Telehealth and Patient Safety

#TelemedNow Twitter Chat Wednesday, February 17 – 8 PM ET Introduction & Welcome: Helen Burstin (@HelenBurstin) – Moderator “Telehealth and Patient Safety”

Q1: Are guidelines/guardrails needed on appropriate, safe use of telemedicine by condition, symptom, or new/existing patients?

A1 Notable Responses: Helen Burstin (@HelenBurstin) – Q1 subs -- Role of specialty guidelines and #telehealth accreditation? Should any patients be excluded from #telehealth? Does #TelemedNow need escalation/safety protocols? Andrew Watson (@arwmd) Really happy AHRQ and TJC are helping us here. #TelemedNow. Stacy Hurt (@stacy_hurt) #Patients need to be educated by clinicians on which appointments are appropriate for #telehealth vs. FTF; “We can handle this via telehealth if you’d prefer” would be welcomed & greatly enhance the #patientexperience #TelemedNow Helen Burstin (@HelenBurstin) Great point @stacy_hurt. Patient safety is a team sport and the patient is on the team so patients need to share if virtual care works or if they prefer FTF! #TelemedNow Jamey Edwards (@JameyEdwards) Guidelines & Evidenced Based Protocols are appropriate for every situation, not just limited to use of #DigitalHealth tools, but applied to whole encounter especially as we move toward hybrid visit & different modalities being used at along the continuum. #TelemedNow Ritu Thamman (@iamritu) need tele triage guidelines like those already in place for chest pain Proactive VS reactive that Integrates remote data collection into triage #TelemedNow need triage criteria that can be validated in large cohorts so outcomes are known to payouts Ceci Connolly (@CeciConnolly) Definitely need guardrails, but, need to make sure we’re balancing with usability. Big thing is to set consistent, transparent standards shaped by industry feedback; docs are more invested than anyone in keeping patients safe. #TelemedNow Ceci Connolly (@CeciConnolly) Yes, I still fear too many drs in fee-for-service are pushing in-person to generate revenue (extra tests, scans). See it with my 82-yr-old mother in Fl all the time. Andrew Watson (@arwmd) Yes, we have a significant dependence upon FTF medicine, and using the facilities that are being depreciated and also are real revenue generators. This is not a criticism, but a reality. This challenge may be greater than the #telemedNow operational models we are creating. Ritu Thamman (@iamritu) Great ??? #TelemedNow Yes specialty guidelines are needed ie @ACCinTouch If language barrier or il literacy hard to do telemedicine & just like IRL safety protocols are needed that have proven outcomes Aditi Joshi (@draditijoshi) great question! think by type of visit: acute, chronic, pre/post surgical. It matters how the patient presents, type of information (diagnosis or actionable/next step?). symptoms/condition matter less than what patient needs in that moment. #TelemedNow Komal Bajaj (@KomalBajajMD) Great point, @stacy_hurt. The learnings that are starting to emerge from this past year should include data (clinical outcomes as well as staff/patient experience) so that we know more on the best applications of telemedicine. Helen Burstin (@HelenBurstin) Great point @iamritu. Chest pain is already a great test case. We need validated triage criteria by diagnosis/complaint. Ceci Connolly (@CeciConnolly) In other words, time to stop distinguishing #virtualcare from #care. These are just ways of delivering services Andrew Watson (@arwmd) Re point 2, in all of medicine we have inclusion and exclusion criteria that we rely upon. At this point I’m reluctant to spell this out for #Telemedicine. We do rely upon clinical judgment. Options – Poll: - Lay out inc/exc criteria - Clinical judgment alone Ritu Thamman (@iamritu) 100 that should be part of #healthliteracy #TelemedNow #patientengagement #PatientExperience Dr. David W. Baker (@DrbakerTjc) How do you decide which patients are safe for telehealth and which need to come in to be seen for at least part of their visit (i.e., history taken by telehealth and then face-to-face visit for physical exam)?#TelemedNow Divvy K. Upadhyay (@DrbakerTjc) Would love to have such a list of reasons or red flags -- especially if we could standardize at least few red flags for high harm, high probability diagnosis. (Likes of abdominal or chest pain, dizziness, headache, etc). #telemedNow Neelam Sharma (@Nee2Sha) I believe guidelines are necessary to guide patient throughout the tele-visit. Mainly for new patient #TelemedNow Brittany Partridge (@bspartridgeCIS) @arwmd can I have both? I don’t think it should be exhaustive for inc/exclusion but some high level screening upfront and then a lot of clinical judgement if not clear? #telemednow Dr. Salim Saiyed (@dr_salim_MD) - Let specialty board develop best practices around use of #telemednow - broadly no patient should be left behind, open access - new/old patient is an old paradigm built by payors for billing.. it has no substance in a patient-physician relation over #telemednow Andrew Watson (@arwmd) If we are giving patients the ability to self schedule, including #telemedicine as part of that has been transformative. This also gets to same-day appointments. The concept of “tele-triage” Helen Burstin (@HelenBurstin) Agree -- we probably don't need to exclude patients if we have good protocols and triage, including when to escalate or convert to in-person care #TelemedNow Andrew Watson (@arwmd) This is one of the key areas it needs to be explored, triage and using #telemedicine. Brittany Partridge (@bspartridgeCIS)For sure and I see it being used in three contexts: 1) Teletriage for read video visits, 2)In the ED to get orders started 3) In the field like project ETHAN Helen Burstin (@HelenBurstin) Thanks @bspartridgeCIS. Agree on context being key. Can you share more about Project ETHAN? Helen Burstin (@HelenBurstin) But are there special guidelines/circumstances unique to #TelemedNow? Need for safety and escalation protocols? Ritu Thamman (@iamritu) There’s a fine line b/w information needed for triage and abusing that information like profiling pts by their zip code which is a #SDOH Brittany Partridge (@bspartridgeCIS) Should this first eyes on be done at the physician level or is their benefit in an eyes on triage nurse for this type of determination? #telemednow Judd Hollander (@JuddHollander) Opposed to excluding patients. Assumes they have other options. Some dont. #telemednow Jamey Edwards (@JameyEdwards) Love this viewpoint @JuddHollander. Totally Agree. #DigitalHealth is another toolkit in the clinicians medical bag. nothing more, nothing less. Although the medical bag in this #gif is scary... Q2: What challenges does telemedicine pose to patient safety, including diagnostic safety? A2 Notable Responses: Ritu Thamman (@iamritu) -if don’t know which symptoms are acute or chronic can be tough -if no video can’t see rashes or JVD may be harder to make diagnosis so may worsen digital divide -Chatbots can do triage ( empathetic cute ones like a @zoom cat avatar Andrew Watson (@arwmd) It certainly is a benefit, I suspect over time it will become an enormous benefit, we need more data to prove it. This is the exact same journey as laparoscopy. In 2003 it was heresy..We as surgeons @SWexner @AmCollSurgeons have been down this road before. Aditi Joshi (@draditijoshi) like in other parts of medicine, clinicians deviating from standard of care or not working at limits of TH, patients delaying care, relying on tH for access when they need more emergent or chronic care that gets ignored. not a panacea. #telemednow Divvy K. Upadhyay (@DrbakerTjc) Lack of physical exam is an obvious one but I wonder what happens to context or longitudinal care if patients have to meet brand new doctors that may not be connected to the patient's pcp or doctor of choice. Matt Sakumoto (@MattSakumoto) Clinicians can't rely on old habits/patterns. Pts can present earlier in dz time course (since barrier to visit is lower), and really need to hone those HPI skills. #Telemednow Stacy Hurt (@stacy_hurt) Misdiagnosis via #telehealth is a real concern. But the 80% of this room who raised their hands are all #colorectalcancer #patients that were misdiagnosed & it had nothing to do with telehealth. There were FTF visits & conversations & tests and it still happened #TelemedNow Komal Bajaj (@KomalBajajMD) Misdiagnosis via #telehealth is a real concern. But the 80% of this room who raised their hands are all #colorectalcancer #patients that were misdiagnosed & it had nothing to do with telehealth. There were FTF visits & conversations & tests and it still happened #TelemedNow Stevland Sonnier (@StevlandS) While patients are becoming more familiar with telemedicine, a key challenge will be ensuring patient privacy. This can be difficult if the TH visit is in congregate settings or public spaces. Dr. Salim Saiyed (@dr_salim_MD) just like all technology, it is important for users (doctors and patients alike ) to understand the limits, to work within those boundaries. pushing outside those boundaries can post patient safety risk. #telemednow Resa Lewiss (@ResaELewiss) Challenges? Aspects of the physical examination which really care limited by the technology. #TelemedNow Helen Burstin (@HelenBurstin) Agree @ResaELewiss. Tele-dx frequently cited as safety concern related to missed exam findings and urgency higher than expected. Connie Hwang (@hwangc01) Risk of misdiagnosis can occur both in-person or via #telemednow. On positive side, Kaiser Permanente has studied & uses smartphone tech 95% time for derm visits, where 10% more skin cancers have been accurately dx'd in 40% fewer visits. @aboutKP @_ACHP Helen Burstin (@HelenBurstin) Thanks @hwangc01. During your #NHPC21 panel today, @DrRicardIsaacs said @about KP reviewing 7M visits since #COVID19 to assess value/appropriateness of #TelemedNow visits! Treasure trove of data! Dr. Salim Saiyed (@dr_salim_MD) I always give the example of one of our patients where they missed a huge neck mass in ED, but was picked up by the #telemednow doc cause paying very close attention and spending more time getting history, less distraction, etc. Jamey Edwards (@JameyEdwards) Challenges are more how a Clinician practices #healthcare. Some may be great at #DigitalHealth & in-person, some one or the other, & others neither. Good practice is about being kind, detail-oriented & invested in outcome regardless of tools. Neelam Sharma (@Nee2Sha) In terms of patient safety there is higher chance of misdiagnosis due to lack of physical exam. #TelemedNow Komal Bajaj (@KomalBajajMD) I often think about the times when a FTF visit has come to a close and in those moments just as my hand is about to hit the door handle, my patient says the thing they actually wanted to talk about. How do we capture that beautiful moment in #TelemedNow? Jamey Edwards (@JameyEdwards) Sometimes patient are more honest over #telemednow than in person due to fear of judgment. Nothing preventing doctor from lingering and not leaving the call before the patient does. Might be a good protocol. #TelemedNow Komal Bajaj (@KomalBajajMD) Love this @jameyedwards - it's the physical cue piece that sometimes might help a patient share information that "Anything else you'd like to discuss today" might not elicit. #TelemedNow Judd Hollander (@JuddHollander) Shouldnt the patient have some say over how much privacy they want? If they want to call from @Starbucks, why not treat them? Just politely ask if they realize other people might see and hear. #telemednow #empowerpatients Jamey Edwards (@JameyEdwards) I agree. 9 times out of 10, patient is in control of their experience and environment they call in from, whether or not they are on speaker on on headphones...etc... #TelemedNow Q3: What resources (IT, tools, guidelines) have been used to navigate safety concerns? A3 Notable Responses: AHRQ (@AHRQNews) This @AHRQNews issue brief applies #patientsafety principles to telehealth, including quality and safety of diagnoses:… Jamey Edwards (@JameyEdwards) Training (I am comfortable doing this), Checklists (Did I cover all the bases?), QA Process (Someone May be Checking on My Performance), End of Encounter Surveys (what did patient think?), can all help contribute to a safe practice environment. Janice Tufte (@Hassanah2017) Co designed checklists for a variety of scenarios, simulations, virtual mock patient-provider calls, follow ups with rapid quality improvement processes #telemedNow Ritu Thamman (@iamritu) IT help apps or digital navigators to help folks onboard or pre visit checks/forms by students ,volunteers entrepreneurs Phone a digital friend- or a third party that logs into your computer and helps a pt check in or download an app etc or “share a screen” Stevland Sonnier (@StevlandS) @CCIVoice has an excellent set of resources in their telehealth toolkit. These resources provide an in-depth guide that looks at assisting patients from diverse backgrounds Stacy Hurt (@stacy_hurt) This is where we’ll see AI/ML emerge as check edits for certain #telehealth voice and/or face recognitions or symptom patterns. I as a patient welcome that technology to help enhance my care #TelemedNow Andrew Watson (@arwmd) One of the biggest risk mitigation strategies will be paired bio peripherals. #TelemedNow there are many out there, but the best is yet to come. These type of surrogate examinations will be important. @iamritu was describing #POCUS over dinner. Amazing. Aditi Joshi (@draditijoshi) clear guidelines on clinical conditions that can be treated, good training, quality assurance. Allowing the patient to ask questions and give feedback of their needs. We have to allow patient input to know where we can improve. #TelemedNow Resa Lewiss (@ResaELewiss) #POCUS will partner with #TeleMedNow nicely. As previously quoted 2005

Q4: In addition to avoiding Covid-19, in what other ways has telemedicine help make care safer? A4 Notable Responses: Jamey Edwards (@JameyEdwards) need for travel, slip & fall risk, financial strain, more timely care, deferred care, easier follow-up, remote patient monitoring, anxiety for both patient & provider, clinical decision support tools, access to specialists...The list goes on & on! Andrew Watson (@arwmd) Access. Access. Access. #TelemedNow when we have a more synergistic healthcare system that links payers and providers, said in general, this will truly re-define how we create digital healthcare and access. hopefully without too many digital front doors. Ritu Thamman (@iamritu) -also allow more timely care for patients, -monitor home-quarantined COVID-19 patients -Enable docs who are quarantined but asymptomatic to see pts remotely -Less use of PPE -patients without transportation can still connect & get care #TelemedNow Stacy Hurt (@stacy_hurt) Our country is having one heck of a winter. #Telehealth is protecting #patients with mobility issues (like my son) from risk of falls or other injuries and alleviating stress for the #caregiver (me) from getting him there #TelemedNow #accessibility #elderly #disability Judd Hollander (@JuddHollander) We should consider tapping into more telemedicine for educational purposes. Attendings at home can watch interns take histories. We dont need to wait till morning to round on patients. Supervision, supervision, supervision can be our friend. Janice Tufte (@Hassanah2017) Patients with communicable conditions do not have to be out among the populous possibly spreading infection, Patients do not have to drive in traffic, Make up for missed appointments. Behavioral Health uptick #TelemedNow Aditi Joshi (@draditijoshi) getting more investment by patients, clinicians, more visits equal more data. We have a larger group to find out what works, what doesn't, and how we make it safer for patients in the future. It is a tech modality, so CAN lead to quick iterations. #TelemedNow Q5: Any special medical liability concerns with telemedicine? A5 Notable Responses: AHRQ (@AHRQNews) Even though not all states require informed consent for #telehealth visits, there are sound reasons for doing so. @AHRQNews has a sample telehealth consent form with easy-to-understand language. Judd Hollander (@JuddHollander) Think about the law suit for not using telemedicine. Had it available and did not engage the patient or did not supervise the resident.... #telemednow Jamey Edwards (@JameyEdwards) For medical liability, there should be less concern w/ #telemedicine visit, because default protocol is if not confident in diagnosis, refer to in-person visit. Clinicians will need to learn new communication driven physical exam, using patients hands. Ritu Thamman (@iamritu) #TelemedNow may not capture incidental findings that might otherwise be detected during an IRL visit, lack access to internet/ video, If patients are using a shared computer in a public place, such as library or home/car,they may lack privacy to discuss their medical issues Nathaniel Lacktman (@Lacktman) the standard of care will continue to evolve as technology-enabled healthcare services become more ubiquitous and affordable. #telemednow Stacy Hurt (@stacy_hurt) I would hate to see my clinician friends in a situation where they/#telehealth are blamed for a poor outcome that would’ve happened anyhow. Sadly, I’ve witnessed that grief & desperation from families first hand #TelemedNow #advocacy Janice Tufte (@Hassanah2017) Heightened privacy & security concerns overall. Also patients might not be able to fully to share their medical concerns worrying that household members might overhear #telemedNow Dr. Salim Saiyed (@dr_salim_MD) not a lawyer... but all concerns remains the same as it would in person care.. ok to ask to get diagnostics /labs, don't shy from asking patient to follow up, or come in refer when appropriate explain / and document always COMMUNICATE

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