How Can Research Inform the Future of #Telemednow?

#TelemedNow Twitter Chat Wednesday, August 12 – 8 PM ET Introduction & Welcome: Jamey Edwards (@jameyedwards), Ceci Connolly (@CeciConnolly), Ami Bhatt (@AmiBhattMD), Andrew Watson (@arwmd), Ritu Thamman (@iamritu) – Moderators Reliving / revisiting some of our top questions from weeks past.

Q1 How do we expand access to care using telemedicine? Access is such a key topic for payers and providers alike. Does #telemedicine make access easier or harder at times?

A1 Notable Responses: Jamey Edwards (@jameyedwards) #Telemedicine puts #healthcare at the fingertips of #patients, using #technology we already know (smartphone, PC, TV...). It’s sits at the crosshairs of convenience (no travel or parking, minimal waiting or missing work), quality & efficiency = increased access. Ami Bhatt (@AmiBhattMD) how this has changed! Patients and providers alike are now much more tech savvy! Matt Sakumoto (@MattSakumoto) Access = broadband, devices, and tech literacy for many different patient populations. Great recent studies on older adults, rural, and other vulnerable populations Aditi Joshi (@draditijoshi) expanded and affordable connectivity, education of pts/providers, improved integration with EMR, devices and already available data. Recognizing not everyone understands both tech and medicine in the same way and learning how to adapt it. Aditi Joshi (@draditijoshi) also, need the first stop/site patients see to be in multiple languages. We have interpreter services but that doesn't help with setting up an account/understanding what telehealth does Ritu Thamman (@iamritu) Availability does not mean access There are real barriers for women, older pts, pts whose first language isn’t English, & those with the lowest income - challenges we need to overcome Jamey Edwards (@jameyedwards) Agreed. Language Interpretation on a localized translated site based around accessibility is available today. Just need right platform... Andrew Watson (@arwmd) #TelemedNow and from a payers perspective, offering replacement services is so important, not just additive services. It’s still very hard to quantify this, especially cost avoidance. Arti Bhan (@ArtiBhan1) Working with an inner city population, I felt that is improved access for my patients, especially the elderly who rely on public transportation. However, they chose telephone more often compared to video visits Michael Bagel (@MichaelBagel) Temporarily removing geographic restrictions and originating site requirements has allowed patients to receive #telehealth where they are and when they need it. Also gives providers flexibility in delivering #virtualcare. Need to make it permanent! Shreeesepubhlth (@ShereesePubHlth) We expand access by leaving remote care options in place post pandemic while not increasing cumbersome regulations. We evolve our tech solutions so care fits more seamlessly into lives of All patients. Ritu Thamman (@iamritu) 1. Make access to internet/broadband a right just like water and food; for those who can’t afford offer an internet card like a phone card pre visit 2.make the @CMSGov @HHSGov temporary waiver authority permanent thru legislation Connie Hwang (@hwangc01) Positive start w/ CMS' new CHART model offering rural health providers upfront investment & capitated payments. The model includes opportunities to use #TelemedNow for home health visits, remote patient monitoring programs & in SNFs. @_ACHP Ginny Whitman (@GinWhitman) @_ACHP members have been seeing this as well! Access goes beyond video platforms. Telephones have to be part of the long term picture Matt Sakumoto (@MattSakumoto) And concern for rural health disparities "Telehealth in Response to the Covid-19 Pandemic: Implications for Rural Health Disparities"… Ritu Thamman (@iamritu) There are differences among even the elderly population in terms of #technology help at home- some have family to help on boarding, some can’t & we do phone call instead Jim St. Clair (@jstclair1) Cross-state credentialling please! #TelemedNow Cory Simpson (@CorySimpsonMD) Re-visiting State-based licensure for #TelemedNow is a key way to improve pt access to specialists. Especially for those in rural areas and those with rare diseases. Keeping docs in State-shaped boxes does not make sense when #telemedicine makes physical location irrelevant. Ryan K. Louie (@Ryanlouie) Part of the movement is to let the public know that #telemedicine plays a special role and can do things that in-person visits might not be able to do. #TelemedNow is doing great work right now for this. Rashmi Mullur (@rashmi2008) Educational efforts can improve access by letting patients and providers see the benefits and critical uses of telemedicine. Patients need more Telehealth literacy, providers need to understand how virtual tools can support in-person care—esp for chronic disease Jan Oldenburg (@janoldenburg) Just curious, what would be different from making broadband a public utility vs #telemedicine? Andrew Watson (@arwmd) It’s about democratizing the need for this, and ensuring that all parties respect that the patients are at the center of this. The patients need this fundamentally. Jan Oldenburg (@janoldenburg) I agree--I think the healthcare need for broadband goes beyond access to #telemedicine services & includes access to remote monitoring tools; integrated apps, sensors, & wearables; & access to contextual education. All of them matter for informed & empowered patients #telemednow

Q2 How can #telemedicine bridge the gap between rural and urban populations? A2 Notable Responses: Jamey Edwards (@jameyedwards) #Telemedicine breaks barrier of geography to load balance the #healthcare system and bring high quality clinicians into underserved areas, rural or urban, allowing #hospitals & #clinics to broaden their reach & make progress towards leveling the playing field. Matt Sakumoto (@MattSakumoto) Greatest gains probably around specialty care access. @UNMProjectECHO has a great model for this. Also @ucsfhealth Remote Second Opinion program Connie Hwang (@hwangc01) I'm a big fan of Project ECHO. In 2017 @PresHealth received $3.5M from NM to design & implement an innovative care model to address opioid dependence. This telementoring program significantly expanded access to MAT for SUD patients Michael Bagel (@MichaelBagel) #Telehealth should be personalized to the community - whether rural or urban. Benefit of #virtualcare is that patients, providers, plans, communities can all use it to deliver individual, affordable and high quality care. Janice Tufte (@Hassanah2017) Offer #Patients physician and specialty services in rural areas. #Telehealth #Telemedicine saves on transportation dollars. #Telemed can offer opportunities to see into the lives of rural patients Aditi Joshi (@draditijoshi) on the heels above question, access! specialists/information/consults at its most basic form. It also allows for more free flow of data, allowing us to understand population health better, when it is bridged. Makes care feel closer between the 2 regions. Cory Simpson (@CorySimpsonMD) Many sub-specialists practice in academic centers, which are concentrated in urban areas--this sets up a disparity for those in rural areas. Using #TelemedNow, any sub-specialist can connect with patients whether they are 3 hrs away due to physical distance or just traffic! Aditi Joshi (@draditijoshi) 100% and can allow them to get treatment in their communities saving on transportation for them and their families/loved ones. Eve (#AmericaMaskUp) Bloomgarden (@evebmd) The bridge needs to be on the physician side. Specialist access without driving for hours and taking days off of work. Also view this as a great opportunity for asynchronous e-consults !! Matt Sakumoto (@MattSakumoto) @Rubicon_MD has a great model for async e-consults that we use at my practice. Saves the patient time and $$ Jan Oldenburg (@janoldenburg) By the way, my congressperson, @SpanbergerVA07, is working hard on rural broadband services and has a bill up for consideration. Talk to your congressional rep about supporting it Rashmi Mullur (@rashmi2008) Totally agree. This is the VA model for Telemedicine hubs with remote “spoke” sites Ritu Thamman (@iamritu) Thru both access & education -if both populations have same access to broadband it will overcome the #DigitalDivide -if there is a campaign to educate people on how to use the technology tools so not only urban folks know how to use it & amplify the merits of #Telemednow Andrew Watson (@arwmd) The cost to payers in others about transportation are significant. I was just talking about this with a colleague in the department of surgery @PittSurgery. inter hospital transfers have huge cost. JK Han (@netta_doc) Broadband definitely important, but also need to provide devices that are accessible, affordable and easy to use. Many simply do not have smartphones, tablets or computers. Cory Simpson (@CorySimpsonMD) I'd hope NORD (@RareDiseases) would also advocate for patient access to #telemedicine--those with rare diseases deserve access to those who can best diagnose and treat them. Specialists can use #TelemedNow to reach them, no matter where they reside. Ritu Thamman (@iamritu) Nord @RareDiseases does use #socialmedia to amplify their knowledge & it could be applied to #TelemedNow in a similar fashion- using it to crowdsource solutions/treatments Salim Saiyed (@SalimCMIO) #Telemednow have a #rural strategy to reach out partner with rural community for access points deliver specialty care in critical access hospitals w/ goal to keep patients there lot of opportunities, but needs a rural focus! Jim St. Clair (@jstclair1) Let's start with data-driven evidence down the zipcode of 1) utilization rates 2) conditions by zipcode 3) broadband availability 4) density of providers by type/specialty Ceci Connolly (@CeciConnolly) Some of same hurdles to delivering rural health care today are hurdles to delivering #telehealth to rural pops. Infrastructure remains huge problem & we need a real commitment to expanding #broadband. Q3 How should we teach and evaluate telemedicine virtual visits with students/trainees? A3 Notable Responses: Jamey Edwards (@jameyedwards) #Telemedicine techniques need to be integrated into #MedEd curricula nationwide with training on #websidemanner & remote management of the physical exam. New skills for the next generation of #clinicians where #Healthcare has a Digital Frontdoor. Aditi Joshi (@draditijoshi) first we have to create standardized visit parameters, quality metrics (adapted from already used metrics is key), clinical protocols that are similar to what we do in in-person care, and ensure we are tailoring to level of student. Aditi Joshi (@draditijoshi) there have been few if any standardized visit guidelines. we are currently working on validating a checklist that can be used for training. we also have created a number of modules/education at @TJUHospital although are based on our experience. Aditi Joshi (@draditijoshi) should be stressed that we first have to recognize what is going to be the future health workforce, how telehealth/digital health/change to value based care will affect it and then tailor our education from med school and teach this from that level. Aditi Joshi (@draditijoshi) anything less is a disservice as educators to the future workforce Ritu Thamman (@iamritu) Great points @draditijoshi What are the best resources to do this ? #TelemedNow is evolving so fast & need to evaluate students on proficiency & competency Aditi Joshi (@draditijoshi) it's true! hopefully the checklist created with other experts, also figuring out how we gauge quality - again, should be similar to what we do in person with some additions for the different venue and modality. using current rubrics and tailoring them to TH visits. Aditi Joshi (@draditijoshi) this also requires anyone involved in education to know the basics so they can also precept, teach, and gauge proficiency. It's a fascinating time because the different levels of clinicians learnt together - now we have to make it standardized for our students and schools. Salim Saiyed (@SalimCMIO) - develop #telemednow rotation for #MedStudentTwitter & residents - routine grand rounds, lecture in each specialty - create incentives for residents work life balance - 1/2 day virtual clinic from home - evaluation criteria same as in person - medical skills, empathy, etc. Eve (#AmericaMaskUp) Bloomgarden (@evebmd) our fellows @NMEndocrinology pivoted to all telemedbc of #COVID19. Shared video chat and mute, then they gather history and evaluate data and then we video patient together. A good history lends itself to teaching quite well. And data review w screen share JK Han (@netta_doc) Understand that you can still actively staff patients with your housestaff doing as you would with F2F visits. Log into the same virtual patient room, housestaff presents with the patient present. Review data actively in the session together. Teach! Matt Sakumoto (@MattSakumoto) Tele-rounds are also great for #MedEd teaching. Would ask my M3s "What PhysEx would you theoretically want to do and why?" Forces Clinical Reasoning based on Hx and Observation Arti Bhan (@ArtiBhan1) Modeling. And observation in real time has been very successful with our trainees. Cory Simpson (@CorySimpsonMD) Agree modeling/shadowing are important in the beginning for trainees learning #TelemedNow. Practicing #telemedicine requires a different skillset that has to be explicitly taught. Should be considered a separate milestone as virtual practice will be essential even post-#COVID19. Rebecca Steele (@RlindstSteele) Teaching #telemednow should include telemedince etiquette and agree that creating a flow that is standard will allow the patients to have an understanding of what to expect next. We should also be including nurses in this education as well! Janice Tufte (@Hassanah2017) Agreed #WebsideManner, Send Patients #VirtualVisit expectations ahead of time, #NursesRock! Ritu Thamman (@iamritu) Agree; @AAMCNews will have their #TelemedNow competencies forthcoming -& they divide the learners into students/trainees/attendings each with slightly more objective goals/milestones to reach @LisaDHowley Iris Thiele Isip Tan (@endocrine_witch) I did a limited literature review for this presentation. Various ways that telemedicine has been used for training for medical students and residents (as short as 2 hours to as long as 4 weeks) are in the latter part of the deck.

Q4 What Challenges Prevent Patients or Providers from Using #Telemedicine? Doesn't seem like it is a technology issue now does it? Culture? Training? Reimbursement? A4 Notable Responses: Jamey Edwards (@jameyedwards) Telemedicine is not panacea, but new tool for physician's medical bag integrated into continuum of care. Still need to change bias (culture) of in-person being gold standard. Standard should be most appropriate modality for condition. Ryan K. Louie (@ryanlouie) Maybe the perception among the public that virtual things are "not as good as" in-person (clinic visits, classes, conferences, etc.) JK Han (@netta_doc) Infrastructure, infrastructure, infrastructure! Clinicians need infrastructure and support to be able to have a proper workflow for #DigitalHealth and to do #telehealth successfully. Matt Sakumoto (@MattSakumoto) Best counter argument I heard was "People thought @amazon was inferior to bookstores because you couldn't browse and hold the books" Virtual care is not better or worse than in-person care, just different.” Aditi Joshi (@draditijoshi) exactly! or you can't trust your money somewhere without a standing bank. Tricia Brooks (@TBrooks_ACHP) My father-in-law still goes inside the bank for every transaction. Some people will never transition. But that is okay. Focus on the obstacles preventing people who want to access telemedicine who can’t. Aditi Joshi (@draditijoshi) Medicine still suffers from the asymmetry of information, although it is lessening due to the dissemination and ease of finding information. This is helpful actually to overcome possible provider hesitation if patients want telehealth and demonstrate this. Aditi Joshi (@draditijoshi) However, patients have to be able to easily find information on what virtual care CAN do, find their doctors or specialists being able to see them, having knowledge of where to f/u locally. In short, education and access - ties in all questions tonight! Stevland Sonnier (@StevlandS) Unaffordable and unavailable #broadband limits access for both patients and providers. While reimbursement is critical for supporting providers, broadband is the #pipeline for service delivery, esp. if #telehealth is mandated to be video-only. Ritu Thamman (@iamritu) Workflow must be seamless for doctors & other #HCW because already swamped & on the patient side access & more education om how to best use the technology efficiently & therefore more effectively Matt Sakumoto (@MattSakumoto) Do you have a sense for which docs need the most help? Is it a tech issue or just unwillingness to change issue? And patient buy-in is key! It's very love-hate bimodal with my panel. Arti Bhan (@ArtiBhan1) It’s nothing to do with age or years in practice. More to do with practice patterns and level of comfort with change. I found it hard to predict who my early adopters would be. Dr Sharifah AlDossary (@Sharifah_AD) Maybe because many providers are using phone calls as their only telemedicine approach,and we all know the limitation of that. For some type of appointment phone is fine and better than nothing,but for many other appointments you will need video or at least to send pictures! Salim Saiyed (@SalimCMIO) this includes the #EHR, #billing , #portal workflows. please take note #cio #cmio Cory Simpson (@CorySimpsonMD) But does this necessitate studies showing non-inferiority of #telemedicine compared to in-person care? I'm a firm believer in #TelemedNow, but we do need to look at clinical outcomes, patient satisfaction, etc. This will be important data for payors as well. Arti Bhan (@ArtiBhan1) It’s lack of elbow support for clinicians. And from the patient side it’s a perception of “sub optimal” care. Patients feel that they didn’t get value for their money if an exam is not done. Eve (#AmericaMaskUp) Bloomgarden (@evebmd) obstacles are also coming from the uncertainty of reimbursement so hospital systems are setting goals to go back to in person and following those metrics closely. We need consistent messaging and payment parity

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