Transcript has been lightly edited for clarity and readability.

Kerry Whittemore: Welcome to M.ED: Medical Education for the Practicing Clinician. I'm your host, Dr. Kerry Whittemore, a pediatrician with the University of Utah Health. This podcast is brought to you by the University of Utah School of Medicine. Today is the first in a two-part series with a fantastic guest, Dr. Stephanie Lyden. Dr. Lyden is a stroke neurologist at University of Utah Health and is a telemedicine expert. She's going to help us figure out the best way to set up a telemedicine visit as a provider, how telemedicine has changed rapidly as a result of the COVID pandemic and ways to succeed and overcome the challenges of telemedicine. She'll also discuss how to continue to teach while in a telemedicine or virtual environment. Enjoy. 

KW: Welcome, Dr. Lyden, thanks for agreeing to talk to us about telemedicine today. 

Stephanie Lyden: Great, thank you for having me, I'm excited to be here. 

KW: So why don't you tell us a little bit about your background and how you became interested and involved in telemedicine?  

How did you get into telemedicine?

SL: I originally grew up in Wyoming where access to specialty care was very limited, so my family would have to drive about five hours to Denver for an appointment with any specialist, so we would have to secure lodging for the night, which could be very expensive. My dad was our primary income for the family as a teacher, and so sometimes appointments would be rescheduled or cancelled based off of logistical issues with scheduling these appointments. When I was in medical school, I saw telemedicine as a means to maybe help reduce this challenge and improve access to health care in rural environments. I remember asking my preceptors in medical school their thoughts about telemedicine and this technology, and even back then, there was a lot of hesitancy due to concerns about privacy, questions about accuracy with the physical exam due to the virtual barrier, and the difficulty of establishing rapport with a patient over a virtual medium. I was still interested that this technology could have some benefit, so I have pursued with these efforts even in practice. 

KW: Did you ever see telemedicine in medical school or in residency? I haven't seen it until very recently. 

SL: Yes, in residency, I requested to shadow one of our stroke docs for a day, and that was literally the only exposure I had during residency, and that's really what prompted me to do my stroke fellowship at the University of Utah, because they have such a robust Telestroke network across Wyoming, Utah, Nevada, Colorado, Idaho. I wanted more experience. 

KW: Tell me, what do you think is necessary for a successful telemedicine encounter to take place on both ends, the provider and location?

What makes a good telemedicine encounter for both provider and patient?

SL: There's many components to this question so I'll break it up:

• Fast, secure Internet or reliable cell service. This can be a barrier in more underserved rural areas, but there are some creative solutions that people are trying to tackle. For example, in the Navajo Nation in McKinley, there is a broadband network called FirstNet that's a public-private partnership with AT&T that allows priority access to cellular networks for first responders and health care workers. In that area, they actually had primary care docs identify high-risk patients that didn't have access to reliable Internet or reliable cell service, and they would go out and take tablets that were equipped with access to this cell tower, and we're able to do telemedicine visits during the pandemic. I think that's a creative solution for places that don't necessarily have great Internet or cell service. In the future, there's talk that maybe even Internet should be satellite-based and something that's allowed for all people, it's definitely something way down the road. 
• Physical and scheduling setup. I like to split encounters up into setup, where there's both a physical setup that the provider is doing and then a scheduling setup, and then how you conduct yourself during an actual visit and wrap-up. I think this is extremely important, the scheduling setup and during that, at least within our clinic, this is where patients are offered a virtual or in-person visit, and if they elect to do a virtual visit, it's really important for the scheduler to go over consent at that time, and we'll go into some of the state requirements, but that is something that we are required to also document in our physician documentation is the consent, and that's really for the patient to be aware that they can elect to be involved in this or not. It's not a requirement. 
• Educational resources for patients. If patients have questions about setup, there should be educational resources that have been made with instructions on the platform that is being used for the clinic. That's another reason it is important to have Internet access or cell service where we could then email the patient these setup instructions, and then if for example you're using the Zoom platform, the link can be sent to the patient. Or if it's MyChart, they can get MyChart activation instructions. And then during the scheduling, which during COVID this is going to take much more time than previous, because this is also the opportunity for the scheduler to recommend certain equipment. So if you need a blood pressure cuff, if you need pull socks, or for OB visits, a Doppler, a scale to measure your weight, the patient can then have time to get all of that equipment before the visit so when I go over the MA scheduling, having that available so that we have all that data once we're actually in the visit with the patient. 
• Having a family member present. I think also during scheduling if we can advise patients to have a family member present, if they feel comfortable, to help troubleshoot different technological issues. Also, from an exam standpoint, there are certain exam maneuvers that even me as a neurologist I can't do unless there is somebody else present that can help me with that.
• Explaining what to expect. For example is an MA going to be calling the patient maybe a day before their visit and updating their medical history. Do they need to have all their medications available so the MA can go through their medication checklist? That provider is likely going to do an exam, so you need to dress appropriately. I've had visits where patients are in their pajamas in bed and were not expecting me to ask them to get up and walk so I can assess their gait. So all of this during the scheduling portion is really a crucial part of the setup.  
• Getting an up-to-date phone number. In case your connection gets lost, or if you get in an emergency situation, making sure that you have an up-to-date phone number in the electronic medical record. Even an emergency contact needs to be updated. I think those are all very important for that scheduling component.
• Model the clinical environment and remove any distractions. For example, you don't want a fan rotating in the background where a patient could be distracted by that. You don't want a lot of clutter in sight. You want the patient also to be in a private, quiet area with minimal background noise, so no TV or music that's blasting, is really important. You don't want there to be back lighting because that's going to cause the patient to be really shadowed from the front, or even yourself to be shadowed, so you want there to be front lighting. 

KW: Should you tell the patient all these things ahead of time?  

SL: Yes, so that's where I think part of these instructional resources is extremely important, and really sitting down and working with your MAs, working with your schedulers, working with the docs to think of ways that you're going to create all these resources and how to get them to patients is really important. Sometimes you are going to have barriers where if you overwhelm them, they're not necessarily going to do that. You can give them this instruction even during the actual visit. I also think for providers this is important. You don't want a door sometimes in view, because they've done studies that if a door is wide open, patients will report that you spent a lower amount of time compared to a provider that does not have a door in view. These are all just little tricks. 

KW: Is that a subconscious thing that they think you're going to leave at any moment or something maybe?  

SL: Exactly. If you can't have that sort of clutter-free environment, there are backgrounds. For example, on Zoom, you can put a very plain background where all you see is a blank color or something instead of seeing the back of your office. Those are other options that you have available. 

What are some tips for the actual visit?

During the actual visit, there are a lot of tricks:

• Ask patients to show identification. This is just to make sure it’s actually the patient you should be seeing, and then establishing who all is going to be involved in the visit, if there's a family member, having them sit in view of the camera as well. Write their name down because you don't have body language to be able to direct questions, so you're going to be asking their name.
• Ask patients to place phone or computer in a stationary setting. It can be extremely distracting for the provider if the phone or computer is moving all over the place during this conversation. 
• Frame your face in the middle of the screen and hold eye contact. If part of your head is chopped off, that's going to be very distracting. Wear your lab coat with your badge showing to add a sense of security that you are their provider and you are who you say you are. The other very counter-intuitive thing is your eye contact. You'll often be looking at your picture on the screen or the patient's picture. But in order to have good eye gaze, you should be looking at the camera. Explain to the patient, "I have multiple monitors. I'm looking at your electronic medical record," during parts of the encounter, or "I'm looking at your imaging," so they don't think you're distracted.
• Communicate clearly and succinctly. Your communication needs to be a little bit more paced, because your recommendations can get lost in translation a little bit easier over a virtual medium. Since you don't have body language and sometimes if audio isn't very well, it creates another barrier. Allowing for a very well-paced, succinct explanation of your recommendations and then asking patients to report back to you or read back verification of your recommendations is going to help with their understanding.
• Wrap up. This is another component where there's new systems that need to be worked out in every clinic. During an inpatient visit, you can use body language to cue that this is the end of the visit, you have a scheduler that can schedule that patient's next visit right then and there, you have an MA that can come draw labs, you have the ability to print out their after-visit summary with all of their recommendations. For a virtual visit, we don't have that, so in my EMR with Epic, I have to CC the scheduler say, "This is the follow-up," and then the scheduler calls them a couple days later to schedule their follow-up visit. I then have to CC my MA with any additional diagnostic tests so that the MA has to call the patient and maybe help them through if there's anything like additional steps to get those diagnostic tests done. Sending patients a summary on their MyChart of what we talked about or any additional educational resources all takes much more time, but is important to factor into your visit. 

KW: That's a lot for one visit. How long are your normal office visits as a specialist?  

SL: That's where I think as a neurologist we have a luxury compared to other providers, because we definitely value, for new patient visits, a very thorough history and exam. So ours are at an hour, and so we definitely have much more time than other providers to try to cram in all of this. 

KW: I'm just thinking as a primary care doc, my appointments are 20 minutes, but there are some primary care doctors that even do 15 minutes. And all that prep sounds like it takes more than 15 minutes, it puts a big onus on your support staff. 

How do you conduct virtual appointments when an interpreter is needed?

SL: That's definitely something we've seen. There is an increase in the demand of needing more support staff with these virtual visits than what we've previously needed. 

KW: If you have a non-English speaking patient, how does that work, or do you just not do it if they don't speak English?  

SL: That goes back to our scheduling component. Usually, what our schedulers will do is if a patient needs an interpreter, they will list on our Epic view for scheduling, "Translator needed." They'll have the phone number listed for interpreter services, and then they post on that the link for Zoom or whatever medium we're doing their visit in. When I come to initiate the visit, I first will call the interpreter based on the phone number listed, they will then get the patient's MRN and date of birth. And then they'll see the link, the Zoom link or whatever, and then they will join the visit and be present. 

KW: So they'll be in front of a computer and also a participant on the Zoom meeting?  

SL: Yes. It's the same with telephone calls. I'll call interpreter services, and they'll connect me to the patient. There have been issues with our emergent Telestrokes and emergent Teleneurology where if an ER doc has an interpreter on the phone, and they're on speaker phone, the sound quality is so poor, it is a very difficult scenario. In those cases, we really recommend an in-person interpreter to be present in that situation. 

KW: I'm just thinking of my clinic, which is primarily non-English speaking, the challenges of having to do the scheduling separately and the follow-up, like labs and stuff. A lot of my patients have a hard time with communication in general, and then getting somewhere to get the labs and imaging done, that can all be done at once, definitely has its challenges. 

How do you troubleshoot techonolgy issues?

SL: I've been utilizing the MAs much more. Even for the pre-visit check-in, we're actually having them also try to do technology dry runs. Because that was another thing, we would have our visit with a patient, and they're trying to log on. Even though we would recommend they try it before the day of the visit, they may not have it set up, and then you're spending 15-20 minutes at their clinic visit trying to troubleshoot these technology issues. That's another thing that needs to be resolved before their visit starts. 

KW: So the MA's make another Zoom meeting and have the patients do that to see if they can log in?  

SL: Yes. That would be when they are going to verify their medications, that's when I verify their past medical history, either maybe a day before, or it is all in that day of the clinic visit, but they know that 30 minutes ahead of time they're actually going to be getting checked in by an MA. 

KW: Okay, got it. 

SL: Beforehand. 

KW: Right. I've had some telehealth visits where people have been in a car, I don't know if you've had that at all, which can be challenging. Since I'm a pediatrician, they'll be the parents with the kid in the back seat, in the car seat or something, but that's really hard. 

SL: Oh yeah. And then if the service is cutting in and out, and then the noise. 

KW: And then a lot of times it'll end up just turning it into a phone call as opposed to a video call, I don't know if that's something that you guys do?  

SL: We do, definitely. If we are not able to feel very comfortable with the video quality, or if we just aren't able to troubleshoot whatever technology issue the patient's having, we unfortunately may have to switch it over to a telephone visit, which isn't as ideal, because you want to be able to do a comprehensive exam as best you can over camera, and that's eliminating that ability. 

KW: Right. And you mentioned about the consent, so is that something you said that the schedulers do in advance for you?  

What about consent and privacy concerns?

SL: Yes. Usually they will go over consent, and then when we introduce ourselves, we'll also make sure that the patient is still comfortable performing the visit over this virtual medium. That just allows for if there's any additional questions the patient has about privacy or security, we can also address those for them. 

KW: Have you ever had any patient say no and refuse to do the virtual visit?  

SL: I haven't. I think since the question was originally asked, usually it's the patients that had consented for the visit. But I know from our schedulers' standpoint, there are patients that just don't feel comfortable, and they end up either doing a telephone visit or an in-person. 

KW: For sure. Do you want to tell me a little bit more about privacy, such as concerns that you have to address?  

SL: Yes, I think during the public health emergency, there's been some regulations that have been relaxed a little bit to allow for just this uptake of virtual visits so that we can actually see patients. I think that after the public health emergency, there's going to be more of a shift to wanting more dual encryption security and privacy. So for example like Vidyo or InTouch, these already have very secure HIPAA compliance, there might be more of a cry for that than now where you technically could do FaceTime or Skype, and we may see that the public wants more of these privacy standards in place going forward once the emergency ends. 

KW: Yes. And just to piggyback off of that, in terms of COVID, do you think this would be happening if the pandemic hadn't happened, this telemedicine surge, not in the same way?  

How has COVID-19 impacted telemedicine?

SL: No. I've always been a proponent that telemedicine is going to continue to grow, but I don't think any of us that have been telemedicine champions expected the accelerated uptick. That has happened because of COVID, it's definitely increased and changed a lot on the telemedicine landscape where some large health systems have seen an increase of 10 to 100 times in their telehealth visits. 

KW: Wow. 

SL: There used to be limitations based off geographic region where telemedicine was allowed, and now that has been lifted. 

KW: Meaning some states just wouldn't allow it?  

SL: Yes, or you had to meet certain requirements, so it needed to be either in a rural setting, or in an urban hospital that couldn't provide certain specialty access, and so there was just a lot more red tape around it that even some of the services that even allowed CPT codes, so before there was 90 CPT codes, and now there's almost 240. 

KW: That's telemedicine CPT codes?  

SL: Yes, based off of providers that are now allowed to do telemedicine. 

KW: Oh okay. I get it. 

SL: Before allied health providers like PT, OT, speech, social work, they were not allowed to really bill for telemedicine services, there was a lot of restrictions in place, right now that has been expanded. The reimbursement rates have also been less restricted there where services are being billed as though an in-person service took place during the public health emergency. 

KW: So not for a phone visit right? Just for a video visit?  

SL: Yes, correct, just for the video visit. And each state also has different kinds of requirements, so it's important depending on where you're practicing, that you're aware of those different kinds of regulations. An important thing to know is that if you are licensed in Utah, but you're seeing a patient in Wyoming, you need to also be licensed in Wyoming to perform that visit. A lot of states are allowing temporary licenses, and they're doing so in an expedited fashion, and they're allowing extended deadlines if you were previously credentialed or had privileging at a hospital for renewal, they're extending out those renewal deadlines. So all of that, I think, has been liberalized where there's not as many regulations, but this is something that's constantly changing and to constantly be updating yourself about. 

KW: Awesome. Well, it was really great talking to you. I learned a lot and I think our listeners will too, so thanks so much for joining us.