Hi. I'm Rebecca Canino, I'm the Administrative Director for the Office of telemedicine here at Johns Hopkins. Today we're going to talk about a basic intro to telemedicine, and I hope you walk away with an understanding of the modalities of telemedicine, be able to describe some specific offerings, and know the tools that are available to you. If we start at the very beginning, it's well-known, telemedicine has no specific definition at this time. It is murky, and gray, and changing every day. Each state has their own definition of what is actually telemedicine in their state. The American Telemedicine Association defines it as a transfer of medical information via telecommunication. This encompasses both the asynchronous and the synchronous modalities of telemedicine, which we're going to talk about further on. World Health Organization has a very long definition and very specific, I really like it, and where it all boils down to healing at a distance. Let's dive into telemedicine. The main buckets of telemedicine or the asynchronous things that don't happen at the same time, the synchronous, which we all think about is telemedicine, having a video visit with the provider, and then remote patient monitoring, which is a mix of both. But on top of those three buckets are the two main ways that it happens, so telemedicine can happen provider to provider, or it can happen patient to provider. In all three of these buckets, you mix them all up, and that's how you get the flavors of telemedicine or the different offerings. Now, before we talk about specific types of telemedicine, let's talk about some terms that you're going to hear out there as you embark on your telemedicine journey. Some people are going to call it telehealth, some people are going to call it mHealth, eHealth, well, we're hearing all terms out there. Basically, it's delivering care. If you're doing education, that's when you get into the eHealth realm. Typically, when you're practicing medicine, that's where you get into telemedicine, but there's a mix across that spectrum. Synchronous is when it's two-way audio, or two-way video, or the mix of both. There's some component of that meeting that has to happen in real-time between the two parties, that's when it's synchronous. Asynchronous means that it can happen not in real-time, I as the provider sends up then off, you as the patient receive it at a different time, or the other way around. I as the patient asks for help, the provider sees it a few hours later, answers that call for help and then I read it maybe six hours later and enact that plan of care. That is asynchronous. Store and forward is synonymous with asynchronous. Same meeting, you'll hear the two interchangeably. Remote patient monitoring or affectionally, RPM is when you're monitoring patients asynchronously, or synchronously, or both in inpatient or outpatient setting. We're going to talk about this a lot as we go further into our presentation. Let's dive into some specifics and talk about some synchronous telemedicine offerings. We're going to go through these very briefly. The text is there for you to read in-depth. The most ubiquitous form of synchronous telemedicine is a video visit where the patient is at home. They're typically using their device, patient at home, provider is anywhere, you could have peripherals or you may not. An assisted video visit is where someone is with the patient helping them through that video visit. Think about it in a skilled nursing facility. There is someone there walking the patient through. Another way you could have an assisted video visit is in a health department where the patient is onsite at the health department, there is a nurse there with that patient, but the provider is anywhere. A clinic-to-clinic video visit, a patient comes into a primary care clinic to have a video visit because that provider is in a cardiology-specific clinic providing that care. A location-based video visit is all of these that we just talked about, but you could include hospitals, correctional facilities, schools, anywhere where that endpoint could be. Other synchronous telemedicine offerings could be a Teleconsult. Now, this is a term that people are using interchangeably all over the place. We haven't settled on a national definition of Teleconsult, but this is a face-to-face synchronous virtual visit between multiple providers and a patient could be there or not, so this is provider to provider is a Teleconsult. Typically, we see Teleconsults in the inpatient realm, but you could see them in the ambulatory setting as well. A telescope training is also a term that is being batted around differently. We at Hopkins use this in our EDs where a patient is onsite at a facility and is going through screening to determine if are the acuity, whether it's can be a level 1 to level 5 visit, and what type of provider is needed. Mid-level or an AP could do the telescreening and if it's low acuity, do the entire visit via telemedicine or they could hand off to an onsite acute care provider. That is telescreening. A kiosk video visit, you're seeing things like this in your local CVS, or somewhere where you're walking in, you're going into a cubicle. There in the cubicle is the video visit, all the stuff you need for that, and perhaps some peripherals there as well. An urgent care video visit is happening in all flavors. Right now you can go online and get an urgent care video visit with Teladoc, or American Well, or with your own health system, and those are on-demand and usually for low acuity, things like pink eye, or a sore throat, or flu, or COVID. This is your urgent care video visit. Those were some of the synchronous. Let's move into our asynchronous. Now remember, this is where care happens at different points at different times. Most used for asynchronous would probably be eConsult, and this is where a primary care provider, perhaps is looking to change up meds for their patient, realizes the patient is on also diabetes medication or heart failure medication, and sends a note over to their cardiologists or to their endocrinologists and says, this is my planned plan of care. How is this going to interact with your meds? Then that provider writing back saying, nope, that looks good or actually studies are proving switch to this dosage or switch to this med, so there's lower side effects or interaction between the patient's co-morbidities. This saves the patient time. Typically the provider would say, I want you to go see your endocrinologist and just ask them, I started this, should I be doing anything differently? Instead of waiting that nine weeks for that appointment and going in and asking that question, the providers can just ask that question simply to each other and very quickly with low patient impact, make that decision and actually have a high patient impact on how the treatment affects the patient, and shortcut all that waiting and trialing of different things and get to the solution that's needed right away. Another thing that's very common is an eVisit, and this is where a patient goes on, they go on to their Hopkins portal, or their other portal and they say, I have pink eye, they answer a questionnaire. It started two weeks ago. This is what it looks like. They upload a picture. This is what I think it is. The provider takes a look at that and then makes recommendations based off of that. Again, this is for low acuity in specific disease states. Though a lot of health systems are moving open into an open eVisit format where the patient can ask a targeted question, upload any information they feel is relevant and a provider can look at that and send back. They are having great success with high provider satisfaction and patient satisfaction. This totally eliminates the need for a visit, totally eliminates the need for synchronizing schedules, for leaving the house, for even getting on a video, but just gets the patient the exact care they need. Another way that people are using this is on Electronic Medical Second Opinion. Second opinion is you're really looking at records, you're looking at lab results, you're looking at imaging, and so being able to do this, send it over to a whole nother health system, to a whole nother specialist, this can save a lot of time. I think the research shows that 60 percent of the time it changes the care plan, so it's significant being able to get that Medical Second Opinion and being able to do it electronically and easily. Let's jump into Remote Patient Monitoring. I wanted to show you this graph because Remote Patient Monitoring is a huge spectrum and that spectrum is a long acuity, and so moving from the green to the red, you've got your ambulatory then your chronic disease, your acute episodic care, and your inpatient. Remote Patient Monitoring can happen across the security scale. If you look at the top to your location, low acuity, you can do this at home, and as you move into your higher acuity, you're going to need to be in a facility to do this. The type as you go down to the bottom, at low acuity, I can intermittently say, what's your vitals today or your vitals this week? As we move down the acuity scale, I'm going to need to be constantly monitoring you. We're going to talk about Remote Patient Monitoring using this flow. Here are the four main offerings under those four main buckets. Primary care is really using that ambulatory. This is we're managing your high blood pressure, we're managing your diabetes, and this is not in the acute phase, but this is in your stable phase where you are stable or meds are working. Let's get your vitals every day. Let's get your blood pressure every day. Let's get your blood sugar every day. Let's get your weight if we're monitoring your weight management, and the patient goes in, enters these, they flow up to the provider. They get aggregated into a flow sheet view. Perhaps the provider is only looking at this once a week or every month when you check in, or a nurse is assigned to look at this once a day, and if you are out of scale, if your blood pressure is wildly out of limits, you'll know what to do based on a pre-plan. If it's this, increase your Lasix here, let's talk about if this is heart failure, and then let's check into your vitals again, and then if you're still off the charts, let's pull it a provider to look at you. This is just in time, but low acuity. Let's take a look at you and monitor you. Chronic care is moving over into that diuresis for heart failure or into diabetes where maybe you've been out of bounds for a bit, and I want to look at you every day and follow an algorithm to take care of you. Acute episodic care is we have not been able to stabilize you at home, maybe we have you come into the ED, we stabilize you there. Maybe we bring you into the diuresis clinic, we diuresis you in the clinic and then you go home. Here, I'm monitoring you maybe every few hours. You're hooked up to something that's giving me continuous data. But I'm not going to be looking at that except for every four hours, every six hours. Then we move into the hospital, at home or acute remote patient monitoring in the facility. This is where someone 24/7 is monitoring you and as you get out of bounds, it sends an alert. I as a nurse off site, I'm looking at that, I call the bedside nurse, go take a look at Mrs. Jones. We take a look at it. Let's dial in. Let's get the doc on the line. Dr. Anna, what's going on here, what do we need to intervene? This is from low acuity to high acuity, how remote patient monitoring works. Let's talk about virtual care during COVID-19. The pandemic has normalized telemedicine. It has expanded it a thousand fold. It brings people together. This is just a general graph about how telemedicine is structured. You have the patient and their family in the middle, you have all of their primary care, their specialists, their inpatient, all the folks taking care of them. Then you have their family, friends, and caretakers that can now join in on those visits. You can see under the three modalities, asynchronous, synchronous, remote patient monitoring. We put a few different things that we have put into place here at Hopkins. Under asynchronous where you have care companion where folks can put in their symptoms. That can go up and we can asynchronously take care of those symptoms. Also, eMocha was very popular at the beginning of the pandemic to follow employees with their symptoms and be able to manage that. We also created not on this side, but Prodensity, which is an app that employees can put in their symptoms every day and if they are well and pass the screening, they get a green badge on their phone that they can use to enter the buildings to take care of patients. That's also been pushed down to patients, that before their visit, they take their questionnaire, they get a badge for the day and a green badge until we know that we don't have to screen them, take their temperature, etc,, to come into the building, they have been screened offline. Some synchronous things that we've done. CART where patients had don't have PCPs, can come online and get care, get triage over the phone, get matched to care, get matched to testing. Doing the same thing at a state level for folks outside of the Hopkins system. Virtual rounding inside of our facilities are to cut down our PPE and to connect patients to their loved ones. While visitors restrictions are so tightly shut down, eICU, enhanced ICU. All the things that we talked about under the modalities. These are things that are happening here at Hopkins. Also, home care with telemedicine and we're able to provide a portion of the care virtually while still having those home visits and coming into the home. Also, ElderPlus was able to go up on telemedicine. This is a program, a skilled nursing facility without walls. We use to bring our folks that were enrolled in and all their care would happen around them. Now, they're at home and we bring all their care to them. Some remote patient monitoring for COVID. After you're discharged from the hospital post COVID, our pulmonary team follows you and make sure that you are recovering well at home, we have pulse ox hit home for that. We're also taking care of you with home care. Not only do you get a pulse ox, but home care comes to your house and takes care of you. These are some of the tools. This is what a patient uses. Most patient just use their phone. Some use laptops, some use tablets. We send peripherals home, such as the pulse ox device, home blood pressure. We send skills home depending on your disease state. We also have apps that you put on your smartwatch that are communicating back to your medical record. For the clinician, they are working at home using their phone, using their tablet. They're also using different peripherals so that when folks on site are getting their heart sounds, they're actually hearing it through their headphones in real time. We also have carts that are roaming the hospital. These are our roaming mobile carts. What specialties can utilize telemedicine. I just wanted to bring up that every specialty here at Hopkins has utilize telemedicine. How they utilize it, you can't do surgery through telemedicine yet, but you can do your pre-visits and your post-op visits. Neurosurgery is one of our largest users of telemedicine because they're looking at test results to get you ready for surgery, and walking you through that, then doing some assessments post. There really has not been a specialty that hasn't used telemedicine. All the different specialists and providers are using telemedicine. Our physicians, our nurse practitioners, our dietitians, our genetic counselors, our surgeons, our therapists. Everyone's using telemedicine. That brings us to the end of our module today.
