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Conducting a Primary or Acute Care HIV Telemedicine Visit

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Conducting a Primary or Acute Care HIV Telemedicine Visit

John Nelson, PhD, CPNP
A Collaborative Effort of the South Central AETC and the AETC NCRC

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Acknowledgement
These slides were developed as a collaborative project between the South Central AETC and the AETC National Coordinating Resource Center.
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Telehealth Definition
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“The use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration.”
(HRSA, 2020)

Telemedicine Definition
“Two-way, real time interactive communication between the patient, and the …practitioner at the distant site.
The use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.”
(CMS, 2020)

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Telehealth and HIV care
Telehealth helps to bridge that gap, in terms of both direct patient–provider contact and training local primary care providers to offer comprehensive HIV care thereby expanding the clinical HIV workforce.

To keep pace with advances in technology and improve care delivery to hard-to-reach clients, the Health Resources and Services Administration’s Ryan White HIV/AIDS Program (RWHAP) supports programs that supplement traditional HIV care with telehealth.
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Laura W. Cheever, M.D., Sc.M. Associate Administrator for the HIV/AIDS Bureau, HRSA
CAREAction Newsletter October 2019
Telehealth: a tool to provide quality patient care and, ultimately, to help end the HIV epidemic.

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Impact of Telehealth
Increased to quality health care while reducing demand on resources (time and cost)
Direct telehealth has been shown to result in similar positive health outcomes as “in-person” care
Similar clinical outcomes including treatment adherence, quality-of-life, psychological and emotional status for people with HIV taking antiretroviral therapy (ART) compared to “in-person” care

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HRSA. 2019. Telehealth Programs. www.hrsa.gov/rural-health/telehealth/index.html.
Young J, et al. 2019. IDSA Position Statement on Telehealth and Telemedicine as Applied to the Practice of Infectious Diseases.
Clin Infect Dis 68(9)1437–43.
Rural Health Information Hub. 2019. Telehealth and Use of Technology to Improve Access to Care for PLHIV/AIDS.
www.ruralhealthinfo.org/toolkits/hiv-aids/2/improve/technology.
Dandachi D, et al. 2019. Integration of Telehealth Services in the Healthcare System: With Emphasis on the Experience of Patients Living with HIV. J Investig Med 67(5):815–20.

Know the Telemedicine Policy/Law in your State/Territory
Keep in mind
What is “legal” and what is “reimbursed” are not always the same
What is allowed by state law may not equate to specific professional licensure regulations

Specific issues to note
Can a provider establish care (initial visit) via telemedicine?
Restrictions about where patient and provider are physically located during visit?
Can telemedicine be provided via telephonic (audio only) or requires both audio and video communication?
Restrictions when a provider requires “supervision” by another provider?
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Policy/Law Resources
The National Consortium of Telehealth Resource Centers

State or District Department of Health

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General Principles of Telemedicine
Should not be used for any condition where an in-person exam is required like severe symptoms, certain protocol-driven procedures, or involved interventions

Ensure the patients understand how the technology works

Inform patients of any service limitations and what steps should be taken to get additional care

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General Principles of Telemedicine
Get informed consent specifically for telemedicine visits from the patient before providing telemedicine care

Assure to document the use of telemedicine regarding examination and specific type (video and/or telephonic)

Make sure both patient and provider can attend to the visit without being disrupted by others, there is good lighting, and both have a functional equipment as required for the visit

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Before the First Visit
Explain in simple, clear language to patients how telemedicine at your center works
Explain any limits on confidentiality
Designate a plan if there are telecommunication disruptions
“If we get disconnected will call you back. Wait for my call.”
“We have this “room” until 1 pm. If we get disconnected, please log back in as soon as possible. If you can’t, I will give you a call later today.”
“If you do not hear back from me in 15 minutes, please try and call this number _________.”

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Explain in simple, clear language to patients how telemedicine at your center works (when service is available, scheduling, privacy, etc.)
Explain any limits on confidentiality (i.e., minimize risk by doing the visit when patient is alone if possible)

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Before the First Visit (2)
Explain protocols for contact between virtual visits, prescribing policies, and coordinating care with other health professionals
Establish a plan for emergencies and communicate it to the patient before the visit:
Make sure to have all information on hand for referrals
Try and have camera at the providers eye level to avoid altered perspective
Be aware what is in the view of your camera and adjust as required
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Establish a plan for emergencies and communicate it to the patient before the visit:
“If you are experiencing a medical emergency please go to the ER or call 911”
Be aware what is in the view of your camera and adjust as required (e.g., other charts, personal pictures)

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Conducting a Clinical Exam via Telemedicine
Subjective and objective findings are both valuable
Expand your subjective data collection as required
Objective measure: Document what you see and are confident that you are observing

Skin and mucus membranes may be seen via video

Patients can perform specific actions and report tenderness, pain, hardness
Observe not just location of “self exam” but degree of skin displacement to measure depth of palpation

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Subjective and objective findings are both valuable when examining any system
Subjective includes ROS= review of system
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Conducting a Clinical Exam via Telemedicine (2)
If you are not able to observe something, document that it was not observed
If you think the patient is NOT able to count their heart beats for 10 seconds, to calculate a heart rate, then do not document that assessment
If you cannot clearly observe the patient’s respiration rate via video, then do not document it

If using home-based tools (thermometer, scale, BP) consider accuracy. Document the type of monitor used (i.e., oral, digital thermometer, blood glucose monitor, etc.), and whether calibration was done or checked

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Adding to a Telemedicine Assessment
It is acceptable practice for providers to direct patients to perform self-examination.
Observe patient while conducting self exam to determine adequacy:
Displacement of skin when asked to palpate an area for tenderness or masses
Correct hand placement, use of hand verses finger
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Adding to a Telemedicine Assessment (2)
Ask patient to move camera or reposition themselves to assess specific physical symptoms as indicators

Recommending patients use a light source from a common flashlight or table lamp can be highly effective

Using other household items to assist in exam is appropriate:
Use a tape measure or coin to determine size of lesion
Use tissues to wipe and observe the amount of discharge

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Telemedicine Physical Exam: Vital Signs
Temperature: ask if patient has a working thermometer to use to take temperature
Heart Rate: ask if patient has a watch or clock with seconds hand for taking pulse, otherwise walk patient through measuring their own heart rate
Respiration Rate: ask patient to sit quietly and watch chest movement
Blood Pressure: patient may have a BP cuff at home, watch as patient measures their own BP
Weight: ask patient to stand on scale and show you the results. Assure the scale is calibrated in advance.

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Telemedicine Physical Exam: Head, Eyes, Ears, Nose, and Throat (HEENT)
General appearance and energy level
Head: note any visible swelling, asymmetry, alopecia, or other irregularities
Eyes: look at patient’s eye on video to assess for injection, icterus and symmetry; instruct patient to move eyes to evaluate extra ocular movements; have the patient use a flashlight to evaluate for reactivity if required
Ears: if discharge let them show you or describe what it looks like

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evaluate extra ocular movements (they can follow your finger on the computer screen),
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Telemedicine Physical Exam: HEENT (2)
Nose: observe any nasal flaring, rhinorrhea or “sniffling;” have patient press on sinuses if needed to assess for sinus tenderness
Oropharyngeal: ask patient to open their mouth and adjust the camera to evaluate the tongue, buccal mucosa, teeth/gums, pharynx and tonsils – noting any lesions, bleeding, redness, exudates and swelling (patient use of flashlight may help)
Observe/listen for cough (note characteristics – wet, dry, productive, non-productive), throat clearing
Neck: notice any asymmetry, swelling, guarding or stiffness

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Telemedicine Physical Exam
Skin: ask patient to move in front of camera to view the skin as best as possible and note abnormalities

Lymph Nodes: ask patient to press over specific area of lymph node chains and report any tenderness or enlargement, and if palpable nodes are fixed or not – monitor patient’s degree of pressure based on skin displacement

Respiratory: listen for cough, auditory wheezing, speech rhythm

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Skin: ask patient to turn on additional light if needed
Lymph notds: nodes are fixed (do not move)
Respiratory: listen for cough, auditory wheezing, speech rhythm (if a person can not breath, it is difficult to complete sentences, or say consecutive letters of the alphabet without stopping for breath)

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Telemedicine Physical Exam (2)
CV: look for edema in extremities, ask patient to press to determine degree, or use a tape measure
GI: have patient palpate all 4 abdominal quadrants and demonstrate areas of tenderness
M-S: observe patient and note limitations as they move about, stand, sit, walk, bend over, raise arm
Neuro: conduct standard CNS assessments as well as patient cognition, orientation, degree of history congruency and note any limitations observed
GU: utilize video inspection as necessary and note descriptive findings
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GI: look at skin displacement to determine degree of pressure
Neuro: conduct standard CNS assessments (inclusive of cranial nerve assessment) as well as patient cognition, orientation, degree of history congruency as would be done in an exam room and note any limitations observed

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Assessment, Diagnoses and Plan
Communicate your assessment and the next steps (plan)

Order labs and discuss with patient where to go for labs and any necessary instructions

Remember that certain tests cannot be done at all lab facilities so check with the lab first

Provide the patient with instructions on any referrals, new or renewed prescriptions, and follow-up plans

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Labs: give necessary instructions (i.e., do first thing in the morning after fasting and before eating or drinking)
Remember that certain tests cannot be done at private labs (i.e., throat cultures, lesion cultures, extragenital gonorrhea/chlamydia NAATs)

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Telemedicine Summary
The use of telemedicine greatly increases the impact of clinical practice including for the care of people with HIV;
IDSA & HIVMA support use of telehealth in the care of PWH
Telemedicine will increase “access” to care, but also present “new” challenges:
Decrease barriers created by distance or time, but may initially create discomfort for some providers and patients
Highlight barriers that exist regarding limited telecommunication infrastructure, and individual technology skills (“digital divide”)
Without limits placed by physicality, demands on providers may increase

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PWH=people with HIV
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Additional Thoughts
Additional Models:
VA's HIV Telehealth Program
Telehealth Use in Medical Case Management

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AETC Program
Contact your regional AETC for further training and capacity building in the area of care of people with HIV:

MidAtlantic AETC
Midwest AETC
Mountain West AETC
New England AETC
Northeast/Caribbean AETC
Pacific AETC
South Central AETC
Southeast AETC

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AETC Program (2)
For clinician-to-clinician consultation, use the National Clinician Consultation Center warmlines:
HIV Management Service (Warmline): 800-933-3413
Post-Exposure Prophylaxis Hotline (PEPline): 888-HIV-4911 (888-448-4911)
Perinatal HIV Consultation and Referral Services (Perinatal HIV Hotline): 888-HIV-8765 (888-448-8765)
Pre-Exposure Prophylaxis Service (PrEPline): 855-HIV-PrEP (855-448-7737)
Clinical Substance Use Consultation (Substance Use Warmline): 855-300-3595
Hepatitis C Management: 844-437-4636 or 844-(HEP-INFO)
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THANK YOU!
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