Dr. felissa goldstein gpt conference2015

Everything You Wanted to Know About Telemedicine But Was Afraid to Ask

Felissa P. Goldstein, M.D.

Board Certified Adult, Adolescent, and Child Psychiatrist

GPT Annual Meeting

March 2015

Marcus Autism Center

Disclosures

I have no financial disclosures

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Objectives

• Describe three ways telehealth benefits patients and providers

• List 3 considerations when designing a telehealth room

• Describe 3 techniques to optimize audio and video quality during telehealth appointments

• Explore 3 methods to fit telehealth into a busy schedule

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My Patient Despises Telemedicine. How Can I Convince Them It Is A Good Thing?

• Ability to see specialists

• Fewer missed school and work days

• Save Money

• Less time spent in car

• Easier for some patients to connect

• High video quality simulates in person encounter

• Overall telemedicine patient satisfaction rates vary from 71% to 100 % (Gutske et al. 2000)

• Telehealth located in PCP office shows PCP endorsement of telehealth

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How Can I Convince Providers Telemedicine Is A Good Thing?

• Ability to see patients over a wide geographical area

• Seamless transition from one patient to the next

• Less travel

• Fewer expenses

• Less time away from family

• High quality video simulates in person experience

• Being part of a large telehealth program helps us advocate for policy, licensure and reimbursement changes

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What’s the Catch ? What’s Bad About Telemedicine?

• Hard to schedule emergency appointments

• Longer time to receive prescriptions

• Families and providers may miss in person connection

• Problems at sites with scheduling or equipment

• Increased paperwork i.e. mailing scripts and forms

• Lack of providers in other specialties

• Reimbursement varies

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What Kind of Room Should Telehealth Be Done In (Or Why Can’t Telehealth Be Done in a Closet? )

• Room is large enough to enable patient to walk around, play with toys, or be wheeled by caregiver

• Able to accommodate patient and at least one caregiver with option for other members of treatment team

• Limit items or extraneous equipment in the room to prevent overstimulation or distraction

• Room needs to be big enough for an exam table or stretcher

• Mental health appointments require 2-3 chairs facing camera and monitor

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What Kind of Room Should Telehealth Be Done In (Or Why Can’t Telehealth Be Done in a Closet? )

• Need neutral nondistracting background

• Minimize noise other than conversation amongst family, patient and provider (i. e. fax machines, people, telephones, PA announcements , extraneous conversations ,telephones)

• Minimize people coming in and out of room during the appointment

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Why Do We Need a Neutral Background ?

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Help, My Telemedicine Screen Is All Pixelated! Why Can’t I See My Patient?

• High quality video Requires

– Adequate bandwidth > 384 kbits per second

– > 30frame/ second

– High quality video necessary for provider to see fine movements, tics, tremors, coloring, markings or other abnormalities

– See patient affect

– Prevents video and audio dyssynchrony

– AIMS (Abnormal Involuntary Movement Test) is as reliable via telemedicine as it is in person (Amerendran 2011)

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Who Can Sit In During Telemedicine Appointments?

• Anybody if family gives permission

• Avoid doing appointments in busy places (i.e. nursing stations)

• People not involved with appointment should not be in room at either site

• For appointments at school family must sign a release of information for school staff to be present

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• Move microphone closer to patient

• Ceiling microphones diminish quality and increase echoes or interference

• Carpet and draperies dampen ambient noise

• Carpet outside telemedicine room helps dampen external noise

• White noise machine helps maintain confidentiality

• Avoid doing telemedicine near open windows

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What Do I Do If I Hear Ambulances More Than I Hear My Patient?


Can Telehealth Be Done At Home ?

• It varies

• Critical to have refill, safety and emergency plans esp. if doing mental health appointments

• Connectivity is limited by connection speed at patient’s house which lower s video quality

• Patient experience limited by patient’s internet connection

• Still must follow licensing, privacy and regulatory laws

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How Do I Maintain Good Relationships During Telehealth appointments?

• Optimize eye contact

– Camera placement

– Patient and provider look at camera instead of screen

– Mobile camera that can be adjusted to focus on person talking

• Utilize picture in picture to see what you look like and assess what other side sees

• Picture in picture may need to be shut off when working with kids

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How Do I Maintain Good Relationships During Telehealth appointments?

• Engagement

– Have kids share pictures, sing songs, play games like peek a boo or hide and seek

– Ensure families have emergency contact info

– Engage with staff at rural site

• “office hours”

• Informal chats

– Understand the community culture

– In person visits at patient sites

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The System

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Before

After


How I Fit Telemedicine Into An Already Busy Schedule .

• Efficient patient appointments

• Great trained staff supporting you at both sites plus billing and scheduling

• Patients must arrive early enough so that they are ready to be seen at actual appointment time (with registration, vitals, and paperwork already done)

• Clinic flow with one patient right after the other

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How I Fit Telemedicine Into An Already Busy Schedule

• Support staff calls and confirms patient appointments to decrease no show rates

• Maintain a list of patients waiting to be seen ASAP to fill slots after last minute cancellations

• Efficient documentation (i.e. staff gets vitals off fax and places in chart, templates)

• See telemedicine patients during blocks of time

• Avoid seeing alternating and telehealth patients back to back

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Why Buy Fancy Equipment When I Can Just Skype with my patients ?

• Skype is not HIPAA compliant

• There are other platforms that are HIPPA compliant

• Two types of systems

– Standard Grade

• Systems communicate only with other standard grade systems

• Follow standards defined by International Telecommunications Union

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Why Fancy Equipment When I Can Just Skype with my patients ?

• Standard systems are open and communication between manufacturers is feasible

• More secure

• More expensive

• Supports higher quality video and audio

• Allows for multipoint conferencing

• Encrypts

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Why Buy All This Fancy Equipment When I Can Just Skype with my patients ?

– Consumer grade

• Communicate through consumer grade networks i.e. Internet

• Unit to unit communication requires same manufacturer

• Lower quality video and audio

• Less secure

• Communication outside of firewall is permissible

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If My Telehealth Patient Moves To California Can I Continue to See Them?

• Yes, if you are licensed in that state and follow all other rules and regulations of that state

• Providers must be licensed in the state where the patient is seen

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Summary

• Telehealth enables patients to see specialists they may not otherwise see, miss less work and school and have fewer expenses

• Telehealth enables providers to travel less, see patients over wider geographic area, and reach patients they may not otherwise see

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Summary

• When designing a telehealth room it should be big enough to hold the patient and 1-2 other people, contain toys, have limited ambient noise

• Audio and video quality are optimized by microphone placement, adequate bandwidth, and frame speed

• Trained staff, smooth patient flow, and templates help expedite busy telehealth and in person clinics

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References

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• Amerendran V: The reliability of telepsychiatry for neuropsychiatric assessment. Telemed J E Health 17: 223-225, 2011.

• Glueck D: Establishing Therapeutic Rapport in Telemental health. In Telemental Health. Ed. Myers K, Turvey C, London, Elsevier, 2013, pp 29-46.

• Gutske S, Balch D, West V, Rogers, L. Patient Satisfaction With Telemedicine, Telemedicine Journal. 6 (1): 5-13.


References

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• Kramer G, Mishkind M, Luxton, D Shore: Managing Risk and Protecting Privacy In Telemental Health : An overview of legal, regulatory, and risk- management issues. In Telemental Health. Ed. Myers K, Turvey C, London, Elsevier, 2013, pp 83-107.

• Spargo G, Karr A, Turvey, C. Technology Options for the Provision of Mental Health Care Through Video teleconferencing. In Telemental Health. Ed. Myers K, Turvey C, London, Elsevier, 2013, pp 135-151.

• www.tmhguide.org Accessed March 2nd, 2015.

http://www.tmhguide.org/


QUESTIONS

Felissa P. Goldstein, M.D.

Medical Director

Board Certified Child, Adolescent and Adult Psychiatrist


1920 Briarcliff Road

Atlanta, GA 30329

Office (404) 785-9405

[email protected]

Healthcare

Dr. felissa goldstein gpt conference2015