R1 EOR Telehealth (Wk 1)

Can you guess the total average time a patient spends at the doctor's office for an in-person visit?

120 minutes

Patients spend ?? minutes face-to-face with the physician and an average of ?? minutes at the visit as a whole

20, 121

Telemedicine

A subset of telehealth that refers solely to clinical health care services

Tele-toxicology

Audiovisual streaming technologies are used for remote patient assessment to accelerate triage and facilitate management of poisoned patients. For example, a physician at a remote site can wear Google Glass® and transmit secure real-time audio and video of the physical examination of a poisoned patient and concurrently transmit high-resolution still photos of electrocardiograms to a consultant at a distant poison control center

Which of the following medications can she prescribe during a telemedicine visit?

Azithromycin, Duloxetine, Acetaminophen with codeine (CANNOT)

How telehealth can be used

Can be used in both ambulatory and hospital-based setting

Components needed for any telemedicine system: Reliable and speedy internet connection

Check download and upload speed

Telemed can be used in:

Chronic care management: The Veterans Affairs (VA) health care system found that the use of Telehealth led to reduced utilization of inpatient care. In 2016, veterans enrolled in home telehealth for chronic care management had a 59% decrease in VA bed days of care and a 31% decrease in VA hospital admissions. Long-term care: Telemedicine is being used in long-term care facilities to deliver care to their residents. This is of particular interest to these facilities because they operate with slim operating margins driven by a predominance of medical coverage by Medicaid. One telebehavioral health program in long-term care facilities was able to offset costs and revenues in the first year, and garner a significant positive margin in its second year and every year thereafter

Which of the following health care payers/insurers cover telemedicine services?

Medicare and state-based Medicaid, Commercial plans

Setting up a telemedicine visit

Meeting host, Informed consent, Confidentiality, Optimizing webside manner, Optimize communication skills, Convey empathy, Optimize your interactions

Four factors to consider for patients covered by Medicare:

Modality: Must be real-time audiovisual visits between a patient and health care provider. Distant provider: Can only be one of the following - physician, advanced practice provider, psychologist, licensed clinical social worker, registered dietician. Patient location: Qualifying rural or underserved area including: rural census tract, health professional shortage area (HPSA), region located outside metropolitan statistical area. Care site: Most be one of the following: hospital, physician's clinic, skilled nursing facility, federally qualified health center

Lack of technical knowledge to integrate telemedicine services

More and more physicians are receiving training during medical school or residency, or undertaking self-education such as offered in this module. Telemedicine vendors can offer educational support as well

According to several recent studies, what percentage of patients were satisfied with their Telemedicine visits?

More than 90%

Is there a difference in antibiotic prescribing practices between patients seen by telemedicine versus those seen in person for acute respiratory infections?

No

Which of the following statements regarding remote patient monitoring (RPM) is correct?

RPM devices can promote engagement in their own health

Visual acuity

ask the patient to download an eye chart application on his phone

Reactivity of pupils

ask the patient to use a flashlight or light on cell phone on own eyes

Health care innovation award:

awards to organizations

Failure to consult a physician from a different specialty if necessary

both telemedicine and in-person care

Incorrect diagnosis

both telemedicine and in-person care

Incorrect interpretation of data or images

both telemedicine and in-person care

Poor communication resulting in a patient's failure to take next steps

both telemedicine and in-person care

be aware of...

cultural competency and demographics or the patient and provider

ALWAYS have plan for ...

emergencies

first minute is crucial for...

establishing relationship and rapport

Patients perceive poor quality of care in telemedicine visits

The concern about poor-quality health care is most often raised by patients who have never experienced a telemedicine visit

State Innovation Model:

funding to advance multi-payer payment and delivery system reform models.

remote patient monitoring examples:

glucose, ecg, eeg, HR, watches, etc to help increase data collection and pat participation

Which of the following is considered best practice when using telemedicine to provide high-level care for patients?

have a plan incase of a medical emergency during the visit

Check if your state limits patient setting to any of the following -

home, doctor's office, school, hospital

Bone fractures

in person care

Crushing chest pain

in person care

Lacerations requiring intervention

in person care

Neurologic changes concerning for a stroke

in person care

Significant shortness of breath

in person care

Extraocular movements

instruct the patient to move his eyes

Patients lack of access to reliable internet or cellular access

The digital divide is shrinking as more Americans gain access to broadband internet services

Injection, icterus, symmetry

observation

Patient setting is also known as...

originating site

In which of the following scenarios is it appropriate for a physician to provide a telemedicine visit to her patient? Select one best answer.

The physician uses the Ottawa Ankle Rules to triage a patient who has injured his ankle.

Check if your state limits health care provider to any of the following types -

physician, physician assistant, nurse practitioner, licensed mental health professional, occupational therapist, speech therapist, psychologist, dentist

Approx.. 1/3 of states...

reimburse for telemedicine encounters

There are a number of factors to consider when choosing the technology for a telemedicine platform. There are a few that are considered "non-negotiable." These include ease of use, reliability and _______

security

ending appt:

share new diagnosis, assure pt, review plan, education

Components needed for any telemedicine system- The platform vendor must...

sign a business associate agreement (BAA) with the health care provider, committing to be responsible for keeping your patient information secure and reporting security breaches involving personal health care information. Avoid a vendor that does not sign a BAA

This type of telehealth most closely resembles an in-person appointment

synchronous telemedicine

Back pain

telemedicine

Headache

telemedicine

Mild respiratory symptoms

telemedicine

Skin conditions and rashes

telemedicine

Sprains and strains

telemedicine

Urinary symptoms

telemedicine

Addressing a complaint such as acute chest pains by telemedicine

telemedicine only

Performing an incomplete physical exam due to audio/video limitations

telemedicine only

Ryan Haight Online Pharmacy Consumer Protection Act of 2008 requires...

that providers who wish to prescribe a controlled substance must first conduct an in-person examination on the patient or meet one of seven narrowly defined exceptions

It is best to match the use of in-person or telemedicine visits to...

the type of visit and to patient's preference

Telemedicine involves...

the use of electronic communications and software to provide clinical services to patients without an in person visit. May be offered in live, synchronous format, or store-and-forwards, ,asynchronous format

Home- and Community-Based Services (HCBS) Waiver:

to provide long-term care services in home and community settings.

neither are suppose to record the appointment (t/f)?

true

when communicating,

verbalize extra and explain more thoroughly

Check if your state limits technology to any of the following types -

video, store-and-forward, remote patient monitoring

Telehealth

The remote delivery of health care services and clinical information using telecommunications technology to improve a patient's health. This includes a wide variety of clinical services using internet, wireless, satellite, and telephone media

Remote patient monitoring

Tracks patient's data from their home, third-party care facility, or a remote diagnostic testing facility for interpretation. Data can be collected from wearable devices, passive sensors, or other peripherals. Data are collected and monitored by medical professionals more frequently than for asynchronous telehealth. Such applications might include a specific vital sign, such as blood glucose or heart electrocardiogram, or a variety of indicators for homebound patients

In contrast, among patients who have experienced at least one telemedicine visit, a majority feel that the quality of care via telemedicine is the same as that provided at in-person visits. In some cases, patients feel that the quality of telemedicine visits is superior to that of in-person visits (T/F)

True

The delivery of medical care through telemedicine in the ambulatory setting is generally felt to put physicians at low risk of professional liability.

True

Ideas for workflow changes

Utilizing telemedicine. Consider how you plan to utilize your Telemedicine program in terms of timing of use during each day, types of conditions that you will treat, types of appointments, and types of patients who can optimize the use of this interaction medium.

Potential wins for fellow physicians and other clinicians from a well-implemented Telemedicine program:

Flexible practice options: Improves the ability for physicians to utilize flexible practice options such as extended or weekend hours. Fill vacant spots: Practices are able to use telemedicine to fill vacant slots created by last-minute cancellations or no-shows. Reduce overhead expenses: Practices are able to reduce practice overhead expenses by extending practice hours without the need for office staff. Patient retention: Physicians find satisfaction in the ability to retain patients who might otherwise migrate to other office-based or telemedicine providers, or possibly increased market share

Tele-infectious disease

Health systems with a shortage of onsite infectious diseases specialists are using virtual care platforms to overcome this barrier. Remote consultation using videoconferencing has slowed the need to transfer patients to other hospitals for care. In addition to the management and treatment of patients, wound evaluation and antibiotic stewardship are tackled using this technology.

Certain subgroups of patient are unwilling to embrace telemedicine

A growing portion of older patients are demonstrating interest and ability in the use of technology, including telemedicine

Tips to limit professional liability when utilizing telemedicine:

Adhere to the same standard of care in telemedicine as for face-to-face visits, Establish a patient-physician relationship before the visit, Ambulatory physicians may choose to limit Telemedicine-based care to low-acuity cases and follow-ups of chronic medical problems, Physicians should escalate appropriate cases to in-person care, Physicians should ensure accurate documentation of the care in their electronic health record or Telemedicine platform. They should record indications for the use of the Telemedicine modality, patient consent to the use of Telemedicine, the modality used, the patient history and findings, clinical decision-making, and patient education.

Synchronous telemedicine

Also known as real-time/live videoconferencing. Enables clinicians and their patients to communicate remotely using desktop or mobile video, kiosk, telephone, or emerging modality such as chat bot or voice assistant

Asynchronous telemedicine

Also known as store-and-forward. Transmits data such as vital signs, diagnostic images, and/or video clips to healthcare professionals for later use. This type of telehealth uses data collected from wearable devices, passive sensors, or other peripherals to help inform clinicians' decisions during diagnosis and treatment

Another patient of Dr. Ahmed's clinic calls in for an urgent appointment at 4:45 pm. The patient has just returned from a hike and feels pain in her right ankle. She is concerned it is a sprain or fracture. Unfortunately the patient needs to wait for her neighbor to drive her to the clinic and won't arrive until at least 5:30 pm. The clinic is scheduled to close at 5:00 pm. Dr. Ahmed wants to take care of her patient but she does not want to require her office staff to stay past the clinic's closing time. Dr. Ahmed determines she has the following options. Which one should she choose

Arrange a telemedicine visit with her patient

Dr. Ahmed determines she has the following options. Which one should she choose?

Arrange a telemedicine visit with her patient

Dr. Ahmed wants to ensure that her telemedicine vendor has robust cybersecurity protections in place. What are some questions that she should ask?

Compliance with laws: Does the vendor operate in accordance with all applicable laws such as the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH). How will a data breach be handled? Network access control: If she is planning to use mobile devices such as tablets or smartphones to deliver Telemedicine care, then she should ask the vendor if they have a Network Access Control solution. This solution should be able to identify and track each mobile device that connects to the Telemedicine platform. Furthermore, she should ask if the vendor utilizes microsegmentation processes to restrict access only to the data that are necessary to provide patient care. Firewalls: Because multiple applications are often needed to create the patient-physician connection, does the Telemedicine platform have built-in web application firewalls to protect against areas of vulnerability in the applications?

Mobile health (mHealth)

Consumer medical and health information includes the use of the internet and wireless devices for consumers to obtain specialized health information and online discussion groups to provide peer-to-peer support

Components needed for any telemedicine system- Documentation of the visit

Dedicated office site for telemedicine visits

fully integrate data to...

EHR of pt

Components needed for any telemedicine system- HIPAA compliance

Ensure that there is 128-bit encryption at a minimum and password protection is required

Appointment scheduling

Ensure that your appointment scheduler understands the Telemedicine appointment scheduling parameters. Designate these visits as "Telemedicine consultation" visits on your schedule, and ensure that the patient receives the appropriate electronic meeting invite information.

Dr. Ahmed's next patient of the day is in for a preoperative evaluation. He is a 65-year old man preparing to undergo knee replacement surgery. He would like to return home on postoperative day 1 instead of being transferred to a skilled nursing facility. As part of his discharge plan, the surgical team has scheduled a Telemedicine visit for his follow-up on postoperative day 2. Although the patient is happy he would not have to travel for the appointment, he expresses concern to Dr. Ahmed about the feasibility of the surgeon to take care of him via a Telemedicine visit. Which of the following would be the best response to the patient's question?

In this particular situation, the surgeon can definitely provide the same level of care through a telemedicine visit as an in-person one

Some barriers that need to be overcome in order to set up a tele-infectious disease program:

Institution-specific credentialing, State licensure, Reimbursement model, Medical records

Tele-intensive care unit

Intensive care physicians and other clinical resources are housed in central care facilities. Audiovisual conferencing and real-time streaming of patient information are utilized to allow these physicians to communicate with bedside staff at remote hospitals to partner on patient care. Tools such as electronic stethoscopes, ophthalmoscopes, and otoscopes that are operated by a bedside nurse or aide are often utilized

Tele-stroke

Interactive videoconferencing technologies are utilized for the treatment of patients with acute stroke. This is usually set up as a distant site-and-originating site program. A comprehensive stroke center typically serves as the distant site primary medical center. The patients physically receive their care at smaller regional hospitals and emergency departments, which serve as the originating site

What are some positive aspects about this setting?

It is a private room ensuring that she can maintain her patients' privacy, It is an uncluttered environment, It has a clean light-colored background wall, It would be quiet and have no background noise, Simple user interface

The inability to conduct a physical examination in telemedicine

It is possible to conduct several aspects of a physical examination through a telemedicine visit, including visualization of areas of the body and patient self-palpation

In other situations, patients can be directed toward in-person care

Lack of confidence in safety and security of virtual care, Appropriate HIPAA compliance and cybersecurity protection must be undertaken

Components needed for any telemedicine system - Audio/video device

Laptop, desktop, smartphone/tablet, headset/headphones, external speakers, external microphone

note limitations of...

PE and other sense cues. vitals, ENT, skin, neck easier, lung, heart, abdomen, musculoskeletal w/ help of caregiver

Which of the following components of a physical examination can be conducted in a telemedicine visit with the assistance of the patient?

Palpation of areas of tenderness, Assessment of range of motion, Visualization oropharynx

There are three main factors to consider for patients covered by Medicaid:

Patient Setting, Technology Used, and the Types of Health Care Providers utilizing Telemedicine to deliver care.

Barriers:

Patients prefer in-person interactions with their physicians, A growing group of patients are seeking the convenience that telemedicine affords them, especially for low-acuity urgent complaints. However, for more serious issues, including the delivery of bad news, patients still prefer in-person visits

Which of the following behaviors will enable optimal patient-physician communication during a Telemedicine visit? Select one best answer.

Periodically looking directly as the web camera of the computer or tablet

Physician must carry a valid license to practice medicine in the state in which the patient is located at the time of the visit

Prescribing medications

Documentation of the visit

Requirements are the same as for a face-to-face encounter in that you need to document relevant history, review of systems, consultative notes, and any information used to make a medical decision. In addition you should include the following: That the service was provided through telemedicine, including the modality, location, and persons providing the service, Why the service was done through telemedicine as opposed to an in-person visit, That the patient gave informed consent for the use of telemedicine for this visit

Potential advantages to the utilization of telemedicine in this setting includes the ability to:

Reserve face-to-face visits for only the sickest patients or those who absolutely must receive in-person care, and thereby reduce wait times for time-sensitive care, Keep at-risk or mildly symptomatic patients with infectious diseases or stable patients with confirmed diagnoses at home while they receive evaluation and medical care, thus limiting their interactions with other patients in waiting rooms or other communal settings, and thus decreasing the risk of person-to-person transmission, Educate large numbers of patients and caregivers on public health initiatives, Minimize unnecessary direct contact between physicians and other health care staff and patients in order to keep the health care workforce safe., Allow physicians who are symptom-free, but who need to remain in quarantine, to continue to provide patient care remotely., Relieve strain on the local health care workforce by substituting clinical care from remote healthcare providers., Permit front-line physicians to consult with specialists, eg, in infectious diseases or pulmonology.

Improved Access to Clinical Care

Rural location, Transportation, Timely access, Continuity of care, Low-acuity conditions, Specialty care, Inter-professional team, Follow-up care

How do you get "curbside" opinions from other physicians? Can you think of how Dr. Ahmed can use Telemedicine in this situation?

Take photographs of the skin lesion, Transmit photographs to dermatologist, Dermatologist reviews the photographs

Step 1:

What is the problem you are planning to address by introducing clinical care through Telemedicine? Why is it important? What is your current state of clinical care? Who is on your team? Can you create a specific, measurable, achievable, relevant, and time-bounded (SMART) goal for this project?

Which of the following trigger questions will allow a clinical team to brainstorm ideas for the step of identifying how to measure change? Select one best answer.

What metrics describe our baseline goal?

Step 2:

What metrics describe your baseline and goal? This can be as simple as "Zero Telemedicine visits at baseline; Goal of 10 Telemedicine visits per week by the end of Month 1."

Step 4:

What workflow changes will you implement? How will you assess success and opportunities for improvement of your telemedicine program? How will you ramp up your telemedicine program?

Step 3:

Which stakeholders do you have to engage to make your Telemedicine program launch a success? What barriers do you anticipate?How will you overcome them? What technology and workflow changes do you anticipate?

Dr. Ahmed's next patient has been under her care for many years. The 72-year-old man has had heart failure with reduced ejection fraction for the past 3 years. He lives in a rural area, a 2-hour drive from Dr. Ahmed's office. He relies on his daughter for rides to the clinic. Dr. Ahmed examines him and finds that he has 2+ pitting edema. After a review of dietary choices, medications, and overall treatment plan she increases his diuretic dose. Dr. Ahmed needs to schedule a follow-up visit with the patient to assess his response to the new dose. Would a telehealth appointment be appropriate for the follow-up visit?

Yes

Dr. Ahmed's next patient is in for a follow-up visit. He is a 42-year old man with persistent shortness of breath. After a series of visits and a stepwise approach to testing and evaluation, Dr. Ahmed feels that the patient will benefit from a consultation visit with a cardiologist. The cardiologist is located at the University Medical Center an hour's drive away. Dr. Ahmed's staff schedules a Telemedicine visit for the patient with the cardiologist. Do you agree with the decision of Dr. Ahmed's staff to schedule a telemedicine visit for this particular situation?

Yes, this situation is well suited for a telemedicine visit. Furthermore, by conducting the visit in Dr. Ahmed's office, she can help answer ant medical questions the cardiologist may have and be a part of constructing the treatment plan

If this patient is away at college in a different state, is it feasible for Dr. Ahmed to take care of this patient in a telemedicine visit?

Yes, under a specific condition

Intersperse Telemedicine visits into your daily schedule.

You can offer Telemedicine visits in the evenings or weekends to patients who cannot come in during weekdays due to their work schedule limitations.

Consider scheduling change options:

You can set aside a portion of your day that you know from past experience is typically slow (eg, Wednesday afternoons).

Medicare-Medicaid Dual Eligibles:

a capitated model in which the Centers for Medicare & Medicaid Services (CMS), the state, and a health plan collaborate to provide comprehensive and coordinate care.

The system should keep...

a record of the visit, how much time was on screen, etc - this record plus the office notes with ensure that possible auditors will get what they need to justify the virtual visit