COVID-19 has Turned Telemedicine From a Luxury to a Necessity Overnight
By Erika B. Bliss MD
Imagine the potential for breaking down the walls of our clinics, medical centers and hospitals and bringing care to our patients in new and better ways even after we have grappled with COVID.
This is not a guide to how to bill for these visits, what platform to use, or what workflow is best. Instead, I’m sharing pointers and things to think about from a clinical and clinician perspective when you set about converting your care from in-person to virtual:
1. I let people know that they can expect me to contact them when it is time for their phone or video appointment. That way if I am running a bit behind, they aren’t calling the clinic wondering if they were supposed to call me. If I am running late, I try to text them or have my assistant let them know I’ll be contacting them soon. My patients also know how long we are scheduled for; I usually schedule for 15 or 30 min, and sometimes new patient intakes are scheduled for up to 1 hour. That said, if you only need to chat with them for 5 min, then do not feel you have to go any longer!
2. Start by establishing rapport just like you usually do. It pays to take a few minutes to put the person at ease. Smile even if you are on the phone, they can tell. Ask how they are doing, what have they been up to, especially right now when people are cooped up. It is worth taking the time to do this as it puts the visit on the right footing and makes it more efficient in the end.
3. I usually then go to, “OK, let’s get down to business — what’s on your mind?” or “So it sounds like you are concerned about X” or “So we scheduled this call/video visit to go over your ___, how has that been going?” etc. and let them talk for a minute or two.
Do not feel pressured to “run” the visit too much. A lot of telemedicine, just like regular medicine, is about reassurance, and it takes a little more work to make the person feel like you are present and listening.
4. If you want to type notes while you are listening to them, let them know that is what you are doing. I don’t like to write and then transcribe into the EMR because it wastes precious time. I’m a loud typist, so I just tell them “I’m listening, I’m just typing while you talk so I get everything down, keep going” to reassure them.
5. Try to resist the temptation to look at other things on your computer that are not pertinent to that patient while you are doing the visit. It’s easy to get distracted and miss what they are telling you, just like in regular visits when the computer is in front of you.
6. If you are doing a video visit, you can make the picture screen smaller in the corner so you can simultaneously look at their medical record, but monitor your image to make sure you are making eye contact with them as well during the “call”. If you have a second screen, tell them “if I’m looking to the side, it’s because I’m looking at your chart” so they do not think you are ignoring them.
7. I used to think that video was often not necessary and regular phone calls were enough, and I already did a lot of care via telemedicine prior to COVID-19. However, during the past two months I have changed my perspective and have come to believe that video does add a tremendous amount of value. That said, a lot of people do not have the option, or feel uncomfortable on video, so don’t feel that you can’t do enough just with the phone. If you need to see something, have them snap a picture and text or email it to you (make sure they take a moment to really focus the picture).
8. If it is for insurance billing, you have to do more documentation, but I sometimes don’t even put much in the HPI and put most of it in the A/P, especially if it’s really brief. You can observe a great deal and record that in the physical exam section. You can have them show you things with their camera on their phone or computer, or even have them press on their body, or move their arms and legs around do your psychiatric examination, etc. You can also record self-reported vitals, or if they have BP monitors and such, have them measure things right there in front of you and show you the numbers (just note them as self-reported).
9. I still review with people at the end what the plan is, just like a regular visit. And if it is a little complicated, I send them a visit summary. It’s pretty much the same as having them in the office except they aren’t physically in front of you.
10. You can get really creative with video visits for people who are home bound even without COVID being the issue driving telemedicine.
You can have them or their caregivers use their video-enabled phones or computers to show you around their homes to do a virtual home visit.
Have them show you where they sleep, what their inside space is like, look inside the fridge/pantry to see what their food situation is like, get a sense of the level of cleanliness/clutter, is it light/dark in there, how well are they getting in and out of bed/chair, and on and on. You can have them do a peak flow and show it to you, you can watch them eat and swallow, take a drink and see if they are coughing/aspirating, the list is endless.
I once saw a program they have in Spain where they do virtual physical therapy where the PT instructs people how to do PT at home and monitors their progress through video conferencing.
Imagine the potential for breaking down the walls of our clinics, medical centers and hospitals and bringing care to our patients in new and better ways even after we have grappled with COVID.
We have not even begun to scratch the surface of the potential we already have with the technology we already have now. Hopefully, we will not let this crisis go to waste and will run with this — I think we are going to find that our patients will be unwilling to go back to the old way anyway.
Erika B. Bliss, MD is a family physician in Seattle, WA with a direct primary care solo practice where she has incorporated telemedicine as a regular part of her practice for many years.
