Telemedicine in a COVID-19 World

® Tania S. Malik, J.D Robert Caudill, MD May 14, 2020

Basic Definitions ®

Originating Site: Where the patient is Asynchronous: Not at the same time Distant Site: Where the clinician is Synchronous: At the same time Store and Forward: Basically asynchronous Virtual Health: More expansive than telehealth and can include e- visits and MD to MD consults ®

1834(m) of SSA Requirements for Reimbursement for Telehealth

Definition of originating site Type of provider is basically rural and location (physician or of the patient at the time of practitioner) care has to be: •PA, NP, Clinical Nurse, •Physician office Midwife, Psychologist, •Federally Qualified Health Center social worker, RD Presenter is not •Critical Access Hospital required. •Hospital •Rural Health Clinic •Hospital Based ESRD clinic •Skilled Nursing Facility •Community Mental Health Center

Covid-19 NC Dashboard ® ® ®

Will these changes stay?

ATA will advocate for the changes to be permanent. Need you to keep good records and data of success.

Licensing

Prescribing Ryan Haight Act Reimbursement Patient’s Home as an Originating Site Rural vs. Urban Distinction ®

Adapting Clinical Processes for Telemedicine Robert Caudill, M.D. Robert Caudill, MD, DFAPA, FATA Professor, Residency Training Director Director, Telemedicine and Information Technology Programs Department of Psychiatry and Behavioral Sciences University of Louisville, School of Medicine Past Chair Telemental Health SIG, American Telemedicine Association ®

INTROduction • The first step is to address the operational and regulatory aspects of Telehealth. This should be getting done by the administrative team. • The skills one needs are learned by repetition. You already know the hard part – patient care. This is about adding telepresence skills • Most of you will not (soon at least) be involved in providing care via store and forward applications. I’m happy to address this separately. • Real time, synchronous, encounters require not only technology considerations but also “webside manner” skills • All telemedicine encounters require clear communication skills, both written and oral.

5/14/20 COPYRIGHT 2019 AMERICAN TELEMEDICINE ASSOCIATION – ALL RIGHTS RESERVED 16 ® The Ever Evolving World Of Electronic/Virtual Social Etiquette And Conventions. 3 scenarios: 1. Room with person(s) 2. Room with machine(s) 3. Room with something in between (AI, bots, avatars, or ME on a screen) ® The “telemedicine wave”

Sending cues • Standing up is impractical • Shuffling in chair not always noticed • Eye discipline Parallax – i.e., Gaze angle ® Eye Contact – CAMERA LENS = EYE Rule of Thirds Think TV news anchor ®

Effective Use Of Videoteleconferencing Technologies Mute status awareness Cameras and microphones can be muted at either end of call. Framing Close up to empathize and emphasize Far back to create space, distance and perspective Inverse square law and hands. Background Backgrounds (tailored to patient population and environments, professional and appropriate, balanced between over busy and bland/neutral) Lighting – from side and above. Not behind or below. Watch out for silhouetting – especially with natural light from behind. POINTERS – Some Things To Avoid Don’t place political, religious, or even sports items in background. For privacy, keep your room’s doors or windows closed, not open. Keep the room well-lit, so the patient can see you. Consider where shadows fall.

The webcam should be placed above the computer screen, not below or to the side.

Don’t sit too far or too close to the camera. Your head should take 2/3rd of the screen.

Always introduce others in the Wear solid colors, not stripes or room to the patient and keep them other patterns. in line of sight.

Diagram and illustrations by @StevenChanMD. Content based on Peter Yellowlees & Jay Shore. CLOTHING TIPS FOR APPEARING ON-CAMERA • Your outfit is NOT what you want people to remember about you. • White shirts reflect light; subtler colors like light blue or beige often work better. • Refrain from wearing distracting trims like large bows or numerous ruffles. Remove pens and eyeglasses from pockets. • Avoid small high contrast patterns or lines, like herringbone, as well as bold checks or plaids. Solid colors with a colorful scarf or tie look good.

https://www.cabq.gov/culturalservices/govtv/tips-for-appearing-on-camera ®

Tips For Appearing on-camera Color • Mild or pastel colors and subtle patterns work best under bright lights. • Avoid pure white and black clothing, as they make skin tones appear harsh. • Bright reds and oranges sometimes "bleed" or smear on television. Avoid them. Accessories • Avoid shiny, reflective jewelry; it reflects light and can create a flaring effect. • Choose solid colored accessories or ones with simple patterns that don't appear too busy. • Keep jewelry simple so it does not make noise when you move your head or body. • Avoid dangling earrings which can distract viewers.

https://www.cabq.gov/culturalservices/govtv/tips-for-appearing-on-camera ®

Critical Telemedicine Skills • Clinical expertise with population being served • Comfort level with the technology involved • Presentation skill/Camera-mic awareness – “Telegenic” – not necessarily “photogenic.” Willingness to take this into account and develop it. Own your Avatar! ®

Psychological Issues: • The patient and the clinician each come to the appointment with some attitude toward the technology, and • The patient and the clinician are in the same environment when in-person but not when doing telemedicine.

http://adventuresintelepsychiatryblog.patrickbarta.com/2009/10/telepsychiatry-whats-lost-part-two/ ®

What should the patient do: Improving the experience: Things to help a telemedicine patient shape his or her environment to make the interaction better. • Privacy • Quiet • Comfort with the technology • Freedom from interruptions

http://adventuresintelepsychiatryblog.patrickbarta.com/2009/10/telepsychiatry-whats-lost-part-two/ ®

How In-home Telehealth Differs From In-clinic Environmental scan in home Appropriateness (safety and confidentiality during session) Information on patient (organization, style, function, lifestyle) Active Management of image and environment with patient Awareness of any safety issues or concerns ®

Adjunctive technologies and personnel • Secure Communications with scheduling • (Instant messaging) • E-prescribing – (EPCS) • Electronic Medical Record • People and Content • “Store and forward – in reverse” ®

Musings Not better or worse – just different. Cameras do not confer expertise. Nothing about the clinical encounter is made easier by the introduction of this technology. Handling the pace (↓ no show rate?) Risks – are patients on video “real?” We’re used to seeing “people on TV.” A monitor is not a window. THE END? QUESTIONS?