#TelemedNow for Surgeons

#TelemedNow Twitter Chat Wednesday, November 18 – 8 PM ET Introduction & Welcome: Andrew Watson (@arwmd) - Moderator #TelemedNow for Surgeons - How does #telemedicine impact surgery and procedures?

Q1: What is the value of #Telemedicine for surgeons / proceduralists? #TelemedNow How does it directly impact our practices? Geographical expansion? Operational efficient? Recruit more cases? Less driving?

A1 Notable Responses: Helen Burstin (@HelenBurstin) With #COVID19 on rise, incentive for patients to avoid hospitals. @andrewibrahim recently shared that #telehealth allows him to meet 2/3 patients on day of surgery @CMSSmed #DigitalMed2020. Game changer! Ceci Connolly (@CeciConnolly) This is the sort of insight we need to share with #Congress and #Biden team; value and virtues of #telehealth are far beyond what most ever dreamed #TelemedNow Andrew Watson (@arwmd) Early results on surgery #telemedicine emerging -- #TelemedNow Primary outcome was achieved in 90% of the conventional follow-up group and in 74% of the telemedicine group (P = 0.003).

Dr. Salim MD (@dr_salim_MD) From a #healthcare #telemednow perspective - Reduce care desert, by bringing access to more patients - Transfer only patients that make sense - Efficiently access other #surgical experts in OR Andrew Watson (@arwmd) That is an impressive statistic. I was talking to our bariatric surgeons, and they are doing the same here @UPMCnews@UPMCpolicy #TelemedNow We have a lot to learn about the virtual examination, and the virtual preop clinics. Janice Tufte (@Hassanah2017) Telehealth can be excellent support for surgery practices through offering #PreAndPost virtual visits. #TelemedNow Ritu Thamman (@iamritu) - teach/do remote training/simulations in #Covid19 #Telesurgery - ease of virtual F/u appointments & consults - Teach pt’s care partner how to do wound check during #TelemedNow visit - RPM for adherence to Rx, potential to prevent /ER visits - ease provider burden & burnout Matt Sakumoto (@MattSakumoto) I imagine all of the pre-op and post-op visits can mostly be done virtually. And surgeons already have an advantage of these being bundled payments, so reimbursement parity isn't a big concern, right? Ritu Thamman (@iamritu) Bundled payments in cardiology have been tough & part of the reason low uptake of certain lifesaving therapies like cardiac rehab #TelemedNow Ceci Connolly (@CeciConnolly) Terrific point -- so more convenient for patients, families and physicians; lower risk in #COVID19 era and possibly reduced use of resources #TelemedNow Matt Sakumoto (@MattSakumoto) I esp love increasing the #caregiver involvement in post-procedure care. They are definitely a key team member in team based care #telemednow Helen Burstin (@HelenBurstin) Pretty strong case for #caregiver involvement in pre-op too! #TelemedNow Ceci Connolly (@CeciConnolly) Of note, @_ACHP members @KPNorthwest @KPMidAtlantic @HarvardPilgrim now offering virtual first plan products. Will be interested to see how the virtual front door guides patients needing surgery. #TelemedNow JK Han MD (@netta_doc) It has allowed patients to minimize visits prior to procedure & keep safe from #COVID19 - only coming in for quick labs with all other pre-op discussions, consent, etc occuring via video #telehealth + same-day d/c.

Here's our Pre-op #EPeeps flow:

Ami Bhatt (@AmiBhattMD) Agreed. Even before COVID, we did about 7% of pre/post op visits virtually! #TelemedNow Andrew Watson (@arwmd) That’s a good metric to track, to measure what percentage of visits we can decrease, that is face-to-face versus #telemedicine. Aditi Joshi (@draditijoshi) Excuse the non-surgeon :) improving efficiency ( ie Transportation when geographical distance from sub specialists), access (bigger patient population, access to education and procedural training). #TelemedNow Jessica Spencer Castner (@DrCastner) nables automated monitoring for post surgical complications in the home environment with ROI #TelemedNow Ceci Connolly (@CeciConnolly) Another reason why #telehealth flexibilities must be part of next #COVID19 relief package; this is critical care element during this crisis #TelemedNow Chad Ellimoottil (@chadellimoottil) Helpful for patients who want to have multiple opinions before choosing a surgeon. also helpful for surgeons to manage their own patient concerns/complications rather than having them go to the local ED. Dr. Salim MD (@dr_salim_MD) The #ED issues happen more frequently than we realize. Lot of surgeons can prevent readmissions with #TelemedNow Ami Bhatt (@AmiBhattMD) #Telemedicine for proceduralists and surgeons is essential. Pre and post procedure visits enable patients to save short term disability days in addition to convenience. The use of PROs with these visits is key for improving visit quality and triage when needed! #telemednow Ceci Connolly (@CeciConnolly) And also perhaps bring in other specialists as needed -- even from far away? Andrew Watson (@arwmd) Yes And this is the potential of surgical Tele mentoring. A middle of the night complication, or another pair of eyes on a difficult situation, or sub specialty care needed briefly. #TelemedNow Kamala Tamirisa MD (@KTamirisaMD) - We have been outreach clinics via telemedicine. No travel. No travel costs for the group. Time saved is immense. - Patients transmit device check info & see us remotely. No day off needed. - Wound checks can be done from convenience of home etc.

Q2 What #Telemedicine workflow issues do surgeons need to consider? #TelemedNow See the website below? How do we create the best operational model? A2 Notable Responses: Helen Burstin (@HelenBurstin) Pre-op assessment is major element of surgical workflow. Recent article @UCLAAnes found cancellations driving time with pre-op Janice Tufte (@Hassanah2017) 1)Provide written instructions for pre visit, 2)Plan for and take into account internet snafoos= always have call in back up option> 3) utilize wait times (what can you do during wait times that could benefit patient) #TelemedNow JK Han MD (@netta_doc) Get buy-in from & include all members of your team to mirror what would be a F2F visit. Here is our post-op / wound check flow that involves, our case manager RN, tech & of course the patient, using #digitalhealth tools & #remotemonitoring. It takes a village!

Andrew Watson (@arwmd) Yes Helen, and as we have discussed before we are also seeing less no-shows. #TelemedNow One area we need to check his frailty, can this be assessed using #telemedicine? Andrew Watson (@arwmd) #TelemedNow and remote anesthesia for fetal and maternal outcomes.… Literature review, looking at 20y of rising pregnancy deaths. Can #telemedicine help? Ceci Connolly (@CeciConnolly) Absolutely what our health plan members are reporting, especially for #mentalhealth care visits; some have ZERO no-shows for #telehealth Ritu Thamman (@iamritu) - streamline workflows/data capture &make the user interface efficient & interoperability is - bringing data together for pooled analyses is tough cause different healthcare systems speak different languages:PROs another quagmire in this interoperability landscape Dr. Salim MD (dr_salim_md) - Create protocols on selecting patients for #TelemedNow - Build tools to capture those patients within existing process & workflows. Works best right at DC - Requires lot of staff training & support Matt Sakumoto (@MattSakumoto) @draditijoshi or @AmiBhattMD I'm interested in your takes on the Urgent/Emergency telemed integration into the proceduralist workflow. Does @JeffersonUniv or @HarvardHealth have any current telehealth workflows to improve access and time to OR? #telemednow Ritu Thamman (@iamritu) Frailty Data collection is key: But that data is absent from EHR #TelemedNow Without clear documentation, positive or negative (eg, a formally documented “frailty” indicator), an abstracted variable may appear as null Ami Bhatt (@AmiBhattMD) So important to focus on both clinical, tech and administrative workflow when operationalizing! #TelemedNow Matt Sakumoto (@MattSakumoto) And important to "plan thrice, implement once" to get it right the first time! Patient and provider impressions are key to uptake of new workflows #TelemedNow Aditi Joshi (@draditijoshi) We do have a big catchment area and surgical specialties use in variety of ways, tele-consults to hubs, pre-op visits/clearance, post op visits - what works for them. This is similar to many other academic spots. Not sure about the OR workflow, better ask a surgeon ;)#TelemedNow Ami Bhatt MD (@AmiBhattMD) Orthopedics has done a great job of using patient related outcomes surveys to help triage patients based on progression of symptoms. Hoping to apply PRO in pre-procedure patients in cardiology to utilize as part of #telemedicine triage. #TelemedNow Helen Burstin (@HelenBurstin) Some great work Judy Baumhauer @urochestermed using #PROMIS to assess appropriateness in orthopedic surgery…

Q3 How do surgeons adapt to the new virtual exam #Telemedicine #TelemedNow? @JuddHollander @draditijoshi @AveraHealth are leaders. Is imaging a proxy for the exam? Is there a “tele-triage model” that is effective? Vascular studies? Bio-peripherals? A3 Notable Responses: Ritu Thamman (@iamritu Ask pt to be your “hands” & self palpate abdomen etc request pt to use 1 finger to point to the maximal area of pain & to delineate any radiating pain. Can demonstrate exam maneuver for patient physical exam guide from @DrBenzigerHeart #TelemedNow Andrew Watson (@arwmd) Head and neck virtual exam - good graphic here for the setup. Andrew Watson (@arwmd) “certain telehealth assessments have been shown to allow for quicker examinations without compromising the communication of crucial information from the patient to the physician, or vice versa.” Dr. Salim MD (dr_salim_md) I think this is a bit easier compared to other specialties that might be dependent on listening to heart/lung sounds. Most surgeons are adept at visual inspection, specially in wound #TelemedNow We have a primary care and specialty #telemednow training tracks Helen Burstin (@HelenBurstin) A key part of surgical adaptation for virtual exam will be reimbursement. Important resources from @AmCollSurgeons #COVID19 Telehealth Resources @pturnerMD @SWexner… Ami Bhatt MD (@AmiBhattMD) Bioperipherals are additive to the exam on video alone. Oftentimes for new providers, it also provides a source of comfort that grounds them in the exam and assists with adoption. #TelemedNow Matt Sakumoto (@MattSakumoto) I think #POCUS from home or a hub site has a lot of utility in the initial surgical eval. Would love to hear thoughts from the actual surgeons in the room #telemednow JK Han MD (@netta_doc) Think creatively & be agile. * Video- #telehealth works well for wound check - pt can palpate & zoom in on incision. *Use disposable thermometer (temp-a-dot) for temp check r/o fever. * If no AppleWatch/or Kardia, can download smartphone #mApp to check HR. Andrew Watson (@arwmd) Yes, and I think that we need to teach patients how to take her vital signs at home. Especially heart rate in temperature. I suspect overtime more people will have a home blood pressure cuff. Watches can give us pulse oximetry. #TelemedNow Aditi Joshi (@draditijoshi) Yes- care team planning in advance, with the tools the patient may need. And even training in the physical exam components they may need to know at home for virtual post op visits or even chronic care #TelemedNow Ceci Connolly (@CeciConnolly) My mother has the blood pressure cuff; uses it almost every day, keeps a log. She is 82. #TelemedNow Matt Sakumoto(@MattSakumoto) Many of my younger patients live at home with parents, so most are just one degree of separation from a BP cuff #telemednow Ami Bhatt (@AmiBhattMD) Current day blood pressure cuffs make HR and BP easy to obtain ... the hardest part of it is downloading the app for blue tooth transmission! #TelemedNow JK Han MD (@netta_doc) Yep - unfortunately, not all have BP cuffs at home tho'. Smartphones are ubiquitous & can work for HR in a pinch :) (and not all have smartphones either!) Vahagn Nikolian (@VNikolian) Clinical reported vital signs, when’s the last time they changed surgical decision making for an elective operation? Asking for patient reported vital signs, though relatively easy to perform, adds unnecessary layer of complexity to the evaluation. #telemednow

Q4 What is the value of #TelemedNow to surgical patients? How does our virtual work benefit them? What types of #telemedicine to patients want to use? RPM? Video? eICU? A4 Notable Responses: Ritu Thamman (@iamritu) Safety during #Covid. -No travel -Easy access. - Better patient engagement leads to better outcomes Need access to internet & there are barriers for women, older pts, pts whose first language isn’t English, & those with the lowest income #TelemedNow Janice Tufte (@Hassanah2017) You need to testify in favor of #virtualvisits> great synopsis. #telemedNow Helen Burstin (@HelenBurstin) Strong patient benefits from post-op surgical #telehealth. Review article @Journal_mHealth @VNikolian Comparable clinical outcomes AND ˄ satisfaction and confidence ˅ time ˅ costs Helen Burstin (@HelenBurstin) @VNikolian may want to share more info on their new Surgical Telehealth Analytics and Research (STAR) Collaborative #TelemedNow Dr Salim MD (@dr_salim_md) Stay at home for pre and post op care - saving of time & $ for patients - improved adherence - most importantly its fun #TelemedNow Judd Hollander (@JuddHollander) Should be from PAT thru post op care. Add in remote family visits whole in hospital. #TelemedNow Q5 How should surgeons use #Telemedicine #TelemedNow to approach research and education? Education - how do we educate residents / MS virtual? Research - what types of research should re focus on? @chadellimoottil How should academic medical centers position themselves? A5 Notable Responses: Helen Burstin (@HelenBurstin) Need #telehealth training for all clinicians across full continuum. What's surgical equivalent of #webside manner? @AAMCtoday #telehealth competencies… Vahagn Nikolian (@VNikolian) Many elements to telemedicine that can be explored. I tell my team that they can focus on a speciality of interest or an aspect of telemedicine they want to improve that spans specialties. Vahagn Nikolian (@VNikolian) just this week, @mudassir_akhter presented granular data related to the experiences of hernia surgeons in the @ACHQC. We have been able to identify specific case types more conducive to successful telehealth evaluation. Janice Tufte (@Hassanah2017) #AsMuchasPossible! and Research and Education can and should be provided virtually when possible. Aditi Joshi (@draditijoshi) U of IA studies for rural teleconsults noted that spoke providers felt more comfortable and improved their procedural skills with the increase in telehealth (wasn’t their primary outcome). Can that translate to procedural training for UME/gme/cme? I’d enroll! Ami Bhatt (@AmiBhattMD) Here is an @NEJM take on #telemedicine research. Many facets to it ... important to remember that the field moves faster than RCTs will allow! QI may be essential for publications. #TelemedNow Ritu Thamman (@iamritu) participation in research via PRo’s but recognize there are problems w pt reported outcomes ie in AMI rates of underreporting were high for all groups even for events(AMI)that occurred w/in a month of interview often( 1 in 4) underreported Ami Bhatt (@AmiBhattMD) Virtual education is essential. AR, VR, Video proctoring, Video consults all helpful!! This is as true for surgeons and proceduralists as for imaging training and even complex physical exam, digital stethoscope use #TelemedNow Matt Sakumoto (@MattSakumoto) @RJelinek worked on MedEd competency model for residents. @draditijoshi @JuddHollander have excellent edu models and telemed fellowships. @HelenBurstin @AAMCtoday also with telemed competencies. Just need to put the pieces in play #telemednow Helen Burstin (@HelenBurstin) Agree. In my quick lit scan today, many surgical subspecialties with #telehealth research Matt Sakumoto (@MattSakumoto) Urologists also leading the way with great lit by @chadellimoottil @anobelodisho and colleagues #telemednow

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