This Month in Telemedicine: August 2018

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July 1 traditionally starts the academic new year as we welcome new residents, faculty and medical students beginning their clinical studies. Of course, one of the sections our residents take part in is Telehealth.

We began this part of their education about two years ago, based on the fact that we have a 24/7 Telehealth service that is staffed by emergency medicine faculty and we have an emergency medicine residency. Since part of the faculty worked in this section and the enterprise wide program is run by an EM faculty, it made sense to expose our residents to it.

Of course though, the questions are how and what. We believed in the why, that exposure to this care delivery modality was necessary for their future careers. However, telehealth training and education is nascent, the field itself is new and there aren’t mature established programs or examples.

As we go into our third year of education, some of the question – for which I don’t necessarily have a clear answer – should be considered:

  • What is the clinical need for telehealth education: what makes it different from in-person visits that deem it necessary?
  • How is the best way for it to be done: residents are already strapped for time.
Why?

The first one is an interesting question because as we argue that telemedicine is simply a care delivery model, then learning how to be a good clinician should be enough. Does it become necessary to train someone on webside manner and telehealth physical exam?

The answer is yes, but not because our skills can’t be transferred to video visit, but because there are parts of the medical encounter in person that we take for granted. Identifying patients, knowing where and how they can get follow-up, and how much meds cost are some of those examples. Calling back your patients can lead to understanding the effects of your discharge plan in the ER, regarding both its successes and failures.

As for doing the actual visit, it does take practice, skill and understanding to feel comfortable only looking at someone over video for diagnosis and disposition. There are also no outside distractions and so the patient has time to ask specific questions about discharge planning, disease progression and specific warning signs. One will never know the gaps in their knowledge unless questioned in this manner. In EM we are good at acute care, but not as knowledgeable about long-term effects. Sometimes doing these one-on-one visits opens your eyes to these areas of knowledge gaps.

How?

There are a few programs that offer medical students or resident Telehealth education. Most offer something similar to what we are currently doing; callbacks, on demand visits and we are starting with teletriage based on our program of remotely triaging ED patients. However, it hasn’t been completely validated whether this is an effective method, mainly because effective Telehealth encounters are still to be defined. If we train on webside manner, patient communication, discharge counseling, understanding disease progression and telehealth physical exam, only two of them are specific to telehealth.

There is evidence that repeated encounters and practice improve clinical adherence and outcomes so simply doing repeated visits can prove beneficial. It has anecdotally led to more comfort moving onto attending positions with a Telehealth component.

Conclusion

As we go forward, we will have to find and test what parts of Telehealth require training, how we do it and what it entails. Likely this can also add to how we train our current providers. I look forward to seeing where we head in this direction; as utility of telehealth is not fully realized, there will likely be many iterations.

ABOUT THE AUTHOR

Dr. Aditi Joshi is an Emergency Medicine Physician who has worked in Telemedicine for over five years, beginning at a startup and moving onto an academic institution. She is the current Medical Director of JeffConnect, part of Thomas Jefferson University Hospital's Telehealth program. She is particularly interested in the issues of patient access and engagement, provider education and fostering international collaboration.

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