This Telehealth Tuesday article was written by Trevor Cunningham, a telehealth consultant on the Ingenium Team.
This article is the second in our three-part Telehealth Tuesday series on building strong, scalable telehealth policies. In last week’s piece, we explored why maturing healthcare organizations must transition from ad hoc virtual care guidelines to purpose-driven telehealth strategies. We examined the risks of “makeshift” policies and outlined the hallmarks of a truly strategic framework.
This week, we’re moving from the why to the what — breaking down the 6 essential building blocks of a high-functioning telehealth policy. If your organization is ready to elevate your policy from reactive to resilient, these are the components that should be front and center.
The Anatomy of a High-Functioning Telehealth Policy
In the early days of the pandemic, the phrase “We need a telehealth policy” often signaled urgency rather than strategy. Organizations scrambled to put something — anything — on paper. At that time, necessity outweighed nuance. Understandably, many teams were forced to improvise, crafting virtual care protocols on the fly as healthcare delivery transformed overnight.
But today, as hybrid care cements its role in modern healthcare, temporary fixes are no longer enough. A telehealth policy can’t be a forgotten PDF buried in a shared folder. It must be a living framework — one that reflects not only regulatory compliance, but your organization’s values, workflows, and clinical priorities. When done well, it sets the tone for professionalism, promotes patient safety, reduces liability, and fosters consistency across care teams.
So what separates a solid policy from a merely passable one? What does it take to move from reactive documentation to a proactive playbook?
Let’s take a closer look at six core components every healthcare organization should consider — along with real-world examples and practical strategies for implementation.
(1) Professionalism and Presence — Redefining Webside Manner
Professionalism is often assumed in traditional care settings — but in virtual care, it must be explicitly stated. Without a shared understanding of what professionalism looks like through a webcam, clinician behavior and patient experience can vary wildly.
Consider dress code: A strong telehealth policy should clearly require that clinicians adhere to the same dress standards virtually as they would in person. This might mean white coats, business attire, or branded scrubs — but it definitely doesn’t mean gardening or work out clothes.
Environment matters, too. Clinicians should be in quiet, private spaces with neutral backgrounds, appropriate lighting, and minimal distractions. No one should be taking a call from a moving vehicle or a kitchen table mid-laundry.
To ensure consistency, some organizations have adopted clinician checklists covering camera angles, lighting, posture, and audio setup. Others use brief training modules to reinforce virtual etiquette. These simple steps reinforce patient trust and build a more equitable care experience — especially for first-time telehealth users.
(2) Informed Consent — Beyond the Checkbox
Informed consent is more than a regulatory requirement — it’s an opportunity to establish transparency and trust.
Forward-thinking telehealth policies go beyond requiring a signature. They call for verbal consent at the start of each visit, even if written documentation already exists. This verbal acknowledgment serves two purposes: it reinforces patient understanding, and it reminds clinicians to slow down and orient the patient to the virtual setting.
Effective policies also outline how consent should be documented. One community health clinic, for example, trains staff to begin every virtual note with: “Patient provided verbal consent for today’s telehealth visit.” Embedding this language into EHR templates or smart phrases ensures consistency and reduces documentation gaps.
Don’t forget to address what happens if the visit cannot proceed—whether due to technical issues or a clinical need for in-person care. Setting expectations up front reduces patient confusion and supports appropriate triage.
(3) Technology Standards — More Than Just the Platform
Choosing a HIPAA-compliant telehealth platform is essential — but policy should go further by clarifying how and when technology is to be used.
This includes:
🔹 A list of approved platforms, ideally with a smooth integration into the clinician schedule
🔹Fallback protocols — such as defaulting to a phone call after five minutes of unresolved technical issues
🔹Clear guidance on device security, including restrictions on personal device use unless secure, encrypted apps are in place
Why does this matter? Because technical inconsistency is a fast track to clinician frustration and patient dissatisfaction. A well-defined tech section eliminates ambiguity and protects the integrity of your virtual care experience. Standardization is quality’s best friend!
(4) Billing and Reimbursement — Because Clarity Is Kindness
Vague billing guidance is a hidden liability in many telehealth policies. Without clear direction, clinicians may under-document, coders may misinterpret, and organizations may miss out on legitimate reimbursement.
Your policy should specify:
🔹Which services are eligible for telehealth billing, including payer and modality-specific differences
🔹Appropriate modifiers and place-of-service codes
🔹Documentation requirements to support audit readiness
This isn’t just about revenue integrity — it’s about giving clinicians and billers the clarity they need to operate with confidence.
(5) Clinical Guidelines — Ensuring the Right Fit
At the heart of appropriate telehealth delivery is a simple principle: right patient, right modality, right time.
Your policy should help clinicians make that determination by providing:
🔹A modality matrix — outlining which visit types are suitable for video, phone, or need in-person encounters
🔹Escalation protocols for redirecting patients to urgent care, the ED, or in-person visits based on red flags
🔹Decision support tools, such as screening questions or triage flowcharts
One FQHC developed a scheduling flowchart for front desk staff, enabling them to direct patients to the appropriate modality without delay. The result? Smoother scheduling, better clinical outcomes, and fewer last-minute reschedules.
(6) Licensure and Scope of Practice — Practicing Telemedicine with Confidence
As telehealth expands across state borders and to different clinicians, licensure policy must keep up. The best policies clearly define by whom and where care can be delivered based on both clinician licensure and patient location.
Other key elements include:
🔹A process for tracking temporary waivers or participation in interstate compacts
🔹Guidance on malpractice coverage for virtual care across jurisdictions
🔹Defined responsibilities for monitoring changes in licensure laws
Ambiguity in licensure can expose organizations to risk. A proactive policy ensures both compliance and continuity of care.
Evolving the Policy — From Static Document to Living Resource
A great telehealth policy is not a one-and-done project. It should grow alongside your organization, shaped by regulation, technology, and user feedback.
Consider these best practices:
🔸Review annually, or more often when legal or reimbursement changes occur
🔸Incorporate clinician and patient feedback into revisions
🔸Share policy in multiple formats: full documentation, one-page reference guides, and training slides
Your telehealth policy should be more than compliant—it should be cultural. When policies reflect how your organization shows up for patients, they move from bureaucracy to belonging.
Final Thought: Culture, Codified
At its core, a telehealth policy isn’t just a list of do’s and don’ts or a training manual. It’s a declaration of your organization’s commitment to appropriate, high-quality, and consistent care — regardless of the clinician.
This second article in our series is all about putting structure behind your vision. And next week, we’ll take it one step further: How do you bring your policy to life in your operations? We’ll explore how to embed telehealth standards into workflows, training, compliance audits, and continuous improvement efforts.
So ask yourself: Does our current policy reflect where we’ve been—or where we’re going?
If the answer feels uncertain, now is the time to revisit, refine, and reimagine. Because in the evolving landscape of hybrid care, a well-crafted policy isn’t just a legal safeguard — it’s a leadership tool.
Need a fresh set of eyes on your policy? Let’s work together to strengthen your framework for the future of care. Set up a complimentary call with us to explore how.
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Christian Milaster and his team optimize Telehealth Services for health systems and physician practices. Christian is the Founder and President of Ingenium Digital Health Advisors where he and his expert consortium partner with healthcare leaders to enable the delivery of extraordinary care.
Contact Christian by phone or text at 657-464-3648, via email, or video chat.
