Danielle Hebert, DNP, ANP-BC, Director of Education

When I wrote my previous article on telehealth, I had no idea what type of response NPACE would receive in terms of your experiences with it over the past two months. But, WOW, we had a tremendous response and wanted to thank you for taking the time to share your experiences with us. Several of you were happy to share with our audience, which I share with you now. It is my hope that some of these experiences may resonate with you and perhaps give some comfort in knowing that others are experiencing the same feelings and that we are in this together as we learn more. Please stay tuned for future updates and information from NPACE regarding telehealth.

Nancy H. shared: “I have been doing Telephone visits with my primary care patients for the past 3 weeks, as well as half-time working at a dedicated COVID-19 TeleHealth center for calls related to COVID-19 health concerns. As an NP, our strong assessment skills can be used to obtain all the important components of our patient’s history and subjective information. Our nursing background in therapeutic communication is especially helpful in TeleHealth. My experience has been overwhelmingly positive. My primary care patients are very grateful that I am contacting them, that they can receive care without leaving the home, as they are keeping social distancing. It is reassuring to them that there is someone to call if questions or problems, and to ensure that they have timely refills also. I have ordered home blood pressure cuffs and pulse oximetry for patient use when indicated. Regarding the specific questions about COVID-19, it is essential to keep up-to-date on recommendations and resources on testing, home care, and other relevant information. We need to be factual and consistent with information that is relevant in your state and local area.”

Kathy B. shared: “I am one of the providers “thrust” into telehealth due to coronavirus. To say I was hesitant would be an understatement. Have I fully embraced it? Not at all. I have a limited type of patients I will see via telemedicine. These patients include mental health and medication checks for certain conditions such as ADD, pain management, and some chronic conditions. I have done a hypertension check but the patient regularly monitors her BP at home. I will not do diabetes, thyroid or any other visits that potentially require lab work. I fully expect telemedicine to become a normal part of our world in the future but I will stand my ground that most patients need a physical exam and need to be seen in the clinic. I am currently using Skype. My employer is trying to implement some type of video conferencing into our EMR. The future is uncertain that is for sure.”

Patti D. reports: “I own a small private practice treating those with diabetes. The Telehealth visits have been very important for my patients. It does not take the place of the regular 3 month diabetes visit, but I have found the electronic visits very helpful. The patients can upload CGM and pump data for my review and then we use Telehealth for the visit so we can review trends and make changes in the regimen. This was extremely important for those who had started CGM, insulin therapy or pumping prior to the “stay at home” order. At first I was using Skype, FaceTime and Google Duo. This was time consuming and confusing for scheduling.  Now I use Updox with my EMR and can have a Telehealth visit with any type of phone that has a camera or computer with camera and microphone.

I’ve been billing for these visits just since the 17th of March so haven’t received any remits yet. My billing company has been great getting the billing end up to speed. One other noteworthy use: one of my patients who lives about 2 hours away began with an infected tooth. Her PCP would not help and all the dentists are closed. Going to the walk-in was not an option as she lives in a high incidence CoVid area. I was able to do a Telehealth visit, taking a picture of the infected tooth and treated her accordingly. The picture is uploaded into my EMR. I’m only three weeks into this but will keep you posted if you’d like.  Not only has this been beneficial to my patients with diabetes, it has maintained some income for me to stay afloat until we are able to have face-face visits.”

Sandy H. shared: “Our practice is now 90% telemedicine. I see both assets and liabilities to this process. First, telemedicine is certainly better than no contact with these patients at all. Currently I am dealing with more anxiety and depression which is easy to deal with via telemedicine. My concern is my accelerated hypertension patients that aren’t able to assess their blood pressure. Will they have a CVA at home? My heart failure patients that are unable to weigh themselves, now we cannot auscultate for rales.”

Rita K. reports: “I am a nurse practitioner and work for the Department of Veterans Affairs. I have used Telehealth for 20 years. The VA has been using this service to provide care for over twenty years. We have published extremely positive patient, quality & financial outcomes. It is always good to see others in the private sector recognizing the benefits of using Telehealth.”

Jackie in Northern California shared: “I work in a hospital affiliated RHC clinic. There are 4 specialty docs, 5 MDs. I see everyone’s patients, same day and urgent care with a small panel of my own. Trying to get patients into video visits ,we have facilitated our EHR video component, FaceTime, Google Duo, Doximity and even drive up (where we provide the patient a tablet to have a video visit with their provider). Recently I had an appointment with an 80 yo recently widowed woman who I know well. She is homeschooling her 15 yo grand- daughter (her son died at 51 with 2 littles). The day of the visit we taught her how to use FaceTime. It was her grandson’s 22nd bday. I typically give her a “social assignment” and that day she was excited to FaceTime her grandson. She was thrilled to be able to surprise and celebrate him. Good medicine!”

Julie I. reports: “I work for the largest Health Care system in New York State, we are over 70k employees. I am an Adult Nurse Practitioner with a specialty in wound care. Our wound care center has 8-10k patient visits/yr. Our center is fully immersed in telehealth now, my boss is the director for wound care for the entire health system. She acted swiftly to ensure we were up and running to safely care for our patients who depend on us. We met with our homecare leaders to get them on board, the nurses downloaded the application, so if patients were unable to, this was our safety net. Our nurses in the field have been our lifeline, their contribution to manage these patients is key to successful outcomes. Our goal is to keep these patients out of the hospitals and keep their wounds from deteriorating. Presently we still see some patients in office who need debridement, or a change in their wound status. Currently we have 2 physicians, and myself doing the telehealth visits, in addition our podiatry staff is seeing some of their patients in this forum.

I never thought I would be doing this, and it seemed strange at first. It took me a day to get used to it, we have one screen to visit with our patients and the other is with their open chart and notes, we ask the patient to send a still photo to upload into their EMR, that also serves as a way to closer look at their wounds in case the virtual visit is “shaky” from whomever is holding the device. I am able to order supplies, order medications, change the treatment plan in accordance to what I am seeing and what the patient, nurse, or family member is reporting. I try to accommodate the nurses and set up telehealth visits when they will be with the patient, it is a homerun to have the nurse present at the visit to give measurements and their observations. Some patients do their own wound care or have family or private hires do the wound care, they are rising to the occasion and doing a great job!

When I am speaking to and teaching the family or patient, I keep some teaching props close by in addition to products to enhance their understanding of how to dress wounds and what the products are. We have some patients that are new to our practice and have never been in our office, due to wanting to keep these fragile patients safe, we have been doing telehealth since day one! We think that some of what we are currently doing to manage patients may result in telehealth visits as an adjunct to our current practice, when the dust settles, it may be especially helpful for patients who have difficulty coming to our office. I think the patients are reassured when they see our familiar faces and they are “not alone” during this time of uncertainty, and it makes us as providers feel good that we can be there for them, treat them and keep them safe.”