An Implementation Roadmap for Establishing Remote Infectious Disease Specialist Support for Consultation and Antibiotic Stewardship in Resource-Limited Settings

Abstract

Infectious Disease (ID)–trained specialists, defined as ID pharmacists and ID physicians, improve hospital care by providing consultations to patients with complicated infections and by leading programs that monitor and improve antibiotic prescribing. However, many hospitals and nursing homes lack access to ID specialists. Telehealth is an effective tool to deliver ID specialist expertise to resource-limited settings. Telehealth services are most useful when they are adapted to meet the needs and resources of the local setting. In this step-by-step guide, we describe how a tailored telehealth program can be implemented to provide remote ID specialist support for direct patient consultation and to support local antibiotic stewardship activities. We outline 3 major phases of putting a telehealth program into effect: pre-implementation, implementation, and sustainment. To increase the likelihood of success, we recommend actively involving local leadership and other stakeholders in all aspects of developing, implementing, measuring, and refining programmatic activities.

Telehealth is an effective tool for sharing Infectious Disease specialist expertise with resource-limited settings. In this step-by-step guide, we outline how a telehealth program can be implemented to provide remote ID specialist support for patient consultation and/or antibiotic stewardship.

Infectious diseases (ID) specialists, defined as physicians and pharmacists who are formally trained in ID, improve inpatient care outcomes [1–8]. This is accomplished by (1) ID physicians providing consultative care for patients with complicated infections [1–4, 8] and (2) ID specialists leading programs that monitor and improve antibiotic prescribing, that is, antibiotic stewardship programs (ASPs) [5–7]. ASPs are now a requirement for all US hospitals and nursing homes, based on standards and regulations from the Joint Commission and the Centers for Medicare and Medicaid Services (CMS) [9, 10].

Although ID expertise clearly adds value, on-site ID specialists are absent from at least a quarter of US hospitals and virtually all nursing homes [11, 12]. Furthermore, 80% of US counties have no ID physician [13]. Developing strategies to more broadly share the expertise of ID specialists may improve patient care and deliver knowledge and skills important to successful ASPs.

Telehealth is an effective strategy to provide ID specialist expertise to resource-limited settings. Telehealth involves “the use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education” [14]. When telehealth has been used for remote ID physician consultation, patient outcomes have been comparable to in-person consultation [15, 16]. Furthermore, remote ID physician consultation has been associated with fewer hospital transfers and shorter lengths of stay [17, 18]. Telehealth can also be used to support local antibiotic stewardship activities remotely, independent of direct patient care. This approach can reduce antibiotic use, minimize antibiotic-related adverse events, and decrease costs [19–22]. In their Core Elements of Hospital Antibiotic Stewardship Programs, the Centers for Disease Control and Prevention (CDC) acknowledge that stewardship expertise for small hospitals can be provided by telehealth staff [23].

The optimal model for ID telehealth programs has not been defined, and many different models have been described [24–29]. Given the high degree of variability across these models, we convened a panel of ID specialists with telehealth expertise to identify best practices for implementing an ID telehealth program. In this paper, we have outlined how a telehealth program can be implemented to provide remote ID specialist support for patient consultation and/or antibiotic stewardship. Because ID consultation and antibiotic stewardship are both complementary and functionally intertwined, we discuss both services simultaneously, recognizing that some health care institutions may want to advance these as separate entities. Our step-by-step guide for ID telehealth is based on an established implementation science framework and is organized into 3 broad phases of implementation: pre-implementation (4 steps), implementation (2 steps), and sustainment [30, 31].

PRE-IMPLEMENTATION PHASE (4 STEPS)

During the pre-implementation phase, the remote ID specialists and key stakeholders from the local (originating site) hospital or nursing home plan how telehealth services will be implemented while considering the unique resources and needs of the local setting. This phase requires a substantial investment of time. In our experience, the ID specialists are not directly reimbursed for their pre-implementation efforts, which are critical for fostering interprofessional relationships with the leadership, champions, and providers at the local site. The investment of time and resources during pre-implementation should be considered in the overall fees included in the contract. Table 1 provides an overview of the 4 steps involved in the pre-implementation phase.

Table 1.

Checklist for Implementing Remote Infectious Disease Specialist Support for Consultation and Antibiotic Stewardship in Resource-Limited Settings

Phase	Done	Task
Pre-implementation	□	Cultivate support from leadership and stakeholders Secure support from health care administration and executive leadership (IDC/ASP)a Develop a business plan accounting for local resources and ID specialists’ effort (IDC/ASP) Identify local champions (IDC/ASP) Identify stakeholders, including frontline providers (IDC/ASP)
	□	Assess capacity, including local barriers and solutions to telehealth delivery, by engaging stakeholders. When engaging stakeholders, key factors to consider include: Information technology and telecommunication capabilities (IDC/ASP) Number of patients transferred to higher level of care for an infection (IDC) Financial expenditures on antibiotics (IDC/ASP) Interpretation of microbiology and related diagnostic test results (IDC/ASP) Decisions around antibiotics related to discharge processes (IDC/ASP) Responses to CDC's Antibiotic Stewardship Program Assessment tools (ASP) (Supplementary Table 1)
	□	Develop a standard operating procedure tailored to the local setting Develop strategies to address known and anticipated barriers (Table 4) Key practical questions to consider when adapting telehealth to local needs and resources: Will services be synchronous or asynchronous? (IDC/ASP) For meetings, how frequently, how long, what location, and using what platform? (IDC/ASP) How are patients identified and requests communicated to the ID specialist? (IDC) How are recommendations recorded and communicated to the local provider(s)? (IDC/ASP) What are the expectations for workload documentation and timeliness? (IDC/ASP) What are the plans for when the ID specialist is not available? (IDC/ASP)
	□	Address practical aspects of implementation Credentialing and licensing requirements vary as to whether telehealth services are synchronous or asynchronous and whether the services cross state lines. Recommendations should be documented at the local site and ideally also at the ID specialist’s home facility if feasible. Obtain necessary equipment and audiovisual software. Verify that the ID specialist’s malpractice insurance covers telehealth services for the local site. Have a legal expert review the scope of telehealth services and all contractual language Define training needs for using telehealth equipment and the following, as necessary: Develop training materials (IDC/ASP) Train local nurses in coordinating telehealth services and supporting remote examination (IDC) Train local clinical pharmacist(s) on stewardship interventions (ASP)
	□	Design evaluation measures to assess the program's effectiveness. Suggested metrics are: ID consults Number of telehealth encounters scheduled, number canceled, and number completed Time to completion of telehealth consults Perceptions of the quality of care among ID specialists, patients, and local providers Antibiotic stewardship Process measures, such as number of educational sessions presented and number of attendees Acceptability of stewardship processes to providers Standard antibiotic use metrics (eg, days of therapy) Avoidable re-admissions and length of stay for common infections (eg, pneumonia) Number of patients reviewed, number of stewardship recommendations, number accepted Adverse consequences of antibiotic use
	□	Establish baseline (pre-implementation) performance (IDC/ASP)
Implementation	□	Set a timeline for implementation (IDC/ASP)
	□	Complete training for local personnel and test any necessary audiovisual equipment (IDC/ASP)
	□	Disseminate implementation and support tools (IDC/ASP)
	□	Start implementation, as planned (IDC/ASP)
	□	Once implementation begins, report progress to stakeholders, based on the evaluation plan (IDC/ASP)
	□	Reconvene stakeholders regularly to review evaluation measures and iteratively refine implementation to optimize local fit and uptake (IDC/ASP)
Sustainment	□	After the pilot phase is complete, review the evaluation measures and determine if and how the program should be sustained (IDC/ASP)

Abbreviations: CDC, Centers for Disease Control and Prevention; EMR, electronic medical record; HIPAA, Health Insurance Portability and Accountability Act; ID, infectious diseases; IDC/ASP, infectious diseases consult/antibiotic stewardship program.

^aIndicates whether the actions are more specific to infectious diseases consults, an antibiotic stewardship program, or both.

Cultivate Support From Leadership and Other Stakeholders

The first step in this pre-implementation process is deciding that remote ID support is a priority for the health care setting. For implementation to succeed, leadership at the hospital or nursing home should be enthusiastic about starting an ID telehealth program, whether for clinical consultations and/or stewardship. To achieve leadership buy-in, we recommend sharing success stories from similar facilities (particularly those within relatively close geographic proximity) and gaining strong local advocacy through key clinical leaders. Because financial considerations will be a primary driver of leadership decisions, the remote ID specialist team should prepare a formal business case with estimates of the likely return on the investment made by the local hospital or nursing home. These estimates are often based on anecdotal data, but preferably, they would be informed by a more thorough understanding of the patient case mix at the local hospital or nursing home and its reimbursement rates from different payor sources [32]. In many cases, reducing the use of a few high-cost antibiotics can significantly offset programmatic fees.

While the need for remote ID consultations is often readily apparent, the value of ID support for stewardship activities might be underappreciated. Some additional arguments in favor of greater stewardship support may include the positive impact of being compliant with regulatory standards and potential reductions in Clostridioides difficile infections [33]. The Hospital Compare website can provide risk-standardized data on excess length-of-stay for patients with pneumonia, which is a metric that could be positively affected by stewardship support [34, 35]. Similarly, the Nursing Home Compare website describes the percentage of patients who acquired a urinary tract infection and an infection resulting in hospitalization, both of which may be improved through remote ID support.

Identifying local champions is essential in convincing leaders at the local institution to support telehealth implementation. Ideally, champions are local site providers who are respected by their peers and have a vested interest in developing this type of program. For a telehealth program that provides remote ID physician consultation, a local champion could be a hospitalist who wants more assistance with managing complicated infections or a hospital administrator who wants to reduce outgoing patient transfers. For telehealth programs that provide stewardship support, local champions should include a pharmacist and provider engaged in stewardship activities plus an infection preventionist, if available. In nursing homes and other post–acute care settings, the infection preventionist, director of nursing, or medical director may be an ideal champion. In addition to advocating for change, champions can assist the remote ID specialists in navigating the local system and identifying key stakeholders to engage. When feasible, having multiple local champions will drive the pre-implementation phase forward in a timely manner while also broadening the institutional knowledge available to develop a telehealth program suited to the local setting.

Stakeholders are individuals at the local health care institution who will have an indirect or direct role in supporting telehealth adoption. Any preliminary conversations about telehealth should include these stakeholders, which may include administrators, frontline providers, pharmacists, microbiologists, infection preventionists, nurses, the medical director, the pharmacy director, the director of nursing, consulting pharmacists, information technology (IT) specialists, privacy officers, and financial officers. Personnel involved in another telehealth program at the local institution would also be important to engage, particularly if the ASP team has limited experience with telehealth processes.

Certain stakeholders may be asked to join a more formal planning team, led by the local champions, to further oversee program development and implementation. To ensure leadership engagement, we strongly recommend including people from the system's leadership and business offices on this planning team. The remote ID specialists should also be involved, although it may not be necessary for them to attend every team meeting.

Some hospitals, and especially nursing homes, may not have the resources to establish a formal planning team. In these situations, we still recommend that a local champion and/or the remote ID specialists perform the pre-implementation assessments discussed below, but these assessments can be streamlined.

Assess Capacity, Including Barriers to Telehealth Delivery and Potential Solutions

Step 2 of the pre-implementation phase involves learning about the different dimensions of the local health care setting's systems, processes, and organizational culture that may influence implementation of a telehealth program. This assessment, which is sometimes referred to as contextual inquiry, is largely accomplished by the planning team engaging stakeholders. Input can be gathered through short electronic surveys, focus groups, traditional meetings, and informal conversations. Stakeholder engagement will help to clarify needs and priorities at the local health care setting, anticipate potential barriers to telehealth use, identify solutions to these barriers, and guide programmatic adaptions to better match the local setting. We recommend that the planning team review the entire pre-implementation process (Table 1) to identify the different parties from whom they will need input. These early engagements can then be used to gather as much formative input as possible.

As outlined below, these initial assessments with stakeholders will differ based on whether the goal is to implement a telehealth program for ID consultations, stewardship, or both. These preliminary assessments may steer the planning team to decide to prioritize one service over the other.

ID Consultation

When assessing the type of remote ID physician consultation that is needed, some key data points are how often patients at the local institution have been transferred to a higher level of care for ID specialist services, how often broad-spectrum or expensive antibiotics are prescribed, and how often patients are admitted with complex infections that require prolonged courses of antibiotic therapy, including outpatient intravenous antibiotics. To gather these data, local administrative personnel may be able to search existing databases.

Depending on the setting's needs and financial resources, remote ID consultations can be provided through one of the following approaches: (1) telephone advice only, (2) asynchronous electronic consults, or (3) synchronous consults that allow the ID physician to interview and examine the patient through HIPAA-compliant, encrypted, 2-way audiovisual devices. Distinctive features of these 3 approaches are shown in Table 2. Based on these available options, the remote ID specialists and local health care setting will need to determine how often services will be available.

Table 2.

Types of Consultation Services That Can Be Provided by an ID Physician Telehealth Program

Type of Service	Description	People Involved	Tools	EMR Documentation of ID Recommendations	Encounter Can Be Reimbursed
Telephone advice only	The primary provider contacts the remote ID physician by telephone to request recommendations on a specific patient case.	Local provider and remote ID specialist	Telephone or video-conferencing software, possibly EMR if the remote ID physician has access	No	Noa
Electronic consults	The primary provider asks the remote ID physician to perform a comprehensive chart review and to give recommendations.	Local provider and remote ID specialist	Remote EMR access for consultant	Yes	Sometimesa,b
Synchronous physician–patient audiovisual consults	At the request of the primary provider, the remote ID physician interviews and examines the patient using HIPAA-compliant audiovisual equipment.	Local provider, remote ID specialist, patient	EMR, audiovisual equipment, electronic stethoscopes, and other equipment for remote physical examinations.	Yes	Yesc

Abbreviations: EMR, electronic medical record; HIPAA, Health Insurance Portability and Accountability Act; ID, infectious diseases.

^aThese encounters will typically not be individually billed but will instead be covered by an annual subscription fee, which the local hospital or nursing home will pay to the remote ID specialist group.

^bSome payers reimburse for electronic consults done in the inpatient setting.

^cSynchronous physician–patient audiovisual consults provide an opportunity for individualized billing in certain circumstances, such as when the patient is hospitalized in a rural area [14].

Antibiotic Stewardship

Like ID consultations, the nature of remote stewardship support should be tailored to the local setting, such that it could be fairly limited or more expanded (Table 3). The CDC's Antibiotic Stewardship Program Assessment tool is a useful resource for hospitals deciding on which type of stewardship support is most appropriate [23]. For nursing homes, the CDC offers a similar checklist based on their Core Elements of Antibiotic Stewardship [36]. Supplementary Table 1 shows selected questions from these 2 checklists. Responses to these questions will help determine the necessary level of stewardship support. At a minimum, hospitals and nursing homes should leverage telehealth support to implement the CDC's Core Elements and meet applicable regulatory standards (eg, CMS, state-mandated surveys, Joint Commission, etc.). Beyond those basic requirements, there is a large degree of latitude in which additional program elements are delivered through telehealth (Supplementary Table 2). The telehealth program can also guide more robust assessments of local antibiotic use, and any findings can then be used to determine how to structure future telehealth services.

Table 3.

Potential Elements of an Antibiotic Stewardship Program That Is Supported by Remote ID Specialists ^a

Basic Support	Expanded Support
Education: Remote ID specialists provide regular education on stewardship topics.	ID-controlled restrictions: Local requests for restricted antibiotics must first be approved by the remote ID specialists.
Access to expertise: Remote ID specialists are available for patient review and stewardship advice when input is requested by the local site.	ID involvement in routine prospective audit-and-feedback: Remote ID specialists work independently or collaboratively with the local stewardship team to review patients on targeted antibiotics and provide real-time feedback to prescribers.
Data support: Remote ID specialists assist the local team with collecting and interpreting antibiotic use data.	Computerized decision support systems (CDSS): Remote ID specialists oversee the development and maintenance of CDSS software to aid providers in their antibiotic prescribing
Programmatic development: Remote ID specialists assist in the development of local policies, order sets, and antibiotic treatment guidelines.	Training: Remote ID specialists train local pharmacists and other stewardship team members in performing core stewardship strategies.
Project ECHO model: Remote ID specialists attend virtual meetings with groups of local providers. Meetings can include didactic sessions on antibiotic stewardship and/or provide opportunities to seek real-time specialist input on patients.

Abbreviations: CDSS, computerized decision support system; ECHO, extension for community healthcare outcomes; EMR, electronic medical record; ID, infectious diseases.

^aAlternatively, telehealth support for antibiotic stewardship can be divided into 3 broad categories: Fully Remote, Collaborative, and Integrated. In the Fully Remote model, remote ID specialists provide feedback directly to the frontline provider; this model is typically used when there is limited on-site personnel engaged in stewardship activities. The Collaborative model involves on-site personnel leading daily stewardship activities with remote ID specialists providing education, tools, and support, as needed. The Integrated model borrows elements from both the Fully Remote and Collaborative models [40].

Develop a Standard Operating Procedure That Addresses Known/Anticipated Barriers and Adapts Telehealth Services to the Local Setting

The next step of the pre-implementation process involves developing a standard operating procedure (SOP) for the new telehealth service. Information gathered during stakeholder engagement will inform these documents. We recommend that the remote ID specialists, local champions, and planning team prepare an initial draft of this SOP based on their findings from step 2. Local leadership and other key stakeholders should review the draft SOP before it is put into effect. Below we discuss a few broad considerations for SOP development.

Addressing Barriers

In step 2 of the pre-implementation phase, local champions and stakeholders helped identify barriers to telehealth use and potential solutions to these barriers. These solutions will likely overlap with well-characterized methods known as implementation strategies (Supplementary Table 3) [30, 37]. Implementation strategies are tools and methods that will support the local health care institution's adoption of telehealth. The team should prioritize using strategies that are feasible, have a high probability of success, and address known or anticipated barriers [30].

In our experience, common barriers to telehealth implementation include (1) limited financial resources at the local institution to support a new telehealth program; (2) high staff turnover at the local site; and (3) limited local experience working with ID specialists. Table 4 summarizes several barriers and presents potential solutions [38].

Table 4.

Overview of Potential Barriers and Potential Strategies to Overcome Each Barrier When Implementing Remote Infectious Disease Specialist Support for Consultation and Antibiotic Stewardship in Resource-Limited Settings ^a

CFIR Domain	Potential Barrier	Implementation Strategies to Overcome the Barrier	Further Description of Implementation Strategies
Characteristics of telehealth	Financial cost: The local institution has limited financial resources to pay for annual telehealth services.	Adapt and tailor to the local context Access new funding	Offer a limited approach to ID telehealth, eg, training, education, and empowering local ASP champions. Seek funds from public health departments or partner with ID groups doing funded telehealth research. Measure high-cost antibiotic use to learn if telehealth services could help offset program fees.
Outer setting	Lack of external networking: The local institution lacks opportunities to learn from peer facilities.	Facilitation Visit other sites	Facilitate networking with other hospitals or nursing homes that are using telehealth. Encourage local champions to visit similar hospitals or nursing homes that are using telehealth.
	Lack of incentives to use telehealth: The local leadership does not see an incentive to establish an ID telehealth program.	Train and educate stakeholders	Present a formal business case and educate leaders on the published literature: Studies show telehealth services can reduce inter-hospital transfers and length of stay. Hospitals and nursing homes are required to have formal ASPs, which can reduce antibiotic costs.
Inner setting	Limited experience: There is no local experience with using telehealth services or telehealth technology.	Visit other sites Centralize technical assistance Train-the-trainer	Encourage the local telehealth coordinator and local champions to visit nearby hospitals or nursing homes that are using telehealth. Centralize technical assistance within the remote ID specialist’s health care system. Train the local telehealth coordinator in how to train other local personnel in the use of telehealth equipment.
	Networks, communication, and norms: Remote ID specialists and local providers have little experience working together. Local providers may be unsure when to request ID support and/or are unfamiliar with the expertise that an ID specialist can provide.	Develop stakeholder inter-relationships Use evaluative and iterative strategies Develop educational materials	The remote ID specialists can do the following: Visit the local hospital or nursing home in-person to meet key individuals and learn the local culture. Build trust and familiarity with local providers through collaborating on program needs. Develop educational materials with clinical pathways and guidance for requesting consults or stewardship support. Maximize availability of ID support and try to be useful regardless of the circumstances. Be responsive to feedback and suggestions.
Readiness for implementation	Limited leadership engagement: Institutional leadership is not engaged in telehealth implementation.	Fund and contract for clinical innovation Identify champions Perform a needs assessment	Present an estimated return on investment for the local hospital or nursing home. Share telehealth ID success stories from other facilities. Seek unique perspectives at the local institution on how remote ID support could be financially beneficial. Involve local leadership in all preliminary conversations and assessments.
	Limited resources: The local health care setting lacks HIPAA-compliant video-conferencing or remote physical exams.	Adapt and tailor to the local context Develop resource-sharing agreements	Be flexible about platforms used for telehealth. Provide any necessary equipment and incorporate costs into the initial telehealth contract fee. Create an example resource request document that sites could submit for equipment purchases or upgrades.
Characteristics of individuals	Poor identification with the organization: The local institution relies on locum tenens providers and agency staff instead of their own employees; turnover is high.	Train and educate stakeholders	Encourage frequent engagement with as many local staff as possible, particularly local champions. Develop standardized training for new staff. Remind stakeholders that an established consultative service will improve continuity of care and support quality improvement projects.
	Knowledge and beliefs: Local providers are skeptical that telehealth will be beneficial to their practices.	Identify/prepare champions Develop and implement tools for quality monitoring	Identify local champion(s) to guide implementation and engage skeptical providers. Review the telehealth process and develop tools for quality monitoring. Highlight success stories about the value of telehealth.
	Limited self-efficacy: Local providers and pharmacists are unsure when and how to request input/consultation from ID telehealth pharmacists and physicians.	Develop educational materials Support providers and pharmacists	Develop clinical pathways for common infections and guidance on when to request ID support. Distinguish between infections that should be managed via formal ID consultation vs stewardship and any overlap. Highlight how ID specialists can improve patient care. Maintain a low logistical barrier to placing a consult.
Process	No champions: There are no local stewardship champions and/or no protected time for champions to participate in telehealth activities.	Identify and prepare champions Adapt and tailor to the local context	Ask local leadership to identify a local champion and formally appoint him/her to help with implementation. Provide training to the local champion in how to support telehealth implementation. If local resources prohibit providing dedicated time to a champion, adjust the model based on what is feasible.

Abbreviations: ASP, antibiotic stewardship program; CFIR, Consolidated Framework for Implementation Research; ID, infectious diseases.

^aThe CFIR framework outlines a comprehensive set of factors that potentially impede or enable the implementation process. It is made up of 5 domains (intervention characteristics, outer setting, inner setting, characteristics of individuals, and process) and multiple constructs within each domain.

Adapting Telehealth to Local Resources and Needs

In addition to addressing barriers, any telehealth SOP will need to be intentionally structured to fit the local setting. For example, if the telehealth program will be providing stewardship support, any new stewardship services should complement existing stewardship activities at the local site. Other key considerations for adapting a telehealth program are shown in Table 1.

Practical Considerations

For both ID consultation and stewardship programs, a telehealth SOP will need to address several practical considerations, such as credentialing, reimbursement, confidentiality, documentation, and liability, as well as physician and pharmacist licensure when the remote and local sites are located in different states. A more in-depth discussion of these issues can be found elsewhere [14].

Clear discussions on how billing is to be conducted are an important part of the pre-implementation phase. Annual contract fees are commonly used to pay for ID-related telehealth programs, although synchronous physician–patient audiovisual consults do provide an opportunity for individualized billing in certain circumstances. Even when annual contract fees are in place, it is still important to capture workload for each encounter to monitor the program's impact.

Training Local Staff

The SOP should also outline training needs. For example, if telehealth will be providing stewardship support, the local pharmacist champion may need training on how to perform stewardship interventions. If telehealth will be providing remote ID consultation, the local site may choose to train a nurse to be the telehealth coordinator. This individual would be responsible for ensuring that all telehealth equipment is operational and might also be a single point of contact to facilitate follow-up telehealth visits, especially when the remote ID physician will provide ongoing care after discharge.

If remote ID physicians will perform direct synchronous patient visits with physical examination, then local nurses will need to be trained on ways to support the physician's examination. This would include instructions on patient positioning, guidance on how to optimize lighting, and training on specific examination procedures, such as spinous process palpation and costovertebral angle tenderness assessment. If remote physical examinations will make use of telehealth peripheral devices (eg, digital stethoscopes, otoscopes), nurses will also need to be trained in their use. Many successful telehealth programs create training videos or quick reference guides for each of these components. A quick reference guide, which can be kept near the local site's telehealth equipment, should include key telephone numbers and required steps to assist with and troubleshoot a 2-way audiovisual camera visit successfully. If direct patient assessments are not planned, we recommend developing the means to take bedside photographs of conditions that benefit from a visual assessment (eg, rashes, wounds); these photographs can then be uploaded securely into the patient's electronic medical record.

Create an Evaluation Plan and Establish Baseline Performance

Before the telehealth SOP is implemented, there should be consensus on which metrics will be tracked to assess whether the program is having the desired effect. Metrics should be relevant to the delivery of care and should reflect input from all stakeholders. Table 1 outlines some potential metrics.

In addition to choosing specific metrics, the remote ID specialists, local champions, planning team, and local leadership also need to decide how and with what frequency these metrics will be monitored and who will be monitoring which metrics. Depending on the specific metric, data sources could include administrative data warehouses, prospective manual data entry, and targeted electronic surveys. Metric tracking should begin at baseline or, if feasible, several weeks to months before program implementation. Settings with limited resources to access and/or analyze antibiotic use data might consider assessing metrics periodically, such as the same 1-month period every year.

While a variety of personnel may be involved in tracking these metrics, we recommend that a single individual assume responsibility for compiling all metrics into periodic reports. Although this responsibility can be assumed by the ID specialists, assigning a local champion to this role will improve the local institution's ownership of the program. We recommend that local champions compile reports quarterly and share them with stakeholders at their hospital or nursing home. Certain metrics (eg, antibiotic use) may need to be reviewed less frequently, as large month-to-month variations will likely occur due to small denominators. In general, providing timely feedback on implementation progress will promote iterative problem-solving during the next phase of implementation.

IMPLEMENTATION PHASE (2 STEPS)

During the implementation phase, the telehealth program is initiated, and its progress is closely monitored. Strategies are leveraged to support frontline providers in learning and adopting these new services. This phase can be divided into 2 steps:

Implement the Telehealth Program After Finalizing the Standard Operating Procedures and Disseminating Support Tools

At this step, the telehealth SOP is finalized, and the implementation timeline is established. The local champion(s) and/or telehealth coordinator(s) should use a variety of communication modalities to educate clinical staff, especially providers, about the telehealth program's start date. To manage local expectations, it is also important to communicate which service(s) will be included in the new program. If the telehealth program involves remote ID physician consultation, key points to communicate will be how to place consults and which key data elements should be included in a consult request. These points may be best summarized in a quick reference guide.

In addition to email announcements, the local institution might consider inviting the ID specialists to present at a staff meeting, Grand Rounds, or a similar venue well attended by providers. This type of presentation, whether it occurs in-person or through videoconferencing, will not only introduce the ID specialists to the local clinical staff but can also demonstrate the specialists’ credibility and expertise. Scheduling short, one-on-one introductory meetings between the ID specialists and individual stakeholders also provides an additional opportunity to build rapport.

Report Progress on Implementation to Stakeholders and Adjust the Implementation Plan Based on Their Feedback

Once the implementation process begins, continuous quality monitoring is essential to ensure that implementation is proceeding as intended. In general, frequent and direct communication between the remote ID specialists and the clinical staff at the local health care settings during program implementation facilitates a healthy learning environment, improves trust, and can promote accelerated use of telehealth services.

During the implementation phase, the specific outcomes identified during the pre-implementation phase (step 4) should be tracked and reported to the ID specialists and the local stakeholders at least once a quarter. Sharing these outcomes at an already established meeting provides a venue for reflecting on the data and discussing whether telehealth processes should be refined. When adaptations are made, ongoing quality monitoring permits real-time assessment of these changes.

A key outcome to track at this stage is the acceptability of programmatic services. To this end, the remote ID specialists should work with local champions to continually seek feedback on whether the program is meeting local needs and how the program could be improved. Feedback must be sought from providers, pharmacists, nurses, and patients. One practical tool for seeking feedback is an electronic survey, which can be created through any number of readily available online tools and distributed through local e-mail lists [39]. Survey questions might address the reliability of telehealth equipment and connectivity, ease of communication with the remote ID specialists, overall satisfaction with the telehealth interaction(s), and likelihood to use the service again. Surveys can provide valuable feedback early after implementation and be monitored serially for improvement after problem areas are identified and addressed. While surveys do not require specific approval for research purposes, they should be approved by the local site's leadership before use. As much as possible, the ID specialist team should be responsive to the survey feedback by making appropriate programmatic adjustments.

SUSTAINMENT PHASE

The goal of the sustainment phase is to incorporate successfully implemented telehealth services into routine clinical workflows. In successful implementation efforts, the pilot data will show that the program is effective and appropriate to the care setting.

During the sustainment phase, the local champions should re-convene stakeholders to review the collected data. In general, given low patient volumes and the time required for learning new processes, the pilot phase should last at least 1 year, although some large-scale efforts at providing stewardship support through telehealth can take up to 2 years to see a benefit [24, 25].

A telehealth program that warrants sustainment is seen as essential to routine clinical care and is valued by both local providers and leaders. If telehealth services for ID consultations and/or stewardship meet these criteria, then stakeholders should discuss a long-term funding mechanism and how to keep monitoring key outcomes. At this point, adaptations to the program may be necessary to maintain its effectiveness. Alternatively, if the telehealth program has not been effective, leaders at the local institution will need to decide whether the program should be altogether abandoned or whether adaptations could be made to improve the program's impact.

CONCLUSIONS

Telehealth is an effective tool to provide ID specialist expertise to resource-limited settings. We have outlined key steps in designing and implementing an ID telehealth program. Our primary focus has been the pre-implementation phase. The relationship building, needs assessment, and project planning done in the pre-implementation phase lay the groundwork for the program's future success. Quality monitoring and frequent communication throughout the implementation process are essential, as these help to continuously evaluate the program and justify its sustainment. Within this semistructured framework, there is an overarching need for iterative adaptation based on the needs and resources of the local setting.

Supplementary Data

Supplementary materials are available at Open Forum Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.