The video consultation format discussed here would be that of the doctor being at one end and the patient being at home or an appropriate location of their choosing, as opposed to the patients going to a dedicated institution or clinic to have the video based visit. It is important to know the difference for both technical and billing purposes.
What is Telehealth, Telemedicine and Virtual Care and are there differences?We often find that telehealth, telemedicine and virtual are used interchangeably. However, there are differences between these terms. Telehealth is a broad term that refers to electronic and telecommunication tools and services that are used to provide care and services at a distance. Telemedicine is basically practicing medicine at a distance using these technologies. In other words, providing real time clinical care when the healthcare provider is in one location and the patient is in another. The difference between telehealth and telemedicine is that the former is a broad term that can also encompass remote healthcare that is not clinical/physician-led. For example when a doctor has a video consultation with a patient, that is telemedicine. When a pharmacist connects with the same patient to provide remote counselling about a medication, that is considered to to be telehealth. Telemedicine is considered to be a subset of telehealth. Reference: AAFP (2020).
Another term that is used quite often is “virtual care”, this again a broad term, defined as follows: “any interaction between patients and/or members of their circle of care, occurring remotely, using any forms of communication or information technologies, with the aim of facilitating or maximizing the quality and effectiveness of patient care.” Reference: WIHV (PDF)
Do I have to be “tech savvy” in order for me to do video consultations?Not in the classical sense, but you should be able to know some basic technical aspects like navigating the software you would use. Knowing how to configure your mic and video camera settings would be also very useful for troubleshooting. You should also know how to direct the camera to ensure adequate clarity and lightning. These skills are not difficult to learn and with practice you should get better. They are also increasingly essential skills to have in this day and age. The same would ultimately apply to patients as well, thus there will be an initial learning curve, but things will get easier. Furthermore, many software developers have greatly improved their applications to make them easier to set up and configure, and this trend will likely continue making such platforms even more easier to use.
I want to begin providing care via video, what do I need to get started?To start, we have to remember the same rule of privacy and professionalism will apply when using video for your clinical care needs. The various considerations related to video consultations will be summarized as follows: Technical and environmental considerations:Technology is rapidly improving, but as a general rule, it should be accessible, reliable, secure and also compatible with what patients are using. As a first step, you would need a mechanism to confirm that the patient has the tools. Patients and care providers would need to have a working device (laptop or smartphone/tablet) and a viable internet connection. As an example, having poor internet connection is a barrier, as the quality of video may not be sufficient. Also, not knowing how to navigate the software or how to adapt the camera or mic to your needs can waste time, and sometimes compromise privacy. Here are some tips to help optimize the interaction: Location:- A safe, quiet, private place would be required and for both parties. The privacy aspects will be discussed in the privacy section. Some tips:
As some people will be working from home, to ensure that you have a private quiet place where you will not be disturbed and for your security, not to have any identifying features for your home or family members. One tip is to close the door, and to put a “do not disturb - virtual clinic in session” sign at the door.
The background should not be “noisy” and some people put a plain and adequate colored screen behind them to improve clarity and to hide office or room objects.
Make sure that you have nothing in the background that could compromise patient or research related privacy. Having files or certain labels or a screen behind you with an open EMR can potentially compromise data.
If possible, ask the patient to sit somewhere where there is room behind/near them, at least 6 feet. This will allow you to ask them to stand up and to move back so you can see other parts of their body or to assess their gait etc.
Having a nearby coach (or equivalent) may also be helpful for a virtual physical examination (see below in the physical exam section), if you want them to lie down and do knee and hip range of motion.
Professionalism and appearance:Some people will do some of their clinics from home, and while it is tempting to be more laid back, it’s important to note that we have to always be careful with regards to our appearance. Wearing PJ’s may be relaxing at home, but it is not recommended!
Please follow the same dress code as you would at the office, but if you prefer you can take your shoes off!
Bright and reflective clothing on both sides is to be avoided as this could worsen the quality of the picture.
If you anticipate that you will need to view the knees or feet etc, you make as patients to wear appropriate attire to allow for the viewing of these areas (i.e. socks off, or have loose pants or adequate shorts etc)
Technical equipment:This could be a potential barrier, but both parties would need:
Adequate device with a webcam and mic:
PC/Laptop: Usually Windows, Mac and Linux driven laptops should be fine. Laptops bought within the last 10 years should have a built in webcam and mic. Desktops would require a seperate webcam and mic set-up. Thankfully, most patients have a laptop, so the camera/mic issue should be sorted. For yourself, if you use an EMR, having a dual monitor setup makes life much easier. You can have the video conference app up on one screen and your EMR on the other, to allow you to type and check things, whilst still seeing your patient, rather than flipping between two different windows.
Cellphones/Tablets: These can be either iphone or android based and a seperate app would have to be installed. These are discussed below.
Internet connection: Both parties should have the following minimum speeds: download 5 Mbps; upload 0.77-1 Mbps). You can check your or their internet speed by asking them to go to Fast.com
Technical/visual aspects:1- Lighting: -Make sure that for both you and for your patient that there is adequate lighting. This is important as you would want to see the patient clearly both to establish identity, rapport and potentially for your virtual physical examination. As a rule of thumb, you should be able to see your patients face clearly -You can ask patients to place their laptop or device on a table and preferably to sit opposite a window or in a well lit area. The camera itself should not face a window or a light source as this would obscure the picture. So for example, there should not be an open window behind a patient as they talk to you. 2- Some other tips to improve visual quality:
Patients should have their face and upper body visible and should move their device appropriately to get the best frame. You should be able to see their eyes and make eye contact.
Ask the patient to place their device on a hard surface (e.g. a table), as some patients would hold it and it can be distracting due to the constantly moving video.
As mentioned above, if possible, it’s preferable that patients have some room behind them to allow them to step back so you can view other aspects of their body for the virtual physical examination. Also ask them to have another chair nearby. This extra chair can be used to place their device on, so as to allow the camera to be at a lower level so you can see their knees and lower limb, and the other so they can sit on it if needed to do various aspects of a knee exam for example.
Technical Audio Aspects:Most modern devices have built in mics today, but external mics are still used and having some familiarity with the settings would be very important. Some tips:
- Audio checks can be tedious to set up, but software is getting better. You should ensure that your mic is working before you start the session.
- The conversation should occur in a quiet place. TV’s, radio’s, music etc should be switched off.
- If you have an external mic, make sure not that it remains at a fixed and adequate distance.
- For the party that is not speaking, it may be wise to mute the mic while they hear the other participant.
Speak clearly and do not shout. If you are needing to shout, please see the next point. There can be some delay, so you may need to wait a few seconds for the reply before speaking.
- Using the phone: Ask the patient to keep their phone nearby for back up, just in case you need to use it if the video connection is disrupted. If you are finding yourself shouting to be heard. and the other party the same, one really good alternative is to keep the video going, ask the patient to mute their mic/speakers and do the same as well and call them by phone. You can use the phone for voice whilst the video keeps running. This often works nicely as the phone would pick up more voice nuances and it will allow for better conversation flow, whilst still having the advantage of a video connection.
What are the Patient Privacy aspects of telemedicine?Protection of patient privacy is essential in all aspects of healthcare, including in telemedicine. The following are some of the measures that you can take to help ensure privacy, but please these are not exhaustive, please review some of the provided links for further information. Informed patient consent should be obtained, as will be discussed, and this outlines the importance of security and privacy and the potential risks of virtual visits. With regards to the software security related requirements, please see the dedicated section. Some of the privacy considerations in video consultations:
You have to be in a quiet private place where other people can not hear the conversation or see or record the video feed from the patient (if needed, do not disturb sign outside your door).
If you are working from home, protect your own privacy and that of your family as well.
If you want to share your screen to show an x-ray or blood result or to explain something, make sure that all other patient related information is closed and make sure that your EPR/EMR screens are also hidden.
Medical record privacy: Make sure that you take adequate steps to ensure privacy of any exchanged information, esp. related to medical records, forms etc.
Do not record the session without specific guidance and explicit consent. If any pictures are taken during the session, you should ensure that there is consent for this from the patient and that it is stored in a safe encrypted place as per PIPEDA and your institutional regulations.
Your webcam: It is better that you have the ability to cover it physically during and in between interactions, in case you inadvertently forgot to switch it off. If your camera does not have a dedicated camera, one useful tip is to use a standard 3M sticky post it sheet to cover the webcam, as this can peel off easily without damaging or scratching the camera.
If you are using applications like skype etc, make sure not to use the text or documentation transfer feature as this is not safe and not encrypted. Please note that many institutions do not allow applications like Skype or WhatsApp, and FaceTime, so check with them before proceeding to use these applications.
What are the software considerations for video consultations?There are many options to consider and more are becoming available. The main thing to consider:
Security and privacy features: Rule of thumb: the software should be PIPEDA/ HIPAA compliant.
Accessibility and ease of use: Patients should be able to access the software application and the software requirements should not require advanced or expensive equipment. It is better if it can work in all platforms, like Windows, Mac and via mobile applications. Many applications now have a browser version where no software is required to use, so all parties can access the software through a browser like Chrome or Firefox.
Cost: There are free and paid options available, with the non-free options providing extra options, including the ability to send documents etc.
Billing requirements: In Ontario, using the OTN platform has the advantage of allowing equivalent billing, without the need for using the more tedious phone code. So with OTN you can use the standard billing code and a separate tracking “B” code and for platforms like Doxy.me, you use the phone code equivalent. This is further explained in the billing section below.
What software can I use for my video consultations?Some software/platform options are dedicated telemedicine applications and some are not but have been adapted for this use..This is a rapidly changing landscape, it is important to keep updated on the available options via trusted sources. I would suggest that you keep checking the recommendations made by the OntarioMD and OMA pages for news about this area, which includes software and platform recommendations. Regardless, you should pick tools that use encrypted video conferencing and they should be PIPEDA/ HIPAA compliant. I will discuss 3 options (you can click on the pictures to visit the corresponding websites):
1- OTN (The Ontario Telemedicine Network):
This is a government agency and it runs a very large telehealth network in Ontario. You would have to register for this tool via your one-mail account. This is likely going to be the most used tool for all of us. Advantages of OTN:
Secure and government sponsored (PIPEDA/ HIPAA compliant.)
PC/Laptop: Browser based, and easy to use and you do not need to download or install any extra software for your computer.
If you have a phone or tablet, you can easily install an application called Pexip, which is easy to install and use. This website explains the process to patients.
From late April 2020, residents and fellows can now register for the service as well.
You can invite upto 18 people in addition to your patient.
Billing: With OTN: you can bill with standard codes as you would by seeing in person patients (see billing section below).
Disadvantages of OTN:
Lack of sharing tools: You can not share files and pictures via this tool. Any documents that you want to exchange with your patient would have to be sent via different methods.
Lack of annotation tools.
Video quality: Some have mentioned that the video quality is not that great.
For those who have never used OTN, I made a video tutorial to explain how to use this application, please see dedicated question. Further information can be found in their official OTN website: https://otn.ca/ 2- Doxy.me
For alternatives to OTN, especially if you can not access OTN or if your residents do not have an account, Doxy.me is a viable alternative. They have a free instance, which you can use for basic encrypted video calls, and it does the job nicely. It meets HIPAA, PIPEDA, and GDPR data privacy requirements. The paid version allows you to share documents and share screens etc. It is being recommended and used across Canada by clinicians and the OntarioMD website lists it as one of the recommended platforms. It is also web based/browser, thus no software download is required. Advantages of Doxy.me:
I had some feedback that the video quality maynot be as good as Zoom (I am not sure if this was the free or the paid version).
Cost: The better paid version costs 35 USD/month for individual accounts and $50USD/month for group accounts (May 2020 pricing).
Servers outside of Canada
3- Zoom for Healthcare
Please this is NOT the same as the free zoom video conference application. This is a paid for application that is PIPEDA/ HIPAA compliant. The free/regular zoom is NOT PIPEDA/ HIPAA compliant. Some hospitals have paid for this tool, so it can be free to use for some people. For example, the Sick Kids hospital has paid for this application and thus doctors can use this for free. For others, it can cost ~$200 per month. Advantages of Zoom for Healthcare:
Can inviate many people to the same session (as you can with OTN)
Can record sessions, however, be careful, this may not be allowed where you work.
Disadvantages of Zoom for Healthcare:
Cost: Can cost >$200 per month if you do not have an institutional account.
Servers outside of Canada
Despite the PIPEDA/ HIPAA compliance, the generic Zoom did have some security breaches.
Now I have some background, how can I conduct a video consultation?Please check this checklist that can provide a quick summary of what to do. Before any virtual consultation or visit, please make sure:
- Location: Make sure it is set up in the manner discussed above. It should be private and quiet and minimize risk of being disturbed.
- As with standard visits, have your patient records ready for you to review and use. Having an EMR, will have the advantage of obtaining your patient records outside of work. For those using paper records, this would mean being onsite.
- Patient phone number: You should have this ready to use in case you can not connect or you lose the connection.
- Patient email address: For many of the used portals, you would need the patient’s confirmed email address to invite them to the session.
- Test your “setup” before your clinic, to make sure everything is working well.
- For OTN, you can either “email invite” them just before the session, for this you would call them by phone, and guide them through it (process takes 3-4 minutes) and then await them to connect. Alternately, email invitations can be sent ahead of the clinic via your assistant. On the day of the clinic, when you log into OTN, you will have a list of patients ready for you. Every time a patient logs in via their invitation at the specified time, an indicator will show you that they are now online and you can connect.
- Other privacy related issues: Close all other patient/non-participant related information on your screen.
Starting the video consultation/visit:
- Start the virtual visit by calling or inviting the patient via the portal you are using.
- When the patient responds and connects to the call. Ensure that they can hear you correctly and that you have adequate visual and audio connection as per above section.
- If this is a new patient: Introduce yourself and then CONFIRM the identity of the patient. Ask them for their name, and date of birth. Some physicians even ask patients to show their health card to the camera.
- If you have invited a resident or student, also introduce them and ask your patient to consent to their presence or to take the initial history etc.
- Take consent from the patient: You can either take written consent from the them (prior to the visit, this can be emailed securely to be signed and emailed back as per your local email regulation) or ask the patient for verbal informed consent for the consultation.
There is a paragraph statement which was developed by the OMA (and vetted by the CMPA) or blurb you can use to initiate your session and then document in your chart, which is as follows:
“Just like online shopping or email, Virtual Care has some inherent privacy and security risks that your health information may be intercepted or unintentionally disclosed. We want to make sure you understand this before we proceed. In order to improve privacy and confidentiality, you should also take steps to participate in this virtual care encounter in a private setting and should not use an employer’s or someone else’s computer/device as they may be able to access your information” Use the following as well to document in your chart or EMR (also via the OMA): “Informed verbal consent was obtained from this patient to communicate and provide care using virtual and other telecommunications tools. I explained to the patient the risks related to unauthorized disclosure or interception of personal health information and steps they can take to help protect their information. We have discussed that care provided through video or audio communication cannot replace the need for physical examination or an in person visit for some disorders or urgent problems and the patient understands the need to seek urgent care in an Emergency Department as necessary.”
- Ensure that the patient is in a private place and document where the patient is at the moment you spoke to them (i.e. esp. Confirm that they are in Ontario!). Ask who is them for this session and document that. Sometimes they would have someone next to them but outside the field of camera. - Address any privacy concerns that may arise before proceeding.
- If all is fine, start the consultation.
During the consultation:-You can determine your workflow and efficiency as per your need and experience. Follow up visits should be easier to conduct. - You can use a virtual template that you can follow to help guide the visit if needed. This may be especially helpful for residents or learners. For learners, for standard follow ups, you can ask them to include the following in their assessment:
Subjective: What are the main issues today?
Any recent investigations?
Do you need any refills etc?
Virtual physical examination: Please see below. This is limited, but there are some things you can potentially do.
At the end, summarize the main things discussed in the meeting, which includes any investigation, treatment and follow up plans. Ensure that you have all the necessary details for faxing lab-work forms, prescriptions etc. I.e get their pharmacy fax number (this can be obtained via the pre visit form you send them).
If there are no more questions from the patient, ensure that you have logged out of the session and mute the mic and cover the camera.
After the consultation:
- Complete your documentation etc. Ensure any faxing of forms etc is arranged or tagged for follow up. - If there were technical issues, try to fix them or ask for assistance.
- If you are with a learner, you could choose to debrief online or via phone if time allows prior to the next patient.
How can I learn to use OTN?
For those who have never used OTN, I made a video tutorial to explain how to use this application:
This can be challenging, but there are a few things you get from the video call for your virtual rheumatology examination. Some of these things can be adapted as per need, esp. given the technical and time constraints. Even if the physical examination can not be done, the new virtual patient consult can serve to get to know the patient and start the therapeutic relationship. The physical examination can be deferred to the next in person clinical follow up. For follow up of established patients, the physical examination may not be as important, especially if you know the patient well. Rheumatologic cases that rely on history to the more difficult to do remotely, this is assuming that triaged cases are not acutely or seriously unwell, which of course will need hospital:
PMR, SpA, Gout (in cases that not ? septic joint) - diagnosis more reliant on story
Myositis and inflammatory arthritis - diagnosis reliant on story but also physical exam
A few tips:
Ensure that the patient has adequate lighting
It’s preferable that the patient has room to step back 6-8 feet from the camera to allow assessment of gait, and lower limb joint ROM
Having access to a couch, you can ask the patient to lie down and you can assess things like hip flexion, knee ROM etc
The laptop or device can be placed on a lower level, i.e. a chair to allow for a lower gaze at the knees etc.
An extra person with the patient can take the device and point the camera at the feet or other areas of the body (i.e. back etc).
The extra person (a patient relative) can also be asked to assist if appropriate, esp. To ensure safety of gait etc. You can also show them how to do a muscle strength testing, either by the shared screen or a video. This can be useful to follow myositis patients.
You can ask patients to send you pictures of skin lesions, etc.
Patients can be asked before the visit to have ready some basic home equipment that can aid in your examination, things like: a tape measure, a flashlight (most cell phones now have flashlights). You can also ask them to have some currency, like a coin or a paper note that you can use to collaborate any measurements for any pictures you may take of any lesions or limb/body height etc. Increasingly, patients will also have thermometers, BP machines, some have fitbits (for HR), and some even may even have O2 sat machines. Don’t forget the weight as well. Please keep in mind that these machines may not be collaborated.
Virtual MSK exam scheme: The following scheme can be used to discuss with your learners as well, some points are adapted from the literature online resources and personal practice (please check references): The easier joints to see are the more amenable for video exam (Hands, wrists, elbows and shoulders.): - Ask the patient:
Any new joints that are newly painful, swollen, red or different?
Is there anything you need to show me? Esp. Hands, wrists, elbows and shoulders. Knees and feet are more difficult.
Examine one joint at a time
Examine the Skin and nails. Ensure adequate lighting.
Self Palpation: Patients can self feel for tender and sometimes swollen joints (the latter if they are trained). To feel for Fibromyalgia points for example.
Hands: Make a fist slowly and see the hand joints ROM. See the MCPS at the front and check for swelling, compare both sides. Assess the Wrist joint ROM. Prayer sign. Tendonitis: Finkelstein's test can be shown via camera. Special nerve tests (see below) Elbows: Bend them and show them to me: check for swelling and nodules and stretch outwards to see the angle at extension and range of movement. Tests for Tennis and Golfer’s elbow can be shown. Shoulders: Range of movements, including checking for painful arc and you can do virtual empty can. A speed test can be done if there is a relative with a patient, they can be easily shown how to help. TMJ: Open your mouth, and assess for ROM and pain. Knees/feet: difficult, but if they have someone available, they can point the video camera towards the foot and ankle etc. Inspect and check ROM. Hips: As mentioned above, the patient can lie in a nearby coach, and you can ask them to place the device on a chair, and they can flex their hips etc. Back and neck: Ask them to step back and assess posture and ROM. Occiput to wall, and lateral flexion distance can also be done.
Can I do a virtual neurological exam? There are resources for this online. A modified cranial nerve exam can be done, including checking for pupil reflexes via the patients mobile phone flashlight. Observing patients for tremors or abnormal movements. For muscle strength, checking for proximal weakness through standing from sitting position with arms folded. One tip is to ask them to use an everyday item like a carton of milk (these tests can act as stimulus for a research study to validate these tools to correspond to a standard MRC scale).
For our Rheum purposes, one example of a neurological exam is I have been recently following a patient with eGPA who had eGPA and she had an MNM that affected the radial, ulnar and median nerves. I use this trick to assess these nerves, which the patients can follow and remember easily:
“ Can you slowly do Rock, paper and scissors with your left hand”:
Rock: Median nerve
Paper: Radial nerve
Scissors: Ulnar nerve. (they can do the scissor motion to assess movement)
For median nerve, the Phalen’s and Tinel’s test can also be done and checking for thenar muscle bulk. For the lower limbs: one example, stand on your heel and walk = L5 or peroneal nerve (if painful, tests for fasciitis/enthesitis!) Try to walk on the tips of your feet: S1 testing
What other tools can I use to assess my patients? I.e. Can I use Patient reported outcome measures?
Prior to the visit, you can send the patient some forms to complete, including a tailored intake form, and some patient outcome measures you are familiar with such as the BASDAI score, MDHAQ, RAPID 3 score etc.
Are there solutions to the problem of getting them complete such outcome measures? The challenge is how to securely send and receive back these forms. This would be discussed in a seperate post as there are few options, each with some pro’s and con’s.
One solution is to have online versions of such measures. As an example, I have developed an online web calculator that patients can use to get the MDHAQ, pain, global and RAPID 3 scores. You can send them the link to the calculator, they can quickly go to the website, complete the online calculation and report back to you the scores vs. reading each point to them which can take a long time and then taking time to calculate etc. While they are using the web calculator, you can use the time to document in the chart, or alternately the link can be sent prior to the clinic and you would have the scores ready for the virtual visit.
The link to the MDHAQ/RAPID 3 score web calculator*: https://www.rheumguide.ca/rapid3.html *Dr. Ted Pincus generously gave me formal permission to adapt this tool and thus I can now distribute it for our use.
NB: To make it easy for your patients to navigate to the required form, I tried to make the web address simple to read out as well:
- So for the MDHAQ and RAPID 3 page, you can tell the patient during the video call: “please visit rheumguide.ca “forward slash” rapid3 (one word), i.e “rheumguide.ca/rapid3”.
-For the BASADAI form, please visit “please visit rheumguide.ca “forward slash” basdai (spell out b-a-s-d-a-i), i.e “rheumguide.ca/basdai”.
How do I bill for my virtual visits?*As per current guidance, at the time of this report, please follow the following guidance to help you with appropriate billing:
If you used the OTN Platform: If you are registered for telemedicine and OTNhub and your video assessment of a patient is via OTNhub that’s when you are eligible to bill your regular codes plus the B tracking code. · i.e. A485 + B103A OR A485 + B203A oB103A $0.00 Hosted video visit oB203A $0.00 Direct-to-Patient video visit § Although the tracking codes are $0.00 they still must be attached to all OTN claims as the ministry keeps track of OTN assessments vs regular assessments If you used another Video Platforms (non-OTN) If you use any other video platform (e.g. Doxy.me etc) you are eligible to bill the K083 code in units; K083 is a telephone OR video assessment that’s not via telemedicine/OTNhub like the above. previously; see below: Based on the previous SOB fees (services up to Mar 31, 2020): 485 you will bill K083 x 31, will pay $155 483 you will bill K083 x 16, will pay $80 484 you will bill K083 x 12, will pay $60 481 you will bill K083 x 14, will pay $70 488 you will bill K083 x 8, will pay $40 Based on the updated SOB fees (services effective April 1, 2020): 485 you will bill K083 x 34, will pay $170 483 you will bill K083 x 16, will pay $80 484 you will bill K083 x 13, will pay $65 481 you will bill K083 x 15, will pay $75 488 you will bill K083 x 8, will pay $40 *Many thanks to Ms.Rita LoMagno who kindly provided to me the above billing guidance.