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Telediagnosis During COVID19 and Beyond



#TelemedNow Twitter Chat Wednesday, August 19 – 8 PM ET Introduction & Welcome: Helen Burstin (@HelenBurstin) – Moderator Telediagnosis during COVID19 and beyond Q1 How has telediagnosis of #COVID19 advanced after 5-months? Any new insights or clinical pearls to share? How does #COVID19 testing fit into the virtual environment?

A1 Notable Responses: Jamey Edwards (@JameyEdwards) #Telehealth & #Telemedicine are becoming the #DigitalFrontdoor to our #Healthcare system. As that firstline of defense, remote diagnosis will help #patients wayfind as well as resolve many low acuity issues w/o in-person visit. Ceci Connolly (@CeciConnolly) Very early in the #COVID-19 outbreak many of our nonprofit community health plans provided free virtual screening for #coronavirus including @ssmhealthwi

Salim Saiyed (@SalimCMIO) Smartphone-Based Self-Testing of #COVID-19 Using Breathing Sounds https://www.liebertpub.com/doi/10.1089/TMJ.2020.0114 Ceci Connolly (@CeciConnolly) It's helped streamline the process, esp for non-cases. For example, @GeisingerHealth has launched a chatbot designed to help triage/screen patients remotely, referring likely cases to testing. Andrew Watson (@arwmd) Great question, and IMO the largest advance is the denominator of physicians who now understand #telemedicine. #telemednow. There is NOT a lack of an exam, but a different exam. The experience we all have with this new exam to make diagnoses is critical, and growing.. Ritu Thamman (@iamritu) Ability to use saliva is a game changer & we need point of care testing for #Covid19 which is a @NIHDirector RADx Initiative (Rapid Scaling Up of Covid-19 Diagnostic Testing) Saliva would be easiest to test #TelemedNow https://bit.ly/2ZYnzPO Andrew Watson (@arwmd) Yes, chat bots are a great way to screen #TelemedNow. And help larger volumes of patients. Helen Burstin (@HelenBurstin) I really like the idea of a #DigitalFrontDoor! Even for complex complaints that may need in-person care or testing, the virtual door has been much safer for patients during #COVID19 Ryan K. Louie (@ryanlouie) With #telepsychiatry, I believe that we as a community are being able to outreach more and understand more about the #mentalhealth impacts of #COVID19. Ritu Thamman (@iamritu) This is a critical area as there is ˄ anxiety/depression in patients & ˄ burnout in HCWs #TelemedNow https://bit.ly/2YhrOoA Matt Sakumoto (@MattSakumoto) Watching the evolution of excellent work from @trishgreenhalgh has highlighted the earliest TeleDx of COVID, and now Dx of the "Long COVID" #TelemedNow https://bmj.com/content/370/bmj.m3026 Salim Saiyed (@SalimCMIO) We had thousands of #covid19 test ordered via #telemednow during crisis. Which means docs and patients both feel comfortable in telediagnosis. There are few key physical exam pearls to follow Andrew Watson (@arwmd) and for telepsych, the exam does not require palpation which makes it easier, and the use case that much stronger. Hardeep Singh (@HardeepSingh) As a start we now have a definition of #telediagnosis and a conceptual model to guide us #TelemedNow Vinny Arora (@FutureDocs) Really the question now for clinicians is when is in person needed and ehy? #TelemedNow Andrew Watson (@arwmd) Yes and how we tie PROs into clinical records through interoperability. #TelemedNow. A lot of people can consider remote monitoring PRO‘s of a sort. #telemedicine. Matt Sakumoto (@MattSakumoto) We're considering a Virtual First policy for our clinic to help patients social distance, and screen for those that would truly benefit from an in-person visit (only charging them once) #TelemedNow Connie Hwang (@hwangc01) AI-driven chatbots were deployed by @Intermountain & @GeisingerHealth early in the #COVID19 pandemic, directing patients to #telemednow or in-person options based on risk. Intermountain chatbots did >121k screenings in March, significantly offloading COVID19 call center. @_ACHP Matt Sakumoto (@MattSakumoto) Similar concept and results here at @UCSFHospitals to screen patients. EHR integration and incorporation of their responses into the note was a nice bonus! #telemednow Ritu Thamman (@iamritu) And there is evidence that many people with #covid19 have prolonged symptoms https://bit.ly/2Qalevu @cdc multistate (phone) survey of symptomatic adults + #covid19 aged 18–34 years with no chronic medical conditions, 1 in 5 had not returned to their usual state of health #TelemedNow Aditi Joshi (@AditiJoshi) rapid expansion and engagement leading to more understanding. Now less barrier to trying to move education and training forward Aditi Joshi (@AditiJoshi) This type of triage can also be considered as decreasing the asymmetry of knowledge between physicians and patients - allowing real time educAtion and understanding of how and why one needs higher level of care #TelemedNow Jamey Edwards (@JameyEdwards) Gold standard in #healthcare is no longer the in-person visit. The gold standard is most appropriate care modality for the condition across all modalities. SuzSchrandt (@SchrandtSuz) And think about the options for including videos or photos of "what's been going on"--it's like when you take your car to the mechanic and it doesn't make the sound it always makes. This could be such a game-changer! #TelemedNow

Q2 What are the limitations of virtual diagnosis? What are key metrics and research questions we should consider? What are we more likely to misdiagnose with a virtual exam? A2 Notable Responses: Jamey Edwards (@jameyedwards) Limitations of Virtual Diagnosis? The doctor's skilled hands. That being said, it is really MD's mental capabilities we pay for (think Dr. House)...their ability to understand symptoms & solve the puzzle. Much of that can be remote & escalate to in-person later. Andrew Watson (@arwmd) The biggest limitation IMO is the hands on exam, and can we substitute with eyes, ears, and peripherals? Yes ! As @JuddHollander @draditijoshi and others continue to point out. @TytoCare is quite cool. #TelemedNow. SuzSchrandt (@SchrandtSuz) For people with pre-existing conditions like my disease, the key differentiator is the ability to see your own provider vs. an urgent care provider. Having someone who knows YOU is key to determining when something is really out of the ordinary. Helen Burstin (@HelenBurstin) Thx to @PCORI, @ImproveDx launched new work to identify "must-know" questions for safe and effective #telediagnosis. @CMSSmed is a project partner. https://improvediagnosis.org/diagnosis-and-telemedicine/… Ritu Thamman (@iamritu) Broadband is key a study evaluated accuracy of measuring physical function found that choice of bandwidth affected measurement validity & reliability for fine-motor tasks, with some speeds falling far below quality and community standards @AjitPaiFCC https://bit.ly/2CRQxsh Salim Saiyed (@SalimCMIO) metrics to consider 1 14 & 30 day in person return for similar diagnosis 2. Antibiotic stewardship for viral diagnosis 3. Patient satisfaction / understanding with #telemednow diagnosis rendered Vinny Arora (@FutureDocs) This is an interesting question. It may be that history taking is better or you see things in a natural environment you would not. So may balance each other out. Role of wearables in future important #telemednow Judd Hollander (@JuddHollander) The trade off, if any, is you see into the home. Its actual social determinants, not best guess. #TelemedNow Joshua Bress (@Joshua_Bress) Non-accidental trauma in pediatrics Aditi Joshi (@draditijoshi) what quality metrics do we use in person and how do we adapt to virtual dx. And then how do we teach it to colleagues and students. Barrier is those new to the practice having to teach, lack of standardization of training and qualify #telemednow Aditi Joshi (@draditijoshi) overall lack of disparity that exists in society and healthcare are similar to what plagues telehealth #telemednow #SDOH Hardeep Singh (@HardeepSingh) Need to study misdiagnoses systematically but anecdotes are also good for learning/thinking. One relative received 3 different diagnoses on high-resolution pics from 3 different dermatologists. But - that might happen in in-person visits too #TelemedNow Ritu Thamman (@iamritu) Agree & given high rates of misdiagnosis IRL Clinic pts even more critical with #TelemedNow to get the diagnosis right Matt Sakumoto (@MattSakumoto) Continuity is so important. With work from home (and shorter visit times), we have actually increased our primary care provider slot availability to try to accommodate continuity #TelemedNow Janice Tufte (@Hassanah2017) If an established trusted #PatientClinician relationship exists then misdiagnoses I expect are < less where patient hx and tx preferences are known. #DeferredCare concerns might be #SelfDiagnosed and this can lead to #misdiagnoses and #missedopportunities#TelemedNow Q3 How does the diagnostic approach change with virtual care? Can we compensate for missing non-verbal clues or full exam? Can peripherals or RPM help support telediagnosis? A3 Notable Responses: Andrew Watson (@arwmd) From our friends / colleagues from 2017 ! @draditijoshi @JuddHollander #TelemedNow https://bit.ly/2E0rvrv We simply use our power of observation better. There is a lot of information to be gained looking through the camera Patients can also aid in their own examination Jamey Edwards (@jameyedwards) Communication=#1 diagnostic tool for clinician. Remote Physical exam demands even better communication skills as MD needs to guide "remote hands" (the #patients) during exam. Video helps address non-verbal cues & RPM supports intuition w/ data. Helen Burstin (@HelenBurstin) The patient as "remote hands" is a great concept (and feeds right into our next question on pt engagement!) #TelemedNow Ceci Connolly (@CeciConnolly) Totally acknowledge some non-verbal clues are missing in #telehealth but I suspect others (environment, family support) may be MORE visible #TelemedNow Helen Burstin (@HelenBurstin) Amazing interview with diagnostic guru Gordy Schiff @BrighamWomens: “We worry about what we miss when we don’t see patients in person, including the loss of non-verbal cues and especially the absence of a hands-on physical exam.” https://betsylehmancenterma.gov/news/patient-safety-expert-addresses-telediagnosis-and-health-disparities-during-the-pandemic… Ritu Thamman (@iamritu) nonverbal cues are (key) look for inconsistencies b/w signs of nervousness like fidgeting or evasive eyes; if nonverbal behavior seems to run counter to whats being said maybe pt is not comfortable with what they are saying #TelemedNow Salim Saiyed (@SalimCMIO) Another change is getting family & friends engaged in the care, comfortable with guiding along in exam. Truely believe #healthcare is a team support & #telemednow encourages that SuzSchrandt (@SchrandtSuz) I've been working with a cadre of RA patients for 20+ years, all trained and certified to teach medical students (and others) how to perform musculoskeletal exams to Dx RA. If patients can teach clinicians, we can also learn to self-examine. #TelemedNow Aditi Joshi (@draditijoshi) short answer yes with creativity, understanding our clinical skills and engaging patients. Everyone wants to understand more about their health. Peripherals helps with increasing data just like we get other info in person #TelemedNow Salim Saiyed (@SalimCMIO) time is essence on #telemednow. Patients report more FaceTime spent w/ #doctor that needs to be leverage in dx. patient must be involved through exam & guided. #rpm access is key & great for chronic conditions Janice Tufte (@Hassanah2017) #RPM use and #VirtualVisits are great for monitoring existing known conditions and can assist both #Patient and #Clinician especially #complex and #chroniccare patients. #HealthLiteracy and #CulturalConsciousCare are important as are #VisualEducationalAids#telemednow Ritu Thamman (@iamritu) Now the issue is what to do with all this asynchronous data? What data is actually useful or “clean” and will actually improve outcomes #TelemedNow https://bit.ly/34k6d2z Jamey Edwards (@JameyEdwards) Lets also acknowledge that some people are more honest over #telemedicine than in person. Drs' presence can be intimidating and there is fear of judgement. Could remote exam in certain instance be better than in person? A little bit of distance may be healthy. Ceci Connolly (@CeciConnolly) Is this being taught in medical schools? yes, seems basic but some incredibly valuable #telemedNow Janice Tufte (@Hassanah2017) Yes this is true though not across the board #IHaveVisionIssues eyes move around, I look around normally #TelemedNow Q4 Let’s move onto our fourth question. If there are limitations to #telediagnosis, how can patients and help support improved telediagnosis? A4 Notable Responses: Jamey Edwards (@JameyEdwards) Prepare for #Telemedicine visit like a real visit. Have medications at the ready, test #tech in advance, be well lit, find a quiet private space, clearly communicate how you are feeling. Andrew Watson (@arwmd) Interesting article from @nytimes- https://nyti.ms/3kWeyj3 And highlights how caregivers are getting more involved with #TelemedNow #Telemedicine Close to this topic, not an exact overlap. Similar vendors.. Janice Tufte (@Hassanah2017) #epatients and #caregivers should participate in surveys, focus groups, delivery co-design opportunities as well as #meaningfulmeasurement and #guideline work so stories can be heard, #issues addressed and #action taken! #PatientDrivenRegistries too! #TelemedNow Salim Saiyed (@SalimCMIO) Make sure #caregivers are available & prepared 2. Guide patient to use home devices bp, pulse ox to have ready 3. Email instructions on difficult exam thats needed e.g angel hair pasta for diabetic foot exam 4. #educate that it’s beyond just 1:1 talking #telemednow exam Aditi Joshi (@draditijoshi) the way they support their own healthcare in general, being engaged, available to help, having their own questions and needs ready to discuss. The difference is being able to engage at home or when issues arise real time. #telemednow SuzSchrandt (@SchrandtSuz) @ImproveDX's PEC created a patient toolkit for diagnosis; we need a 2.0 for TeleDx. Are rashes better appreciated in photo or video? Should I take videos of my cough? How do I best explain pain verbally? #TelemedNow Ceci Connolly (@CeciConnolly) Genuinely asking the clinicians: is this a technology issue? #TelemedNow Connie Hwang (hwangc01) Lots of opportunity for trusted organizations (including your health plan!) to educate individuals on what to expect in virtual visits and how to optimize your #telemednow interaction with biometric devices when available. Aditi Joshi (@draditijoshi) the way they support their own healthcare in general, being engaged, available to help, having their own questions and needs ready to discuss. The difference is being able to engage at home or when issues arise real time. #telemednow Steve Sonnier (@StevlandS) Requesting and incorporating patient perspectives into the process and workflow design of #telediagnosis is critical. We want to ensure patients are on-board with what is happening, understand their encounter with clinicians, and come away with a positive #telehealth experience. Ritu Thamman (@iamritu) need for preparation for both an “informed activated patient” & a “prepared & proactive team” to improve patient outcomes -videos to review pre visit -asynchronous texts RPM to improve glucose control, increase exercise, med adherence #TelemedNow Q5 What educational resources can be used to support training on virtual diagnostic approach? A5 Notable Responses: Helen Burstin (@HelenBurstin) So many great insights from last night's #TeachDx chat. Critical to incorporate teaching #teledx into courses at every stage: UME, GME, and CME! We need to learn across full med ed continuum Peggy OKane (@PeggyNCQA) There is so much to learn, we’re at such an exciting moment. I hope funders recognize the moment. Pace of research is slow and questions often too narrow. Is there a better way to approach this? Aditi Joshi (@draditijoshi) There is so much to learn, we’re at such an exciting moment. I hope funders recognize the moment. Pace of research is slow and questions often too narrow. Is there a better way to approach this? Andrew Watson (@arwmd) Educational resources are appearing, and much more to come. Especially as professional societies engage. @CMSSmed @HelenBurstin #Telemednow #Telemedicine Examples: https://stanford.io/34hgxZo - Stanford https://bit.ly/34hcuw6 - Jefferson https://bit.ly/2E7a3kY Ceci Connolly (@CeciConnolly) Seems like an area that #healthcare could learn from other industries far ahead in the virtual learning space Jamey Edwards (@JameyEdwards) Practice makes perfect. Cool thing is that you are training to be remote which can be done remote :) no expensive bricks & mortar needed. #MedEd needs to include sample videos, training on RPM tools & platforms & #websidemanner. SuzSchrandt (@SchrandtSuz) It may go without saying, but any training should be co-produced #withpatients #patientengagement #TelemedNow Our @PCORI TeleDx project may unearth some ideas here! Aditi Joshi (@draditijoshi) we made some at @TJUHospital however much still needs to be standardized. Anything used for training in any specialty can be tailored to telehealth, updated with webside manner, how to work and get exam components virtually and basic tech troubleshooting #TelemedNow Ritu Thamman (@iamritu) Simulation will be key A study showed that Simulation-Based Mastery Learning Improves Patient & Caregiver Ventricular Assist Device Self-Care Skills compared with usual training #Simulation should work for #TelemedNow too @CircOutcomes https://bit.ly/3kZDWEh Janice Tufte (@Hassanah2017) Educational resources that are developed and co-designed with patients will more likely be more relevant and understandable. Making available resources in multiple languages and format types are a must. Connie Hwang (@hwangc01) Educators may want to start following @PCORI's recent $22M research awards assessing effectiveness of #telemednow usage during #COVID19. Bravo for the strong focus on questions of health equity across diverse populations

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