disease patients: Randomized controlled trial. Journal of
Medical Internet Research, 17(6), e153. https://doi.org/10.2196/jmir.4059
22. Kelly, J. T., Warner, M. M., Conley, M., Reidlinger, D. P., Hoffmann, T., Craig, J., …
Campbell, K. L. (2019). Feasibility and acceptability of telehealth coaching to promote
healthy eating in chronic kidney disease: A mixed-methods process evaluation. BMJ
Open, 9(1), 1–12. https://doi.org/10.1136/bmjopen-2018-024551
23. Krupinski, E; Telemedicine Workplace Environments: Designing for Success;
HealthCare 2014, 2, 115-122, doi:10.3390/healthcare2010115
24. Kruse, C. S., Krowski, N., Rodriguez, B., Tran, L., Vela, J., & Brooks, M. (2017).
Telehealth and patient satisfaction: a systematic review and narrative analysis. BMJ
open, 7(8), e016242. https://doi.org/10.1136/bmjopen-2017-016242
25. Kruse, C., Karem, P., Shifflett, K., Vegi, L., Ravi, K., & Brooks, M. (2018). Evaluating
barriers to adopting telemedicine worldwide: A systematic review. Journal of
telemedicine and telecare, 24(1), 4–12. https://doi.org/10.1177/1357633X16674087
26. Lahey, T and Elwyn, G; (2017) Go ahead and hit 'record' in the doctor's office; STAT -
reporting from the frontiers of health and medicine. Accessed 4 May 2020
https://www.statnews.com/2017/07/10/record-doctors-office-patient-visit/
27. Lee, P.A., Greenfield, G. & Pappas, Y. (2018). Patients’ perception of using telehealth
for type 2 diabetes management: a phenomenological study. BMC Health Services
Research 18, 549. https://doi.org/10.1186/s12913-018-3353-x
28. LeRouge, C., Garfield, M., & Hevner, A. (2014). Patient perspectives of telemedicine
quality. Patient Preference and Adherence, 25. https://doi.org/10.2147/PPA.S67506
29. Luz P. (2019). Telemedicine and the Doctor/Patient Relationship. Arquivos brasileiros de
cardiologia, 113(1), 100–102. https://doi.org/10.5935/abc.20190117
30. Major, J; Telemedicine Room Design. Journal of Telemedicine and Telecare, 2005.
11(1), 10–14. doi:10.1177/1357633x0501100103
31. Miller, T. E., & Derse, A. R. (2002). Between strangers: the practice of medicine online.
Health affairs (Project Hope), 21(4), 168–179. https://doi.org/10.1377/hlthaff.21.4.168
32. National Telemedicine Guidelines of Singapore (2015), (Accessed 20 Apr 2020 at
https://www.moh.gov.sg)
33. O'Cathail, M., Sivanandan, M. A., Diver, C., Patel, P., & Christian, J. (2020). The Use of
Patient-Facing Teleconsultations in the National Health Service: Scoping Review. JMIR
medical informatics, 8(3), e15380. https://doi.org/10.2196/15380
34. O’Connor, S, Hanlon, P, O’Donnell, CA, Garcia, S, Glanville, J, & Mair, FS.. (2016).
Understanding factors affecting patient and public engagement and recruitment to digital
health interventions: a systematic review of qualitative studies. BMC Medical Informatics
Decision Making, 16(120). https://doi.org/10.1186/s12911-016-0359-3
35. Oksman, E., Linna, M., Hörhammer, I., Lammintakanen, J., & Talja, M. (2017). Cost-
effectiveness analysis for a tele-based health coaching program for chronic disease in

Document Version: 8 May 2020 | 17 of 18

 primary care. BMC Health Services Research, 17(1), 1–7. https://doi.org/10.1186/s12913-
017-2088-4
36. Ramachandran, D (2014) When Patients Secretly Record Their Doctor Visits;
KevidMD.com. Accessed 5 May 2020 (https://www.kevinmd.com/blog/2014/05/patients-
secretly-record-doctor-visits.html)
37. Republic Act No 4200. An Act to Prohibit and Penalize Wire Tapping and other Related
Violations of the Privacy of Communications and For Other Purposes. (1965)
38. Rheuban, KS; Telemedicine: Connect to Specialists and Facilitate Better Access to Care
for your patients; American Medical Association. 2018. Retrieved 20 Apr 20. (edhub.ama-
assn.org)
39. Rodriguez, M., Morrow, J., & Seifi, A. (2015). Ethical implications of patients and families
secretly recording conversations with physicians. JAMA - Journal of the American Medical
Association, 313(16), 1615-1616. https://doi.org/10.1001/jama.2015.2424
40. Salaffi, F., Carotti, M., Ciapetti, A., Di Carlo, M., Gasparini, S., Farah, S., & Gutierrez, M.
(2016). Effectiveness of a telemonitoring intensive strategy in early rheumatoid arthritis:
Comparison with the conventional management approach. BMC Musculoskeletal
Disorders, 17(1), 1–11. https://doi.org/10.1186/s12891-016-1002-2
41. So, C. F., & Chung, J. W. Y. (2018). Telehealth for diabetes self-management in primary
healthcare: A systematic review and meta-analysis. Journal of Telemedicine and
Telecare, 24(5), 356–364. https://doi.org/10.1177/1357633X17700552
42. Showalter, G. (2020). Telehealth Physical Exam. Loengard, A., Findley, J. (Eds.).
https://caravanhealth.com/
43. University of South Carolina. Five tips to prepare for your first telemedicine visit. Accessed
7 May 2020 https://hscnews.usc.edu/five-tips-to-prepare-for-your-first-telemedicine-visit
44. Weinstein, Ronald & Krupinski, Elizabeth & Doarn, Charles. (2018). Clinical Examination
Component of Telemedicine, Telehealth, mHealth, and Connected Health Medical
Practices. Medical Clinics of North America. 102. 533-544. 10.1016/j.mcna.2018.01.002.

Document Version: 8 May 2020 | 18 of 18