Table 2.

Barriers and potential solutions to video-based care

Barrier	Solution
Privacy laws and relation to video visits	The US Department of Health and Human Services recently relaxed HIPAA compliance guidelines for the COVID-19 pandemic.28 Consult state and national organizations for further guidance in your jurisdiction.
Video communication programs	Free or low cost apps exist for use on computers and smart phones.29
Secure video telehealth	To prevent an outside party from inadvertently joining the patient encounter, use all available security features of the video platform including a unique link for each appointment and password protection. A valid and reliable telehealth security self-assessment questionnaire is available and very useful.30
Potential malpractice litigation	Contact your professional liability carrier to see if telehealth is covered under your policy.
Reimbursement	For providers of all types, how and for how much telehealth will be reimbursed during the COVID-19 pandemic is an unknown and varies from region to region depending on insurance providers. For more details regarding chiropractic care, consider information available from NCMIC Group.31
Service and coding terminology is confusing	Magoon provides a helpful table that compares various telehealth modalities in Medicare terms, elements of service necessary to define each, and a convenient algorithm to determine which service to code.10
There is a learning curve for the provider and staff when implementing telehealth	Have patience, conduct staff training, and develop protocols. Assume that anything involving new technology will have problems. Plan for at least 1 back up, if not 2 backup plans, in case something fails.
It is difficult to focus on the patient's concerns and exam and enter data into the EHR simultaneously.	A “scribble sheet” from the Washington University Department of Internal Medicine21 is helpful in patient communication and encounter documentation. This is freely available and can easily be modified for chiropractic practice.
It is hard to make a specific diagnosis by video	This may be the case. However, making a specific diagnosis in person is not always attained because there may need to be a therapeutic trial or more tests may be necessary. This can be discussed frankly with the patient; in our experience patients are appreciative of the discussion and willing to accept the limitations of the video visit. Obtain the information that allows you to move ahead with patient management. As 2 authors remarked, “Focusing on actionable information is more important than diagnostic accuracy.”4
My office does not have a script for schedulers to use in communicating with patients about COVID-19	Schmidt has shared 1 for both new and returning patients that is highly relevant to standard office procedures.21
It might be difficult to triage patients with potential systemic problems using telehealth	Immediate practice-relevant protocols and practice aids are available open-access from Washington University Department of Internal Medicine.21 This is also a good time to reach out to local medical doctors, many of whom are also setting up telehealth practices, if referral consultations are needed.