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Teaching Telemedicine Skills



#TelemedNow Twitter Chat Wednesday, July 22 – 8 PM ET Introduction & Welcome: Ritu Thamman (@iamritu) – Moderator Teaching telemedicine skills

Q1 What are tips for teaching the “webside” physical exam ? What are additional remote care tools for this?

A1 Notable Responses: Jamey Edwards (@jameyedwards) The advent of #telemedicine means a re-skilling of america's #healthcare teams, especially for #physicalexam. Need to learn how to use someone else's hands (the #patients). Better communication ("is there pain when you push here?" will be critical. Jamey Edwards (@jameyedwards) #Diagnosis is listening...the HPI & Family History. It's the #patient's voice that sets stage for care. Many #digitalhealth tools do exist though w/ self reporting, #bluetooth & #cellular incl. stethoscopes, otoscopes, EKG's & beyond to aid remote exam. Ritu Thamman (@iamritu) “Tele” implies a stage and “performing” You have to learn where to look: If you want to make eye contact with the pt, you can't look at their eyes on your screen-You have to look at the camera, so that they see you looking at them Andrew Watson (arwmd) There is now focus on the visual replacing the physical, and also involving remote presenters or caregivers. This is a new type of exam. Well suited for simulation. It is a throwback to the "good ole days" of using our eyes and ears more. Not EHRs more... Helen Burstin (@helenburstin) So many remarkable tips online! Thanks to @BenzingerHeart for sharing “Telehealth 10” guide for a patient-assisted virtual exam. Very practical tips with bonus of > pt engagement! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368154/#__ffn_sectitle Helen Burstin (@helenburstin) (cont'd) Telehealth 10 example for leg swelling: show lower legs near window; ask patients to sink thumb into skin for edema; use measuring tape. Ceci Connolly (@CeciConnolly) Not a doc, but believe we need to make #virtualcare standard part of physician training. has been training internal medicine residents on #telehealth since before #COVID19, which set them up for success when the crisis hit. Aditi Joshi (@draditijoshi) know the essentials of physical exam, know your experience of in person exam and tailor it to the exam you need. use adjunct tools either ones that patient has (bp cuff/thermometer) or ones that can help (ruler). Aditi Joshi (@draditijoshi) be creative. use others around. ask patients to be involved in their own exam. tailor the education to the level of the learner. we created a course around this entire question! Matt Sakumoto (@MattSakumoto) It really is about doing more with less. Patient access to remote Bluetooth devices are not at ubiquity so totally agree it’s about the story of illness. Ankitkumar Patel (@DrAnkitKPatel) Great point! Also - set expectations with patient. This is gonna be awkward for you and awkward for me. But we are gonna get through it together. Humor and compassion go a looooong way. And guess what - soon you and patient realize it’s not awkward at all. Jagdish Patel (@jpkca) Remote tools for web exam: Having digital stethoscope is a must ( for me ) Vinny Arora (@FutureDocs) groups focus more on communication than physical exam with telemedicine but I’m guessing my friend @jeannemfarna who teaches clinical skills may have thoughts Ankitkumar Patel (@DrAnkitKPatel) Recent grads will have dealt with #StandardizedPatients where you hf to suspend reality and assume it was a real patient and real office. Same approach to #telemedED - act as if “real” and soon it will feel #REAL. Janice Tufte (@Hassanah2017) more sharing of stories with Patients/Caregivers like this: @tweetsbyHala #PATH #PatientAdvocatesTransformingHealthcare #TuesdayTableTalk with Janice @Hassanah2017 on #HealthEquity and #Telemedicine Vinny Arora (@FutureDocs) Key also is targeted exam based on history so being good at soliciting history still everything IMHO otherwise you may not get to critical parts of exam Jagdish Patel (@jpkca) Set a clinical protocol to including few points like: ‰ H & P ‰ Patient symptoms ‰ Co-morbidities ‰ Current medications ‰ Appropriate & approved medications for each treatment area ‰ Drug-drug interactions check ‰ Refill guidelines Kamala Tamirisa (@KTamirisaMD) For EP clinics move camera to examine legs - edema Skin - rash Incision - healing Neck - JVP Chest - No audible wheezes or rhonchi Eyes & head + device/ILR download Vinny Arora (@FutureDocs) my husband has used home care nurses to facilitate telemedicine for some of his complex older patients Aditi Joshi (@draditijoshi) I wonder if this will change. If someone else is looking at the screen, most of us know instinctively we are *actually looking at the patient/other person and where they are on our screen. Although looking in another direction entirely is the problem... Vinny Arora (@FutureDocs) my colleagues @UChicagoMed have developed best practices for communicating with patients using electronic health records. Team is working on telemedicine webside practices now. It’s definitely a learned skill cc @WeiWeiLeeMD @Alkureishi_L @JOylerMD Andrew Watson (@arwmd) So true and look forward to learning, happy to collaborate. Vinny Arora (@FutureDocs) groups focus more on communication than physical exam with telemedicine but I’m guessing my friend @jeannemfarnan who teaches clinical skills may have thoughts Matt Sakumoto (@MattSakumoto) Is there a focus on “eye contact” based on camera placement or more on content of the conversation? Jamey Edwards (@jameyEdwards) Innovations like allowing the physician to document over the video allow the doctor to maintain eye contact and continue to build rapport. Andrew Watson (@arwmd) Innovations like allowing the physician to document over the video allow the doctor to maintain eye contact and continue to build rapport. Jamey Edwards (@jameyedwards) It would. Some companies like @SukiHQ, @SaykaraAI and others are trying to make it happen. Janice Tufte (@Hassanah2017) Some of us #patients with vision issues actually are not good at #eyecontact a new #Clinician could note this, unless I explained upfront.. Q2 Should we use “simulation patients” or actors to hone our telemedicine communication skills? What communication skills should we emphasize and build? A2 Notable Responses: Jamey Edwards (@jameyedwards) Proper training with experience labs should definitely play a role. The key is integration into current #MedEd curriculum & equip the care teams of the future with skills to thrive w/ digital tools both in #hospital & out. Janice Tufte (@Hassanah2017) Practice #Telemedicine with colleagues, family and friends Andrew Watson (@arwmd) Yes, and it is so easy to scale simulation in education https://wiser.pitt.edu Paul Phrampus and his team have been leaders in this for years. They have created a world class simulation and education center. So much to learn from these types of centers. Ceci Connolly (@CeciConnolly) In my years as journo saw some amazing training for "traditional" medicine w/actors & simulation so seems like a natural progression (& safer than practicing on "real" patients) Ritu Thamman (@iamritu) simulation may help @MediTelehealth has mock #telehealth platform lessons for better student/learner experience beginning e-visit: set a tone of respect & do introductions https://bit.ly/2D2xxqk Key is prepare both students/patients for telemedicine encounters Aditi Joshi (@draditijoshi) We use simulated patients to teach other skills and it is a natural extension of this type of education. We don't always know how we may come off on camera. To this end, we are working on validating a sim TH checklist for use in adult patients. There's one for peds already! Ritu Thamman (@iamritu) Simulation has worked before in so many arenas like #echofirst - will work here in #TelemedNow too Jeremy Louissaint (@jlouissant89) Definitely! “The art of medicine often involves assessment of the unspoken”. How to capture non-verbal communication, which is often very important, is a challenge with televisits but is likely a skill that can be learned! Matt Sakumoto (@MattSakumoto) Is there a focus on “eye contact” based on camera placement or more on content of the conversation? Rasu Shrestha (@RasuShrestha) Simulation has truly "grown up" from dummies and actors to #VR, #AR and #MixedReality. Immersive simulations make for smarter ways to hone one's skills for the next century. That's one thing to be happy for in 2020. Matt Sakumoto (@MattSakumoto) Sim and OSCE felt artificial during Med school but it did help me work out “scripts” Eve Bloomgarden (@evebmd) im in month 5 of telehealth and the experience of being “ in it “ and learning this new way of providing care with your patient enhances the visit and allows for a better relationship Jagdish Patel (@jpkca) I think Web-side manner is a must. I have heard colleagues running out of patience and changing tone

Listening skill and body language are very important Lisa Levitt (@llevitt800) #healthequity needs to be part of #virtualcare training. Very important issue for successful clinical encounter! Gregory Menvielle (@greg_menvielle) We use video voice and big data analysis to monitor fatigue so 100% agree on tracking non verbal. Lisa Levitt (@llevitt800) great use case of AI to support clinicians! Kamala Tamirisa (@KTamirisMD) -Preparing pt & family member prior to appointment is Key - Our MA takes time with new patients before we see them Removes #technology apprehension. & - Taking help of “tech savvy or tech comfortable”family member. (move the camera/where to look etc.) Chad Ellimoottil (@chadellimoottil) Are the MAs interacting with the pt right before the visit or prior to the visit? We have MAs performing and intake 24-48 hours before. Found that easier than right before for logistical reasons. Matt Sakumoto (@MattSakumoto) That's a smart move - I guess our practice is a little more dynamic (self-sched avail up to 10 min before appt time Alarm clock), but for new patients with lead time this is a great idea #telemednow Andrew Watson (@arwmd) I hadn’t thought about the challenge of on-demand scheduling, that does pose a unique operational challenge. Thanks for highlighting that Matt. Aditi Joshi (@draditijoshi) on demand/acute care is what we primarily do in #EmergencyMedicine so have to think about. we have basic troubleshooting skills and have a team to help if beyond our capabilities. also we can 3-way another party in but don't use that fxn for education although probably could. Stacy Hurt (@stacy_hurt) Yes, but use real #patients. We are here to help and the more we know about #telehealth, the more we can help communicate to our networks to help adopt and advocate for its continuation Q3 What tools should be in a telehealth training program for students, trainees and attendings? A3 Notable Responses: Jamey Edwards (@JameyEdwards) Training should include proper techniques for all #telemedicine & #DigitalHealth modalities from Email to phone to chat to video. Could also include @HoloLens #googleglass or other tools. #1 is still communication. #Patient voice is most important tool by far. Janice Tufte (@Hassanah2017) I found this tool in a quick search, what else could be added? https://icollaborative.aamc.org/resource/5010/ Ritu Thamman (@iamritu) one tool is augmented reality: MD wears @Microsoft HoloLens glasses, which streams video to students’ computers & while MD talks to the patient, students can hear both of them through use of two microphones & can pin images https://bit.ly/2ZRfi0k Cory Simpson (@CorySimpsonMD) @SalimCMIO, I love the idea of letting trainees (and attendings!) access the platform in pt role for #TelemedNow, so providers understand what pts see & pitfalls they may encounter. I've had my wife be a mock pt for every platform I've tested so I know how to troubleshoot w/pts. Vinny Arora (@FutureDocs) Reminds me of our prior work —we asked patients what they thought of doctors wearing face mounted computers https://ncbi.nlm.nih.gov/pmc/articles/PMC5228136/ turns out they were ok with it although 46% concerned re privacy Jim St. Clair (@jstcliar1) Wonder what the privacy concern was? Aditi Joshi (@Draditijoshi) this is so cool! and is likely going to influence future education significantly Lisa Doyle Howley (@LisaDHowley) Johns Hopkins began this for #MedEd early in pandemic days for virtual rounds - see free webinar and resources here https://aamc.webex.com/recordingservice/sites/aamc/recording/playback/494ea56ba7c94a56ab3b588d335d4ec1 Ankitkumar Patel (@DrAnkitKPatel) Flexibility for hiccups. They will happen. For the patient and for the provider. #telemednow Sam Lippolis (@samiamlip) 1) Importance of clinical champions 2) use cases O/P, I/P, patient home, RPM, call coverage 3) Roles of the team 4) Workflows 5) Hands on experience not only theory Aditi Joshi (@draditijoshi) For attendings should focus on their specialty and the specific use case like all of us do for any in person training. This applies to residents training in their specialty. Medical students should get a broad based exposure during different clinical rotations Eve Bloomgarden (@evebmd) 1. anticipate glitches and have backup plan. I have two screens, ipad, iphone w charger , two sets of headphones , pen and paper 2. If tech not working know what next. Convert to phone only ? Send a new video link? Pantomime “ i’ll call you back” 3. Smile Salim Saiyed (@SalimCMIO) the tools depend on training level, with students/ trainees have dedicated days on #telemednow rotation give access to platform, etc giveive students access as a patient introduce sources like @AmericanTelemed etc Rasu Shrestha (@ResuShrestha) Beside the usual suspects, I'd add #ArtificialIntelligence to the training toolkit. Let the algorithms augment not just care itself, but also how to learn to care. Rashmi Mullur (@rashim2008) Creating this now with some amazing UCLA IM residents Broadly—4 main objectives so far 1. Legal Regulations, etc| 2. Patient Factors in TH (Tech literacy, digital divide, racism) 3. Virtual PE Skills (🙏🏽🙏🏽🙏🏽 for this chat) 4. Webside Manner skills Salim Saiyed (@SalimSaiyedCMIO) for attending it is key to understand all the digital tools, biomarkers etc that are available so they can choose the right one from their tool box Sam Lippolis (@samiamlip) 3 way video is one option I've observed and given real time feedback during the visit. That works will in I/P. ICU, E/D but a bit awkward in O/P & patients home. Super important when using pan/zoom/tilt cameras to train everyone how to use them and show the capabilities. Q4 How to Precept a Telehealth Encounter? How to evaluate a trainee’s encounter using Telemedicine? A4 Notable Responses: Jamey Edwards (@JameyEdwards) 1) Accuracy of Diagnosis and Treatment Plan 2) Patient Satisfaction Survey at End of Each Call - Net Promoter Score (would you recommend this clinician?) 3) Should also be required to use telemedicine over multiple encounters (stand in the patients shoes) Janice Tufte (@Hassanah2017) You might recommend “Precepting Learners & Telehealth” 7 31 20 Webinar https://dukeahead.duke.edu/events-announcements/events/precepting-learners-telehealth with @HollyCausey1 @MitchHeflin and #colleagues Matt Sakumoto (@MattSakumoto) @jameyedwards I'd love to hear your ideas on methods of measuring Accuracy of Dx and Tx - It's an active area of discussion for #TeleDx at @ImproveDX Ritu Thamman (@iamritu) To assess communication skills,preceptor could assess how the student educated pt on privacy concerns &e-prescribing, shared a screen to discuss diagnostic findings, assessed pt for technological literacy,& helped pt to use virtual health platform Judd Hollander (@JuddHollander) Our scheduled visit program does multi-party visits so students are directly supervised. Get them trained as MS3s. #TelemedNow Eve Bloomgarden (@evebmd) evaluate on empathy,flexibility , communication, wrap up , and fu plan. fellows get history first. Then present via Teams and we look at data/images together. then video call patient. Choose appropriate tests to move patient care forward in pandemic. Matt Sakumoto (@MattSakumoto) We are using Zoom with breakout rooms. Pt in each "Room" w/ resident and attg in "Main Room" to present/discuss. It's...a work in progress Aditi Joshi (@draditijoshi) this is a tough one since most of our attendings are doing these visits in various places. we also are doing TH visits for quick turnaround. we also have change our perception on patients seeing students on TH as we are doing a disservice to their education. Sam Lippolis (@samiamlip) Let's not forget nurses, RT and other parts of the clinical team that take part in #TelemedNow Training for all!!

Q5 What to teach about digital environments that are important for patient engagement? A5 Notable Responses: Andrew Watson (@arwmd) I like the fact that people want to set expectations upfront. Especially if an MA calls them ahead of time. I think much of this has to be sold in the clinics and in the hospitals. #TelemedNow Connie Hwang (@hwang01) Kaiser Permanente recently published in JAMA that patients most likely to use telehealth are those who used it before. So, getting members to at least try ONCE and having a good experience is critical. #TelemedNow https://k-p.li/2ZPfbCo Ritu Thamman (@iamritu) a digital environment makes it more feasible to go down rabbit holes, & harder to get back to context, which is often even less easily accessible online than offline. #TelemedNow environment affects patients’ attitudes, beliefs, practices we can’t see on the surface,need cues Jeremy Louissant (@jlouissaint89) It also starts with teaching providers what the televisit interface is fully capable of. The pandemic necessitated a rapid transition to televisits, but its time to address knowledge gaps about features that can further enhance the visit #TelemedNow Stacy Hurt (@stacy_hurt) Absolutely do as much as you can to remove fear and assure privacy of a #virtualcare visit. I’ve heard some #patients claim they won’t do one because “big brother is watching” Flushed face Need to dispel these types of myths Matt Sakumoto (@MattSakumoto) I've seen it both ways - "Ma'am, are you at the grocery store right now?" Also, "Please pull over your car and call me back when you've parked" Helen Burstin (@HelenBurstin) What can we do in a digital environment that enhances pt/family engagment & learning? Can we use "brady bunch" type views to include patient, family member, attending and learner? Virtual opportunity to see one, do one and teach one with patients! Aditi Joshi (@draditjoshi) in relation to education that there may be a learner there, there may be discussion happening about their best care with someone off camera. essentially letting the patient know what's going since they may or may not see what is happening. communication. Salim Saiyed (@SalimCMIO) we need to learn from other industries on how they do it better than #healthcare #instagram influences that can teach us in #healthcare on how to use #digital environment that can #engage patients I think we haven't figured out the #secretsauce like others have in Rashmi Mullur (@rashim2008) Agree with above. We need to set expectations. I’ve found most patients get it—very rarely has someone signed in while driving Face screaming in fear Also, we need to practice pausing during conversations a bit longer to allow for delays in transmission

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