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. Well 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 incompetence is both the asynchronous and 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 what it all boils down to healing at a distance. So let's dive into telemedicine. So the main buckets of telemedicine are 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 a 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. And 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 sorts of terms out there. Basically it's delivering care. If you're doing education, that's when you kind of get into the eHealth realm. And typically when you're practicing medicine, that's where you get into telemedicine but there's a mix across that spectrum. So synchronous is when it's two way audio or two 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 something 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 meaning you'll hear the two interchangeably. Remote patient monitoring or affectionately RPM is when you're monitoring patients asynchronously or synchronously or both in the inpatient or outpatient setting. We're going to talk about this a lot as we go further into our presentation. Distant site, you'll hear about in legislation or you'll hear about it in CMS. So distant site is where the provider is, an originating site is where the patient is. The distant provider is the provider providing care, this can be a physician, a therapist can be anyone who is providing that care. And the originating site or the originating person is the patient. An endpoint is what's used where the patient is. So that endpoint could be a telemedicine cart in a skilled nursing facility or it could be your phone. A term that is going out of practice is an originating fee. This is by CMS, this is a fee that helps cover the cost of the telemedicine visit where the patient is. So what typically is a very small fee and it's meant to cover internet service, telephone lines, those types of things. A peripheral is what you use at the end point where the patient is and this helps the provider with their diagnosis. So it could be a stethoscope, it could be a pulse ox, it could be a scale and we'll talk about this more as we go along. Okay, 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 okay? They're typically using their device patient at home provider's 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. So 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 on site at the health department, there's 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. Okay so this is provider to provider is a TeleConsult. Typically we see TeleConsult in the inpatient realm but you could see them in the ambulatory setting as well. A tele screening is also a term that is being batted around differently. We at Hopkins use this in our EDs, where a patient is on site at a facility and is going through screening to determine if the acuity, whether it's going to be a level one to level five visit and what type of providers 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 on site acute care provider, so that is TeleScreening. A kiosk video visit, you're seeing things like this in your local CBS 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 visits is happening in all sorts of 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 right? So this is your urgent care video visit. Other synchronous video visit types are an educational video visit. We're seeing these happen all over pre surgical. Learning about the surgery you're about to have for bariatric surgery, having, having something with your nutritionist. Okay, this is all education. It's happening online between that provider and a patient That could be a group education, right? So there could be a bunch of people who are set up for whipple surgery in the next month. We're going to through and talk about what whipple surgery is. We're going to answer general questions and then you're going to have a one on one video visit for your surgery in your special needs. A group video visit could also be used for therapy, right? For support groups. We're seeing this in the communities for diabetes, support folks getting on and learning how to cook healthy meals altogether. We're also seeing this in behavioral help for specific therapy around specific disease states. So cystic fibrosis could have a support group. They could also have a therapy group, right? And they could have an education group all three different different ways but the same modality technically. You could also have a multi provider video visit and this is really interesting. Think about taking your tumor board offline and having a bunch of specialties. All looking at your radio, at your images and coming up with a plan of care. This is really something in the future where we think things are going. Where your specialists in your PCP could be on and deciding what's the best way to handle your diabetes. Really exciting stuff, making life very easy for the patient, cutting out all that back and forth and doing it together all around the patient. We also see virtual rounding video visits on the inpatient side. What used to be in an academic medical center of an attending with all the med students, year three and then year one students in there. Your mid levels, your nursing, everyone going bed to bed and discussing the case. We can now do this virtually. And this is saving on PPE and it's saving on time and it's actually letting families join into that virtual rounding experience. So now families at home can jump on and here the entire team make a plan of care. This is really fascinating. It'll be interesting to see how things move in the future. Okay, so 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. So most used for asynchronous would probably be e-consult. And this is where a primary care provider perhaps is looking to change up meds for their patient realizes the patient is also diabetes medication or heart failure medication. And sends a note over to their cardiologist or to their endocrinologist and says this is my plan to plan of care. How is this going to interact with your meds? And then that provider writing back saying, note that looks good or actually studies are proving switch to this dosage or switch to this med. So there's so there's lower side effects or interactions between the patient's comorbidities. 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. And 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 and 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 pinkeye, 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, right, and the provider takes a look at that and then makes recommendations based off of that. Again, this is for low acuity and 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. And they're having great success with this 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 an Electronic Medical Second Opinion. So 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 another health system to a whole another specialist. This can save a lot of time. I think the research shows that 60% 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. All right, 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 along acuity. And so moving from the green to the red, you've got your ambulatory than your chronic disease, your acute episodic care and your impatient. And 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 it low acuity, I can intermittently say what's your vitals today or your vitals this week. And as we move down the acuity scale, I'm going to need to be constantly monitoring you, okay? So we're going to talk about remote patient monitoring using this flow. Okay, so here are the four main offerings under those four main buckets. So primary care is really using that ambulatory and this is we're managing your high blood pressure. Were managing your diabetes and this is not in the acute phase, but this is in your stable phase where you're stable. Our 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 shape view. Perhaps the providers only looking at this once a week or every month when you check in or nurses assigned to look at this once a day. And if you're 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 her, let's talk about if this is heart failure and then let's check in, do your vitals again. And then if you're still off the charts, let's pull in a provider to look at you. So 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 diary sees 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 dialysis clinic, we dialys you in the clinic and then you go home. And here I'm monitoring you maybe every few hours, right? Or 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. And then we move into the hospital at home. Or acute remote patient monitoring in the facility. And 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 and looking at that, I call the bedside nurse. Go take a look at Mrs. Jones. We take a look at it. Okay let's dial in, let's get the doc on the line. Okay Dr Anna what's going on here? What do we need to intervene? Okay so this is kind of from low acuity to high acuity how remote patient monitoring works, some flavors within that. That last situation that we talked about is called an eICU where offsite nurse is managing a set of patients and then a physician has a set of offsite nurses that they are assisting. So you could have three nurses. Those nurses each have 40 patients that doc has 120 patients on their plate. They're following them closely. An enhanced ICU which is something that really has come to fruition in the last year or so is where in my ICU unit. My nursing station has all the patients on a monitor and has that those alerts right there in the ICU. Why do we need that? This helps alert people to things before the alarms go off in the room. It also lessens our PPE. And so instead of gown ng up each time and going in and checking. I can buy video see my patient, I can see their monitors right? And we can do some things by video if we need to go in we go in or we wrap it in with the next time we need to go in. But this allows eyes on patients in a setting that already had eyes on but gives you more eyes. Now during Covid a lot of units and hospitals around the world turned into ICUs. They were not set up as I see you so they didn't have line of sight to those patients like an ICU does putting in an enhanced I see you getting cameras in those room turns those rooms into line of sight ICU room. So you can be watching those patients. A lot of cameras on things where folks are intubated are focused on those intubation monitors or right onto the face of the patient to make sure. And to follow those respirators and make sure things are working like they should and give you that next layer of protection. A lot of enhanced ICUs have taken all those different ICUs and put those views into a command center right there on site at the hospital or offsite to give you a blended model between the enhanced ICU. And the eICU now you have eICU with remote monitoring. You have enhanced right there on the unit and you have even in the middle a command center that's looking at those ICUs within that hospital. So lots of flavors within this remote patient monitoring. Another way that we use eyes on site with patients in the facility is eSitter. And this is typically if someone is at a fall risk they are scored and they are assigned a person that actually sits in the room with them. This is very expensive, right? An eSitter takes ten of those patients put cameras on them. And a remote Sitter is in another space watching those ten patients to make sure they're not moving Mrs. Jones. Can I help you stay in bed? I'll ring your nurse. I see you're pulling out your line. Let me get someone to come in and look at that stay in place. I'll get someone to bring you that glass of water, right? And really lessen those falls which are so detrimental to both the patient and to the hospital. Its bottom line. Okay education for telemedicine. You can use any of these models. Synchronous asynchronous to do education. The Echo model is something that is taking the world by storm. This comes out of the University of New Mexico. Take a look at that. This is so that areas can up their specialty and so you would have a grand rounds of sorts where the specialists would be talking about opioid treatment. And primary care offices would join other health systems would join primary care folks would jump on. And we would all learn how to take care of our patients, better go back, take care of the patients, come back the next month's share lessons learned actually review cases and de identified ways. Just up the education of all the providers around the state, around the nation around the world and disseminate that knowledge for the betterment of our patients. So really cool model. Okay, let's talk about virtual care during Covid 19. The pandemic has normalized telemedicine. It has expanded it 1000 fold. It brings people together. So this is just a general graph about how telemedicine is structured. So you have the patient and their family in the middle, you have all of their primary care. They're specialists, they're impatient, all the folks taking care of them and then you have their family, friends and caretakers that can now join in on those visits. And 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. So under asynchronous you have care companion where folks can put in their symptoms and that can go up and then we can a synchronously 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 pro density which is an app that health systems can now use 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. And so we know that we don't have to screen them, take their temperature etcetera to come into the building. They have been screened offline some synchronous things that we've done CART where patients that don't have PC PS can come online and get care. Get triaged 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 to cut down on PPE. And to connect patients to their loved ones. While visitors restrictions are so tightly shut down. eICU enhanced I see you all the things that we talked about under the modalities. These are things that are happening here at Hopkins also home care went live 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. And this is a program, a skilled nursing facility without walls. We used 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 a pulmonary team follows you and make sure that you are recovering well at home. We have pulse ox at home for that and we're also taking care of you with Covid with home care. So 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, homes such as the pulse ox device, home blood pressure, we send scales 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. And these are our roaming mobile carts. What specialties can utilize telemedicine. I just wanted to bring up that every specialty here at Hopkins has utilized telemedicine, how they utilize it, right? You can't do surgery through telemedicine yet, but you can do your pre visits and your post visits. Neurosurgery is one of our largest users of telemedicine, right? Because they're looking at test results to get you ready for surgery and walking you through that and then doing some assessments post. So there really has not been a specialty that hasn't used telemedicine. All the different specialists and providers are using telemedicine. So our physicians or nurse practitioners, dietitians or genetic counselors are surgeons are therapists, everyone's using telemedicine. And so that brings us to the end of our module today. I hope you enjoyed it. And I will see you on all your other modules. Be safe.
