Telemedicine services may include one-on-one interactions, consultations with a patient and family members (e.g., pediatric or elderly patients), examinations supported by a telemedicine presenter located with the patient. Specialty services (such as dermatology or orthopedics) may be provided, and each type of service may have specific needs for lighting and space to support the clinical function. Thus, it is important to know what services will be provided in the telemedicine space to achieve a functional design.
The ATA Human Factors Special Interest Group (SIG) suggests a larger context of “telepresence,” which is independent of the clinical content of the encounter. Telepresence is a synthesis of technology, environment, and human factors that encompasses the demeanor of the patient and provider along with quality of the encounter, including the ambient environment—lighting, sound/noise, and room appearance (Krupinski & Leistner, 2017).
Telemedicine requirements for the built environment were introduced in the 2018 Hospital Guidelines and Outpatient Guidelines. Requirements were included for the size of telemedicine spaces, privacy, acoustics, lighting, interior surfaces, site identification, and storage for equipment. Where low patient volume makes provision of a dedicated telemedicine room impractical, the FGI Guidelines stated a telemedicine room could also serve other functions such as a physician's office, exam room, or conference room (Facility Guidelines Institute, 2018b, 2018a).
As previously stated, it is important to note that the FGI requirements for telemedicine spaces are not intended to apply to virtual visits that do not require a physical examination of the patient or visits that originate from a physician’s or patient's home. However, with ads promoting how to “look your best” on video calls during the 2020 work-from-home lock downs, there are many strategies that are generalizable to a home setting (e.g., controlling glare, direct and indirect light).
Space for telemedicine should accommodate the patient, a family member and/or presenter, necessary furniture (e.g., chairs for the patient and family member, an exam table, a charting station) and equipment. According to the FGI Guidelines, where telemedicine is used for patient examination, the space must be sized so an exam table can be situated within view of the camera and the following can be accommodated: fixed or mobile telemedicine equipment, peripheral devices, an on-site caregiver or patient presenter, a hand-washing station where hands-on exams are provided, and a documentation area (Facility Guidelines Institute, 2018b).
The telemedicine room should be large enough for the patient and a patient presenter to move around comfortably for the clinical service being provided.
Additional considerations for sizing a telemedicine space in the FGI Guidelines are recommendations based on the guidance in the various reviewed sources. One of these is the proximity of the camera and microphone to the patient. The camera and exam table should be positioned so a presenter using and manipulating telemedicine peripherals can see both the patient and the monitor with images being transmitted to the remote clinician’s site (CTEConline, 2011). While some technologies (e.g. a laptop) may include embedded microphones, some organizations have opted for USB add-on omnidirectional microphones due to due to poor microphone quality on standard computers (Vilendrer et al., 2020). Space for microphones should be available in front of and close to the individuals speaking in the videoconference, ideally about 4' from the telemedicine workstation to prevent audio feedback (EMTN, 2018; PHSA, 2013). An omnidirectional microphone can be also hung from the ceiling (Krupinski et al., 2007).
The telemedicine room should be large enough for the patient and a patient presenter to move around comfortably for the clinical service being provided (CTEConline, 2011). For example, for a rheumatology examination that includes gait evaluation, the telemedicine space should be large enough for this activity to be captured by the camera (Krupinski, 2014).
Telemedicine spaces should be designed with speech and visual privacy based on the room’s clinical function (Belz et al., 2009; Krupinski, 2014). For privacy, the space must also permit arrangement of monitors, screens, or other image or data projections so they are not visible from outside the telemedicine space. Doors can be both a distraction and a privacy concern and should be out of view of the main camera to avoid perceptions that someone might “walk in” (Major, 2005; PHSA, 2013). A separate room is preferred, and while the Guidelines only address healthcare facilities, this is also considered good practice in homes where a patient may not have not disclosed a health condition to their family and might be overheard or where family in the background become a distraction (Almathami et al., 2020).
Telemedicine rooms must have an acoustic environment that facilitates speech intelligibility and communication (Facility Guidelines Institute, 2018b). Hard surfaces may result in echo, reducing audio quality. As a result sound-reducing materials such as acoustical ceiling tile and carpet should be considered (CTEConline, 2011; Krupinski et al., 2007; Major, 2005). Background noise levels in telemedicine rooms must be suitable for the clinical functions performed in the space. The room should be in a quiet location that minimizes exposure to background noise that can be picked up by microphones (CTEConline, 2011). For example, locations near open office areas, busy corridors, stairwells, parking lots, waiting rooms/areas, HVAC systems, and toilet rooms are unsuitable.
Additionally, a telemedicine room also must be designed for the sound isolation rating appropriate for its clinical function. In designing to achieve the minimum Sound Transmission Coefficient (STC) rating, consideration of all portions of the room envelope is recommended, including walls, floor/ceiling assemblies, doors, and glazing as well as field conditions that may affect the performance of those elements. Specific requirements for speech intelligibility, sound isolation, and background noise are outlined in the Guidelines.
According to the ATA, lighting is an underappreciated aspect of telemedicine encounters (Krupinski & Leistner, 2017). Given the recent focus on the importance of lighting for work-from-home video conferencing (Aten, 2020; Graham, 2020), including recommendations for “light kits” to improve appearance, awareness may have increased. However, lighting is more than “looks,” and proper lighting should ensure natural color rendition as well as even illumination levels. Lighting can contribute to clinical and social success and satisfaction in telemedicine, and should include both ambient or fill light (typically ceiling and wall-mounted) and point lighting (table lamps) to reduce shadows on participant faces (Krupinski & Leistner, 2017). Shadows (Figure 2) impact perception of skin tone, eye color, hair color, and facial expressions (Krupinski et al., 2007). While high-end cameras may have automatic gain and white point balance for correction, lower-end cameras might have limited tools to adjust image quality as lighting changes (Krupinski & Leistner, 2017) or to correct for any lighting problems (CTEConline, 2011).
All spaces intended for telemedicine services must allow direct frontal lighting (Major, 2005; Raymond et al., 2016). The use of both direct and indirect lighting also supports the creation of images with even lighting and accurately reproduced colors (CTEConline, 2011). If there is only one light source, the ATA Quick Guide to Telemedicine Lighting states it should be placed as close as possible and from same direction as the camera (Krupinski & Leistner, 2017). However, multiple light sources (both backlighting and fill lighting) are recommended, and the ATA Guide suggests a 60:40 ratio as the ideal balance of ceiling and wall lighting, while the California Telemedicine and eHealth Center (2011) recommends diffused light shining diagonally toward the patient to reduce shadows on the face caused by overhead lighting or a light source behind the patient or provider.
Full spectrum or warm, white light (3200–4000 K) is suggested (Krupinski & Leistner, 2017; Major, 2005; PHSA, 2013) with a minimum light level of 150 footcandles (Belz et al., 2009; Krupinski, 2014). Colored lighting (i.e., from lamp glass), as well as color inherent to the technology (e.g., narrow-spectrum blue light from an LED) should be avoided, although some specific clinical applications may call for colored room light (Krupinski & Leistner, 2017). Means for controlling glare from natural and artificial light sources is also required. For example, shades or blinds can reduce light and glare in rooms with windows (CTEConline, 2011). It should also be possible for clinicians and/or patients to avoid sitting in front of a window unless backlighting can be adequately addressed.
Eye contact is an important aspect of visual communication, but when using a webcam, perceptions of eye contact are affected by the location of the camera (Chen, 2002). In videoconferencing (and telemedicine), a webcam is typically positioned on top of the monitor or laptop screen. As shown in Figure 3, the resulting angle between the eye and the camera, and the eye and the center of the display, the visual target, is the gaze angle (Grondin et al., 2019; Tam et al., 2007).
Research has established that due to our perceptions, videoconference/web cameras should be placed above the screen monitor, preferably resulting in a gaze angle less than 5º (Chen, 2002). Additional research highlights that even what might seem like insignificant changes make a difference in our perceptions. For example, when Tam and colleagues (2007) studied differences in gaze angle, they found a lower angle (7º or less) resulted in perceptions that the subject was ‘happier,’ ‘warmer,’ ‘more approachable,’ ‘more confident,’ had ‘better rapport,’ was ‘more engaged,’ and more interested in what the observer had to say. At a higher angle (15º), perceptions were more negative with perceptions that the subject was ‘reserved,’ ‘shy,’ ‘timid,’ ‘sad,’ ‘depressed,’ ‘stoned,’ ‘lost,’ ‘hiding something,’ ‘not being forthcoming,’ looking through the observer, distracted by something, not focused/engaged in the conversation, and not giving full attention.
A more recent study tested the use of a gooseneck webcam mount to lower the webcam over the edge of the monitor screen, along with a slightly raised chair height (Grondin et al., 2020). Grondin and colleagues (2020) found this allowed a decrease in the gaze angle down to 2.5°, mitigating conditions of “downward tilting” eyes that result when the webcam is mounted in a traditional location. Camera placement can also be a barrier to communication. In one study, patients felt unheard and perceived that the provider was not paying attention due to lack of eye contact when the provider looked back and forth from the computer monitors (Gordon et al., 2020).
When using a larger freestanding monitor, this may mean greater viewing distances—for example, 4'11" for a 42" monitor up to 8'2" for a 65" monitor (Ben-Arieh et al., 2016). While a “passport” picture view (head and shoulders) is suggested for introductions, the camera may subsequently be adjusted (or zoomed in/out) for a better view of the body and any non-verbal cues (Ben-Arieh et al., 2016; Grondin et al., 2019; Nguyen & Canny, 2009).
The distance between walls determines the patient to camera proximity, and this may vary by service depending on desired “framing” (how much of the head and/or body is viewed): a full view of the patient and others, a view of the upper body to recognize non-verbal cues, or just the face (Raymond et al., 2016). In some specialties, such as dermatology, there may be a need for close-up and wider views for context (ATA Teledermatology Guidelines Work Group & ATA Practice Guidelines Committee, 2016). A small room can force the camera to be located too close to the patient, limiting the clinician view (CTEConline, 2011).
Virtual Urgent CareFraming of the view was found to be important in providing the desired “psychological” distance for both clients and therapists in telepsychotherapy (Grondin et al., 2020), as well as perceived empathy (Nguyen & Canny, 2009). The distance and range of view may influence other perceptions, as well. For example, the view of a desk in services such a telemental health is not universally accepted—some experts suggest the view of a desk can create a “buffer zone,” but others feel it may be perceived as an obstacle (Raymond et al., 2016).
The finishes and colors selected for a telemedicine space must be able to support the natural rendition of color and pattern. All sources referenced in the development of the text were consistent in finding that light to medium blue or light gray matte finishes (Figure 4) are best for proper color rendition and facilitating picture clarity (Belz et al., 2009; CTEConline, 2011; Krupinski, 2014; Major, 2005; PHSA, 2013). These shades are preferred because they offer minimal light absorption and light reflectivity (Belz et al., 2009). If a space is used for other functions, screens or curtains may be used to provide the appropriate background color or to hide clutter (Krupinski & Leistner, 2017).
The FGI Guidelines require the backdrop wall color to have a light reflectance value of 30-40%. To avoid glare and reflections, a surface finish rating of level 1 or 2 (flat finish) is recommended rather than a gloss rating of level 5 (semi-gloss) or 6 (gloss finish). Recommendations for avoiding glare and contrast include specifying light reflectance values for surfaces: 80-90% for ceilings, 25-45% for furniture, and 20-40% for flooring (Facility Guidelines Institute, 2018b).
Facility identification must be provided at the telemedicine site so it appears in the transmitted image unless such identification is embedded in the electronic telemedicine platform (Figure 5). This signage is sometimes required for reimbursement but is also helpful for reminding clinicians and patients where the person they are speaking with is based when telemedicine services are offered between multiple locations (Major, 2005; PHSA, 2013).
Secure storage is required for telemedicine spaces where portable equipment and peripheral devices (e.g., digital cameras, task lighting, EKG devices, etc.) are used (Krupinski et al., 2007; PHSA, 2013). Additional guidance for equipment used for telemedicine services includes provision of temperature controls based on the heat the electronic equipment may generate (Charness et al., 2011; CTEConline, 2011); this is also a consideration for the comfort of the patient who may be unwell. Depending on the complexity of equipment used, multiple outlet types (e.g., phone, data, power) may be required (CTEConline, 2011). Locating required outlets near any equipment will mitigate the risk of hazards such as cords and cables across the floor (Charness et al., 2011). Finally, select and install telemedicine equipment to facilitate cleaning and support infection prevention practices (Krupinski et al., 2007).
“Telehealth is not about technology, it’s about people” (Martínez-Alcalá et al., 2013). Telemedicine and telehealth have evolved quickly over the past few years, and notably, the past several months, suggesting this aspect of healthcare will now be accepted more than ever as the “new” way of doing business. As technology advances and organizations become more familiar with platforms and service options, minimum built environment standards to support these practices may need to be refined.
Language in the FGI Guidelines has been established with a small amount of verbiage as required minimum standards and more extensive recommendations in the appendix, allowing flexibility for organizations to ascertain their own level of need based on services rendered. As the industry evolves and more evidence is made available, some design requirements may also evolve with practice guidelines. However, while remote communications via electronic equipment can be a necessary supplement to in-person care, especially in a pandemic context, the design of telemedicine spaces should facilitate natural communication for the widest range of participants, including elderly patients, those unaccustomed to electronic communication, and those with vision, hearing, or cognitive impairments. Designing spaces used for telemedicine communications should always strive to maintain the level of safety, privacy, quality of care, and patient experience that would be expected for that same communication when it takes place in person.
Language in the FGI Guidelines has been established with a small amount of verbiage as required minimum standards and more extensive recommendations in the appendix, allowing flexibility for organizations to ascertain their own level of need based on services rendered. As the industry evolves and more evidence is made available, some design requirements may also evolve with practice guidelines. However, while remote communications via electronic equipment can be a necessary supplement to in-person care, especially in a pandemic context, the design of telemedicine spaces should facilitate natural communication for the widest range of participants, including elderly patients, those unaccustomed to electronic communication, and those with vision, hearing, or cognitive impairments. Designing spaces used for telemedicine communications should always strive to maintain the level of safety, privacy, quality of care, and patient experience that would be expected for that same communication when it takes place in person.
The College recognizes the role virtual care plays and will continue to play in the provision of medical care to Nova Scotians.
The medical profession is still learning about the strengths and limitations of virtual care. The decision by a physician to provide virtual care requires an exercise of professional judgement considering the circumstances and condition of the patient.
The regulation and provision of virtual care is quickly evolving. The College will be revisiting this standard on a regular basis to keep pace with this evolution.
Physicians licensed in Nova Scotia who deliver virtual care to Nova Scotians are subject to the regulation of the College, irrespective of where the physician is located.
Physicians licensed in Nova Scotia who deliver care into other jurisdictions in Canada will be held to the standards of that jurisdiction, while subject to the regulation of this College.
Physicians licensed elsewhere in Canada who deliver virtual care into Nova Scotia will be held to Nova Scotia standards but subject to the regulation of their licensing authority.
1. offer virtual care to patients only in conjunction with in-person care, not as an absolute alternative to in-person care;
2. coordinate their clinical schedules so that patients have reasonable access to either in-person care or virtual care as required;
Physicians are encouraged to review the College’s Professional Standards and Guidelines Regarding Informed Patient Consent to Treatment. In addition to the requirements of this document, the patient-consent process for virtual care services must ensure the following information is reviewed by the patient:
