Telehealth Best Practices: How To Best Care For Your Patients When They Are Not Physically In Front Of You

An Interview With Jake Frankel

Originally posted at Authority Magazine

One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?

In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing?Dr. Geoff Rutledge.

Dr. Geoff Rutledge is a physician, formerly on clinical and research faculty at Harvard and Stanford, who has been in clinical practice for the past 35 years. As co-founder and CMO of the pioneering virtual healthcare company HealthTap, he oversees the medical group that delivers virtual primary care to people all across the USA. He also built the HealthTap Doctor Network, where more than 95,000 US-licensed doctors in 147 specialties have helped hundreds of millions of people by giving millions of free answers and peer reviews of answers to health questions. Doctor Rutledge earned his MD at McGill University and a PhD in medical computing at Stanford. He achieved board certification in both Internal and Emergency Medicine, and is an elected fellow of the American Academy of Medical Informatics.

Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?

After residency training, I joined the clinical faculty at UCSD and then Stanford, but gave that up to complete a PhD at Stanford in medical computer science, before joining the faculty at Harvard Medical School where I taught clinical medicine and researched how we could use computers to improve bedside clinical decision making. It was the early days of the Internet, and I realized what I wanted to accomplish was only going to happen in the entrepreneurial world of venture-funded startups. I quit my tenure-track faculty position, returned my research grant to the NIH, and joined my first startup. I built the first and most successful consumer-health information web service (originally Healtheon, it became WebMD), and later was Chief Medical Officer at the leading mobile health information service for doctors (Epocrates). I combined my experiences with consumer and physician online and mobile health as the foundation for what we would do at HealthTap. I’m now delighted with the progress we have made to bring both patients and doctors to our platform for an astonishingly convenient and effective, low-cost virtual healthcare experience.

Can you share the most interesting story that happened to you since you began your career?

As a doctor delivering healthcare on HealthTap via virtual consultations, and in outpatient clinics, and as an attending in the emergency room, and while giving emergency care via Life Flight helicopter, I have quite a few interesting stories I could tell. I could describe the impact of assessing and managing a patient with severe stress and work-related anxiety with counseling and a prescription antidepressant that also controls anxiety. Just this week, at her follow-up visit, she was transformed from being wrought with anxiety to someone with a radiant smile, thankful for the help she received.

At the other extreme of medical practice, I once was called by a highway patrol officer who witnessed a high-speed car crash. He asked for the helicopter rescue of a driver who was trapped, unconscious, behind the steering wheel. We arrived by Life Flight helicopter within minutes, and I climbed in through the broken rear windshield. Then, as the jaws of life were deployed to pry apart the dashboard, I intubated her (passing a tube through the nose to secure the airway) before quickly transporting her from the helicopter directly into the operating room at the hospital. It turned out she had an azygos vein rupture, a condition that is usually fatal within the hour. She survived because we were able to get her to the trauma surgeons inside the OR at the hospital in less than 30 minutes from the time the accident occurred.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

My favorite is: “If you don’t know what your patient has after you finish taking the history, you haven’t finished taking the history.” This underscores the importance of doctors connecting with and understanding their patients as the foundation for figuring out what is really going on and helping them.

None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?

My training in medical school at McGill University (and at University College Hospital in London, England) inspired me to be a clinician in the traditional role of a healer — and for that, my inspiration was Dr Alan Hoffman, who was the source of the “life lesson quote” above. He modeled for me the kind of knowledgeable, competent, caring, and compassionate physician that I aspired to be.

Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different from working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?

The most important point to emphasize is that the essential physician–patient interaction is direct face-to-face communication that allows a doctor to connect with their patient, engage with them, and enable them to share in detail what is going on with their lives and their health. And that this critical face-to-face communication can occur equally well either in an in-person, in-office setting or via high-resolution video and audio consultation.

It’s worth noting that when doctors see and engage patients in face-to-face communication, they also are observing their patients, whether they are in the same room or communicating via remote video consultation. This is a physical examination that occurs by inspection, without touching the patient. It is highly revealing of many aspects of a patient’s condition — an experienced clinician often knows the most likely diagnosis for a patient’s problem based on observation even before hearing in their own words what their symptoms are. Key observations that help with this assessment include appearance, attire, affect, posture, gait, motor movements, eye movements, pupil size and reactions, facial symmetry, skin color or rash, voice tone and tenor, speech quality, and more.

Can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?

The good news is that the vast majority of patients who need outpatient primary care services can be served as well or better by virtual consultation than they can be via in-office care. This is demonstrated by the fact that most office-based primary care doctors do not routinely do physical exams unless there is a specific concern or medical reason to do so. Even when they do perform a physical examination, it is often cursory, because it is expected rather than needed. Many people do not at first realize it’s possible to choose and meet a doctor, get to know them, and then turn to them for advice and guidance when new medical issues arise. The virtual care doctor should anticipate and understand these prior notions that people have, and address them directly during their visit, reassuring their new patients that they really can expect their virtual primary care doctor to be there for them in future.

The main challenge for virtual care is how to manage patients who need more than is possible to do via virtual consultation.

Just as there is a scope of practice for any setting in which a doctor provides care, there is a defined scope of practice for giving virtual care. For example, when a patient arrives at a doctor’s outpatient office with shortness of breath and substernal chest pain, that is beyond the scope of practice for an office visit, and the doctor will call for an ambulance to transport the patient to the emergency department. They may also provide guidance to the patient immediately, by offering an aspirin or starting an IV.

A less extreme example is a patient with moderate to severe abdominal pain, when a physical examination of the abdomen is an important component of the evaluation. When such a patient presents for a virtual consultation, the virtual care doctor will assess the need for hospital-based evaluation (for example, if the doctor recognizes that even after an in-office physical examination, a CT scan of the abdomen will be needed) and arrange with the patient for transportation to the hospital for further evaluation. If hospital-based care is not likely to be needed, but the diagnosis and treatment requires a physical examination, then they may refer the patient for a visit with an office-based primary care physician. The virtual care doctor may also order initial laboratory testing to be performed so that the office-based doctor will have important test results to guide the evaluation at the office visit.

Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You ?

Doctors who undertake to give care via remote consultation, using digital technology, should take the time to understand the strengths and limitations of digital remote care. HealthTap was a leader in educating doctors about this new modality of care, creating a free educational and certification program for doctors interested in virtual care, in 2016! This course is now several years old, but still offers valuable insights for doctors: virtual_care_course. Other valuable and current resources for doctors are AMA’s Return on Health: Telehealth framework for practices, and the AMA’s Telehealth Implementation Playbook

Here are 5 things that doctors who give virtual consultations should do:

1. Begin each consultation from an appropriate, professional location with good lighting, and wearing appropriate professional attire. Introduce yourself to your patient, greet them warmly and reassure them that their visit with you is both private and confidential.
2. Most important: Remain silent for at least 30 seconds, while maintaining direct eye contact with your patient. Allow them to answer you in their own words, without any interruption.
3. When you do need to look away from your patient (for example, to review their chart), explain what you are doing so your patient knows you remain focused on them.
4. After you carefully explain your assessment and recommendations to your patient, ask them to repeat back to you what they understood.
5. At the end of the consultation, after asking if there is anything else they would like, thank them for the opportunity to take care of them. It’s remarkable how much your patients will appreciate that sentiment.

Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?

Here are some of the benefits of virtual primary care:

1. Increased accessibility: Virtual care allows patients to access health care services from anywhere, as long as they have a device and an internet connection. This can be especially beneficial for patients who live in remote or underserved areas, or for those who have mobility issues that make it difficult for them to travel to a doctor’s office.

2. Convenience: Virtual care visits can be scheduled at a time that is convenient for the patient, and they can be completed from the comfort of the patient’s own home.

3. Cost-effectiveness: Virtual care visits can often be more cost effective than in-office visits, as they may require fewer resources and may result in fewer unnecessary tests or procedures.

4. Preventive health. Virtual primary care doctors offer effective and convenient wellness and preventive care services. They evaluate and document a wide array of health risks, and provide screening tests for high cholesterol, high blood pressure, diabetes, thyroid function, and STIs. They also can perform screening tests for cognitive impairment. Based on the USPSTF recommendations, they do preventive screening tests for colorectal cancer, and order mammograms and other procedures that require referral to a specialist, such as annual retinal examinations for patients with diabetes.

Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?

The main tool to enable high-quality and effective virtual visits is a high-quality video and audio connection with a high-bandwidth internet connection. To overcome the inability to take vital signs remotely, a few devices that are easily accessible and used at home can also be helpful.

For example, a home digital blood pressure cuff enables patients to take their own blood pressure readings at home before or during the consultation to share with their doctor. An oral thermometer is needed to document if fever accompanies acute illnesses. The weight scale provides important information, especially when following conditions that can cause fluid retention, such as congestive heart failure. Patients with asthma can use a home spirometer or peak expiratory flow (PEFR) meter to track their wheezing and airflow restrictions. And of course, patients with diabetes should have a fingerstick meter and report on their home blood glucose measurements

Other tools such as home otoscopes and stethoscopes or portable ultrasound devices may eventually have a role, but have yet to prove their effectiveness.

If you could design the perfect Telehealth feature or system to help your patients, what would it be?

I’d be crazy if I didn’t mention HealthTap here! I truly believe our team at HealthTap has cracked the code in creating an ideal telehealth system where our members feel seen, heard and cared for at every juncture of their lives. One of the great features of the HealthTap platform is that it is modular and scalable, so it is straightforward to integrate it into the workflow of just about any other healthcare system or EHR.

Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?

Patients often are under the impression that a doctor must perform an in-person physical examination to evaluate them. The most important — and often the only — information to support a doctor’s diagnosis is a thorough patient history, including all the relevant past medical history, social history, risk factors, details and the presenting complaint(s). In fact, for routine in-office visits, doctors do not usually perform a physical examination. When doctors do examine the patient, it often is little more than the “laying on of hands.” It’s done to connect with the patient and establish a rapport — and because it is expected. In routine practice, and when there is no suspicion of a specific problem, the percussion, palpation, and auscultation elements of the physical examination are rarely done in a thorough manner, and almost never provide information that has any impact on the care delivered.

Another common misconception is that doctors have to meet a patient in person and perform a physical examination in order to develop a trusted, caring relationship. It is counterintuitive, but it turns out that when a doctor’s only contact with their patient is via video, the doctor actually pays increased attention to their patient, hyper-focusing on details of their patient’s appearance and attire, mannerisms, affect, mood, voice, verbal tone, intonation, facial and eye movements, skin color and complexion, posture, and motor movements.

Technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?

Virtual and augmented reality tools are fascinating and may eventually find a place in certain types of routine medical care. For example, group therapy can be a very effective mechanism for counseling to help manage a variety of psychological and psychiatric conditions, and can be achieved effectively via virtual reality without requiring everyone to be in the same location. Treatments with operant conditioning may also benefit from virtual reality implementations. For common interactions between doctors and family members, it would be very helpful to have shared discussions in a virtual meeting room, rather than only as images on a video screen.

The most recent excitement has been around the newly available ChatGPT service offered by openai.com. This AI-based service is a language model called a “Generative Pre-training Transformer” that creates highly readable and understandable narratives that answer informational questions. ChatGPT can create well-written descriptions of answers to common questions that people have. For example, ChatGPT answers the question “What is the meaning of a high cholesterol level?” with three clear and concise paragraphs that convey in lay terms the medical meaning and significance of this abnormal lab finding.

This is not to say ChatGPT and other more medically-adept language models can replace doctors. They currently are poorly able to distinguish areas where their knowledge is incomplete, and can provide answers that are either missing important elements, or answers that are simply wrong. They cannot reason with uncertainty or deduce answers that require chained logical conclusions. However, there is incredible usefulness of these models in the hands of experts. As long as the expert actually knows the answer to a given question or problem, the generative language model can provide a remarkably helpful draft or proposed answer that can dramatically reduce the effort required to create thorough, accurate, and understandable answers for patient problems.

Is there a part of this future vision that concerns you? Can you explain?

It is critical that people understand the limitations of AI and not rely on it without guidance or supervision. It is all too natural for people to come to rely on and have faith in AI-based solutions, especially when they have an authoritative tone and are confident of their answers, even when they are sometimes wrong. AI-based solutions should be deployed in a supporting role, and be incorporated into workflows that include expert supervision and guidance.

Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)

The movement I would like to inspire — and the mission that HealthTap is on — is to get everyone to have a primary care doctor that they know and trust. We need to inspire people with the knowledge that having a doctor who knows you is essential for health and well-being. Having a doctor who knows you enables you to turn to a trusted expert who can guide you away from misinformation, calm your concerns about health issues, and direct you to needed care and away from unnecessary or excessive care.

Currently, primary care doctors are pressured to see more people more quickly, so they often do not have enough time to spend with their patients to get to know them, understand the totality of their health concerns, and identify the right diagnosis.

How can our readers further follow your work online?

You can follow my work by checking out my posts on the?HealthTap Blog. I also often write articles for KevinMD. You can read my most recent article, Myths and Misconceptions about Virtual Primary Health Care,?here!

Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.