Telemedicine

Aka: Telemedicine, TeleHealth, Virtual Healthcare Visit, Electronic Visit, EVisit, Telemedicine Musculoskeletal Evaluation

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II. Definitions

  1. Telemedicine
    1. Telecommunications (voice, video) to provide off-site health services to patients
  2. Synchronous Telemedicine
    1. Realtime virtual patient care
  3. Asynchronous Telemedicine
    1. Patient specific medical data recieved for later review and response
  4. Remote Monitoring
    1. Health data continuously collected from patient (Blood Pressures, Glucose monitoring)

III. Precautions

  1. Employ a HIPAA compliant mode of communication
  2. Use Test Patients first before using in practice
  3. Assess patient's appropriateness for Telemedicine
    1. Digital literacy
    2. Internet connection and compatible device (e.g. smartphone or computer)
    3. No significant language barriers (not a contraindication if Interpreters are available for visit)
    4. Adequate Vision and Hearing
    5. Patient or family willingness to send clinical data before visit (e.g. Glucose logs, diet log, Blood Pressures)
  4. Additional contact may be needed in between Telemedicine provider visits
    1. Phone calls
    2. Electronic messaging
    3. In person visits (new concerns, concerning findings on Telemedicine)
  5. Patients may lack the electronic and internet resources to allow for Telemedicine
    1. Telemedicine locations are being established in rural communities (e.g. VA partnerships with Walmart, American Legion)

IV. Technique

  1. Set expectations and goals for visit at the start of the encounter
  2. Maintain Bedside Manner while online
    1. Making eye contact with the patient requires the provider to look at the camera
    2. Maintain a pleasant speaking voice
  3. Clear verbal communication is key
    1. Social cues and body language are often hidden when communicating online

V. Protocol: Clinic Staff

  1. Ensure patient has necessary devices (facilitate DME prescriptions as needed)
    1. Electronic Device and connectivity
    2. Glucose monitoring (e.g. Continuous Glucose Monitoring)
    3. Blood Pressure Cuff
    4. Weight scale
  2. Employ the patient's home devices for Vital Signs
    1. Portable oximeter provides Heart Rate and Oxygen Saturation
    2. Smart watch provides Heart Rate (or teach a patient how to check their pulse)
    3. Weight scale
    4. Peak Flow meter
  3. TeleHealth setup and troubleshooting with office staff
    1. Obtain back-up phone numbers in case of technical difficulty
  4. Obtain consent for visit, billing and privacy discussion
  5. Gather previsit history and Review of Systems
  6. Inquire about new concerns
  7. Update medical record including medications, habits, recent hospitalizations and surgeries
  8. Remote Glucose monitoring (esp. Continuous Glucose Monitoring) is ideally performed between visits
    1. Review Glucose trends, time in range, average Glucose and low Blood Glucose
    2. Medication adjustments may be made between visits
    3. Cloud services include manufacturers (Dexcom, Clarity, Libreview) and platforms (Glooko, Tidepool)
  9. Obtain clinical data before the start of the visit
    1. Vital Signs (Blood Pressure, Heart Rate, weight)
    2. Blood Glucose readings
    3. Lab test results ordered at last visit

VI. Protocol: Clinical Encounter by Medical Provider

  1. Confirm that patient has appropriate environment for visit (privacy, safety) and reschedule as needed
    1. Patient not driving a vehicle or operating machinery
    2. Patient can devote full attention to visit (not speaking to others, no significant background noise)
  2. History
    1. Review together any previsit history, positive Review of Systems and new concerns
    2. Review Vital Signs
    3. Review clinical data
    4. Review lifestyle (diet and Exercise)
    5. Consider having patient demonstrate the food they eat, items in their refrigerator
    6. Patient might demonstrate their process for medication use (e.g. pill boxes, use of Insulin Pens)
  3. Telemedicine Focus Areas
    1. Avoid sensitive exams via Telemedicine (e.g. genitalia)
    2. Focused Telemedicine exams are available for many chief complaints
  4. Plan
    1. Adjust medications and lifestyle interventions
    2. Review lifestyle modifications
    3. Send patient an after visit summary
  5. Follow-up Visits
    1. Plan future labs before next visit
    2. Consider alternating in-person and Telemedicine visits for chronic medical problem management
    3. Arrange in-person visit for additional concerns, complications

VII. Evaluation: Musculoskeletal

  1. Upper Extremity Telemedicine
    1. Shoulder Exam
    2. Elbow Exam
    3. Hand Exam
    4. Wrist Exam
  2. Lower Extremity Telemedicine
    1. Hip Exam
    2. Knee Exam
    3. Ankle Exam

VIII. Evaluation: Chronic Medical Care

  1. See Telemedicine Diabetes Mellitus Evaluation (Telediabetes Care)

IX. Imaging

  1. Decision rules may help guide who needs further evaluation with imaging
    1. Consider obtaining imaging followed by in person follow-up exam on same day

X. Management

  1. Exercise caution in underevaluating patients virtually
    1. Red flag findings should prompt in person evaluation
  2. Home care online instructions
    1. Telemedicine evaluations may direct online resources (e.g. rehabilitation Exercises)

XI. Resources

  1. AAFP Telemedicine
    1. https://www.aafp.org/practice-management/health-it/telemedicine-telehealth.html

XII. References

  1. (2020) presc lett 27(5):27
  2. Yedlinsky (2021) Am Fam Physician 103(3):147-54 [PubMed]

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