Tips for navigating telehealth visits in endocrinology
The COVID-19 pandemic is now in its third month, and providers across the country have worked to smooth out the rough edges of an unprecedented, rapid shift from in-person health care visits to primarily telehealth. For endocrinologists, that shift has meant making adjustments large and small, from delaying lab work and bone density scans to talking a patient through a self-administered thyroid exam.
Healio spoke with Gregory Dodell, MD, assistant clinical professor of endocrinology, diabetes and bone disease at Mount Sinai Health System, and Rachel Pessah-Pollack, MD, Endocrine Today Editorial Board Member and clinical associate professor of medicine at NYU Langone Health, about the how to interact with patients during a telemedicine visit, tips for improving workflow, and the future of virtual visits after COVID-19. – by Katie Kalvaitis and Regina Schaffer
What have been some of the biggest adjustments regarding virtual visits as an endocrinologist in the wake of this pandemic?
Pessah-Pollack : I did not practice telemedicine prior to COVID-19. I am an outpatient endocrinologist with a very busy practice. What I found is that during this time, I still needed to see my patients, but I also needed to protect their exposure as well as my own and my staff’s exposure. What telemedicine allowed me to do is continue to care for my patients without putting them at an increased risk for exposure. I have many patients who have been very grateful for the ability to do appointments via telemedicine. I have a practice where people often travel an hour or more to get to an appointment. In many ways, this is allowing them safety but also more convenience.
Dodell: I was conducting some telehealth visits with thyroid patients, specifically, pregnant women. I didn’t feel they needed to come in every month for me to examine them — they were seeing their OBs and it can be a lot to leave work repeatedly. The pandemic forced me to do a lot more telehealth. I believe that going forward, telemedicine will become more prevalent and useful. We are just all getting the hang of it as we go.
What are some changes you have made to better adapt to telemedicine visits?
Pessah-Pollack: I have really been evolving with the physical exam and how I have my patients participate in the exam with me. For example, many of my patients don’t even know where their thyroid is. I will work with them to show them where it is, how to feel to see if it enlarged, have them swallow. This makes the visit an educational opportunity, too.
Dodell: It is amazing what can be done just by looking at people, asking them to palpate their own neck and swallow. Additionally, you can see their overall appearance and the environment they are in. Obviously, when the patient is in your office, you don’t see that. That’s an interesting insight into people’s lives.
Pessah-Pollack: I have many patients who I’ve known for a long time and I’ve never met their family members. Now I am learning who their kids are. I’m meeting their husbands. This situation definitely provides a different level of insight into their home environment.
What are some of the challenges you are dealing with right now?
Pessah-Pollack: There are limitations with technology. There are patients who think they know how to sign on, but they are not able to. I call them and try to walk them through it. That remains an issue, which is resolvable, but still an issue. Of course, all of this also requires a smartphone or a laptop to connect.
For me, a lot of the data entry was often done before I saw the patient. Now I’m doing most of the data entry myself. My visits are actually longer because of the additional questions I’m answering and asking. You are also on a schedule of seeing patients within a certain window of time — let’s say 20 minutes between visits. Patients expect that they’re going to sign on to that visit at exactly 2 p.m. sharp and that’s when you’re going to see them. You don’t have the same leeway for running late that you maybe would have if in the office, when they might expect to sit for 10 minutes waiting.
Dodell: The workflow is a little different because we’re used to patients walking into the reception area, checking in and being taken into the exam room. We now have to replicate that flow even though we’re not in the same place and our staff is doing different things. I have my staff available during these visits just as they would be in the office. I’ll text them and say, “Can you check on my 2 p.m. patient? They haven’t logged on yet.” After the visit, I’ll send them a telephone encounter and ask that they set up the next appointment, just as we would in the office at the end of a visit. You don’t want patients to get lost in the shuffle of everything.
What tips would you offer to ensure a smooth telehealth visit for endocrinologists?
Pessah-Pollack: I look at my schedule in advance and I can “pre-chart” with notes. I try to take a look to see if it is a new patient and what are they being referred for. If they have diabetes, the likelihood is they had blood work done previously. Can I get a copy of those labs in advance? Anything you do that could facilitate a smoother visit when you’re on with a patient is beneficial.
Dodell: Be prepared. Know who the patient is, review their labs before you log on. It is a little more difficult and challenging to be navigating the screen and also making good eye contact. Looking at the patient the same way you would if you’re in the exam room is important. Having that eye contact and acting as if there is not a barrier of technology there, is important.
Also, it may sound trivial, but having good lighting and sound quality is reasonable. I have small kids at home, so I try to lock the door because I don’t want anyone running into the middle of an appointment. You want appointments to appear as professional as possible despite working remotely.
Pessah-Pollack: Agreed. Typically, in my office, I don’t wear a lab coat. Now I am always wearing a lab coat for telemedicine visits. It sets it up for the patient that this visit, even though they are seeing me in a different environment, is professional. Additionally, the AMA and the American Association of Clinical Endocrinologists offer telemedicine guidelines, which are regularly updated with tips on Medicare reimbursement, how to document visits.
What recent changes would you like to see carried forward once we return to normal?
Pessah-Pollack: After things settle down, maybe we’ll be able to look again at some of the rules that were more restrictive and see if we can open things up a little bit more. Hopefully, we can also get some data from practices regarding how patients feel with the experience during the pandemic, how physicians feel, and the type of care it is generating as well. In endocrinology, we do a lot of lab testing. That has presented an interesting challenge. Unless something is really urgent, I’ve been advising patients to hold off on routine labs. Biopsies were delayed because all nonurgent procedures were on hold.
I have many patients who move out of state and maybe come to New York once a year and would still like to continue care. Throughout this pandemic, I have been able to see some of these patients through telemedicine, even though they may have relocated outside of New York. Going forward, I hope to continue to conduct telemedicine visits with them and offer continuity of care, even though they are not living in New York.
Dodell: With everyone now working remotely across different areas of careers, people are going to realize that working from home, while difficult at times, is feasible. You are going to see companies pushing employees to do more telemedicine and maybe even offer options like separate conference rooms and kiosks, where people can go for 15 minutes or 30 minutes and conduct an appointment so they don’t have to leave the office to see their provider. You will see a much higher demand for telemedicine because people are going to say, “Well, we did it during COVID-19. Why can’t we keep doing it going forward?”
It will be nice once patients can go back and get their lab work done, or go for a bone density scan, and other things that we use to make an assessment. Those things will make telemedicine even that much more user-friendly because the real barrier is patients not being able to get their tests. Hopefully, when things are back to whatever normal will be, it will be easier to practice telemedicine because we’ll have all the data we need.
Disclosures: Dodell and Pessah-Pollack report no relevant financial disclosures.
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