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RealityCheck

Telemedicine - ethical, realistic, forced on us? Let's talk.............

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The mammoth organization I work for is unbelievably heavy into promoting telemedicine.

I am appalled and do not EVER want to participate in it - ever.

 

I am old school and love the hands on and the gut feeling I get when I enter the room.

Strep has an odor.

Mono has an odor.

Lungs have sounds...........................

Nothing can replace the feeling of grasping a swollen calf or checking for pitting edema.

 

So, I feel it is being forced on me in my organization and is being heavily advertised to employers as a way to keep employees from leaving work but letting them AND their families have affordable healthcare.

 

The concept - a private room at the employers site with a skype type set up and "maybe" an MA on site - I guess vitals are optional or they will just leave the DynaMap in the room for the patient to play with........

 

Anyway, we are supposed to see the patient via video and have 2 way audio to ask questions. Then - diagnose and suggest treatment and send in Rxs.

 

I am overwhelmingly against this idea and would never want to compromise my medical ethics or integrity in the name of the almighty dollar - it is advertised as "patient centric and friendly" but there is writing between the lines.

 

Some companies have even hired a new admin position (wow, we need more admins) that is the VP of Telemedicine or some other lovely title.

 

So, let the discussion begin. Does anyone have experience with this? What is the thought process? Are students being taught about this currently?

 

If we are opposed to it - how does one address it within the scope of practice and still keep a job?

 

Does AAPA have a statement about it?

 

25 yr PA

been there, done that

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I'm with you on this. There is a reason we were taught how to examine a pt! I have in some remote sites in AK had pts seen in F/U by specialist consultants via telemed systems, but these are people who have been EXAMINED by the physicians prior to these sessions. We have a pretty good systems here where I can send VS ,X-Ray& EKGs, otoscopic exams, oral photographs ,even heartsounds to the referral hospital . But I am touching the pt and asking for advice , the recipient provider isn't doing the W/U. Yes in" THE WORLD OF BEAN COUNTERS AND SUITS"  this is  the craze, do more with less and see more pts, to bill more. I'm on the downhill side of my career and suspect that this trend will only get larger and don't want to be swept up into it

. My question is how does one justify the billing for these services and will the various entities accept attempts to bill as office visits? Who is willing to face the judge over their billing of these patients?

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Hi Realitycheck,

As you already from my thread I don't have any experience in this, but I wanted to give my opinion on this. Frankly, I do not think this appropriate at all. As a clinician, there are certain illnesses in which you have to SEE and EXAMINE the patient. Most everyday people can't fully explain everything wrong with them. You need to take a look at their throat, listen to their lungs, blood pressure,etc. And I am just mentioning the basics of a physical. I am trying to understand how this would work for all employees of a company, even those with a chronic condition like diabetes.

Seems ridiculous to me. I don't want it either. The whole reason I am pumped about this field is because of the patient interaction that physicians have slowly been losing(those guys are drowning in endless paperwork and supervision).

We need to get these corporate-like folks out of healthcare. I swear they are messing things up.

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I emailed AAPA asking if they have a position statement on telemedicine.

It IS billable in Washington state where I am and the legislation passed with flying colors and includes PAs and NPs.

 

I am curious what it will take to make a statement about this.

 

We are all workers and employees, contract or not. Admins keep making decisions for us without having walked in our shoes or having been deposed...............

 

I think I have hit a point in my career where some stuff just cannot fly or be overlooked. I am having to decide myself how I will handle it when I am told by my employer that it will become a daily part of my routine. Kind of icky.

 

I don't like this feeling. 

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I know a primary doctor that is setting it up at an orphanage in Thailand. There's pretty cool technology where there is a telemedicine otoscope/stethoscope. That's where telemedicine is great, not the I live down the street from the clinic but too lazy to go in.

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There is a proper place for telemedicine. However, the driving force is this tremendous change that healthcare is under right now, where the quality of care is giving way to easy access and trying to find some way to remain profitable in this ACA age.  We do telemedicine, after hands on visit, not for our profit (takes too long to set it up, deal with techinical problems and etc.) but because patients are demanding these easy points of contact and to stay in business, you will have to adapt to some degree.  I can imagine in a decade (when so much as gone telemedicine) there will be a movement back to hands on, touch, smell, taste, sense, that will focus on quality. But someone has to pay for that. Right now, the cards are stacked away from qualitly and more on to checking boxes.

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I totally hear what you are saying jmj, but there are patients out there who do appreciate and look forward to that one-on-one interaction. There has to be some kind of middle ground here. I am not so opposed to using this technology after a hands-on visit on a patient who can't come in regularly. That's fine.

I am also thinking about how this would affect the workload of clinicians and their job market. Would we be asked to try to hit a target x amount of patients per day and also use telemedicine to follow up with x amounts of patients? What about reimbursement for "Skype" visits? Would they be weighed the same as a office visit?

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If you are on the Space Station or in Antarctica then maybe telemedicine is all you got.

 

However, I cannot see it being applicable to the lower 48 states in most cases.

 

I wouldn't mind doing a face to face discussion with a diabetic and going over blood sugar and diet logs or asking about their exercise but I am not able to do a monofilament exam via skype and sure can't accurately see the bottoms of their feet or feel the skin via computer link.

 

When is a cough a PE vs pneumonia vs COPD vs asthma? That 02 clip on their finger only goes so far. If I can SEE retractions and accessory muscles via video we are wasting time and 911 should already be on site.

 

I am just perplexed and frustrated by it. Medicine is not McDonalds........................

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You see we clinicians, have it all wrong, we think it's about good competent care, but those who truly rule medicine in this country the CPAs and B-School graduates and their lawyers say , No-No-No ,you silly people! It's money and convenience that matters! Keep those Price-Ganey scores up and the big buck insurance companies happy and eventually we might even get around to actually doing what's best for the patients when we find a way to make more money doing it.

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The situation I've seen it work is a dual setup in a critical care unit where a hospitalist physician is present with the patient doing the in-person eval and direction, with a telemedicine intensivist who appears as the "doc in the box" that can see and hear what's going on and discuss with the hospitalist how to treat the patient. Dare I say it, but the hospitalist becomes.........a PA to the intensivist! Kinda funny, actually

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TA that's actually the setup that the CHI Franciscan system in Washington is moving towards, only it will be a PA/NP provider on the ground in the ICU rather than the hospitalist.  Sounds like kind of a neat setup, was speaking with the group about the position prior to accepting a different job.  

 

It's interesting seeing the views on here, I can understand both sides of the argument though.  You do definitely miss out on some aspects of the physical exam when you're working telemedicine, and while I'm a couple weeks away from practice myself, and believe that there are some issues that can be simply discussed without a hands-on approach.  

 

I'm not saying the telemedicine is appropriate for everybody or every situation, but if the only way you can get your HTN patient to speak with a provider is via Skype well that seems a lot better to me than not speaking to one at all.  

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Pretty easy, actually.  Just do it like the consulting nurses do:

 

"Hi, I have a cough...."

 

"You need to be seen in person by a provider.  That will be $50 for your telemedicine consultation"

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we have available telemedicine for stroke consults at one of my rural jobs. it's optional at this point. I still call the neurointensivits and present the case on the phone.

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I am thrilled to hear of all the logical uses of telemedicine mentioned in this thread.

My current employer is still pushing this as a full on treatment for what ails ya' to just about anyone.

I find that money grubbing and lazy.

Our locale is not that large that there isn't access to a clinic, UC or ER within a reasonable distance and the likelihood of having good internet connectivity in some regions is akin to snowballs in hell. So, what's the point?

 

I hope I am not forced into it as part of my job and that telemedicine can be used intelligently to benefit patients - not pocketbooks.

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I'm frustrated as well.  We (primary care office) work with an HMO that lost all of their contracts with endocrinologists in town.  So one of my patients was sent to a telemedicine doctor to monitor his testosterone (fluctuating wildly).  The patient also had well controlled DM, A1c of 6.7% on Actos only (failed metformin due to constant cramps at 500 bid)  The telemedicine doc tells the patient to have some labs done regarding his testosterone, and proceeds to suggest changing his actos back to metformin and add in Januvia, saying he might handle a lower dose of the metformin. Her note states she is giving him a labslip and prescription, but she does not.  She tells him to see ME to get the prescriptions and lab tests.  Uh, what?  I don't work for you, lady.  I don't take orders from you.  You want to take over his diabetes, then take it, but don't order me to change what is already working and just expect me to write your orders/prescriptions for you.  I did the lab orders along with some others I needed to check anyway and kept his DM meds the same. My SP agreed with me. Ridiculous.

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Fyrelight,

See these kinds of situations scare me when it comes to telemedicine. Why should you, the present clinician, finish up the work? How much time does the telemedicine doc have to review a patient's medication history? Seems this doc was in a rush frankly firelight. Sorry folks, but I still don't like this.

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Shazzy and Fyrelight - this happens with my consultants NOT on telemedicine. They DO NOT read why the patient is being sent and often miss the ONE TREE in the forest that I am asking for help with. Doesn't matter that the ONE TREE is fully engulfed in flame and screaming for help - the consultant goes after everything else but the point. Happens with PAs and docs, I am afraid. They do not take the time to read my actual note or even ask the patient what is being worked on.

 

The other side of the coin is that the endocrinologist in the example might not be a wiling participant in this either. Not to say she shouldn't have paid attention and done right by the patient..........

 

Unless, we as PAs, out in the real world tell our stories to AAPA, AMA and whomever else will listen - we will continue to be dictated by administrators without clue one what we actually face and do every day of our careers.

 

We can start a whole new thread on this one - but - once I spoke to a high level admin at an EHR company (Allscripts  - or Allcrap as we called it) - I told this man that he had to sit with me for a whole day while I saw patients and that everytime his EHR slowed me down or glitched - I got to hit him with a stick. I told him this would average 600 clicks per patient and he would need to be hospitalized at the end of the day. He stopped being a cheerleader for his product and connected with my very own IT person - who couldn't help because the product is inherently stupid and beyond repair.

 

If any of us want medicine to be honorable and worthwhile - we have to speak up and be part of change and solutions.

 

Ok, I have to go see a patient - so off my soapbox for a minute or two......

 

25 yr PA 

been there, done that

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Shazzy and Fyrelight - this happens with my consultants NOT on telemedicine. They DO NOT read why the patient is being sent and often miss the ONE TREE in the forest that I am asking for help with. Doesn't matter that the ONE TREE is fully engulfed in flame and screaming for help - the consultant goes after everything else but the point. Happens with PAs and docs, I am afraid. They do not take the time to read my actual note or even ask the patient what is being worked on.

 

The other side of the coin is that the endocrinologist in the example might not be a wiling participant in this either. Not to say she shouldn't have paid attention and done right by the patient..........

 

Unless, we as PAs, out in the real world tell our stories to AAPA, AMA and whomever else will listen - we will continue to be dictated by administrators without clue one what we actually face and do every day of our careers.

 

We can start a whole new thread on this one - but - once I spoke to a high level admin at an EHR company (Allscripts  - or Allcrap as we called it) - I told this man that he had to sit with me for a whole day while I saw patients and that everytime his EHR slowed me down or glitched - I got to hit him with a stick. I told him this would average 600 clicks per patient and he would need to be hospitalized at the end of the day. He stopped being a cheerleader for his product and connected with my very own IT person - who couldn't help because the product is inherently stupid and beyond repair.

 

If any of us want medicine to be honorable and worthwhile - we have to speak up and be part of change and solutions.

 

Ok, I have to go see a patient - so off my soapbox for a minute or two......

 

25 yr PA 

been there, done that

Also get the people in Congress that created the HITECH bill and hit them with a stick too.  Hit them twice for every attestation exercise you have to do (data entry).  Hit them a third time for not counting patients seen by a PA in their incentive carrot.

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telemedicine is not necessarily a consultation between patient/provider through distance. it could be a hospital accessing a tertiary hospital for support in order to prevent transfers and potentially allow for greater patient care. 

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I agree, Social Medicine. However, what is being pushed on me is to see and evaluate a patient, make a diagnosis and provide treatment without ever actually touching the patient. It is revenue driven and a disaster waiting to happen.

 

What you are talking about is awesome. Sharing a live interface with a cardiologist who can see the EKG or monitor, hear your amplified stethoscope and KNOWS there is someone competent right there TOUCHING the patient.

 

What my employer wants is McDonalds on the phone and I am not going there.

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I remember once hearing someone discuss data about UTI mgmt in women via phone and there wa some safe data. They probably only took healthy young women w low STI risk. But obviously to have an economical tele urgent care you would be seeing more than UTI. You would probably need a dedicated triage nurse as well to figure out what can schedule telemedicine and that could add to cost. I remember an NPR discussing this recently and the news reporter advocating for it was essentially revealing how they over prescribe antibiotics. The public health impact of tele urgent care in clinical practice might be increased access for higher income groups but likely result in poor patient care. I wonder what happens when a patient pays his/her 75 bucks for the tele medicine eval and then because of an asthma history and some flags in the HPI is told to go to the in person clinic to shell out another 30 bucks for copayment and ultimately told this is a viral URI go home and rest. Is this person ever going to be a return customer ? What pressure will be placed on MD and PA's to treat these tele cases that might not be entirely safe to prevent these issues from coming up. 

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I think that one way that telemedicine is used appropriately is the way we do.  On Thursday I had five telemedicine visits.  These are all established patients, whom we have seen in person and examined for that complaint (it was a follow up of an established chronic illness) and they each lived more than 200 miles away. I do see the urgent care visit for strangers with a variety of complaints as being nice for the patient, nice for the bean counters but not good for medicine.  If one of my established patients a new complaint (which they sometimes do) I then require them to come in and see me or see their PCP and I will not attempt to diagnosis that by Vsee.

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I've seen properly used Telehealth used for things like pre-op assessments and such - the units had stethoscopes with binaurals at one end and a diaphragm at the other for listening to lung and heart sounds and such, but you still can't lay hands on a belly or an ankle and such.  In the wrong hands, anything that is used for good can be used for evil - what I'm hearing here in bordering on evil use.

 

SK

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I am not sure if I agree with this. It may be getting a bit over in your case, but telemedicine has a lot of potential. If you consider the scarcity of time that a typical PT/OT has per patient, eHealth services are definitely a good option to improve the overall efficiency of the system. Not only does it save time for both patient and the doctor, it also improves the response time in an emergency.

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If you listen to anyone these days, nobody has time for anything but themselves.  Fact is patient centric medicine has taken a turn that seems to turn the patient into a customer instead of a patient whre can rule the roost when it comes to what we need to do to safely sort out what is wrong with someone.  It's also a problem in that people that don't practice medicine (or couldn't get into medicine) are dictating how people that do practice medicine actually do their jobs.  I can tell managers about management and leadership because I've been a boss at various levels and trained in management and leadership - however the ones that were never clinicians have little business telling me how to do my job properly and safely.

 

SK 

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