key: cord-0753000-x48rfneu authors: Keswani, Anjeni; Brooks, Joel P.; Khoury, Paneez title: The Future of Telehealth in Allergy and Immunology Training date: 2020-05-18 journal: J Allergy Clin Immunol Pract DOI: 10.1016/j.jaip.2020.05.009 sha: 9bfe68177a8e0b15cf47d9e4d7858b533f34831b doc_id: 753000 cord_uid: x48rfneu Abstract With emerging interest in the use of telemedicine, Allergy-Immunology should be at the forefront of adoption and implementation of these services. Patients report a greater desire for telemedicine services as well as satisfaction with video-based visits with their providers. Interim virtual visits can accommodate overscheduled clinics, reduce burdens of travel to distant sites, improve access to sub-specialty care, and increase adherence during monitoring of chronic allergic conditions. The outpatient nature of Allergy-Immunology coupled with the ease of conducting many aspects of a routine visit via telemedicine makes incorporation of telehealth training into fellowship programs highly desirable. The short-term closure of hospital-affiliated clinics, in particular for vulnerable or immunodeficient patients, in the setting of a global pandemic demonstrates the timeliness of this topic. A framework for implementing telemedicine into the Allergy-Immunology curriculum, training faculty on appropriate supervision, providing elective clinical experience in the form of continuity clinics, and simulating telemedicine delivery is discussed. Proposed telemedicine competencies desired for independent practice of telemedicine are suggested. Telemedicine has recently been highlighted as a medium of health care delivery that 55 can improve patient-physician interactions, access to care(1) as well as increase patient 56 adherence and cost-savings. Telemedicine services have been shown to be effective 57 for improvement in asthma care and quality of life(2). Publications and engagement with 58 telehealth and telemedicine services in Allergy-Immunology have increased since 2015; 59 however, the recent public health emergency has brought telemedicine usage into the 60 forefront quicker than prior attempts to incorporate this technology into the practice 61 environment. Importantly, institutions with Allergy-Immunology training programs have 62 quickly implemented telemedicine programs to both provide continuity of care for 63 existing patients, as well as an opportunity for trainees in a changing educational 64 environment. The outpatient nature of the specialty and the recent precipitous decline in 65 Allergy-Immunology specific patient volume emphasizes the importance of considering 66 virtual training and telemedicine as core aspects of preparing future allergist-67 immunologists for clinical practice. Practice addressed incorporation of telemedicine into practice (3) and triaging of 74 patients to virtual visits (4). Another consideration in addition to practical concerns 75 include use of this technology for continuity of training. Although there is a general 76 desire to incorporate telemedicine training into medical school curricula (5) , at present, 77 the ACGME does not mention this as a Core Program requirement (6). Telemedicine 78 training is not mentioned in the Allergy Immunology Milestones 2.0 planned for July 79 2020; however, the systems-based practice, professionalism and communication skill 80 subparts are well poised for evaluation using supervised telemedicine. In light of the 81 projected duration of the COVID-19 pandemic, ACGME accredited programs should 82 foresee the need to incorporate telemedicine into training, both in direct patient care as 83 well as in the virtual classroom. A framework for the incorporation of tele-training into 84 Allergy-Immunology Training Programs is shown in Figure 1 . be aware of various platforms for videoconferencing and telemedicine services (7) Non-facilitated visits occur between the physician, patient, and trainee directly in real-146 time. History taking and discussion of the patient's assessment and treatment plan 147 should mirror a traditional, in-clinic appointment. As there is no specialized healthcare 148 personnel with the patient at home, the physical exam is more limited; however, 149 trainees can be instructed on aspects of the Allergy-Immunology physical exam that can 150 be assessed by telemedicine (11) with the patient's cooperation using resources created 151 by the American Academy of Allergy, Asthma, and Immunology (AAAAI). For example, 152 patients can be instructed on how to take their own vital signs using home 153 thermometers and blood pressure cuffs as well as directed on positioning for a video 154 exam of their oropharynx or skin. There are limitations to a physical exam by 155 telemedicine, particularly in the ability to visualize the nasal cavity and auscultate the 156 lungs, of which trainees need to be aware. Future considerations for select patients may 157 include procurement of low-cost home-monitoring equipment, digital stethoscopes, 158 spirometry tools, or mobile health apps that may assist in chronic disease management. 159 For most patients, utilizing existing cameras on mobile devices for routine physical 160 exams will likely be sufficient. 161 In addition, trainees will need direction on how to convey empathy and foster the 163 therapeutic alliance between physician and patient in the digital medium. Trainees may 164 find that telemedicine lends itself to multitasking more than in-person visits as the 165 electronic medical record is directly available to review medical records and write orders Store and forward telemedicine can be used to train fellows on dermatologic conditions. 204 For consultation regarding skin rashes or lesions, the patient can take a photograph of 205 the area of concern and send these to the Allergy-Immunology fellow for evaluation. 206 Similar to telemedicine training for dermatology residents(13), Allergy-Immunology 207 trainees can initially independently evaluate the skin condition to create a differential 208 diagnosis and treatment plan based on the appearance, and then confer with the 209 attending physician, or even a consulting dermatologist, for further education in 210 management of skin conditions. Spirometry performed by mobile device apps can also 211 be transmitted to physicians prior to telemedicine appointments. Trainees can learn how One of the more challenging aspects of supervising a telemedicine visit is to promote 298 clinical reasoning, elicit a differential diagnosis, and discuss the care plan while in front 299 of the patient. In a conventional encounter, the trainee would conduct the history and 300 physical, then leave the room to discuss the case with their attending. Some 301 telemedicine platforms allow providers to place their patients in waiting rooms, which 302 can be done while the case is discussed with the trainee. Alternatively, the encounter 303 can be closed, and the patient can be called back once the plan is formulated. A 304 preferred method which would enhance the learning process is to permit the trainee to 305 summarize and formulate their plan with the patient still in the visit. The attending can 306 either agree or explain why an alternative plan might be more appropriate. Faculty can 307 use this opportunity to detail their clinical reasoning to the patient to enhance 308 understanding of the treatment plan. Faculty consistently report evaluation fatigue; 309 however, telemedicine is appropriate for direct "bedside rounds" and performance Adequate supervision can easily be maintained as trainees are directly observed while 337 conducting their telemedicine visits. It is the duty of the supervising attending to provide 338 feedback to the trainee so that they can learn from each encounter. Trainees should 339 become proficient in telemedicine core competencies as detailed in Table 3 . Training in telemedicine can confer a significant educational benefit to Allergy-389 Immunology fellows. Prior to their initial telemedicine encounter with patients, they 390 should be given the opportunity to practice with standardized patients to gain familiarity 391 with telemedicine and to build confidence in their skills. Simulated standardized 392 telemedicine encounters at the end of training, even as a graduation requirement, allow 393 program faculty the opportunity to observe and assess how well a trainee can make 394 appropriate treatment decisions in real time as a factor in readiness for independent 395 practice. As telemedicine visits are likely to be a component of ongoing Allergy-396 Immunology clinical practice, we would offer our trainees a significant advantage in 397 training them in the proper execution of both direct to consumer and facilitated visits as 398 well as the use of asynchronous telemedicine technology during their fellowship. American college of allergy, 456 asthma & immunology position paper on the use of telemedicine for allergists. 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