Welcome to the Clinical Center Grand Rounds,
a weekly series of educational lectures for physicians and
health care professionals broadcast from the Clinical
Center at the National Institutes of Health in
Bethesda, MD.
The NIH Clinical Center is the world's largest hospital totally
dedicated to investigational research and leads the global
effort in training today's investigators and discovering
tomorrow's cures.
Learn more by visiting us online at http://clinicalcenter.nih.gov
>>OUR SPEAKER TODAY IS
DR. PANEEZ KHOURY.
A SENIOR CLINICIAN AND EXPERT ON
DISORDERS AT THE NATIONAL
INSTITUTE OF ALLERGY AND
INFECTIOUS DISEASES.
DR. KHOURY EARNED HER MEDICAL
DEGREE FROM THE ILLINOIS OF
CHICAGO AND COMPLETED AN
INTERNAL MEDICINE RESIDENCY AT
THE OHIO STATE UNIVERSITY.
SHE HOLDS A MASTERS OF HEALTH
SCIENCES FROM DUKE UNIVERSITY
SCHOOL OF MEDICINE AND BOARD
CERTIFIED IN BOTH INTERNAL
MEDICINE AND ALLERGY IMMUNOLOGY.
DR. KHOURY TRANSITIONED TO
BECOME A STAFF CLINICIAN AND IS
CURRENTLY A SENIOR CLINICIAN FOR
THE LABORATORY OF ALLERGIC
DISEASES AND HEAD OF THE
CLINICAL RESEARCH UNIT IN THE
LABORATORY OF PARASITIC
DISEASES.
AS HEAD SHE PERFORMS RESEARCH IN
CONDITIONS INCLUDING HYPER --
SYNDROMES, GRANULAR --
GASTROINTESTINAL DISORDERS AND
DEVELOPMENT OF PATIENT CENTER
OUTCOME AND QUALITY OF LIFE FOR
PATIENTS WITH THESE DISORDERS.
DR. KHOURY HAS BEEN THE PROGRAM
DIRECTOR FOR THE PROGRAM SINCE
2019 WHERE SHE HAS DESIGNED THE
CURRICULUM AND PROGRAMS FOR
FELLOWS IN TRAINING.
DR. KHOURY IS INVESTED IN
BLENDING HEALTH EQUITY JUSTICE
AND INCORPORATING PRACTICAL
SOLUTIONS INTO HER CURRICULUM
AND SHE IS PASSIONATE ABOUT THE
INNOVATION EDUCATION
INCORPORATING ADULT LEARNING
THEORY AS WELL AS CREATIVE
SOLUTIONS TO NEEDS FOR TRAINING
DURING A PANDEMIC.
WHETHER IT BE TRAINING IN
TELEHEALTH OR INCORPORATING
STIMULATION AND FRAMEWORKS FROM
TEACHING ABOUT AUGMENTED
INTELLIGENCE INTO THE PROGRAMS.
DR. KHOURY SERVES AS THE CHAIR
AND IS A MEMBER OF THE NIH STAFF
CLINICIAN COUNCIL.
HER EXTERNAL ACTIVITIES INCLUDE
INVOLVEMENT IN MANY ASPECTS OF
THE AMERICANA ACADEMY OF ASTHMA,
AND IMMUNOLOGY INCLUDING THEIR
LEADERSHIP INSTITUTE.
SHE SERVES ON THE BOARD AND IS
THEIR SOCIAL MEDIA CHAIR.
THE TITLE OF DR. KHOURY'S
PRESENTATION IS LEVERAGING
TELEHEALTH FOR OPTIMAL TEAM
BASED CARE CLINICAL RESEARCH AND
EDUCATION.
PLEASE JOIN ME IN WELCOMING
TODAY'S SPEAKER DR. PANEEZ
KHOURY.
>>THANK YOU VERY MUCH FOR
THAT NICE INTRODUCTION
THANK YOU FOR INVITING ME
DR. BURKLOW.
I HAVE NO DISCLOSURES TO REPORT.
AND SO OUR LEARNING AND
STRATEGIC OBJECTIVES TODAY ARE
TO UNDERSTAND TELEHEALTH USE IN
THE GENERAL HEALTH CARE CONTEXT.
TO INCORPORATE TEAM BASED CARE.
AND TO LEVERAGE TELEHEALTH USE
IN MEDICAL EDUCATION.
SO ULTIMATELY WHAT I WANT YOU TO
LEAVE HERE WITH TODAY IS A
BETTER UNDERSTANDING OF HOW TO
LEVERAGE TELEHEALTH IN YOUR
PRACTICES AS WELL AS HOW FACULTY
AND LEARNERS CAN INTERACT BETTER
IN THE TELEHEALTH ENCOUNTER AS
WELL AS WHAT COMPARES SEES ARE
REQUIRED BY * BOTH FACULTY
RECEPTORS AS WELL AS LEARNERS TO
BE ABLE TO USE THIS TECHNOLOGY
APPROPRIATELY.
SO THIS GRAPH DEMONSTRATES THE
CLAIMS FROM JUNE OF 2020 --
MARCH TO JUNE OF 2020.
AND THIS DEMONSTRATES THE
POSITIVITY OF TELEHEALTH USE
BEFORE THE PANDEMIC AND THEN THE
INCREASE IN TELEHEALTH USAGE.
ONE OF THE THINGS THAT THE
PANDEMIC TAUGHT US IS THERE IS
SOME DANGER IN TYING ALL HEALTH
CARE TO BRICK AND MORTAR
ENTITIES.
WE ALL REALIZED THAT OUR
PATIENTS WHO ARE ON CLINICAL
TRIALS OR WHO HAD OTHER MEDICAL
PROBLEMS NEEDED SOME CARE BUT
COULD NOT PHYSICALLY TRAVEL TO
THE NIH.
AND TO THIS DAY THERE ARE
PATIENTS OF OURS WHO HAVE
RECEIVED LESS CARE THAN THEY
OUGHT TO HAVE DURING THE
PANDEMIC.
FOR EXAMPLE, I SAW A PATIENT OF
MINE LONG TIME PATIENT WHO HAD
NOT HAD THEIR USUAL SKIN CARE
CHECKS AND THEN TWO YEARS LATER
DEVELOPED MORE ADVANCED SKIN
CANCERS THAT REQUIRED SURGERY TO
REMOVE.
ALL OF US HAVE THESE STORIES OF
DELAYED CARE AND SOME OF THE
WAYS THAT WE HAVE TO PERHAPS
THINK ABOUT INCORPORATING
TELEHEALTH INTO OUR PRACTICES.
SO ALTHOUGH TELEHEALTH REALLY
TOOK OFF IN THE BEGINNING THERE
IS A LOT OF HESITANCY AND SOME
OF THAT HAS DROPPED OFF BECAUSE
WE LIKE TO SEE OUR PATIENTS IN
THE CLINIC AND OVER-ALL IN THE
COUNTRY THE TELEHEALTH USAGE HAS
DECLINED SINCE THE PEAK OF THE
PANDEMIC BUT WE'RE STILL IN THE
PANDEMIC AND SO PEOPLE ARE STILL
USING THIS TECHNOLOGY.
WHAT YOU CAN SEE HERE BY
APRIL 2021 OVER-ALL TELEHEALTH
-- DECLINED.
THIS VARIES DEPENDING ON THE
REGION OF THE COUNTRY AS WELL AS
THE PARTICULAR PATIENT TYPES.
AND SOME ENTITIES ARE USING MORE
TELEHEALTH THAN OTHERS.
TELL COUNSELING AND MENTAL
HEALTH SERVICES UTILIZED THIS
TYPE OF TECHNOLOGY.
ONE OF THE THINGS THAT IS
IMPORTANT TO REALIZE IS THAT
IT'S NOT JUST THE CLINICAL
ENCOUNTER.
THERE ARE MANY OTHER WAYS TO IN
CORPORATE TELEHEALTH INTO OUR
CARE.
FOR EXAMPLE, THE VIRTUAL AND
DIGITAL KAREN ABLED OFFICES -- *
MOBILE HEALTH APPLICATIONS
BECAME POPULAR AND U TO -- AND E
TO UNDERSTAND HOW TO USE THESE.
AND I THINK THERE IS A
CONTEMPORARY EXAMPLE -- THE FDA
REVISED THE EUA TO AUTHORIZE
PHARMACISTS TO PRESCRIBE THIS
TYPE OF THERAPY WITH
LIMITATIONS.
THIS EXAMPLES DEMONSTRATE WHAT
THE REACH OF TELEHEALTH CAN BE
AND THAT WE NEED TO BE AWARE OF
HOW TO USE THEM.
SO MOVING TO THE COVID-19
PANDEMIC AND TELEHEALTH USAGE AT
THE NIH.
COVID-19 WAS A HUGE DISRUPT FOR
AND I THINK WE ALL ARE AWARE OF
THAT.
THERE WAS A POSITIVITY OF
INFLATABLE POOLS.
BROADBAND ACCESS WAS A PROBLEM
AS ALL STUDENTS WENT TO VIRTUAL
LEARNING AND WE WERE ALL IN THE
SAME ZOOM ON OUR WiFiS.
TALKING ABOUT THAT SORT OF
DISRUPTION BUT ABOUT THE
TECHNOLOGY AND THE PROCESS
DISRUPTION AND THAT HAPPENED
QUICKLY AT NIH.
SO ON MARCH 13,2020 THE
CORONAVIRUS WAS DECLARED AN
EMERGENCY.
AND IT WAS QUITE REMARKABLE.
ABOUT ONE MONTH LATER THE FIRST
TELL HEALTH VISIT OCCURRED.
HOW WE DO THINGS AT THE NIH THAT
WAS A QUICK PROCESS.
AS YOU CAN SEE ON THE GRAPH WE
DO CONTINUE TO USE IT.
IT'S NOT NEARLY AS HIGH AS AT
THE PEAK AS MORE AND MORE
PATIENTS COME IN.
BUT CLEARLY THERE IS A BENEFIT
FOR PATIENTS.
THIS IS NOT A POLICY TALK.
BUT I WANT TO POINT OUT THAT
THERE IS A MASK POLICY THAT
APPLIES.
THIS WAS DEVELOPED QUICKLY
DURING THE PANDEMIC AND IT DOES
HIGHLIGHT AND HAS BEEN REVISED
TO INCORPORATE SOME OF THE *
WAYS THAT WE DO THINGS AT THE
NIH.
THERE ARE SOME THINGS THAT ARE
DIFFERENT THAN THE WAY PEOPLE
PRACTICE TELEHEALTH IN OTHER
PLACES.
FOR EXAMPLE, OUR STATE LICENSES
NO MATTER WHAT STATE THEY ARE
APPLY FOR THE USE OF TELEHEALTH
WHICH IS A BIG DEAL.
MANY PLACES ARE NOT ABLE TO DO
THAT AND THE BUYERS HAVE TO
OBTAIN LICENSES IN OTHER PLACES.
THE LEGAL REQUIREMENTS DON'T
ALLOW US TO DO CARE FOR
INTERNATIONAL PATIENTS AND THAT
DID POSE SOME DIFFICULTIES AND
WE HAD TO FIND WAYS TO REACH
THEM AND DO CHECK-INS.
AND I THINK IT'S WORTH
MENTIONING BECAUSE OUR TRAINEES
THAT ARE USING TELEHEALTH ALSO
AFFILIATE SO IT'S NOT JUST AT
THE NIH THAT IT'S WORTH
UNDERSTANDING THE LOCAL CON
TAXES.
HOW TO DO CODING AND DOCUMENTING
WHERE YOU ARE GETTING TRAINING
OUTSIDE OF NIH.
OneNoteABLE EXAMPLE IS THAT
AT NIH WE'RE NOT REQUIRED TO DO
A TELEHEALTH CONSENT VERBALLY OR
IN THE DOCUMENTATION BUT IT IS
BEST PRACTICE AND SOMETHING THAT
PEOPLE DO OUTSIDE OF THE NIH SO
IT MAY NOT BE A BAD IDEA FOR YOU
TO THINK ABOUT HOW YOU CAN TAKE
CONSENT AND WHAT YOU MIGHT DO IN
YOUR RESEARCH TEAMS.
ONE EXAMPLE IS DEMONSTRATED
HERE.
SO YOU SAY THIS THIS
ENCOUNTER USES A SEVERE VIDEO
NETWORK BETWEEN NIH AND THE
PATIENT'S PERSONAL DEVICE.
THIS ENCOUNTER IS DEEMED
APPROPRIATE FOR VIRTUAL CARE AS
DEFINED IN THE PROTOCOL TO WHICH
THE PATIENT IS CONSENTED AND THE
PATIENT HAS GIFT IN CONSENT TO
PARTICIPATE IN A TELEHEALTH
VISIT TODAY.
IF YOU'RE WATCHING LIVE IF YOU
WILL OBLIGE ME AND NAVIGATE TO
MENTEE.com AND ENTER THIS
NUMBER.
99854209.
PUT A FEW THOUGHTS OR WORDS
ABOUT SOME OF THE BARRIERS OR
DIFFICULTIES YOU'VE EXPERIENCED
USING TELEHEALTH AND YOU CAN DO
THIS WHETHER YOU'RE A PROVIDER
OF TELEHEALTH SERVICES OR A
PATIENT WHO HAS UTILIZED
TELEHEALTH OR A TRAINEE WHO HAS
BEEN PRECEPT IN THAT FORMAT AND
I'M GOING TO SHOW SOME OF THE
RESULTS OF OUR FINDINGS.
AS WE SEE THERE ARE A LOT OF
COMMENTS ABOUT THAT INDIVIDUAL
-- BAD VIDEO QUALITY.
DIFFICULTY WITH PHYSICAL EXAM
FINDINGS.
WE'LL TALK ABOUT THAT.
NO PHYSICAL TOUCH.
PEOPLE DO COMMENT ON THE LACK OF
CONNECTION.
AND TRYING TO LOOK FOR
AVAILABILITY.
OBVIOUSLY YOU SHOULD BE MORE
AVAILABLE AND WE'LL TALK ABOUT
THAT.
AND THEN OBVIOUSLY THE
CONNECTIVITY ISSUES, PROBLEMS
RELATED TO EQUITY.
SO I'LL LET ME POP-UP A LITTLE
BIT LONGER BUT THEY ARE GOING TO
GET SMALLER AND SMALLER.
AND WE MIGHT NOT BE ABLE TO READ
THEM.
THANK YOU FOREI FOR -- -- ENTERG
THESE.
SO WHY THE TELEHEALTH HESITANCY.
QUITE A BIT OF CLINICIAN
DISCOMFORT WITH THE TECHNOLOGY
AND TROUBLESHOOTING.
WHAT HAPPENS WHEN THINGS GO
WRONG.
PEOPLE WORRY ABOUT HOW
TELEHEALTH HIT RACE SEE FOR THE
PATIENTS * THEMSELVES.
ARE PATIENTS ABLE TO ENGAGE IN
THE FORMAT.
IDENTITY THREAT.
YOU'RE NOT SEEING THE PATIENT IN
FRONT OF YOU.
YOU CANNOT HAVE THAT TOUCH
ASPECT AND CERTAINLY THERE IS
ALSO SOME CONCERNS ABOUT QUALITY
FROM THE PROVIDER PERSPECTIVE.
ARE THEY PROVIDING BAD MEDICINE?
COULD THERE BE HEALTH OF RISK
FOR DISCOMFORT.
RISK FOR A MISDIAGNOSISES AND
DISCOMFORT IN THAT PROCESS.
FROM THE RESEARCH PERSPECTIVE A
LOT OF PEOPLE HAVE COMMENTED ON
THE ABILITY TO OBTAIN THE SAME
SAMPLES AND DATA THAT THEY WOULD
IF A PATIENT WAS IN PERSON AND
THOSE ARE THINGS THAT NEED TO BE
MITIGATED AND ALSO A LACK OF
KNOWLEDGE ON HOW TO MITIGATE
THEM INTO TEAMWORK FLOWS.
IT'S OBVIOUS THAT CLINICIANS USE
MANY FORMS OF OBSERVATION TO
ASSESS A PATIENT'S CONDITION.
AND EVEN OTHER CARE
PROFESSIONALS PARTICIPATING IN
THE CARE.
SO NURSES AND OTHER SPECIALISTS
MIGHT OBSERVE DIFFERENT THINGS
DURING A NORMAL IN PERSON
ENCOUNTER THAN DURING A VIDEO
VISIT.
IF YOU REALLY PAY ATTENTION
THERE ARE SOME WAYS THAT VIDEO
ENABLED VISITS OFFER THE
OPPORTUNITY TO SEE PATIENTS IN
THEIR ENVIRONMENT.
SOMETIMES PATIENTS COME TO THE
CLINIC AND DON'T PHYSICALLY HAVE
THEIR MEDICATIONS.
SO THERE ARE SOME OPPORTUNITIES
AND WE'LL TALK ABOUT SOME OF THE
ADDITIONAL OPPORTUNITIES IN THE
NEXT FEW SLIDES.
BEFORE WE DO THAT IT'S IMPORTANT
THAT WE COMPARE AND CONTRAST AND
IMAGINE SOME OF THE PARALLELS OF
IN PERSON ENVIRONMENT TO THE IN
PERSON ENVIRONMENT.
THE NURSING STAFF OFTEN
INTERVIEWS THE PATIENT AND SOME
CONVERSATION OCCURS.
WHEN THE PATIENT IS IN THE
CLINIC MEDICATION RECONCILIATION
OCCURS BEFORE THE VISIT.
BUT IN THE TELEHEALTH VISIT
SOMETIMES ONLY THE PHYSICIAN OR
THE CLINICIAN IS IN THE VISIT.
THEY HAVE TO BE THE ONES TO
VERIFY THE MEDICATIONS DURING
THAT VISIT AND ALSO DOCUMENT
THAT.
TEAM MEMBERS MAY ASSIST WITH THE
VISIT VICE ALSO AND OTHER FORMS
OF DOCUMENTATION.
ORDERS AND WRITE SCRIPTS.
WHEREAS IN THE VIRTUAL
ENVIRONMENT THOSE VITALS WON'T
OCCUR UNLESS THEY ARE ELICITED
DURING THE VISIT AND THE
DOCUMENTATION FALLS TO THE
CLINICIANS AS WELL AS ORDERS AND
OTHER THINGS AFTER THE VISIT.
THE AFTER VISIT PLANNING.
SOMETIMES IT GETS LOST IN THE
MIX.
THE NOTE GETS WRITTEN AND
NOTHING ELSE HAPPENS.
BUT IN THE IN PERSON ENCOUNTER
THERE IS INSTRUCTIONS.
PATIENT HANDOUTS PROVIDED.
ADDITIONAL TEACHING MIGHT OCCUR.
HOW TO ADMIN MEDICATIONS.
THINGS LIKE THAT.
AND THOSE THINGS OFTEN AGAIN
OCCUR BY THE CLINICIAN DURING
THE ONE TELEHEALTH VISIT THAT
OCCURS.
SO AS YOU CAN IMAGINE THIS MIGHT
LEAD TO QUITE A BIT OF DISTRESS
FOR THE CLINICIANS THAT HAVE TO
DO ALL OF THIS.
AND ONE THINGS THAT WE DON'T
WANT TO DO IS CREATE ADDITIONAL
CLINICIAN BURN OUT.
SO IT IS IMPORTANT AS YOU ENGAGE
IN TELEHEALTH TO OPTIMIZE THE
WORKFLOWS FOR TEAM BASED CARE.
SO MOVING FROM JUST A PHYSICIAN
OR CLINICIAN LED VISIT TO
INCORPORATING THE OTHER MEMBERS
OF THE TEAM TO YOUR DAY.
AND IN THE FUTURE HOPEFULLY
THERE MIGHT BE SOME INTEGRATION.
SO THINGS -- THAT WON'T REQUIRE
ALL OF THE DOCUMENTATION.
SO WHEN WE WERE USING MS TEAMS
THERE WAS NO ROOMING OF THE
PATIENT.
THE PATIENT JUST APPEARED.
THERE WAS NO VIRTUAL WAITING
ROOM AND MEDICATION
RECONCILIATION CAN OCCUR BY
OTHER PEOPLE.
SO IN OUR TEAM WE'VE HAD -- THIS
HAPPEN BEFORE THE VISIT USING
CASE MANAGERS TO CALL THE
PATIENT.
SOMETIMES THEY'VE NEVER MET THE
PATIENT BEFORE OR ESTABLISHED
RAPPORT BEFORE THE PATIENT
ARRIVES EITHER IN THE CLINIC OR
ON THE TELEHEALTH VISIT.
SO WE APPRECIATE THAT TEAM BASED
CARE.
REFILLS AND LAB ORDERS CAN OCCUR
AFTER TH VISIT UTILIZING
ADDITIONAL MEMBERS OF THE TEAM.
THESE JUST HAVE TO BE DISCUSSED
IN ADVANCE.
SO THE FACULTY DEVELOPMENT TIP
HERE IS THAT IT'S IMPORTANT TO
SPREAD THE ROLES ACROSS THE TEAM
AND YOU CAN PRACTICE AND DISCUSS
SOME OF THE WAYS TO ACTUALLY
IMPROVE DATA GATHERING AND BY
DOING SOME WORKSHOPS OR KEY
SPACE ROLE PLAYS.
MODELING THESE VISITS IN A
WORKPLACE SCENARIO SO YOU CAN
INCREASE YOUR CONFIDENCE FOR THE
ENTIRE TEAM.
SO HOW DO WE PROVIDE TEAM BASED
CARE AT NIH?
WE HAVE LARGE TEAMS.
INCLUDING MANY PEOPLE.
INVESTIGATORS, RESEARCH
PHYSICIAN, STAFF CLINICIANS,
STUDY COORDINATORS.
CASE MANAGERS.
SOCIAL WORK.
AND RESEARCH LABORATORY STAFF.
ALL OF THESE PEOPLE ARE OFTEN
INVOLVED BEFORE THE PATIENT EVEN
ARRIVES AT NIH.
SO JUST GETTING TO THE NIH TAKES
QUITE A LOT OF TIME AND
COORDINATION.
THAT CARE COORDINATION AND THAT
IS JUST A BIG COMPLEX TASK.
SO WHAT SOME PEOPLE HAVE DONE IS
INCORPORATE CONSENT LANGUAGE
INTO THEIR PROTOCOLS TO DO A
TELEHEALTH VISIT IN ADVANCE.
AND SOME MIGHT SAY IT'S HARD TO
PROVIDE THE SAME EXPERIENCE IN A
VIRTUAL FORMAT.
I AGREE WITH THAT.
THE KIND OF CARE THAT WE PROVIDE
FOR COMPLEX PATIENTS IS REALLY
DIFFICULT TO DO IN ONE
TELEHEALTH VISIT.
BUT IN THE NEXT FEW SLIDES I
WOULD LIKE TO DESCRIBE SOME OF
THE WAYS THAT TELEHEALTH CAN
BENEFIT YOUR PRACTICES IN
INCORPORATING THIS INTO YOUR
PLANS.
SO REASON NUMBER ONE WE'LL CALL
EFFICIENCY.
WE'VE HAD PATIENTS THAT CAME
FROM AFAR -- MANY CONVERSATIONS
WITH VARIOUS TEAM MEMBERS TO
PLAN IN ADVANCE.
LABS, TESTING -- THAT IS CREATED
AND DESIGNED IN ADVANCE TO
DISCERN THE CAUSE OF THEIR
ILLNESS.
ONE THEY ARRIVE PATIENTS MIGHT
SEE MULTIPLE PROVIDERS,
DIFFERENT CONSULTS.
SIGN ON TO SEVERAL PROTOCOLS.
HAVE A BUNCH OF TESTING.
IMAGING STUDIES.
AND THEN THEY WAY.
-- WAIT.
SOMETIMES THEY ARE IN TOWN A FEW
DAYS.
MAYBE THEY CAN SEE THE CHERRY
BLOSSOMS BUT IN REALITY THEY
SPEND A LOT OF TIME WAITING FOR
RESULTS TO COME BACK AND THIS IS
WHERE THE PATIENT BECOMES
INPATIENT BECAUSE IN A REGULAR
HEALTH CARE SETTING IT'S IN
MINUTES.
BUT AT NIH THAT IS DAYS.
SO AS MUCH AS THE SERVICE AND
QUALITY OF CARE THAT WE PROVIDE
IS FANTASTIC IT CAN BE SOMEWHAT
DISRUPTIVE FOR PATIENTS
ESPECIALLY THOSE WHO ARE
OUTPATIENTS.
WHO HAVE KIDS OUT OF SCHOOL.
PEDIATRIC PATIENTS TO REMAIN AT
THE NIH FOR SO LONG.
SO THAT'S AN OPTIMAL USE OF
TELEHEALTH.
THE PATIENT CAN RETURN HOME.
WITH PLANNED FOLLOW-UP IN A FEW
DAYS OR WEEKS TO DISCUSS THE
NEXT STEPS IN THE PLAN AND IF
YOU'RE INCORPORATING LEARNERS
THAT CAN BE AS SHORT OR AS LONG
AS NEEDED TO ENSURE THAT THERE
IS CONTINUITY IN THE CARE.
THEY CAN CONTINUE TO SEE THE
PATIENT BUT IN TELEHEALTH
FORMAT.
SO REASON NUMBER TWO IS
COMMUNICATION AND TEAM
COORDINATION.
YOU DON'T FREQUENTLY SEE THIS
MANY DOCTORS IN ONE ROOM.
THIS IS NOT AN ISSUE AS MUCH
WITH TELEHEALTH SO YOU CAN
FREQUENTLY ACHIEVE ONE OF
SEVERAL THINGS.
YOU CAN HAVE MULTIPLE IT WILL
DOCTORS ON A VIDEO CALL.
YOU CAN HAVE ADDITIONAL
SPECIALISTS THAT HAVE SEEN THE
PATIENT ON A TELEHEALTH CALL
ALSO PRESENT.
YOU CAN HAVE SPECIALISTS FROM
THE PATIENT'S HOME TEAM ALSO
PRESENT ON THE TELEHEALTH VISIT.
ALSO INCORPORATE THE OTHER
MEMBERS OF THE TEAM.
CASE MANAGERS AND BE AWARE OF
THE CARE PLANS SO THE HAND OFFS
AND THE CONTINUITY EXIST.
SO WHEN THINKING ABOUT THIS IT
DOES REQUIRE SOME THOUGHT ABOUT
WHEN PEOPLE MIGHT JOIN AND IT'S
REALLY POSSIBLE TO DO THAT IN A
TELEHEALTH VISIT WHERE IT'S MUCH
MORE DIFFICULT FOR INPERSON.
REASON THREE ... FAMILY
INCLUSIVITY.
TELEHEALTH IS ONE WAY TO INCLUDE
THE FAMILY MEMBERS IN THE CARE
OF THE PATIENT AND WHEN THIS IS
DONE REMOTELY -- OR IF THE
PATIENT IS HERE AND THE FAMILY
IS SOME WHERE ELSE THIS CAN BE
ACCOMPLISHED WITH A LITTLE BIT
OF PLANNING TO INCLUDE THE OTHER
MEMBERS
FAMILY WHO MIGHT BE RESPONSIBLE
FOR THE CARE OF THE PATIENT INTO
THE PROCESS SO THAT THEY CAN BE
AWARE OF WHAT IS GOING ON.
SO AS YOU'RE AWARE WE STARTED
WITH MS TEAMS AND SOME OF I
MENTIONED VIDEO QUALITY.
IT WAS HARD TO GET A GOOD LOOK
WHEN DOING A PHYSICAL EXAM.
THE QUALITY WAS NOT SO GREAT.
CONNECTIVITY WAS A PROBLEM.
I PERSONALLY HAVE A HARD TIME
SHARING ON TEAMS.
THERE ARE DEFINITELY ISSUES AND
THAT IS ONE OF THE REASONS FOR
PICKING A DIFFERENT TELEHEALTH
PLATFORM AND THIS MOVE TO A NEW
-- ENTITY CALLED AN DOOR.
THERE WILL BE OTHER INTEGRATION
-- INCLUDING QUESTIONNAIRES THAT
CAN BE PERFORMED IN ADVANCE.
AND SO THERE ARE SOME
FUNCTIONALITIES AND WE'LL GO
THROUGH SOME OF THEM IN A
MINUTE.
SO THE BIG ONE IS THE WAITING
ROOM POSSIBILITY.
LET'S SAY THE PATIENT IS IN
PERSON.
THEY CAN ARRIVE AND JOIN A
WAITING ROOM.
THEY CAN MOVE FREELY.
GO GET COFFEE AND AWAIT FURTHER
INSTRUCTIONS AND GET UPDATES AND
TEXT MESSAGES TO RETURN TO THE
CLINIC BECAUSE THE TEAM OR THE
PHYSICIAN IS READY TO SEE THEM.
AND THIS ALSO HAPPENS IF THEY
ARE REMOTE.
SO IF THEY ARE VIRTUAL THE
PATIENT CAN RECEIVE A TEXT TO
LET THEM KNOW THEY SHOULD JOIN
THE VISIT AND ALL OF THESE
THINGS DO STREAMLINE THE VISIT.
SO AS MENTIONED YOU MIGHT GET A
TEXT MESSAGE THAT REMINDS YOU
THAT YOU HAVE AN APPOINTMENT IN
THE FUTURE AND THEN WHAT IS NICE
ABOUT ANDOR IS THAT THE PATIENT
AND YOU WILL ALSO RECEIVE A URL
AND A WAY TO JOIN.
THAT MAKES IT EASIER RATHER THAN
DOWNLOADING AN APP.
HAVE THE SERVICE CONTACT THE
PATIENT AND MAKE SURE THEY CAN
JOIN MS TEAMS.
THERE ARE A LOT OF PATIENT
THAT'S HAD DIFFICULTY WITH THAT.
THE EASE OF USING CERTAINLY A
BIG IMPROVEMENT.
SO TO ACCOMPLISH THE TEAM BASED
CARE IT DOES REQUIRE PREPPING
YOUR TEAM.
TALKING ABOUT -- WHAT THEIR ROLE
IS IN THE PROCESS.
TALKING TO THE NURSING STAFF AND
OTHER MEMBERS OF YOUR TEAM.
WHEN WILL MEDICATION
RECONCILIATION OCCUR?
BEFORE THE VISIT.
IN A PRECALL OR AT THE BEGINNING
OF THE VISIT AND PLANNING THE
SEQUENCE OF THE VISIT.
WE TALK ABOUT THE BACK CHANNEL
IN A SECOND.
WHO WILL DO THE INTRODUCTIONS AS
THE PROVIDER.
YOU'LL DO THE INITIAL
INSTRUCTIONS AND LET THE EARNER
TAKE THE HISTORY AND PHYSICAL
EXAM AND THEN COME IN WITH SOME
ADVICE.
DETERMINING THE LEARNER SKILL
AND TELEHEALTH COMPETENCY IS
IMPORTANT.
NOT ALL ARE AS ADEPT AT USING
THE TECHNOLOGY.
SO UNDERSTANDING THE
CAPABILITIES BEFORE.
AND WHAT EXPECT THE LEARNER TO
DO AND THE REST OF THE TEAM
MEMBERS TO DO.
THE BACK CHANNEL IS IMPORTANT.
TALKING ABOUT YOU MIGHT TEXT
THEM FOR VARIOUS REASONS.
OR YOU WANT THEM TO TEXT YOU TO
JOIN THE CALL AFTER THE INITIAL
PART IS CERTAINLY POSSIBLE.
SO ONE OF THE ISSUES THAT CAME
UP ABOUT THE BEGINNING OF THE
PANDEMIC -- WAS IS THIS GOING TO
BE A PROBLEM?
ARE THERE GOING TO BE PEOPLE WHO
CANNOT ACCESS TELEHEALTH.
SO THIS STUDY TOOK FROM
30 MILLION MEDICARE SERVICE
CLAIMS AND ANALYZED BOTH BEFORE
AND AFTER THE MEDICARE
TELEMEDICINE COVERAGE WAIVER WAS
IMPLEMENTED.
THEY ASSESSED THE USAGE.
A COMPREHENSIVE MEASURE OF
NEIGHBORHOOD SOCIO ECONOMIC
ADVANTAGE.
BEFORE OWITH THE HIGHEST ODDS OF
UTILIZATION SEEN IN THOSE IN THE
MOST DISADVANTAGED NEIGHBORHOODS
SO THIS STUDY DEMONSTRATED THAT
INCREASING ACCESSIBILITY --
ALTHOUGH THERE WERE SOME
DIFFICULTIES IN ACCESSING
TELEMEDICINE DUE TO AGE -- ALL
OF THOSE THINGS DO MAKE IT
EASIER FOR PATIENTS.
IT'S IMPORTANT TO DESIGN THESE
PROCESSES FOR EQUITY.
AND THIS IS A PHOTO CREDIT FROM
UNITE.
TALKING ABOUT DIVERSITY AND
INCLUSION IN ALL OF THE VARIOUS
ASPECTS OF HEALTH CARE FROM THE
PROVIDER TO ASSURING THAT THE
DISPARITIES ARE NOT WORSENED.
SO ASSURING THAT THE TELEHEALTH
PLATFORM HAS ACTIVATED
TECHNOLOGY.
TURNING ON CLOSED CAPTIONING IF
REQUIRED.
ASSURING THAT IT'S EASY TO USE.
THE URLs AND TEXT THAT WE
TALKED B. APP DOWNLOADS.
CONSENT SURROUNDING LANGUAGE AND
LITERACY.
ASSURING THAT TRANSLATOR SERVICE
ARE AVAILABLE.
AND FOR THE PATIENT TO BE ABLE
TO TAKE A LINK THAT THEY'VE
RECEIVED AND FORWARD IT TO A
FAMILY MEMBER TO JOIN.
DIGITAL LITERACY IS A BIG
CONSIDERATION AND WE HAVE A
SERVICE THAT WOULD CHECK-IN WITH
THE PATIENT TO SEE IF THEY COULD
JOIN AND SOMETIMES WE WOULD GET
AN E-MAIL SAYING THEY COULD NOT
CONTACT THE PATIENT BUT WITH THE
NEW PLATFORM THERE IS A SERVICE
THAT CAN VISUALIZE AND BE ABLE
TO HELP.
COST IS A CONSIDERATION.
PHYSICIANS STILL BILL FOR
SERVICES USING TELEMEDICINE.
THERE ARE PATIENTS WITH OTHER
DISABILITIES.
AND IT'S IMPORTANT NOT TO FORGET
THOSE VISUAL DISABILITIES MIGHT
BE A PROBLEM.
HEARING DISABILITIES AND OTHERS
THAT NEED TO BE CONSIDERED IN
TERMS OF ASSURING ACCESS.
SO I'M GOING TO GO THROUGH A
LITTLE BIT, A VIDEO SHOWING ME
ABOUT HOW TO ASSURE THAT YOUR
WEBSITE MANNER IS PROTECT WHEN
DOING A TELEHEALTH VISIT.
SO THINK ABOUT WHETHER AND HOW
PRECIPITATION.
DO YOU OPEN UP A ZOOM TO SEE
WHAT YOUR BACKGROUND LOOKS LIKE
AND LOOK AT YOUR FACE AND BODY
WITHIN THE FRAME.
YOU MAY INTO THE BE ABLE TO DO
MUCH ABOUT THE LIGHTING BUT MAKE
SURE THERE IS NOT A WINDOW
BEHIND YOU.
MAKE ADJUSTMENTS BEFORE YOU
START.
SO YOU CAN MOVE YOUR CAMERA DOWN
OR UP TO MAKE SURE THAT YOU'RE
IN THE FRAME AND IT'S ALSO
IMPORTANT TO MAKE SURE THAT YOU
DRESS IN THE APPROPRIATE DRESS
ATTIRE.
JUST LOOK PROFESSIONAL.
LOOK AT ALL OF YOUR TECH AND
MAKE SURE YOUR PHONE IS SILENCED
AND TAKE ONE LAST SIP OF YOUR
MORNING COFFEE SO YOU CAN AVOID
-- DISTRACTSES.
* RESPOND TO SOMETHING THAT YOU
HAD MENTIONED -- USE ACTIVE
LISTENING.
IT IS IMPORTANT SO SOME PEOPLE
MIGHT LOOK UP AT ANOTHER SCREEN
AND IT'S IMPORTANT TO TELL THE
PATIENT THAT YOU HAVE ANOTHER
SCREEN OPEN ON ANOTHER DISPLAY
SO WHEN YOU LOOK OFF THEY DON'T
THINK YOU'RE DISTRACTED.
IT'S VERY NATURAL TO LOOK AT
YOUR OWN SELF WHEN YOU'RE ON A
TELEMEDICINE VISIT.
BUT MAINTAIN EYE CONTACT.
LOOK AT THE GREEN DOT ON YOUR
CAMERA.
BECAUSE THAT REALLY DOES EMULATE
THE EXPERIENCE.
SO OTHER THAN YOUR PERSONAL
FACTORS AND HOW YOU LOOK ON
CAMERA THERE ARE SOME ADDITIONAL
PATIENT FACTORS THAT ARE
IMPORTANT TO CONSIDER.
ESTABLISHING THE CONNECTION.
PAYING ATTENTION TO THE PATIENTS
BODY CUES.
CHANGES IN THEIR TONE.
JUST LIKE IN THE CLINIC WHERE
YOU MIGHT ASK WHO THEY HAVE WITH
THEM TODAY YOU MIGHT WANT TO DO
THAT TOO.
THERE MAY BE PEOPLE NOT SHOWN IN
THE VIDEO AND ASKING IF THERE
ARE OTHER FAMILY MEMBERS THAT
ARE THERE WITH THEM DURING THE
VISIT.
YOU CAN ADDRESS THESE THINGS IN
YOUR OWN PRACTICE AS WELL AS
OBSERVED LEARNERS USING THESE
SKILLS.
SO THINKING ABOUT YOUR OWN
APPEARANCE AS WELL AS HOW OTHER
LEARNERS ARE INTERACTING IS
IMPORTANT AND IF SOME OF THESE
THINGS DON'T HAPPEN YOU CAN
PROVIDE SOME GUIDANCE TO THE
PATIENT ABOUT WHAT TO DO IN
SETTING UP A TECH FAILURE.
LEAVE TIME FOR QUESTIONS.
ALL OF THESE ARE PART OF WHAT WE
DESCRIBE.
THIS IS NOT A VALID INSTRUMENT
FOR MEASURING BUT THERE ARE SOME
POTENTIAL LESSONS LEARNED.
WHAT THEY USED TO DO IS TAKE
SCREEN SHOTS OF JOURNALISTS ON
THE NEWS AND SHOW WHETHER OR NOT
THEY DID A GOOD JOB WITH THEIR
BACKGROUND.
SO YOU CAN SEE HERE -- IS A
PERSON TALKING ON THE NEWS.
THEY HAVE TWO DOORS BEHIND THEM.
SO THERE IS DATA THAT
DEMONSTRATES HAVING A DOOR
BEHIND YOU IS SIMILAR TO THE
DOOR PHENOMENA.
THE CLINICIANS WITH THEIR DOOR
ON THE KNOB ABOUT TO LEAVE THE
ROOM.
THE PATIENT DOESN'T FEEL LIKE
THEY HAVE THE ABILITY TO SAY
WHAT THEIR LAST THOUGHTS ARE.
SO POSITION YOUR CAMERA TO MAKE
SURE THERE IS NOT A DOOR BEHIND
YOU.
THAT IS IMPORTANT.
NOT TO GET TOO SAPPY BUT -- BUT
HAVING MORE WARMTH ITEMS BEFORE
YOU TO DEMONSTRATE HUMANITY.
SO THAT IT DOES DEMONSTRATE MORE
EMPATHY AND TRUST FOR THE
PATIENT.
I DON'T KEEP PLANTS BEHIND ME
BECAUSE I CANNOT KEEP THEM ALIVE
BUT THERE ARE OTHER WAYS.
PICTURES OR OTHER THINGS THAT
YOU CAN PUT BEHIND YOU TO MAKE
SURE THAT YOU'RE DEMONSTRATING
EMPATHY.
SO SOME OF THESE -- -- THEY CAME
ABOUT BECAUSE PATIENTS HAD A
VOICE IN DESCRIBING THEIR
TELEHEALTH EXPERIENCES.
BEFORE THE PANDEMIC 65% OF
AMERICANS FELT HESITANT OR
DOUBTFUL ABOUT THE QUALITY OF
TELEMEDICINE VISITSES.
NOW MANY WANT TO CONTINUE USING
TELEHEALTH SERVICES AND BELIEVE
THAT THEY WILL BECOME THE NORM
FOR NONEMERGENCY CONSULTATIONS.
THERE MAY BE SPECIALISTS THAT
ARE NOT PRESENT IN THE PATIENT'S
LOCALE BUT THEY MAY BE ABLE TO
ACCESS SOMEONE IN A DISTANT AR
AREA.
IF YOU HAVE A RARE DISEASE --
SOME OF THE THINGS THAT WE DO
HERE ARE NOT POSSIBLE TO OBTAIN
IN TERMS OFND OTHER
PLACES.
RARE DISEASES WOULD BENEFIT FROM
CONTINUED TELL HEALTH ACCESS.
THE PATIENT'S VOICE IS IMPORTANT
IN TERMS OF BEING INVOLVED AS A
PATIENT PARTNER.
AND ASSURING THAT THE PATIENT'S
VOICE IS IMPORTANT IN THE DESIGN
OF SOME OF THE PROCESSES FOUND
IN TELEHEALTH.
SO, IT'S -- ONE THING THAT CAME
ABOUT IS UNDERSTANDING WHAT
THESE MEAN IN THE GLOBAL
CONTEXT.
SO ONE OF THE WAYS IS TO FOLLOW
THE MONEY.
INVESTMENT IN TOTAL VENTURE
FUNDING TO THE TUNE OF TENS OF
BILLIONS OF DOLLARS HIGHLIGHTS
THE FACT THAT THIS FORM OF CARE
IS LIKELY TO STAY AND THEN AS
RESEARCHERS AND CLINICIANS WE
SHOULD BE AT THE FOREFRONT OF
THE TECHNOLOGY AS KEY
STAKEHOLDERS.
IN ADDITION TO PATIENTS DESIRING
THIS PROCESS WE HAVE TO BE
INVOLVED TO ASSURE THE BEST
PRACTICES ARE IN EFFECT.
THE OTHER PIECE IS THAT WHEN THE
EMR WAS ROLLED OUT THEY WERE NOT
A PART OF THE PROCESS.
IT WAS ROLLED OUT FOR BILLING
PURPOSES.
AS TELEHEALTH GAINS TRACTION
OTHER TELL OPPORTUNITIES GAIN
TRACTION, WE HAVE TO BE AT THE
TABLE AS KEY STAKEHOLDERS TO
ASSURE THAT THESE PROCESSES
DON'T CREATE A WORSE CLINICIAN
BURN OUT FOR US.
SO I WOULD LIKE TO PIVOT AND
TALK ABOUT ASPECTS RELATED TO
MEDICAL EDUCATION.
I'LL POINT OUT SOME KEY TAKE
AWAYS AND RESOURCES.
YOU SEE THE KEY THAT IS A
REFERRAL.
AND THE FACULTY DEVELOPMENT
OPPORTUNITIES.
AS WELL AS SOME RESOURCES THAT
CAN BE USED.
PRETTY EARLY IN THE PANDEMIC WE
REALIZED THAT USING TELEHEALTH
AND TELA TRAINING WAS GOING TO
BE VERY IMPORTANT AND THIS IS A
PUBLICATION MYSELF AND THE SITE
DIRECTORS AND THE PROGRAM HEADED
PUT OUT TALKING ABOUT THE
ELEMENTS THAT MIGHT BE IMPORTANT
IN TERMS OF VIRTUAL TRAINING.
ISSUES RELATED TO SUPERVISION.
ASSESSING AND ADDRESSING ISSUES
RELATED TO PROFESSIONALISM.
HAVING PATIENT CENTERED
DISCUSSIONS AND COUNSELING IN
THE PROCESS.
ACTUALLY UTILIZING THE
OPPORTUNITIES FROM VIRTUAL
CONNECTIONS.
PROVIDING SPONSORSHIP AND
MENTORSHIP AND CONNECTING
TRAINEES WITH PEOPLE OUTSIDE OF
OUR LOCAL REGION WERE IMPORTANT.
WE DEVELOPED VIRTUAL CLASSROOMS
AND MANY HAVE CREATED HUGE
LIBRARIES OF VIDEOS OF TALKS AND
THINGS THAT WERE GIVEN DURING
THE PANDEMIC.
AND THEN GETTING OPPORTUNITIES
FOR TRAINERS TO PRESENT SOME OF
THEIR SCIENCE.
AND THAT ALLOWS YOU TO CONTINUE
TO INTERACT WHEN THERE ARE
DISRUPTIONS IN THE NORMAL
PROCESS.
FAST-FORWARD -- WE HAD TALKED
ABOUT SOME OF THE COMPETENCIES
IN THIS PAPER ABOUT THINGS THAT
WE HAVE TO YOUR TICKET TO A
BETTER NIGHT'S SLEEP. EASE FOR.
FAST-FORWARD TO 2021 THE AMC PUT
OUT DOCUMENTS THAT TALK ABOUT
COMPETENCIES ACROSS THE LEARNING
CONTINUUM AND THESE INCORPORATE
-- RELATED TO PATIENT SAFETY AND
TECHNOLOGY ACCESS.
ASSURING EQUITY.
DATA ACQUISITION AND ASSESSMENT.
COMMUNICATION PRINCIPLES AND
ETHICAL PRACTICES AND THE LEGAL
REQUIREMENTS THAT ARE NECESSARY
TO UNDERSTAND.
SO THERE ARE SOME POTENTIAL
PITFALLS AND SAFETY CONCERNS.
THE FIRST ONE IS DIAGNOSTICS.
INCOMPLETE HISTORY.
COMPETENCY IN ELICITING THE
PHYSICAL EXAM.
INADEQUATE MEDICATION
RECONCILIATION.
YOU ALSO HAVE TEAM BASED CARE AS
WE TALKED ABOUT.
LOSS OF CONTINUITY IN THE FORM
OF FOLLOW-UP.
THEY HAVE A TELEHEALTH VISIT AND
NEVER BE CONTACTED AGAIN.
LACK OF SUMMARIES.
AND THEN FROM THE RESEARCH
PERSPECTIVE THE CONCERNS CAN BE
LOSS OF STRUCTURED ASSESSMENT.
MISSING SAFETY LABS.
MISSING RESEARCH END POINTS.
PROTOCOL DEVIATIONS AND
REPORTING AS WELL AS CONSENT AND
PROTOCOL CONSIDERATIONS.
ONE OF THE THINGS THAT WE
REALIZED IS THAT WE HAVE TO
DESIGN FOR THIS UP FRONT.
PUTTING TELEHEALTH AT THE
FOREFRONT OF YOUR DESIGN OF YOUR
CLINICAL TRIAL, ASSURING THAT
THE END POINT COULD BE DONE BOTH
WAYS.
WHETHER VIRTUAL OR IN PERSON.
AND THEN ASSURING THAT WE TEACH
AND THE WAY THAT WE THINK ABOUT
HOW TO ACTUALLY INCORPORATE THIS
MODALITY INTO OUR RESEARCH IS
IMPORTANT.
SO HOW DO WE DO THAT?
WE HAVE TO EDUCATE OURSELVES.
HERE I'VE PUT A LINK.
SOME OF THE KEY VIDEOS -- TOPICS
THAT ARE RELATED TO TELEHEALTH.
YOU CAN GO TO AND TRAIN YOURSELF
ON HOW TO DO AN APPROPRIATE
PHYSICAL EXACT THAT IS SPECIALTY
SPECIFIC.
THERE ARE NO WAYS TO MITIGATE
FOR HEARING IMPAIRMENT.
UNDERSTANDING OF FUNDAMENTALS OF
TELEMEDICINE.
SO VISIT THE SITE.
YOU CAN TYPE IT IN SO YOU CAN
ACCESS IT LATER.
WAYS THAT YOU CAN TRY AND
IMPROVE YOUR OWN ADMINISTRATION
AND TELEHEALTH SERVICES.
I WILL SHOW A LITTLE BIT -- OF A
YOU TOOOH, -- YouTube CLICK.
* IT WILL BE NICE TO WATCH PART
OF IT.
>> RESPIRATORY RATE IS SOMETHING
THAT YOU CAN CALCULATE AS THE
PATIENT IS SPEAKING WITH YOU.
NEXT LET'S DO THE -- HE --
EXAMINATION.
NEXT LOOK AT THE EYES.
YOU CAN ASK THEM TO LOOK UP.
DOWN, TO THEIR LEFT TO THEIR
RIGHT.
DIAGONALLY.
AND WITH THAT YOU'RE ALSO
DOCUMENTING ASPECTS OF A
NEUROLOGICAL EXAM.
IF YOU WANT TO LOOK IN THE BACK
OF THE THROAT HAVE THEM OPEN
THEIR MOUTH AND DO A BIG AAAH
INTO THE CAMERA.
IF YOU CANNOT SEE YOU CAN ASK
THEM TO ADJUST THEIR ANGLE.
I ALSO SOMETIMES ASK PATIENTS TO
GRAB A FLASHLIGHT TO SEE DOWN
INTO THE BACK OF THEIR THROAT.
>> AS YOU CAN SEE IT CAN BE
AWKWARD AND YOU HAVE TO BE
COMFORTABLE TO ASK THE PATIENT
TO DO A FACILITATIVE TELL HEALTH
EXAM.
AND YOU HAVE TO BE CREATIVE IN
TERMS OF THINKING ABOUT THEIR
ENVIRONMENT.
SOME PATIENTS HAVE BLOOD
PRESSURE CUPS.
THEY MIGHT HAVE A PULSE OX
METER.
* WHAT ABOUT COUNSELING?
TALKING ABOUT MENTAL HEALTH
COUNSELING.
TELEHEALTH IS A VERY NICE
OPPORTUNE TIME TO OBSERVE
LEARNERS DOING COUNSELING AND
GIVING PATIENT INFORMATION.
YOU CAN BE THERE FOR THE WHOLE
TIME AND SOMETIMES YOU MIGHT SAY
-- INTRODUCE THE PATIENT TO THE
LEARNER AND TELL THEM THAT
YOU'RE GOING TO TURN THE VIDEO
OFF.
YOU CAN ALSO JOIN THE VISIT
LATER.
SO DEPENDING ON TIME FRAMES.
AND THEN ALLOW THE TRAINEE TO
GET THE HISTORY EXAM AND THIS --
ALLOWS THE PATIENT TO PROVIDE
ADDITIONAL INFORMATION IF
NEEDED.
SO AS THE LEARNER IS GIVING
INFORMATION TO THE PATIENT THIS
IS ALSO A GOOD TIME TO ASSESS
COMMUNICATION SKILLS.
RAPPORT BUILDING AS WELL AS
DEMONSTRATION OF THEIR MEDICAL
KNOWLEDGE AND MANAGEMENT
REASONING.
I MEANT TO MENTION THAT THE --
EDUCATION PLAYBOOK IS A GOOD
RESOURCE AND GOOD RESOURCE FOR
BOTH LEARNERS AS WELL AS FACULTY
TO THINK ABOUT SOME OF THE
ASPECTS OF THE TELEHEALTH
ENCOUNTER WHEN INCORPORATING A
LEARNING.
-- LEARNER.
*.
ALSO THE AMC COMPETENCIES.
THIS IS ACTUALLY A DOCUMENT THAT
TALKS ABOUT THE VARIOUS
COMPETENCIES.
I'LL MENTION SOME HIGHLIGHTS.
THE FIRST ONE IS ACCESS AND
EQUITY.
YOU WANT AS FACULTY MEMBER TO
ASSESS SOME OF THE THINGS DURING
A TELEHEALTH ENCOUNTER.
SO OBSERVING WHETHER THE
TRAINING MITIGATES IMPLICIT AND
EXPLICIT BIASES DURING A DEATH
HEALTH ENCOUNTER.
WHETHER THEY ARE ACCOMMODATING
OF THE PATIENT'S NEEDS AND
PREFERENCES.
AS WELL AS ABILITY TO MITIGATE
FOR LINGUISTIC BARRIERS DURING
USE OF THE TECHNOLOGY.
AND IF THE TRAINEE IS NOT ABLE
TO DO THOSE THINGS THIS IS AN
OPPORTUNITY FOR TEACHING.
WHEN THE FACULTY MEMBER STEPS IN
THEY CAN ROLE MODEL HOW TO TALK
TO THE PATIENT ABOUT SOME OF THE
ISSUES AND ADVOCATE FOR IMPROVED
ACCESS.
TALKING ABOUT COMMUNICATION.
OBSERVING WHETHER TRAINEE CAN
BUILD RAPPORT WITH THE PATIENT
USING EYE CONTACT.
APPROPRIATE TONE AND BODY
LANGUAGE AND UNDERSTANDING
NONVERBAL CUES OF THE PATIENT.
CAN THEY READ THE ROOM.
ARE THEY ABLE TO ESTABLISH A
RELATIONSHIP.
DO THEY HAVE GOOD LIGHTING.
GOOD SOUND?
DO THEY INCORPORATE PATIENT'S
SOCIAL SUPPORTS WITH THE
PATIENT'S CONSENT.
AND THEN AGAIN A NICE TIME TO
DEMONSTRATE SOME OF THE
COMMUNICATION SKILLS AND
COUNSELING IF NOT PERFORMED BY
THE TRAINER DURING THE VISIT.
WHAT ABOUT DATA COLLECTION AND
ASSESSMENT?
THIS IS ALSO A GOOD TIME TO
ASSESS WHETHER THE TRAINEE CAN
GATHER THE HISTORY PERFORM THE
EXAM AND INCORPORATE THAT INTO
THE MANAGEMENT PLAN.
DO THEY RECOGNIZE AND CLINICAL
RESEARCH LIMITS.
DO THCAN THEY UTILIZE REMOTE PAT
MONITORING TECHNOLOGY AND
ILLICIT DATA COLLECTION.
AND IF NOT AN OPPORTUNITY TO
ROLE MODEL AND GUIDE THAT ARE
SPECIALTY SPECIFIC.
SO ALL OF THIS REQUIRES AGAIN
PLANNING ON THE PART OF THE
FACULTY.
TALKING ABOUT SOME OF THE
OPPORTUNITIES.
IF THERE ARE TECH FAILURES.
PRESPECIFY A BACK UP PLAN SO YOU
CAN USE A TELEPHONE OR
RESCHEDULE A VISIT.
AND THEN ONE OF THE THINGS THAT
AS FACULTY IN A VIRTUAL SETTING
-- IS WHAT HAPPENS IF THERE IS A
DISAGREEMENT WITH AN ASSESSMENT.
YOU MIGHT WANT TO TALK ABOUT AND
PRESPECIFY WHEN YOU'RE GOING TO
STEP IN.
IT'S IMPORTANT TO BE ABLE TO DO
THIS IN AN APPROPRIATE WAY AND
INCORPORATE SOME TEACHING DURING
THE VIDEO CALL FOR BOTH THE
TRAINEE AND THE PATIENT.
THERE ARE WAYS TO MITIGATE
WITHOUT IT BEING REALLY AWKWARD.
SO NOW I'LL TALK ABOUT SOME OF
THE RESOURCES.
A LOT OF THE CONCERNS OUTSIDE OF
NIH ENVIRONMENT ARE RELATED TO
POLICY AND LEGAL REQUIREMENTS.
THESE ARE TOPICS THAT WE NEED TO
BE AWARE OF.
THERE ARE A FEW RESOURCES.
ONE IS THE CENTER FOR CONNECTED
HEALTH POLICY.
THAT IS SHOWN DOWN ON THE BOTTOM
LEFT AND THAT SHOWS SOME OF THE
STATE BY STATE GUIDANCE FOR
USAGE OF TELEHEALTH.
THERE IS A FULL PAGE THAT TALKS
ABOUT TELEHEALTH TRENDS AND
POLICY RELATED ISSUES.
YOU CAN NAVIGATE THERE.
AND THERE ARE VIDEOS.
AND AMERICA TELEMEDICINE
ASSOCIATION HAS A LOT OF
DOCUMENTS AND ALSO MEET UPS AND
OTHER VIDEOS THAT ARE PART OF
THEIR PAGE.
SO I WOULD ENCOURAGE TO YOU GO
THERE FOR ADDITIONAL RESOURCES.
AND BEFORE WE RUN OUT OF TIME
WE'RE GOING TO SHOW A SIMULATED
ENCOUNTER.
NO PATIENTS WERE USED FOR THIS
VIDEO BUT I DO CREDIT MEGHAN AND
TRICIA FOR OBLIGING ME WITH
CREATING A SIMULATED ENCOUNTER.
>> AS YOU CAN SEE I'M ADJUSTING
MY SCREEN.
>> I THINK OUR PATIENT WILL BE
JOINING US SHORTLY.
I'M GOING TO INTRODUCE YOU AND
MAKE SURE SHE IS OKAY WITH YOU
JOINING BEFORE WE PROCEED.
>> IS THIS A GOOD PLACE FOR YOU
TO DO THE TELEHEALTH VISIT
>> YES.
I HAVE MY DOOR SHUT
>> I JUST WANT TO DO OUR
TELEHEALTH CONSENT BEFORE WE
START SO YOU KNOW WE'RE USING A
SECURE NIH NETWORK AND WE'LL
KEEP YOUR INFORMATION PRIVATE
AND TALKING ABOUT YOUR ASTHMA
TODAY.
IT'S APPROPRIATE FOR A
TELEHEALTH VISIT.
UNLESS WE FIND SOMETHING OUT
DURING THIS VISIT THAT REQUIRES
AN IN PERSON VISIT WE CAN
PROCEED.
I JUST WANT TO TELL YOU THAT I
HAVE A STUDENT WITH ME TODAY.
MEGHAN IS WITH US TODAY.
AND AS LONG AS YOU'RE OKAY WITH
HER BEING HERE WE'LL PROCEED
>> SURE.
THAT SOUNDS GREAT.
>> SO TO INFORM YOU I HAVE A
SCREEN WHERE YOUR PATIENT
RECORDS ARE UP THERE.
IF I LOOK AWAY I'M NOT
DISTRACTED.
I'M JUST LOOKING AT YOUR
RECORDS.
YOUR ASTHMA IS DOING WELL.
OUR NURSE NOTATED THAT WHEN SHE
CALLED THAT YOU'RE DOING WELL
AND NOT HAVING ANY PROBLEMS.
CAN YOU TELL US MORE ABOUT HOW
THINGS ARE GOING?
>> THEY'VE BEEN GOING WELL.
I HAVE BEEN CONTINUING MY
MEDICATION AND I HAVE NOT HAD
TOO MANY SYMPTOMS.
OCCASIONALLY WHEN I'M OUTSIDE
AND THERE IS A LOT OF HEAT AND
THE HUMIDITY IN THE AIR TENDS TO
ACTIVATE THINGS BUT OTHERWISE
I'M DOING GREAT.
>> 80 -- TWICE A DAY.
ARE YOU STILL ON THE MEDICATION?
>> YES.
I THINK THAT IS THE CORRECT
DOSAGE.
I DON'T HAVE IT WITH ME BUT I'M
PRETTY SURE THAT IS RIGHT
>> AND -- AS NEEDED.
>> CORRECT.
>> HAVE YOU NEEDED TO USE IT
>> NO.
>> IN NIGHTTIME SYMPTOMS?
COUGHING OR ANYTHING AT NIGHT?
>> SOME MILD COUGHING BUT
NOTHING THAT KEEPS ME AWAKE.
I'VE BEEN DOING GREAT
>> AND HOW OFTEN WOULD YOU SAY
THAT HAPPENS?
>> MAYBE ONCE A MONTH.
NOT MUCH AT ALL
>> AND WHEN YOU'RE EXERCISING OR
DOING ACTIVITY YOU DON'T HAVE
ANY LIMITATIONS?
>> NO.
NO PROBLEMS.
>> GREAT.
THAT ALL SOUNDS GREAT.
I'M WONDERING SINCE THE LAST
TIME THAT WE SAW YOU I SAW THAT
YOUR RECORD NOTE STATED THAT YOU
HAD SEVERAL PETS.
WHAT ARE YOUR PETS?
>> YES, I DO.
PROBABLY NOT THE BEST IDEA WITH
MY ALLERGIES BUT I HAVE TWO DOGS
AND TWO CATS.
BUT THAT HAS BEEN GOING WELL AND
WE'VE ALL BEEN GETTING ALONG
GREAT IN THE HOUSE SINCE I'VE
BEEN TAKING THE ALLERGY SHOTS.
>> AND THE SHOTS ARE GOING WELL,
ACCORDING TO THE RECORD.
I SEE THAT YOU'RE TOLERATING
THEM FINE AND YOU'RE NOT HAVING
ANY ADVERSE REACTIONS OR
PROBLEMS IN TERMS OF THE SHOTS.
>> NO PROBLEMS.
>> WELL THAT SOUNDS GREAT.
A SHORT VISIT.
YOU SEEM LIKE YOU'RE DOING VERY
WELL AND WE CAN SEE YOU BACK IN
THE OFFICE FOR YOUR REGULAR
CHECK UP FOR SIX MONTHS.
>> OK.
AND SHOULD I CALL TO SCHEDULE
THE APPOINTMENT.
>> DO YOU NEED ANY REFILLS?
>> NO.
I THINK I'M GOOD.
BUT I KNOW HOW TO GET A HOLD OF
THE NURSE.
>> OUR NURSE WILL REACH OUT JUST
TO VERIFY FOR APPOINTMENTS AND
REVILLES AFTER WE'RE DONE.
WE'RE GOING TO STAY ON THE LINK
AND YOU CAN TAKE OFF AND ENJOY
THE REST OF YOUR DAY.
>> OVER-ALL I THINK IT WENT
REALLY WELL.
SHE WAS ABLE TO REPORT HER
SYMPTOMS AND THERE WAS A FULL
PICTURE OF WHAT WHAT WAS GOING
ON.
MY ONLY QUESTION IS -- HOW MUCH
INSTRUCTION DO WE GIVE A PATIENT
TO DO SOMETHING LIKE THIS --
[ INDISCERNIBLE ]
>> YEAH.
THAT IS A GOOD QUESTION.
SHE LOOKED VERY CALM.
SHE DIDN'T HAVE ANY DIFFICULTY
TALKING.
SHE WAS IN THE OFFICE.
I WAS NOT GOING TO ASK HER TO
RUNAROUND.
IF THEY ARE AT HOME YOU CAN ASK
THEM TO RUN UP THE STAIRS TO
ASSESS HOW THEY ARE DOING.
MOST OF THE EXAM WAS OBSERVATION
FROM MY PERSPECTIVE IN TERMS OF
LOOKING AT HER RESPIRATORY RATE.
AND SO THOSE ARE THINGS THAT
I'LL DOCUMENT THAT SHE LOOKED
GOOD AND DEPARTMENT HAVE ANY
PROBLEMS WITH HER * REPOSITORY
STATUS.
I JUST NOTICED THERE WAS SOME
CRACKING WHEN UNMUTED YOURSELF.
CERTAINLY ONE OF THE THINGS TO
MENTION, WE DON'T HAVE A CHOICE
OF WHERE YOU SIT.
YOU'RE IN THE LAB AND WE TALKED
ABOUT THIS BEFORE AND THERE ARE
ALSO PEOPLE WALKING AROUND YOU
SO WHEN YOU DO A TELEHEALTH
VISIT IT'S IMPORTANT TO MAKE
SURE THAT YOU'RE IN A PRIVATE
SPOT.
JUST ONE OF THE THINGS THAT
THINK ABOUT AND MAKE SURE YOUR
BROADBAND IS OKAY AND NOT HAVING
ANY TECHNICAL DIFFICULTIES.
WE CAN TROUBLESHOOT BUT ONE OF
THE THINGS TO BE AWARE OF DURING
TELEHEALTH VISITS.
>> OKAY.
THANK YOU.
>> OKAY.
WE HAVE SEVERAL MORE OF THESE.
WE'LL GO OVER THE SCHEDULE AND
SEE IF THERE ARE OTHERS THAT ARE
APPROPRIATE FOR YOU TO JOIN.
THANK YOU FOR JOINING ME AND LET
ME KNOW IF YOU HAVE ANY OTHER
QUESTIONS.
>> SO ONE OF THE THINGS THAT YOU
CAN DO DURING A TELEHEALTH VISIT
IS -- YOU CAN UTILIZE THE
TECHNOLOGY SO SHOW AND SHARE.
YOU CAN PULL UP ARTICLES *
PRECEPT -- AND THE LEARNER CAN
ILLICIT THESE.
YOU CAN ASK THEM IF THEY
WOULDN'T MIND SHOWING YOU THE
ARTICLE THAT THEY ARE TALKING
ABOUT SO IT'S A TWO-WAY PROCESS.
YOU CAN DISCUSS LEARNING
POINTERS AND SOME OF THE
OBJECTIVES AND THE FOLLOW-UP
PLAN.
IS IT GOING TO BE IMMEDIATELY
AFTER ONCE YOU TELL THE PATIENT
TO LEAVE OR LATER IN THE DAY.
AS WE MENTIONED BEFORE ASSESSING
COMPETENCY DEVELOPMENTS CAN BE
CONFIRMED DURING THE ENCOUNTER.
SO FOR CLINICIAN RESEARCHERS TO
OVERCOME THE TELEHEALTH
HESITANCY THERE ARE
OPPORTUNITIES.
ONE IS THAT WE CAN TRACK DATA
STREAMS.
AS LONG AS PHYSICIAN HAVE INPUTS
INTO THE DESIGN AND
IMPLEMENTATION OF TELEHEALTH
THESE ARE TECHNOLOGIES THAT ARE
PRIME FOR USE.
THERE IS POTENTIAL FOR --
SAMPLES.
YOU'RE DOING A TELEHEALTH VISIT
BUT THEY ARE SENDING IN A
SAMPLE.
THERE ARE OTHER OPPORTUNITIES.
AUGMENTED INTELLIGENCE MACHINE
LEARNING APPROACHES.
ASSESSING PATIENT RELATED
OUTCOMES.
AND MOBILE HEALTH POTENTIALLY
USING TELEHEALTH.
AND SO I'M GOING TO WRAP UP BUT
I WANTED TO POINT OUT THAT
HASHTAG TELL MED HEALTH NOW.
YOU CAN LOOK THERE FOR
ADDITIONAL INFORMATION AND
TOPICS RELATED TO TELEMEDICINE.
THERE ARE RESOURCES THAT I
PROVIDED ON MY PRIOR SLIDE.
AND I'M HAPPY TO TAKE QUESTIONS.
BUT BEFORE WE DO THAT I WOULD
LIKE YOU TO DO ONE MORE THING
FOR ME.
SO AFTER THIS TALK -- YOU'VE GOT
A LOT OF INFORMATION.
SO PLEASE TAKE A MOMENT TO THINK
ABOUT WHAT ARE THE WAYS THAT YOU
MIGHT IMPLEMENTOR CHANGE
SOMETHING ABOUT YOUR TELEHEALTH
APPROACH.
WHETHER TO PATIENTS OR OBTAINING
CLINICAL RESEARCH INFORMATION.
IF YOU'RE A TRAINEE HOW YOU
MIGHT ENGAGE BETTER IN A
TELEHEALTH FORMAT.
IF YOU'RE FACULTY WHAT YOU MIGHT
CHANGE AS A RESULT OF THE TALK
TODAY.
NAVIGATE TO MENTEE .C --
MENTI.com.
63163554 AND THEN AFTER A FEW
MINUTES I'M GOING TO SHARE THE
SCREEN AND SHOW YOU SOME OF THE
COMMENTS.
>> ONE PERSON HAS RESPONDED.
CONSIDER BACKGROUND AND SOUND
QUALITY.
MUCH MORE PLANNING FOR SESSIONS
AND ATTENTION TO ENVIRONMENT.
-- PHYSICAL EXAM.
PROFESSIONAL SET UP.
SO WE ARE AT TIME.
SO PERHAPS WE CAN WRAP UP THE
SESSION.
AND WE CAN FORWARD QUESTIONS TO
YOU DR. KHOURY.
THANK YOU VERY MUCH FOR AN
INCREDIBLY RICH TELEMEDICINE
LECTURE THAT HAS REALLY HELPED
EVERYONE I'M SURE.
BEING THOUGHTFUL ABOUT THIS NEW
TECHNOLOGY TO INCORPORATE IT.
AND GET OVER THEIR BARRIERS.
>>THANK YOU SO MUCH.