Exploring Telemedicine Amid the Pandemic & Beyond

Dr. Buch:
Welcome to ReachMD, GI Insights. This is your host, Dr. Peter Buch. The COVID era has certainly demonstrated the usefulness of telemedicine. But what is the future of telemedicine after COVID? Here to answer this question and share his experiences is Dr. Andres Nieto. Dr. Nieto is an internist with Doctor in Demand and an Assistant Professor at the Frank H. Netter MD School of Medicine. Dr. Nieto, Welcome to the program.

Dr. Nieto:
Thanks for having me. Pleasure to be here.

Dr. Buch:
Let’s dive right in. Dr. Nieto, how do you develop an online rapport with a patient who you may not have previously met?

Dr. Nieto:
You know, I actually don’t think it’s much different than when you’re seeing a patient in the clinic. I actually think it’s easier to develop a rapport with a telemedicine visit than in the clinic because you’re, in most cases, you’re in the patient’s home with their family members I feel like I’m a guest in their house and so it’s a, a much more pleasant environment for the patients and so the, a lot of the barriers and the challenges of being in an outside environment where I think the patient is more stressed being in their home it makes things a lot easier so it’s not usually different but actually easier to chat with the patients.

Dr. Buch:
Would you have any suggestions for those who are just coming into telemedicine in terms of developing that rapport?

Dr. Nieto:
Yeah, with Doctor in Demand we have, kind of, different elements, you’ve got, kind of, an urgent care and a virtual primary care setting that we manage patients and I think in both it, it almost supplies, perhaps a little bit more towards the virtual primary care. I think it helps the, for the patients to be prepared for the visit, so if they have their records already uploaded into the system it can makes things a, a lot easier for the patients. So, you know, if the patient is well-prepared for the visit at the beginning of the visit, I’ll often give perhaps a little bit more of a prolonged consent where I, kind of, let the patients know what to expect during the visit to make things go a little bit easier. So, I’ll say something to the effect that I introduce myself to the patient, you know, I like to make sure I’ve got their correct name, their location and their phone number and I think that’s probably one of the most important things to have is their location, their address correct, and their phone number because there are some situations where I’ve had patients collapse and lose consciousness during the visit and during, kind of, more severe settings and we have to have EMS come to the patient’s house and so if you can make sure you’ve confirmed the address and location of the patient that’s helpful if you have to have EMS come. the come to the patient ‘cause they when we submit our emergency button to access the EMS coordinating staff their will need to know, make sure we confirmed everything and usually try to stay on with them. And so I think the introduction is probably the most important part in establishing the rapport and, and, the kind of parameters of the setting, setting the right expectations.

Dr. Buch:
Very important. Would you kindly share useful remote exam strategies?

Dr. Nieto:
Yeah. This largely depends upon what you’re seeing the patient for. In most cases, particularly during the pandemic, you know, this we’re seeing, kind of, more upper respiratory. I'll have the patient, you know, take in a deep breath with a large full exhalations and sometimes you can hear an auditory expiratory wheeze. I always like to have the patients in, even if I’ve seen them outside of an upper respiratory, I always tell them it’s a good idea to have a pulse oximeter; that’s extremely helpful to have particularly when evaluating a COVID patient. So, when I’m seeing somebody with COVID or concern for COVID, I like to have them do some ambulatory oximetry and so I’ll have them first check the pulse ox while they’re sitting if everything, you know, use the oxygen spine are not particularly tachycardic and then I’ll make them walk for a few minutes and then I’ll just watch to see how low the oxygen gets and if I see anything  93 or below, that’s my prompt for having them seek a higher level of care. And then with gastrointestinal issues and stuff like that it’s useful to have a, you know, a blood pressure cuff, many cases the patients don’t the pulse ox is helpful for, you know, assessing for tachycardia I’ll try to do a cursory or pulse statics just based on heart rate increase from sitting to standing if I get a, you know, above a 20 heart rate increase sitting to standing then  I’ll say that, “look you’re, you’re very tachycardic and so I think you’re, you know, you’re dehydrated, you’re dehydrated enough I think to warrant a higher level of care.”

And in a lot of cases the patients don’t have that and so one of the things I’ll have and do is download a heart rate app on their phone. And, in many cases, especially with the gastrointestinal issues the dehydration and so forth, you know, you’ll see a pretty notable tachycardia and the patients are wondering, “Can I manage this at home or can I, or do I need to go in, do I need IV fluids?”, and so when they’re, a lot of times they’re sitting around their house with their family, whose really pushing them to go and they don’t want to but when they see the, the severity of the tachycardia that’s often the needed nudge that I can get them to go so, kind of, getting those, you know, objective measures can be very helpful for assessing the patient. 

The throat exam, one of the things I’ll often do with patients is with most of the, the newer phones you can flip to the rear camera and turn on the flashlight on the back of the phone and just guide them you make sure they know many cases you’ll say, “OK, now I’m gonna have you put your finger over the camera”, so that they know where the camera is, ‘cause a lot of patients will think the camera is, kind of, somewhere in the middle of the phone and they’ll hold it there so if you put your finger over the camera, that’s where the camera is once they, I can see it over there, so that they know and then I’ll have them guide the flashlight to their mouth and we can do the a good throat exam. The older phones you can’t really do that with and so I like natural light and so I’ll say, “I’m gonna have you go to the window,” and then when you’ve got natural light shining in the it illuminates the throat rather well, and you get a pretty good throat exam with that. So, those are, kind of, some of the different use for remote exam strategies that, that that I use. There are more but those are, kind of, the more common ones that I’ll use.

Dr. Buch:
Thank you. What are your thoughts about a telemedicine visit prior to a physical exam?

Dr. Nieto:
That actually happens a lot just yesterday I had a patient for that, that same reason and I think it’s, it’s, it’s actually very useful. The patients, in many cases they have a lot of concerns and the visits with their primary cares locally are sometimes very time-limited and so they’ll, they’ll wanna know what things they should focus on when they go in for their physical exam, what questions to ask their primary care although the visits with us are actually relatively short, they’re about 15 minutes visits. The time spent in those 15 minutes is more maximized in a sense that the intake is so much less they go directly to me, I have the information there, I’m in their house, I can reconcile their medications in their own medicine cabinets, you know, with them.  Family members can ask questions and so forth and so, and then, you know, at the end I can give them a summary, ”these are the things I think would be important, pertinent to bring up when you see you’re, physician locally or your specialist’ and so it, kind of, helps you get a little bit, more synergy with the in-person exam with the telemedicine visits. And so, yeah, I think it’s very helpful to have the telemedicine visit prior to flush out the more pertinent things that can be focused on during the in-person physical exam.

Dr. Buch:
Yeah, I think the key is helping the patient focus.

Dr. Nieto:
Yes.

Dr. Buch:
For those of you just joining us, this is Dr. Peter Buch. We’re joined by Dr. Andres Nieto who is discussing telemedicine. Dr. Nieto, how do you minimize medical liability in telemedicine?

Dr. Nieto:
So, I think there’s, kind of, a few things, like I mentioned earlier the consents, I think, you know, the, at the beginning of the visit, setting the stage for what the patient can expect is very important at the start of the visit. And then I think close follow-up is also very useful.  

My threshold is a little lower for having somebody get seen locally for something that may be cardiac, I’ll push them to, you know see an urgent care or primary care. We got the emergency button to access EMS if we need to. So, I think with liability a lot of it is just some transparency, you know, letting everybody know what you can do and then make it very clear to the patient that there are limitations to what we can do and, in some cases, you’ll need to be seen locally.

One of the other challenges, as well, and it can get a little bit more complicated with medical liabilities in the sense that we’re dealing with multiple states. I’m licensed in 14 states and with pandemic several other states had asked for support and so they’ve given temporary licenses, so I’m licensed in several other states outside of the ones  I usually cover. I mostly cover the northeast and Florida and a few states in the Midwest and now I’m covering Idaho, Texas, Iowa, Kentucky as well. And so, the way the law works is you have to be licensed in the place where the patients is located. And so, you know, in some cases, the patient’s driving a moving vehicle or some patients will call from an airplane, we don’t do the visits if they’re on an airplane, that gets complicated legally. Some patients will call from outside the country. Outside the country we can give advice but we cannot prescribe. And so I think it’s useful to have the resource when you’re outside the country for it so I give guidance to patients when they need to be seen, especially for travelers diarrhea, and, and so forth.

And that, that’s one of the things that helps you establish the rapport. In many cases, I always tell the patients, I’m the doctor in your pocket, I go with you on vacation with you and you can access me whenever you need me, but there are limitations when you’re outside the country. And so, it all comes back to, I think, to transparency and making sure everybody knows what you can do but it’s, I think the risk is somewhat less, is largely less when you, when you make sure that’s clear.

Dr. Buch:
Thank you. and before we conclude, today, what additional thoughts would you like to share with our audience?

Dr. Nieto:
We talked about, kind of, the newer technologies and so forth I think there’s a lot of opportunities with some of the newer technologies that are available. there’s technology with the Kardia device for checking your EKGs at home. A lot of patients have them on their Apple Watch and it can, kind of, give you a one-lead on the Apple Watch. I think that needs to be used with caution but it’s a helpful tool for picking up, you know, certain types of arrythmias and so forth. So, I think there’s a lot of opportunity with some of the newer home monitoring devices. There’s the devices on the otoscope devices that attach to the phone, I’ve had the opportunity to use that in a few cases with patients. I think it’s very neat, novel technology. I think down the road they’ll be coming up with the ability for us to be able to auscultate remotely and so forth, as well, so it needs to be used with caution. I think transparency needs to be there. So we just have to, kind of, take it with, kind of, guarded optimism when we use these newer tools.

Dr. Buch:
Great. That’s all the time we have for today. I want to thank Dr. Nieto for sharing his insights on telemedicine.

Dr. Nieto:
Thanks for having me.

Dr. Buch:
For ReachMD, this is Dr. Peter Buch. To access this episode, as well as others, visit ReachMD.com/GIInsights, where you can be part of the knowledge. Thanks for joining us, today.