Author Archives: Andrew Barbash, MD
One of the challenges we all face who do Telemedicine consults at many different hospitals or facilities is the need for an easy way to securely access information in the EMR without having multiple different passwords and logins. In the absence of this, one has to ask for documents to be faxed back and forth, or ask a nurse to look through different aspects of the record and provide the information verbally, then transcribe it. The nature of the interaction with an EMR in support of Telemedicine consults is different than for other aspects of care because the consult process itself is different—by definition it is a real time and/or asynchronous “collaboration” between a remote healthcare professional and a nurse, mid-level, physician other other enabling clinician at the patients bedside. There are important roles each plays and the nature of the relationships unique.
A highly secure, highly private and very pragmatic method involves the same tools that would be used by “remote tech support” to assist with something on one’s computer. While the specialist is on video with a nurse, he or she launches a secure remote utility like Logmein, GoToAssist, TeamViewer or other….and asks the nurse to “open your EMR, go to this URL and enter the following security code”
Within a minute, the telemedicine physician is looking at the screen within the EMR for that particular patient. Remember, the physician is also interacting live on video (or voice) with the patient and nurse and family at the same time, in the same place. Therefore, one can easily argue this is MORE secure and private than having the nurse verbally repeating information to the doctor. The physician can take over mouse control while the nurse or other on site clinician remains in total control over whether screen sharing is live, and they can work together to get to the right information at the right time. Everyone benefits, everyone is more efficient, and it is all done as an extension of the actual live consult.
Obviously in these new roles of Telemedicine, there are new behavioral norms one develops and follows……the remote clinician is not “typing content into the record” under someone else’s login of course!…and one is not “clicking around to view other patient records”…because the nurse on the other end is in control.
I would argue that if you step back and think about what we do now..having notes printed and faxed to other numbers, then phone calls back and forth, or other nurses making parallel phone calls to transcribe certain labs and vitals….that this is more secure, more reliable, and safer overall.
I personally use GoToAssist because it is rare for a hospital IT firewall or computer “lock down” to block this highly secure tool….as these are also needed for use by IT groups to help provide desktop support. And I would argue, if you have an IT person controlling your desktop to fix something and you are not around and the EMR is logged in, you have a big privacy concern also….so its all about the presumed real time collaboration and new norms of behavior around information to support new models of care.
Once you do this successfully at a few different facilities, as a telemedicine physician with high levels of accountability…..and the nurses love it, the patients and families love your deeper awareness of their core data, etc…there is no turning back
Most of us find our email inboxes, whether work or personal, are inundated with messages from people and entities we did not request information from. As appealing as it is to have “one email i like to use on my smartphone and work” in fact it is far better to complete separate out your clinical professional life from everything else. Why” because the rules of what you need to do with content, who needs to get it, what is done with it, etc are completely different and customized to your needs.
Clinicians who use Zoom Video conferencing tools for Telemedicine can make it very simple for nurses, doctors, staff or even a family caregiver present at the bedside meet for a video consult without relying on special carts or hardware. This is particularly important when one encounters “local” issues where the “telemedicine cart” is having technical issues, bandwidth issues, or other challenges that is interfering in that instant with an effective consultation.
If you have a Zoom user account then you have in your profile a “personal meeting room link” that is static, does not change, can be customized by name if you prefer, and can be placed on your personal home page or other location that has an easy URL for others to remember.
In my case and in our “virtual clinic” it is easy to add one workflow item to this if interested… an intermediary Podio Web Form that does two things……the visitor goes to your home page and gives you their name and mobile phone and reason to visit (in case any issues you can text back). The form then immediately takes them into your Zoom consult room. As soon as people arrive you can “lock and later unlock” the room for privacy. In addition, the clinician is immediately notified that someone is visiting, who it is, how to reach if any issues, etc. The workflow is phenomenal, reliable and highly respectful of the participants need for ease of access and privacy as well.
Anyone can easily get a URL that is easy to tell people by phone or to have their support staff tell the nurse on the other end…
“Oh, Dr B will meet you now from your own mobile device, dont worry about the technical issues with the cart or our hospital computer”..Pick up your smartphone click to “www. (your favorite URL) com” and you will be connected for a secure clinical consultation right now, including screen sharing of images, secure chat, etc
Wow do I love Updox. I am a full time Telemedicine Neurologist and use it many times a day for many purposes. Now to be fair, I am one of its founders but to be equally fair I USE it because it helps streamline so much workflow.
A common issue is being able to get feedback on interesting cases when you see them in so many different states, hospitals, facilities and health systems. Patients will be transferred to other centers often for special procedures, etc.
Who is the best source of “patient centered feedback” on how the patient is doing, what important tests were done, getting you a faxed copy perhaps of an MRI report, or the names and contact info for key other physicians that might have become involved?
Telemedicine engages family members directly on video initially so that relationship is already established.
So what do I do?…..as can ANY clinician with an Updox user account?
I ask the main family member right while we are on video..for their full name and email address.
I open the Updox address book, and create them as a patient/family caregiver.
I send out an initial intro email with a set Updox custom template so that with one click the person receives this….
While we are on the video consult the family member looks at their smartphone and confirms seconds later they got my email.
Then what? Oh, 12-24 hours later i get a nice followup from them with an update on how their family is doing. I can easily import that into another EMR or tracking database as well. I can then invite in any other clinicians whose email addresses i get, to setup a secure messaging relationship, etc
Continuity of care in telemedicine.
I love it
I am part of a large group of Telemedicine physicians. We use Zoom all day long for secure collaboration within our clinical network. In addition to the outstanding Video tools, of course, is also the nicely implemented secure chat, with added features, and mobile access
I have recently started to show colleagues how one can use the “add an instant chat group” feature for clinical cases.
As a team you might have one large discussion board in which many people might post things about many cases., That can get confusing and also at some point people want to follow certain cases but not others, and avoid “notification overload”…
You are seeing a patient, which in this example we would call “Mr Test”.
You would like some comments about the CT scan or the case in general.
You use the feature of “create a public group” (this is only “public” within your private network so in fact its really a secure group with limited access”
You name the group “Mr Test Case”
All you do in the main group is post “hey, if anyone interested, join my public Mr Test Group and comment on the case”
All users can then click “add group, JOIN public group, easily search/find that case and add themselves in”
Then you can comment, and later leave or rejoin the case discussion
The case “owner” can just delete it all later when the case is done.
A feature Zoom could think of adding later is maybe having all groups have a “link” so that someone could copy the link into another chat and make it easier to find
But this is a really nice way to balance collaboration, security, and manageable notifications for clinical care
Today I had a great experience leveraging the new Medical Image Uploader plugin for ShareFile
A family member went for an MRI at the request of a consulting physician
All she had to do was get a copy of the CD before leaving the imaging center
She went home, and put the CD in her computer
Because I have remote control granted, i literally opened ShareFile from that computer (with the dual factor mobile phone authenticator code, which is very cool) and the sharefile medical image plugin recognized the format of the CD
It asked for a folder name, quickly imported the entire MRI study in easily used format for anyone else to view
Secure Link sent out to email address of the specialist
I got notified a few minutes later they had been able to access the images and report
Amazingly simple workflow
In our Virtual Clinic at http://www.nowdox.com, this is one of the tools we make accessible to our subscribed members also
So easy, and its the simple secure collaboration across practice boundaries that is so wonderful and efficient
I often am asked the question…..
“I understand that the best vehicle to use video conferencing is on a PC, mac or laptop. However, I would like to know if I can engage in a video conference with my 4G device as you demonstrated? If so, how can I try it ?”
This is an interesting issue because it gets to the heart of what one expects to happen within a video conference. The advanced tools that enable complex screen share, multiple participants, recording, two way interactions among a group, etc are MUCH better done on a larger screen and a true computing device, not just for video, but because of value of having mouse, larger screen and a more controlled audio environment. Its the difference between participating in a conference call when sitting at a desk or table and when driving in a car distracted with other things.
I use ZOOM very actively for all types of meetings and I no longer do “phone calls” because there is no reason to not see each other when talking in real time about anything important.
The more one uses these in the real world the more one is impressed with the advances in mobile video interactions, as long as one’s bandwidth is sufficient. The tablet approach eliminates all the issues found with variability in audio/video devices for any given computer.
However, that is not suggesting that participating in a meeting with complex information sharing and collaboration workflow is optimal from a tablet or smartphone. It all depends on the purpose of the “meeting” and group dynamic.
As someone who does a huge amount of video conferencing for meaningful personal or group interactions, my prediction is that alot of people might “connect via a tablet or smartphone” initially, but rapidly realize how nice it will be when, say in 15 minutes they can get themselves to a real computer with large monitor and controlled audio setup..and really have a meaningful interaction. Or, if they have to leave a meeting early and go mobile, but dont want to miss the last part of it. The more one plans to shift one’s workday to be on video interactions with people, the less one should be travelling around being forced to use smartphones and tablets for all this stuff anyway!!! (THAT is the real transformation in workflow, in my opinion….it is when people literally stop moving around in order to meet effectively with many different people in different settings!)
This whole arena is a moving target with advances in the devices, the connectivity and the applications themselves. But it is the cultural change among people and how they work (especially those who still travel all over the place just to make presentations to others) that will likely lag the technology!
Your thoughts and comments appreciated.
An ER physician contacted me recently at 1230 AM because an aquaintance of his, who also was a patient in the ER, had some unusual visual event earlier in the day and a somewhat confusing interpretation of CT/MRI. The ER physician was logged into Google Talk from his desktop, identified as the “ER Physicians Desktop 1” in my list.
He sent me quick text message noting that even though my “status” was “asleep-urgent only”, that in fact this was an urgent question. I texted him back to ask for the medical record number so I could take a look at the scans. I sent the ER doc a link to my home page that directs him to click/connect into my virtual consult room. He does so, and within 30 seconds he is online. The patient had no neurologic deficits at the time, was fully conversant, and could provide some additional details himself.
We roll the cart into the patients room to not only get added history, but to show the patient the scans, come up with a care plan, and ask about any questions or clarification. We were able to reassure all involved of the probably nature of the issue, the reason for getting some added tests, the risks of any interventions and what to expect over the next few days.
Then a brief note is entered into the hospital’s electronic online medical record (or could have been in an office based electronic record if needed, or ones own document repository)….
Then used Snagit to grab a copy of the notes and images, delete or cover over any names or identifying info, and send a copy as a secure email attachment to the nurse practitioner who will pick up the case in the morning on daily rounds.
We just recently experienced a situation in which a patient arrived with a few seizures, having had a stroke in the past. There was some concern of a new stroke but the more history we got about the last few hours it became clear it was most likely this was a seizure related to the old stroke from 2 years ago and that his recovery from the acute event should be very good, as long as no new complications arose. His wife was present along with a close friend. His daughter is a social worker in another state 200 miles away. She has 2 small children and a teenager, so there would have been challenges travelling between metropolitan areas on a Friday. We got her email address from her mother in the ER and right from the neurologists’s smartphone we sent a brief email to her, confirming she was the right person (for privacy reasons this is our general practice the FIRST time a patient or family is sent an email, to confirm their identity and that they alone check this email account). That confirmation occurred within minutes.
Early on the following day, his daughter wanted to be able to “visit” to see how he and her mom were doing. We sent an email with a hyperlink that sent her right into the “neuro icu virtual consult room” and ran a test to make sure the webcam, sound and connection were ok on her end. All went well in 5 minutes. We then arranged that 30 minutes later we would have her visit virtually. She “pinged” that same link and it rang and launched into a high quality video interaction on the mobile cart that we had already wheeled to the patient’s bedside. His daughter was able to see him gradually awaken from some of the sedating agents, talk to him to let him know she was “with” him, and talk with her mother to review the situation and feel that the whole family was present at the bedside. His daughter was able to meet the nurses and one of the transport assistants attending to her dad. We then rolled the cart around to show her the IV lines and monitors and the room, and then a brief “tour” of the Neuro ICU so that she could be comfortable with the nature of the facility, the staff caring for her father, and hear directly from her mom her impression of the care. The level of confidence in the care process was brought to a level such that she did not even need to leave home but would plan to followup online each day if desired. Even those of us who do this frequently had tears in our eyes. THIS is WHY we do virtual care. The technology is merely there to enable the process to occur seamlessly.
Please note, a copy of this image, marked up for privacy, was sent to the patient’s daughter for her approval before anything was posted online in this story. Click the image to expand.
Also, 24 hours later, after the MRI scan was done, we were able to email to his daughter and review online an anonymized snapshot of select MRI images with a few comments of explanation and reassurance.
I love finding tools that help us get our work done. In this case we have 2 care navigators and a client/caregiver all communicating in real time about some clinical issues. Think of a similar model in which sharing of electronic notes or images, or educational materials would be done in real time as people are discussing the information as well. Or think of a scheduled “specialty virtual rounds” twice a week for a community health clinic in which each area of specialty might be able to schedule an hour, virtually, and review interesting cases that had come in that week…(click to enlarge any images)