Course prepares health care professionals for telehealth’s evolution

It’s telehealth, or telemed, and while it’s been around a number of years, it mostly was available through companies like Teladoc Health and Doctor on Demand. Such companies offer an affordable and convenient way to obtain a diagnosis and a prescription for conditions — such as sinus infections — that don’t require hands-on exams.

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The pandemic has broadened telehealth’s appeal and reach. Patients and private practice health care providers alike have embraced it as an alternative to a crowded waiting room or urgent care setting where the risks of COVID exposure still linger. It served to keep doctors and patients safe and preserve personal protective equipment. And, insurance companies and Medicare began covering the cost of the visits.

Consequently, many health care professionals wished to climb on board, but lacked training regarding telehealth’s policies, practices and protocols, according to Lisa Rebeschi, associate dean of the School of Nursing. Preparing software to enable doctor-patient video calls was just the first step.

The School of Nursing promptly stepped into the vacuum to educate them in real time.

“At the start of the pandemic, our leadership team quickly identified the need to address the gaps in knowledge, skill and attitudes regarding telehealth technologies. We developed a course called Navigating Telehealth to address those competencies,” Rebeschi said. The 3-credit course, offered for the first time in the summer and again during Fall 2020, was geared not only to Quinnipiac’s nurse practitioner and doctor of nursing practice students, but also to licensed doctors, physician assistants, nurse practitioners and social workers who needed to become familiar with telehealth guidelines and standards.

Issues surrounding licensure, credentialing, reimbursement and legal/regulatory requirements were explored. Rebeschi said more programs are being considered in response to continuing educational needs related to telehealth.

Rebeschi created the course with colleague Laima Karosas, clinical professor of nursing, chair of graduate nursing and director of QU’s online nursing programs. Karosas, a nurse practitioner, also works one day a week for online telehealth provider Lemonaid Health. Neither Rebeschi nor Karosas were aware of any other university offering a course like it. While the first two course offerings were for academic credit, plans are in motion to offer it as a certificate or badge to working professionals seeking to upscale their skills.

The American Medical Association estimates that, since the start of the pandemic, 60–90% of physicians are using some sort of telehealth services to stay engaged with patients, and about half of them are using the approach for the first time. Quinnipiac’s course did provide pointers about how to conduct successful video visits, but Karosas said the people who took the course felt competent in that area. Most of them would be conducting telehealth visits with patients whom they’d seen before, perhaps going over lab results, doing surgical follow-ups and other non-emergent primary care. Others in the course were contemplating starting their own telehealth businesses or applying to one of the established online providers.

“You do need to know how to translate your skills from seeing and touching a patient to an online encounter when the person is not there,” Karosas said. “If someone calls with a UTI, I know the symptoms to ask for and what kind of prompts I can give to get the answers I need to treat them, but then I need to know how to translate that into a note and how to follow up for medication. A whole system has to be in place.”

She emphasized that offering telehealth services is so much more than just talking to a patient. “The people who took the course wanted to learn skills such as how to document a visit and how to bill insurance companies, and there is a learning curve on the rules and regulations that govern telehealth,” she added.

“If you can’t bill, you’re not making money, and you can’t keep the lights on,” Karosas noted.

Some frequent questions that come up in class include: Can I bill for something I have not seen someone in the office for? And can I bill for an email exchange with a patient? There are also patient privacy regulations and liability issues to take into account.

Telehealth Online

Karosas practices with Lemonaid Health on a part-time basis. It’s a convenient way for her to maintain her nurse practitioner certification and license to work with nurse practitioner students. She is licensed to treat patients in 14 states. Lemonaid’s fees are much lower than paying out of pocket to see a provider — a fact that is true of most telehealth companies. People fill out a questionnaire, detail their health history, and can be chatting with a health care professional within an hour or so, either via video, text or phone call. Visits also can be scheduled for a particular time or date.

If medication is indicated, Lemonaid can fill a prescription through its own pharmacy or send it to the patient’s pharmacy. Karosas mentioned that patients often find their medications are less expensive through Lemonaid. The types of non-urgent visits that Lemonaid commonly handles include erectile dysfunction, birth control, anxiety, depression, hair loss, asthma, urinary tract infections, acne, migraine, flu, sinus infections, acid reflux and STD testing. Its name correlates with the company’s mission: to make health care “refreshingly simple.”

For some complaints, such as sinusitis, a video visit is mandated. “I want to see what the patient looks like — are her eyes puffy, does it hurt when she looks down, and is she in distress?” said Karosas. She described a typical telehealth scenario: “It’s 7 o’clock on a Friday night, your physician’s office is closed, and you are sure you have a UTI. Who do you turn to?” She said telehealth providers can diagnose it that night and order meds, and the patient can start her recovery that night instead of being uncomfortable all weekend.

“We can prescribe and diagnose using practice guidelines and treat it without a urine culture. If the patient is not feeling better in three days, we’d recommend the patient see a provider in person,” Karosas added.

The pandemic has been a boon to companies like Lemonaid Health. But will consumers continue to embrace telehealth post-pandemic or opt to return to their doctors for hands-on care? Alex Gerity Pandajis ’11, DNP ’15, believes telehealth visits are just as productive, if not more so, than traditional visits. She serves as one of three instructors for the telehealth course and has been with Lemonaid Health for more than 18 months.

The reviews on the Lemonaid website indicate patients are satisfied with the service they received, and the level of attention. Pandajis thinks the stigma of online care is gradually fading as people try it and become comfortable with it. “We are trying to change the notion of losing that face-to-face connection. I talk to my patients without distraction, with no alerts going off, and nobody knocking on my door. I’m giving them all of my attention and patients don’t feel rushed,” she said.

Pandajis had been a nurse practitioner at an outpatient clinic in Charlotte, North Carolina. As she was contemplating a job change, she met someone who told her that telehealth would allow her to do primary care online and combine her tech and nursing skills to reach many more people than she could at a clinic. They referred her to Lemonaid. “I looked at their website and was immediately impressed with the company. It was my dream job that I never knew existed!” she said.

Pandajis “sees” patients from her home office in North Carolina, where she lives with her husband, Bryan, an ICU nurse at Atrium Health’s Carolinas Medical Center. Sometimes, the stories he tells make her miss the hands-on aspects of nursing. But the benefits — keeping people safe at home, cost effectiveness and being able to serve people in rural areas across the nation— outweigh any downside, she said. There’s that, and the fact that during her first year on the job, Pandajis treated more than 17,000 patients. Sometimes, she sees them more than once.

At Quinnipiac, Pandajis was the first nursing student to go straight from a bachelor’s degree in nursing to a doctor of nursing practice. As she transitioned to the world of telemedicine, she employed the same work ethic. On her own, she applied for nursing licenses in all 50 states, a process that can take years for many. That required close to 120 applications, fingerprinting, background checks, up-to-date educational credits to meet varying state requirements, and obtaining college transcripts — and that’s when she caught up with Karosas and told her about the company. Pandajis completed the licensure process in only two months. Now it was Lemonaid’s turn to be impressed!

She explained that many of the people who use online health care providers have lost their insurance along with their job, or must wait too long for an appointment with backlogged primary care physicians. Others have moved and have yet to find a new doctor and just need a prescription refill.

One of the services most in demand via telehealth is mental health, owing to the increase in people experiencing anxiety and stress from the pandemic. Pandajis is well versed in mental health; she did a fellowship year at the West Haven, Connecticut, VA Medical Center, obtaining a considerable amount of experience with patients suffering from anxiety and depression.

Obviously, complaints about chest and/or abdominal pain, bleeding during pregnancy and other potentially serious conditions necessitate an in-person visit to a health provider. And there is a chance, Pandajis noted, that a patient might not disclose all the prescriptions they are taking to online providers as requested, which could result in dangerous drug-to-drug interactions. Fortunately, with up-to-date software, some online telehealth providers are able to access a patient’s prescription history, which allows more safe and secure prescribing.

Webside Manner

Creating a professional environment is among the telehealth do’s that students in the Frank H. Netter MD School of Medicine have learned this fall. The realistic exam rooms in the Standardized Patient and Assessment Center within the Center for Medicine, Nursing and Health Sciences went dark after Quinnipiac switched to online classes last spring, and the schools had to create safe alternatives to teaching clinical skills. Unlike some medical schools, students at the Netter School begin patient interaction early in their first year, so the telehealth pivot not only allowed them to continue their education, but it introduced telehealth into the curriculum.

“Interaction during a telemedicine interview requires a different skill set than what we teach in person in the S-PAC,” said Dr. Listy Thomas, director of the Clinical Arts and Sciences course and assistant dean of simulation at the School of Medicine. “Our students, preceptors, staff and standardized patients have all had to work collaboratively to teach and learn clinical skills in a new way, especially during the pandemic.”

Recognizing that formalized training in telemedicine is not widely offered to physicians-in-training, the American Medical Association adopted a policy in 2016 aimed at ensuring that medical students and residents learn how to use telemedicine in clinical practice. A unit on telehealth had been contemplated at Quinnipiac Netter before COVID-19, but the pandemic pushed it to the fore. Thomas believes that current and future physicians alike will need to gain proficiency with telehealth.

Thomas is an emergency physician at St. Vincent’s Medical Center in Bridgeport, Connecticut, one of the medical school’s principal partners. She also picks up shifts occasionally for a telehealth company. “Even at home, I have my white coat and stethoscope on so the person on the other end knows they are speaking to a physician, in a safe space. The background should be appropriate, and we tell students to adjust the webcam so they are looking into a patient’s eyes, not down at the patient’s image on the screen,” she said. Observing nonverbal visual cues also is important, and it’s considerate to refrain from typing unless you tell the patient you are documenting the conversation or looking something up, she said.

To that, Pandajis would add that a well-lit quiet room, good audio and reliable Wi-Fi are essential. She has several monitors at her desk so she can check electronic records during a call. Lemonaid Health banners are behind her.

“We also tell the patient that we cannot do all the things we normally could together, and we set clear expectations about what is possible in a telehealth encounter,” Thomas said.

Medical students learn the importance of a physical exam in making a diagnosis. “It’s an opportunity they miss when doing telehealth,” Thomas said. However, there are a few ways to get around that. For example, if a patient complains of throat pain, a doctor or nurse can have them open their mouth wide and shine a flashlight at their throat or use the flashlight app on their smartphone. The patient also can be asked to palpate or press on an area of the body that is painful so the doctor can get an idea of their symptoms.

In the emergency department, Thomas appreciates the opportunity to share CT scan or MRI results with a radiologist in another part of the nation or world who can evaluate the images and give her a report in the middle of the night when local radiologists are getting some rest. Using teleconsultation services, she can call on specialists in the off hours, such as neurologists, who can help manage patients who may be presenting with conditions such as acute strokes.
The future is bright for patients as well. Thomas notes technological advances in Fitbit-like devices can enable health data, like vital signs and blood sugar readings, to be imported directly into electronic patient records.

Acting the Part

The hired “actors” who play the roles of patients in the SPAC have had to learn some new tricks to prepare for their telehealth roles and to evaluate medical students conducting an exam via a Zoom call, during which the students verbalize the things they would be doing in a hands-on physical.

Griffin Kulp, a standardized patient since 2017, has had no trouble adapting. Depending on the case—appendicitis for example —a medical student might ask him to press or palpate his abdomen while they observe. Standardized patients receive a script they memorize before each case so they can flesh out their character, he said. Sometimes they are asked to be affable, and other times, a bit on the combative side to give medical students a range of experiences. Kulp watches for such things as students’ nonverbal communication, whether they are rushing through the questions, or if physical exam maneuvers he is asked to perform are not easy to understand.

Kulp’s advice for real patients using telehealth is to be open and honest with their provider, and he hopes providers will practice patience with people not familiar with the medium and give them their undivided attention. “I think it always comes down to empathy and communication skills, and never more so than with telehealth,” he said. “Some are born with them, and others have to develop them.”

Dr. Marcus Welby’s fictional patients seemed to cherish the relationship they had with the kindly doctor played by the late Robert Young. Thomas acknowledges that the in-person doctor-patient relationship and encounter is paramount, but she said being together on a video call is still a valuable tool.

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