PracticalDermatology

A sense of uncertainty has gripped our communities, including and especially in healthcare. Only one thing is certain: social distancing has settled into our daily lives. Now also becoming routine is the need for telehealth. While its current form is modern, telehealth has technically been around since the 1950s. What is new, however, is the opportunity telehealth offers physicians and patients in these uncertain times. Telehealth visits will help to reduce transmission of the contagious coronavirus, while preserving PPE for healthcare professionals who need it most. Although it has limits that make it less than ideal for certain visit types, the technology can help practices stay open and provide much needed care to patients.

Meeting a Need When Needed Most

I am both a practicing dermatologist in South Florida as well as Chief Medical and Strategy Officer for the health IT company Modernizing Medicine. Much of my time spent outside of the clinic revolves around initiatives to help make medicine better.

In early March, with the impact of COVID-19 evident, we made the decision to invest in our synchronous telehealth solution, modmed® Telehealth, to help current and future clients continue to see patients amidst the quickly shifting landscape of healthcare and widespread office closures. Modernizing Medicine developed modmed Telehealth so that providers can continue to see patients regardless of whether your offices are open or closed.

Telehealth isn’t just a short-term fix, either for patient care or for us as a company. We plan to keep investing in this solution, as well as other patient engagement solutions, adding new features and updating it based on client feedback. We’re all in these rather uncharted waters together, and we will navigate them to keep us afloat. A major goal of creating our telehealth solution was to help physicians and patients reduce the spread of COVID-19 while allowing physicians to see some patients, such as those with acne, psoriasis or eczema, refill prescriptions, or evaluate skin lesions. It was also our intent to create a long-lasting solution that extends beyond the current pandemic.

Building for Tomorrow

With relaxed CMS regulations around telehealth, now is the right time to harness the potential of virtual visits. While general video chat options exist and are relatively easy to start using immediately, it’s important to evaluate how those options may help your practice in the long run. Though it’s hard to envision now, there will be a time when we go back to business as usual.

Regulations during this pandemic have been loosened to allow the use of non-HIPAA compliant video services, but that will likely be temporary. It may not be worth the time and effort to get up and running on a platform that will not meet HIPAA standards once the pandemic passes. It will ultimately result in more work for you and your staff, and may cause confusion for patients down the road. Opting for a telehealth solution that is a part of your current EHR can integrate into your workflow now, as well enable you to work with a familiar vendor using solutions you already have in place.

While an in-person visit is oftentimes ideal, the next best thing is a high-resolution telehealth option. High resolution teledermatology makes it easier for physicians to see small lesions and features of rashes to aid in diagnosis. The ability to use a smartphone with flash during the video phase can help keep the color of lesions consistent.

Launching telemedicine for your practice so quickly may seem daunting, so ideally you want to work with a company well-established in the healthcare space. There is great value in understanding both the doctor and patient workflows, which is something a generic video platform can’t offer.

My Clinic’s New Look

Rambunctious kids, barking dogs, the whirring of a washing machine—all the background sounds of life you thought you’d never hear in your clinic. But as you are most likely working from home now, this is our new normal.

My clinic looks and functions a whole lot differently these days, just as I’m sure yours does. But these differences don’t need to negatively impact the care you can provide to patients.

I have been seeing patients and their responses have been overall positive. Patients seem to appreciate the peace of mind that talking directly with their doctor gives them, while mitigating the risk of exposure for them and their families. My patients have also commented on the continuity of care I am able to provide them. And besides the care, let’s be honest, it’s good to see a familiar face these days.

Your Staff’s Role in Telemedicine

Once you have the tools in place for telehealth visits, let your patients know that you are open for business, albeit virtually. We want telehealth to be efficient and seamless; part of that is trying to operate as normally as possible with the help of staff.

Perhaps one of the most challenging parts of rolling out a telehealth solution is patient adoption. While some patients may be nervous about not being able to see their doctor in person, others may find it challenging to navigate the details of the new technology. Front office staff can help by calling patients to inform them of your new telehealth offering as well as confirm their virtual appointments and help them get set up to meet with you once their appointments are scheduled.

Whatever telehealth option you decide to employ, ensure that the vendor provides materials to help you help patients download the app and covers important information like how to position themselves for easy viewing, and turn on the flash, which can save valuable time for you and your staff.

Your medical assistants (MAs) can also provide valuable help for telehealth visits. In a typical clinical setting, they welcome patients, confirm past medical history, update their medications and allergies, among other duties. The same is true for virtual visits. They can call patients, update their medical history, and ask them to log into the app. As telemedicine software advances, I foresee it being possible to have both the dermatologist and MA in the “same virtual room” during the patient visit.

My Experience: Tips for Using Telehealth

It may seem like common sense, but it’s imperative to find a quiet, well-lit and comfortable spot for your home clinic and ensure you have a strong Wifi connection. I use my laptop for the video stream and earphones so that my conversation with the patient remains confidential. During the visit, I document in my electronic health record (EHR) system using my iPad while maintaining video with the patient on my laptop. This allows me to document in real time to help not forget anything and removes the need to jot down anything outside a patient’s electronic record. Just like in a regular clinical setting, I want to finish my documentation within the visit.

Especially as you’re getting acclimated to your new way of practicing medicine, I suggest accounting for some space in between appointments. This will give both patients and medical assistants time to log on and prepare, and make sure that everything is functioning well. Taking a minute to slow down will help the process be smoother and more comfortable for all. Yes, that means for now we are a little bit slower.

In dermatology, the picture really is worth 1,000 words, so capturing the best image is important. Most smartphones have two cameras: the front-facing camera (for “selfies”) and the back-facing one. The back-facing camera typically has the much higher resolution of the two, and that is the one that you should encourage your patients to use.

Keep in mind that you may often find yourself playing the role of IT support staff for your patient on top of being a dermatologist. I am learning how to do this, too.

If you experience a problem with image quality, walk your patient through checking camera settings and making sure they use the highest resolution setting. Also, the flash should be on and the camera should be ideally held five to seven inches from the target. This provides a much higher resolution compared to many of the other standard telemedicine solutions.

In some cases, you may want to ask the patient to have someone else who lives with them hold the phone for them. Some areas are difficult for most patients to reach themselves, like their backs or the backs of their legs. Other patients may need help due to physical limitations. The exam will go much faster with a little help on the patient’s side; let patients know beforehand (your MA or front staff can do this), so they can have someone ready to assist them.

If you need to examine a rash or a lesion in an area covered by clothing, have the MA communicate with patients before the visit; ask patients to undress and put on a robe, instead of undressing during the visit. This avoids what could become uncomfortable and unnecessarily time-consuming moments.

These details and others make for better patient and physician experiences. Some can only be learned as we go. After a few weeks, telehealth visits become more normalized and smoother.

Disclosure: Michael Sherling is the Chief Medical and Strategy Officer of Modernizing Medicine, Inc, a health IT company.

*The information in this article was current as of April 22, 2020 and may be subject to change. Updates and details on the topics covered herein may be available from CMS, the CDC, and/or commercial payers with which you contract. There is no warranty regarding the ongoing accuracy of the information provided and the foregoing is not intended as legal or medical advice. Consult applicable state and local laws and regulations, as some states are not moving as quickly as the Federal government to adapt to the changes required to help physicians meet the increasing need to provide care outside of a traditional clinical setting.

1. Marilyn J. Field, Telemedicine: A Guide to Assessing Telecommunications in Health Care. Washington, D.C.: National Academy, 1996.