What is the difference between a policy, procedure and a protocol? It is always a best practice to develop written policies, procedures and protocols for your telehealth operations. Here you will find helpful tips and examples to help you as you develop them for your practice.

Policies define your practices' position on what you plan to do, why you plan to do it and what laws, codes of ethics, guiding principles and/or values define and shape your policy decisions.

Procedures describe how a policy will be put into action across all aspects of your program operations. Procedures define roles and responsibilities regarding things like who will do what, what forms will be used, what will need to be documented, and any limits to professional discretion. You will want to develop procedures regarding the scheduling of telehealth visits, paperwork and documentation requirements, when and how to make referrals for lab tests, etc.. For example, if a patient calls to cancel an appointment because they don't have transportation or perhaps are want to mitigate exposure to a viral outbreak, who will they be speaking with when they call? Will that person offer the patient the option of a telehealth visit? If your policy is to only schedule urgent care issues via telehealth and not routine wellness checks, then what will staff need to look for (e.g., appointment.visit type) or will they simply ask the patient to determine if the scheduled visit was urgent vs. non-urgent?  In most cases, procedures help to shape the development of workflows.

  • As an example, the American Telemedicine Association has developed Operating Procedures for Pediatric Telehealth.
  • Some procedures related to roles and responsibilities are included in things like job descriptions.  The California Telehealth Resource Center has put together Sample Telemedicine Job Descriptions.
  • The National Association of Medical Staff Services in collaboration with the American Telemedicine Association has developed Credentialing by Proxy: A Guidebook to assist healthcare facilities with their policies and procedures around credentialing telemedicine providers.

Protocols define particular sets of operating procedures and go hand-in-hand with Developing Workflows.   They are therefore frequently accompanied by workflow diagrams. Protocols define the order of operations and the specific tasks and expectations, serving as a formal agreement and commitment between two or more parties within and/or outside the organization.

Samples and Templates:

  • The Northwest Regional TRC has developed a Telehealth Policy and Procedure Starter (a template that serves as a starting place for building your organization's written policies and procedures).
  • This Sample Telehealth Policies and Procedures includes protocols and workflow diagrams and was developed by an actual health care organization as they were scaling their operations in response to COVID-19.  They have given us permission to strip the identifiers and to share!  Please only use this as a template since this was developed during the COVID-19 Public Health Emergency where there were many flexibilities with telehealth policies that are no longer in place.
  • The California TRC also has Sample Clinic Telemedicine Policies and Procedures as shared by the North Country Telemedicine Pilot Program available on their website for download.
  • AHIMA has developed this Sample Policy and Procedure Template.