Telemedicine Tools & Use Cases: What is the Right Solution for You?

#TelemedNow Twitter Chat Wednesday, May 13 – 8 PM ET Introduction & Welcome: Jamey Edwards (@jameyedwards) -- Moderator Telemedicine Tools & Use Cases: What is the Right Solution for You?

Q1 How do you pick a modality for a specific use? When is one appropriate over the other?

A1 Notable Responses: Andrew Watson (@arwmd) Do we agree that the three main modalities are live video, remote monitoring, and store and forward? It’s an interesting question we need to resolve. #TelemedNow. Monitoring is the new one, Vidyo is really on the rise right now. Ceci Connolly (@CeciConnolly) What about asynchronous communications? #TelemedNow Janice Tufte (@Hassanah2017) Depending on modalities available to both #Clinician & #Patient will be the most effective. Availability of #Broadband and #Devices important. #telemednow Andrew Watson (@arwmd) I should be more specific, stored forward can also be called a secret is, but so is monitoring. It’s almost like we have a vernacular issue here. This is representative of how the industry evolved in the last 20 years. #TelemedNow #telemedicine. @SWexner Evan Kirstel (@evankirstel) The key is not to pick or choose but create a comprehensive program that supports many modalities Irma #FlattentheCurve (@IrmaRaste) exactly like that! One use case at a time, but in a sustainable and scalable way. Is #video needed/available? Is #phone call sufficient? Is continuous monitoring needed b/w visits? And so on. Ritu Thamman (@iamritu) exactly like that! One use case at a time, but in a sustainable and scalable way. Is #video needed/available? Is #phone call sufficient? Is continuous monitoring needed b/w visits? And so on. Ami Bhatt (@AmiBhattMD) synchronous video and phone visits are the standard #virtualcare replacements for routine visits, but store and forward like symptom questionnaires can be quite helpful with COPD/asthma, heart failure, stable CAD, behavioral health as a continuous input. #TelemedNow Helen Burstin (@HelenBurstin) Agree. The ability to integrate PROs into practice via telemedicine is a really important use case. We struggled at office visits. Can we do better with telemed platforms? Ceci Connolly (@CeciConnolly) Perhaps this is overly simplistic but should't it be up to the doctor & patient? Combination of best treatment & most convenient/comfortable? Sandeep Pulim (@SPulim) Modality would depend on what the goals are: 1) Is it patient-2-provider or provider-2-provider 2) Level of care/support/interaction needed 3) Access to technology Andrew Watson (@arwmd) Evan, I am a firm believer in a platform as a service model. There’s a lot of good literature on these platforms, and Telemedicine thrives in the platform realm. A #PAAS. #TelemedNow. There is a great article with the title “the rise of the enterprise platform” Irma #FlattentheCurve (@IrmaRaste) Interesting anecdote about @doximity. Last Friday I had a #telemedicine appt with my PCP office. Video worked, but not audio on my #mobile phone. Trying to supplement by a phone call, Doximity could not handle that. So we could only have video OR audio. Ritu Thamman (@iamritu) Yes &platform cannot afford to be clunky- need to check bandwidth & connectivity. A video platform will not succeed if the video is subpar and slows down or cuts out or drops suddenly : this will drive patients away/not engage pts Andrew Watson (@arwmd) Helen, I’m always intrigued how we don’t incorporate PRO‘s in Telemedicine more often. #TelemedNow especially for the medical home model. Ceci Connolly (@CeciConnolly) Gotta chime in in support of phone. Need to meet patients where they are-including places w/out #broadband or fancy devices. Need @CMSGov to include audio only in risk. Can be done w/out big fraud Sandeep Pulim (@SPulim) Here is a great real world example of how a pediatric practice is using a hybrid of modalities to serve the needs of their patients: Helen Burstin (@HelenBurstin) My brother’s pediatric practice in NYC flipped to telemedicine almost overnight. He is amazed how much he can do even during a pandemic (last weekend call was mainly rashes due to fear of #COVID19 inflammatory syndrome). How can telemed be sustained once office open? #TelemedNow Annette Ansong (@kiddiehearts) Peds cards so I use synchronous for my virtual patient visits or doc-doc consults. Asynchronous for non-urgent echoes done at outside hospitals that need interpretation. Use RPM for our fragile interstage single ventricle pts with hosp issued iPads. Annette Ansong (@kiddiehearts) Also testing use of Digital stethescopes for either synchronous or asynchronous use on newborn babies in nurseries at outside hospitals with murmurs. #TelemedNow Cory Simpson (@CorySimpsonMD) In #telederm, if we need a high-res photo to make a reliable Dx, then store-and-forward is a better bet for #TelemedNow. Especially for skin neoplasm #teletriage, static photos are MUCH better than live video feed. Even for some rashes w/detailed surface changes, SAF can be best. Salim Saiyed (@SalimCMIO) A lot of folks are considering telephone/ audio only as #TelemedNow with the recent expansion of CMS $ Helen Burstin (@HelenBurstin) Given current circumstances, telephone visits with payment parity is a good start. But the visual component provides more data on the patient's conditions and their lives. Remarkable peek into their homes and family #TelemedNow Q2 How do you know if a modality is effective? How do you measure success? Which metrics are most important? A2 Notable Responses: Jagdish Patel (@jpkca) Metrix to follow for #Telemedicine - 1. Are we able to address patients' concerns? 2) Prevention of ER visit 3) Reduce readmission 4) Patient satisfaction 5) Saving travel for providers and patients Ritu Thamman (@iamritu) effectiveness can be measured by outcomes with intermediary step as pt engagement: for example Ischemia detection by iPhone But will it change outcomes? Value is tied into effectiveness too Helen Burstin (@HelenBurstin) Sounds simplistic, but we need to ask the users. For clinicians, were you able to adequately assess and address the patient’s issue? What was missing?For patients, were your concerns adequately addressed? What was missing? # TelemedNOW Ami Bhatt (AmiBhattMD) We offer #virtual visit questionnaires after every visit, easy to skip if you are busy, Easy to respond to if something didn’t go well. Ceci Connolly (@CeciConnolly) A note to policymakers: your constituents (ie voters) LOVE #virtualcare. Tune in our for ntl survey results next week to get the deets Janice Tufte (@Hassanah2017) risk stratification is important, make sure #digitaldisparities are addressed #TelemedNow Sandeep Pulin (@SPulim) We are hearing the need for tracking "% of successful connections" as a key metric by clients Ryan Louie (@Ryanlouie) It's kind of like learning a foreign language. That it's ok not to be fluent. You start to feel that you "fit in" for both yourself & the people you are with when nobody even mentions the topic of language. Same applies for #telemedicine. You drop tele & talk med. Cory Simpson (@CorySimpsonMD) Great analogy. Learning #TelemedNow is learning a new but related language. We already know the basics but fluency builds w/practice. Some nuance when not in-person but underlying principles still apply. At its core, virtual care is still just listening to pts, who tell us the Dx Cory Simpson (@CorySimpsonMD) Agree 100%. Have to make sure the #telemedicine workflow and platform are convenient and helpful for clinicians as well as patients. Otherwise, #TelemedNow will just become the next EMR for us to grow to despise! Aditi Joshi (@draditijoshi) Agree with all of @HelenBurstin said. Also was the tech easy to use on both sides ensuring a full visit. Did they need reassessment in *defined time, similar to other QA processes. Does the program meet the goals defined for the program. Ritu Thamman (@iamritu) #TelemedNow Did it answer the patients question & on follow up did it improve pts compliance & medication adherence - we want #Telemedicine to do more than just see the pt Ami Bhatt (@AmiBhattMD) This has been shown in the #psychiatry literature for #Telemedicine improving #medication adherence

Ritu Thamman (@iamritu) Pysch is probably the best use case esp w younger generations prefering #Telemedicine to talking face to face. Sometimes even sending a text, as opposed to making a call & actually speaking to someone, can take a lot of pressure off of someone who is already upset #TelemedNow Q3 How do regulatory & compliance goals impact the use of specific #telemedicine tools? A3 Notable Responses: Evan Kirstel (@evankirstel) #Telemedicine raises multiple compliance issues eg how certain services may be delivered to whom, what telemedicine services may be billed, and how telemedicine businesses must be structured in a given state. Complex! Ceci Connolly (@CeciConnolly) Credit to @CMSGov for flexibilities during #COVID19. One major outstanding issue is risk adjustment for audio-only-and then we must ensure we do not go backward Ritu Thamman (@iamritu) Access is key: 3.8 billion people – nearly 1/2 worldwide population – lacks internet access Compliance may be age related younger generations prefer texting to talking on the phone & older folks may need a helping hand to onboard a #TelemedNow video visit Ami Bhatt (@AmiBhattmd) Great article with older #patientengagement via @AARP: Andrew Watson (@arwmd) Licensing perhaps will be the greatest one. Is currently relaxed and 48 states, but what happens in 6 to 9 months? @jkvedar @JuddHollander we’re recently discussing this in a webinar @Telemedicine_Jn Ceci Connolly (@CeciConnolly) Payment will continue to be crucial issue in path forward; important policymakers include #telehealth in path to value-based system. Would be such a mistake to tack #virtualcare onto FFS chassis

Q4 Are some #telemedicine modalities easier to implement than others? Why?

A4 Notable Responses: Ami Bhatt (@AmiBhattMD) Any phone based modality has an advantage ... @zoom_us @doximity for video calls have been great. Evan Kirstel (@evankirstel) Companies like @Vonage have rolled out video APIs so that developers can build video into existing healthcare tools and applications versus learning something new like zoom Ami Bhatt (@AmiBhattMD) Home monitoring through established #remote monitoring devices have systems in place in #cardiology but #wearable input remains a challenge because of lack of a workflow and infrastructure. Joe Babaian (@JoeBabaian) It's the wild west when it comes to workflow, pretty cool much unrecognizable at scale right now. #TelemedNow Aditi Joshi (@draditijoshi) well telephone is easiest, if we are looking at classic use cases. If you're looking for EMR integration that will be hardest, otherwise there seems to be more options in the last few months for video and chat. Salim Saiyed (@SalimCMIO) #coronavirus pandemic has shown any #telemednow is easy to adopt when the patients, providers are engaged it meets the demand #education, #workflow, plan, support & constant iteration is crucial to making any modality easy to implement Ritu Thamman (@iamritu) Phone is the easiest since nothing new but if pts have an easy on boarding then video may feel the closest to a real office visit but maybe chatbot apps will earn consumer trust Although currently can’t handle complex conditions #TelemedNow Cory Simpson (@CorySimpsonMD) Reducing barriers to entry is key for #TelemedNow. Easiest platforms offer single-click link to browser-based encounter sent via text message. Registering w/yet another password, dowloading a new app, and reading complicated use instructions erode the convenience of #telemedicine Q5 What are the highest value #telemedicine use cases? Why? How do you measure value?

A5 Notable Responses: bloomrhealth (@bloomrhealth) One that addresses all the 3P's Patient - Provider – Payer Ami Bhatt (@AmiBhattMD) this is a unique time. #urgent care, answering patients concerns and evaluating them #virtually before bring them in is of such high value to patients during #COVID19 Ami Bhatt (@AmiBhattMD) For chronic disease care, #telemedicine with video visits to review #imaging has been great. Patients don’t understand reports, can find them frightening, and “your MRI is ok” does not engage the #patient in self-advocacy. #MedEd Aditi Joshi (@draditijoshi) i always think in terms of the NQF framework of improving access, effectiveness, experience and decreasing costs. currently that means availability of care. Screening, evaluation for #COVID19 when things are closed, when feeling especially anxious or having physical symptoms Jagdish Patel MD (@jpkca) (What are the highest value How do you measure value) FYI: Great article by @AmiBhattMD Helen Burstin (@HelenBurstin) The highest value #TelemedNow uses cases will drive adoption: 1) patients like it, 2) docs like it (decr burnout), 3) reduces burden on EDs during #COVID19 3) payers see value and incentivize use beyond #COVID19 to support health status improvement Ritu Thamman (@iamritu) value is key but how a patient defines value and a healthcare system does are different #TelemedNow @rkwadhera found Communication with & trust in healthcare providers were the most important factors for determining the value of a healthcare visit Andrew Watson (@arwmd) Tele stroke is always one of the big ones. #TelemedNow. I think surgical mentoring will also rise to a very high level because of the risk, and the acuity of the problem. Cory Simpson (@CorySimpsonMD) This #pandemic is the single best use case for #TelemedNow. Ex: we use #telederm to triage all inpatient consults to reduce traffic in the hospital, limit #COVID19 exposures, and avoid need to burn additional #PPE during consults to save many masks/gowns for front-line providers. Ami Bhatt (@AmiBhattMD) Yes. Prior to this #telestroke @MassGeneralNews was our best use case. Saving lives, days lost, and cost of care to patients and the system @MGHNeurology Andrew Watson (@arwmd) It’s amazing the telemedicine rate of TPA versus non-telemedicine rate of TPA administration. #TelemedNow Ritu Thamman (@iamritu) . #Covid19 makes us search for the best use cases: ^ AI use to read #Yessct CT scans instantly with high accuracy ^ Delivery apps for contactless delivery of meds ^ mobile payment apps to reduce transmission along paper money #TelemedNow Alex Chang (@alexchangmd) If we can get it right, potentially hypertension management. Home BP monitoring eliminates concern of white coat syndrome, telecounseling to address lifestyle behaviors, frequent results to guide BP medication titration in the comfort of home. #TelemedNow Q6 What will be the best #Telemedicine use cases for the future? Name a use case you haven’t seen but would like to see. A6 Notable Responses: Andrew Watson (@arwmd) I would like to see a combination of monitoring and live video with AI. Especially for payer-based chronic diseases. #TelemedNow The ultimate early warning system Michael Archuleta (@Michael81082) The acceleration of digital transformation is here & the mass adoption of telecommuting is the most explosive change to occur due to #COVID19. The crisis has fully displayed the value of IT and #digitaltransformation. - #TeleMedNow Salim Saiyed (@SalimCMIO) #AR #VirtualReality with physician guidance, intervention & monitor Chat bots and #VoiceAssistant that can guide a patient through most of their visit with physician supervision at the end Ritu Thamman (@iamritu) AI enabled like @CaptionHealth to guide a patient to put the ultrasound probe on the right spot on their chest to capture the necessary images for an #echofirst or to “see” the heart sounds in liu of a stethoscope #TelemedNow Helen Burstin (@HelenBurstin) Build in PROs and capture outcomes over time, provider and setting (a girl can wish, right?) #TelemedNow Cory Simpson (@CorySimpsonMD) Skin cancer screening for high-risk pts remains a big challenge for #telederm. With current tech for #TelemedNow, we aren't able to adequately do full skin exam for lesions needing biopsy. But combining #telemed platforms w/higher-res video and #AI could potentially get us there. Ami Bhatt (@AmiBhattMD) give me continuous and interval home monitoring options with #AI to highlight at-risk patients for just-in-time #virtual care and in-person evaluations only when needed. Ritu Thamman (@iamritu) #CardiacRehab 25% reduced mortality & if can eleiminate the co pays & transportation issues with #TelemedNow - it’s a win win


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