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Digital Health Add-ons: When a Visual Exam is not Enough



#TelemedNow Twitter Chat
Wednesday, May 20 – 8 PM ET 

Introduction & Welcome: Ami Bhatt (@AmiBhattMD) -- Moderator 

#TelemedNow Digital Health Add-ons: when a visual exam is not enough

Video visits have become a mainstay of outpatient care. Patient level data, obtained in the home or local clinic is a necessity to scale telemedicine use and improve access to advanced care. Digital health tools abound. Today we will discuss potential options and engage patients, providers and industry directly to expand the discussion of #TelemedNow — what’s next?

Q1 Vital sign monitoring is the foundation of a clinic visit. How do you address that in a virtual video visit?

A1 Notable Responses: 
Andrew Watson (@arwmd) I wonder what vital signs are truly vital? Moving forward, we can get a lot of this information of peripherals purchased online. I certainly think that we miss a blood pressure and a heart rate with video visits. Open to ideas about how to fix this.

Jamey Edwards (@jameyedwards) There are 1,000's of devices that can be used to provide #vitalsigns during a #telemedicine visit via #bluetooth to a connected device & direct #cellular options. @validic, @Human_API & others have built interfaces to ease data integration.

Andrew Watson (@arwmd) @AmiBhattMD this is an example of what may work, never used it. 
https://vitalconnect.com/solutions/vitalpatch/

Marie Gerhard-Herman (@GerhardHerman) #TelemedNow patient participation definitely Needed with video physical examination. Simple examples include touching the fingertips to the cheek to gauge whether both are the same temperature (or fingertips clearly cold) Very useful with a variety of skin colors.

Ritu Thamman (@iamritu) #TelemedNow perhaps patients can fill their own vital signs 
https://bit.ly/3cSR5KU Can use this pre-visit @myopennotes (published recently in @nejmcatalyst link above) to record the purpose of the visit & vitals 
🌡️temperature 💗heartrate 🩸 pressure ⚖️ weight

Ceci Connolly (@CeciConnolly) Such a great point. Innovators are so far ahead in their thinking about what devices can do. My question as a non-clinician: can't patients be trusted to do some of this and provide to clinician? My mother takes her BP every day and keeps in a handy notebook.

Jagdish Patel (@jpkca) VS - 1/2 of my patinets report BP, Pulse and weight during #telemedcine visit

Ceci Connolly (@CeciConnolly) Recently heard from v hi level Google Health doc that device screens now able to detect many vitals from subtle shifts in image of face

Andrew Watson (@arwmd) And it makes you wonder what happens next with 5G and the promise of IOT. @AjitPaiFCC I actually think it would be beneficial to have the peripherals directly connected to cellular networks, and not paired with phones. Too much of a pain for patients.

Irma #FlattentheCurve (@IrmaRaste) There’s been talk about #voice as a vital sign, evaluating this is definitely possible in the #telehealth world.

Jagdish Patel (@jpkca) I would like to have BP, Pulse, Temp, Weight, O2 saturation, Blood sugar if DM, daily exercise time

Ritu Thamman (@iamritu) And we need good data just like from a clinic-BP is a key vital sign & pts & doctors have to know how best to collect it #TelemedNow @CardioSmart

Andrew Watson (@arwmd) really good point, and at some point it’s a leap of faith. We see a lot of this in our clinics as well. My concern is to other people use the peripherals, are we getting a neighbors blood pressure? Or your sisters weight? #TelemedNow. There is a fundamental responsibility

Helen Burstin (@HelenBurstin) Yes, data alone won’t be sufficient. Busy clincians and patients need AI support to scan through data and provide useful information

Janice Tufte (@Hassaanah2017) there are a number of innovations that could share personal health information patient to provider #TelemedNow

Jeffrey Wessler (@jwessler) This week I observed a pt check her BP, using her home cuff and table/chair setup. We spent 3 minutes on proper technique, and it was at least as useful as the typical home BP log I seen in clinic.

Helen Burstin (@HelenBurstin) Given patient anxiety and the challenge of finding the right size cuff for patients, I’m not convinced that office BP is the gold standard anymore. Need more reliable home BP standard to use for improvement and accountability measurement

Salim Saiyed (@SalimCMIO) We need #HealthInsurance to reimburse for home vital devices such as BP, pulse ox, etc. we need patients to become adept at doing vitals. Create education, genius vitals bar stations for public to learn. Almost like basic BLS we teach to all

Jeffrey Wessler (@jwessler) The hardest part was not interrupting and just watching...in general telemedicine has really sharpened my listening and observation skills Ear Eyes


Q2 Vital sign monitoring is the foundation of a clinic visit.   How do you address that in a virtual video visit?

A2 Notable Responses: 
Jagdish Patel (@jpkca) Love to have ECG, KardiaMobile is good but looking for stand alone technology where we don't have to depend on company interface.

Jamey Edwards (@jameyedwards) @AliveCor, @OmronHealthUS, @sonohealth & others have devices that allow for remote EKG. In addition, patients are wearing "wearable monitors" that can track them over greater time periods while reporting back anomalies.

eko_health (@eko_health) Would you say a single-lead, such as our DUO, is a more convenient method during the screening process? If anything looks out of the ordinary, send off for a 12-lead referral #TelemedNow

Ceci Connolly (@CeciConnolly) Going back into deep recesses of my mind but hoping @EricTopol will keep me honest. Didn't you show us EKG on your cell phone? Please chime in on this important topic of cardiac care via virtual.

Andrew Watson (@arwmd) Said as a surgeon, Face with monocle, is an iwatch good enough?

Ceci Connolly (@CeciConnolly) Does the purpose matter? In other words, emergency situation vs ongoing patient monitoring? Triage from remote location? Determining whether to bring in a patient? Seeking doctor guidance

Ritu Thamman (@iamritu) Key question: (Insert Apple & Watch Emoji) study LED lights & photodiodes used to get photoplethysmogram (PPG) (pulse estimation) Time between PPG signal peaks (intervals between pulses)create a tachogram & if abnormal pt notified & led to virtual visit/ECG patch (“ePatch”)but had low ppv

Kamala Tamirisa (@KTamirisaMD) you summarized the #EKG options well. Cost, insurance payers & legal implications are some things to take into consideration.

Q3 With the current rates of cardiac disease, An EKG is often essential to a visit. How do you accomplish that?

A3 Notable Responses: 
bloomrhealth (@bloomrhealth) AI and Machine Learning models are being trained as we speak

Jorge Rodriguez (@translatedmed) Is this an opportunity to engage patients in assisting with the physical exam ? Or support caregivers?

Jamey Edwards (@jameyedwards) Remote physical exam is new skill that needs integration into med school curriculum. #Dermatoscope, #AI driven computer vision (@Captureproof), & more available today for #telemedicine. #Websidemanner & ability to guide local patient hands will be key.

Helen Burstin (@HelenBurstin) Absolutely. @AAMCtoday draft standards very comprehensive. Funny exchange on twitter about why med students still buy ophthalmoscopes since they don’t really learn how to use anymore. Let’s try teaching them how to use new tech that works! 

Andrew Watson (@arwmd) Ironically, a big thing is to get rid of the fingerprint on the camera. That always makes the lighting horrible. #TelemedNow It can also be difficult to hold the camera still during the visit. At times it looks like the Blair witch Project. All good.

Ami Bhatt (@AmiBhattMD) Let's turn to Diabetes for Q3. Major chronic disease requiring at home care. Can #telemedicine help?

Jagdish Patel (@jpkca) tele Derm is not that difficult. I know Kaiser P. allows Epic-Hiaku take Pic from PCP office and consult Dermatology in EPIC chart, just like that. They are doing before COVID

Andrew Watson (@arwmd) That’s a great point Jamey, I know a lot of people are looking at this. @JuddHollander is one and @KristiHenderson @DellMedSchool I think we’re others that were incorporating this. #TelemedNow

Evan Kirstel (@evankirstel) definitely but even beyond the #telemedicine opportunity, COVID19 may also motivate people to be more proactive about their health in general (me included!)

Salim Saiyad (@SalimCMIO) #webside manners are key not just for new but also existing #docs to learn #TelemedNow. We also need to emphasize family involvement to help guide a physical exam. We had a nurse family member who was great at home #telemednow visit

Marie Gerhard-Herman (@GerhardHerman) A3 office exam skills can be used remotely with patient patient/caregiver assistance.

Kamala Tamirisa (@KTamirisaMD) Adding to @iamritu We have done wound checks successfully. Brightly lit area or a family member to show light at the pocket/incision site.

Jennifer Co-Vu (@DrJenniferCo_Vu) “Webside manner” is an accurate term! As #Telemedicine is utilized more by different fields, the “remote physician exam” should be a new skill to teach Med students!

Jennifer Co-Vu (@DrJenniferCo_Vu) I tell parents of my post op patients to use #smartphone instead of a computer for #Telemedicine because this allows them to just flip the camera to adequately show sternal incisions/chest tube wounds better. Sorry, I went back to talking about Red heart #Telemednow

Q4 #Diabetes is rampant and these patients need continuous monitoring and care. How can #telemedicine optimize and improve diabetes care?

A4 Notable Responses: 
Jamey Edwards (@jameyedwards) #PopulationHealth companies like @Livongo, @omadahealth have built care systems around treating chronic conditions like diabetes that integrate #glucosemonitors, #telemedicine & other modalities very successfully. 

Andrew Watson (@arwmd) Here is where you really get into the heart of remote monitoring. @VivifyHealth @Livongo @ViTelNet so much of this has to be done in an asynchronous fashion. #TelemedNow And @CeciConnolly @GinWhitman @_ACHP where payors will truly benefit.

Ami Bhatt (@AmiBhattMD) The new standards of #diabetes care may evolve significantly to #digitalhealth and #TelemedNow care after #COVID @ADAHouston @AmDiabetesAssn@KLHAGAN

Helen Burstin (@HelenBurstin) Just like with BP, patients often forget to record their home glucose. It would be glorious to move beyond handwritten logs and use remote monitoring data directly from devices for both in-person and virtual visits. Easier for patients and better care #TelemedNow

Ami Bhatt (@AmiBhattMD) Yes. bluetooth enabled measurement of #bloodpressure at home in #cardiac patients has gotten rid of the need for BP logs. It is priceless! 

Jagdish Patel (@jpkca) Comprehensive DM care as a chronic care management will need RPM for *BP, Pulse, BS, PAD check, Eye exam, A1c... all doable with remote check 

Helen Burstin (@HelenBurstin) If we asynchronously review glycemic control and offer patients parameters to adjust meds, it should help underserved patients who often run out of meds since hard to take days off from work, arranging sitters, etc. BUT need supplies and #TelemedNow visits covered by Medicaid!

Ritu Thamman (@iamritu) BP is a key parameter: this recent @JAMA_current study showed a high 73% pts willing to participate in a smartphone enabled BP monitoring & ~2/3 were willing to transmit their data
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2764578

Q5 What digital technologies do you use or want to see available?

A5 Notable Responses: 
Andrew Watson (@arwmd) Either well integrated asynchronous vital signs or haptics. Haptics that could palpate lymph nodes. #TelemedNow

Ceci Connolly (@CeciConnolly) Not sure I am creative enuf to imagine next wave of technologies but want to stress keys to success: convenience for drs & patients, sufficient payment in value-based models, privacy/security, broadband for all

Evan Kirstel (@evankirstel) You name the #emergingtechnology there’s a company /startup working on it that could be leveraged for telemedicine! #5G, #IoT, #cloud, #AI, #Robotics, #satcomms.... sky’s the limit



Marie Gerhard-Herman (@GerhardHerman) #telemednow simple data like activity from health apps, Along with data from all devices (pacer to CPAP). Ideally with access that does not require a lot of work on the patient’s part

Embic (@Embic4) I think we need a facility for "micro-scheduling" so MD's can have (and get paid for) quick chats with patients, on the spur of the moment, as time in their day allows. That might actually lighten their daily load and allow delivery of more care. #TelemedNow

Salim Saiyed (@SalimCMIO) As much as I like all the new cool #digital tools, we need to make the existing #telemednow platforms robust. It has to move beyond #facetime. share EHR screens, captions, integrated interpreters, seamless solutions that make it fun for patients & providers. #patientexperience

Janice Tufte (@Hassaanah2017) I want to see #technologies that are easily accessible, affordable, (covered by insurances) that can be #comprehensive in reading, collecting a number of vital signs and can transmit them to the #cloud for #clinicians to use for informed #shareddecisionmaking #telemedNow

Ajay Kohli (@ahhhjay23) So many options for #telemedicine and #digitalhealth! But are there any legitimate solutions that interface with enterprise health-tech and have automated & clinically useful analyses?
More data isn’t better data. Better data is better data.

Helen Burstin (@HelenBurstin) Given recent evidence of a plateau or decline in telemed visits, we need to quickly learn from docs and patients - what was missing? what digital tech would have helped? We can't afford to slide back

Salim Saiyed (@SalimCMIO) #telemednow agree with @arwmd "well" integrated vitals mean, seamless flow of data into EHR, into the right fields, with the right parameters, with "filters" to remove nuance, AI to alert clinicians for abnormals. It takes a lot. I haven't seen many be successful.

Kamala Tamirisa (@KTamirisaMD) #TelemedNow AI integrated Neuro cognitive assessment & a change in daily routine in elderly.

Ami Bhatt (@AmiBhattMD) #digitalhealth involves more than #technology ... what if new modalities helped us understand how to communicate better w/patients? Think of the effects on chronic disease!! Myers Briggs anyone?

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