key: cord-0986678-t8ixrdpq authors: Persaud., Yudy K.; Portnoy, Jay title: Ten Rules for Implementation of a Telemedicine Program to Care for Patients with Asthma date: 2020-10-08 journal: J Allergy Clin Immunol Pract DOI: 10.1016/j.jaip.2020.10.005 sha: 581d9ea86dd12c10084a8c2f63d65c11336cf047 doc_id: 986678 cord_uid: t8ixrdpq nan has been shown to be effective for treating patients with asthma, only 6% of allergy practices used TM, 67 making allergy/immunology the specialty with the lowest adoption rate of any of the surveyed 68 specialties. Specialties with the highest use of TM were radiologists, primarily due to their use of 69 asynchronous store & forward. Other specialties with high TM use included cardiologists who did a lot 70 of remote patient monitoring and psychiatrists who rely extensively on talk to manage patients. 71 Allergists, who have traditionally relied on skin tests and allergen immunotherapy to manage patients 72 have not been as quick to adopt TM, though this is likely to change due to The pathway to creating a successful TM program should include a thorough understanding of the 74 different telehealth options. Providers should ask themselves what their goals are. It should be clear how 75 their asthmatic patients will benefit from these new programs. Also, patient goals need to be 76 incorporated into the program. A successful program will adhere to state laws and ultimately must 77 generate a strong return on investment. The use of TM has increased in part because COVID-19 has encouraged patients and providers to 80 maintain social distancing which reduces the risk of infection. After all, as mentioned in a recent 81 editorial, the only infection that can be transferred using TM is a computer virus. (19) During the pandemic, this has become the most commonly used type of TM. With DTC the patient 94 is located at an originating site (e.g.: personal residence, school, workplace) and the provider is located 95 at a distant site (e.g.: hospital, office, provider's home). In a typical scenario, a provider located at their 96 office connects to a patient who is located at their home using 2-way live video. The patient uses their 97 own equipment making it possible for them to be seen at their home. Therefore, they need to have use of 98 a smart phone, tablet device or computer with video camera and a reliable internet connection. A physical exam using digital exam equipment is limited to whatever can be observed using the 100 device that the patient has available. While patients can report their current weight, height, pulse and 101 respiratory rate, this usually limits the exam to the skin and general impressions of respiratory distress. Blood pressure can be documented if the patient has a blood pressure cuff at home. An example of a 103 physical exam that can be documented using limited equipment is shown in Table 1 properly evaluate the patient. Depending on the type of examination required, equipment may include 117 digital stethoscope, blood pressure cuff, thermometer, scale, otoscope, ophthalmoscope, dermascope or 118 even ultrasound. This type of visit usually is done synchronously; however, an asynchronous visit for a 119 physical exam to supplement a DTC video visit also is possible. (e.g.: Zoom, Teams, FaceTime, What's App, Google Hangout). Some platforms generally not allowed 203 due to security concerns include FaceBook Live, twitch and TikTok. It is likely that some of non- HIPAA compliant platforms will no longer be allowed after COVID-19 since they could pose serious 205 security risks. 206 States laws specify that a provider needs to be licensed in the state where the patient is located. platform that can be used with a simple link that avoids the need for downloading an application is more 224 likely to keep your patients satisfied. Since many patients are not digitally literate, some hand holding 225 will be necessary in many cases. The platform needs to be HIPAA-compliant, easy to use and reliable with low latency. Some Once the TM infrastructure is in place, it is time to offer patients a choice of an in-person visit, a TM 260 visit, or possibly even a telephone visit. Many patients who are used to being seen in-person may prefer 261 to be seen using DTC, particularly if they have experienced it during COVID-19. It helps to ask rather 262 than to assume that they should resume in-person visits once they become available. After an appointment is made for a DTC visit, the patient should be provided with information about 264 connecting to the visit. An example of this type of information using Microsoft Teams as the DTC 265 platform is shown in Table 3 . This can be sent via a patient portal or by sending a direct URL link via e-266 mail. If e-mail is used, it is important to avoid personal health information because e-mail is not HIPAA It is likely that one type of visit will tend to have a different duration for one type of patient than for 281 another. In general, TM visits tend to be shorter since the visits usually are more problem-focused with 282 less chit chat. Even though less time is spent with each visit, patients usually are as satisfied or more 283 satisfied with TM visits than they are with in-person visits. The best approach may be to see patients AAAAI concluded that "Nebulizer therapy, spirometry, sputum induction and rhinoscopy are all 326 considered high-risk exposure." (47) The American Thoracic Society recommended that "pulmonary 327 function testing be limited to tests that are only essential for immediate treatment decisions and that the 328 type of pulmonary function testing be limited to the most essential tests when possible." (48) One 329 advantage of using TM to treat asthma is that appropriate patients can be encouraged to obtain personal 330 devices that can measure pulmonary function tests such as FEV1 and peak flow without the risk of 331 COVID-19. The results of such home tests can be used to assist management of patients in leu of office 332 measurements. The use of asthma action plans and decisions regarding what treatment to recommend doesn't really 334 change when patients are seen by TM. Allergy testing can be done using in-vitro tests. Similarly, 335 measurement of total and specific IgE along with eosinophil levels, both required to determine the 336 optimal biologic to recommend for patients with severe asthma, can be done at any laboratory equipped 337 to do those tests regardless of how the patient is seen. Telehealth can be used to care for asthmatic patients who are new or in need of a follow up visit. However, at times the diagnosis of asthma can be unclear and the patient will need to have an in person 340 visit to undergo objective measures. The use of office based testing such as spirometry, oximetry, 341 FeNO, can help to distinguish conditions that mimic asthma. In these cases the patient will be 342 encouraged to follow up with the asthma specialist in their office. Once the diagnosis of asthma is clear 343 via history or previous objective measures then future visits can be done via telemedicine. Patients on 344 home biologics can then be followed via a virtual visit. Rule 9: Perform a Physical Examination 346 One common lesson taught during medical training was to be able to determine whether a patient is 347 well or not well simply by looking at them. This principle also applies when observing a patient with 348 asthma by TM. You should be able to determine whether the patient demonstrates any signs of 349 respiratory distress such as nasal flaring, coughing, pallor, use of accessory muscles, cyanosis, chest 350 retractions, unable to speak in complete sentences and prolonged expiratory phase. At times you may be 351 able to hear wheezing with the proper speakers and microphone. Sound-reduction headphones may 352 improve your ability to hear subtle sounds. If the patient seems unstable or is clinically worsening 353 during the evaluation, they should be instructed to call 911 or go immediately to the emergency room. This can be done either by a picture in picture or a double screen. While discharge instructions should be 368 described verbally, the patient should be provided with written instructions that can be sent ideally using 369 a patient portal or less ideally via text, email, fax or by mail to the patient's home. Changes in legislation have allowed for TM encounters to be paid for at parity with in-person visits. Though many health plans paid for TM before COVID-19, it was not necessarily at a rate that was When seeing patients by TM it helps to create a workflow similar to that used for an in-person visit. ( Figure 2 ) TM is not meant to change the way you currently see your patients. It has been common 383 practice for workflows to change, staff to be retrained and job description to change to accommodate 384 these workflows. A simple video capability that has become popular among providers is Doxy.me, 385 especially for private practitioners. A diagnostic telemedicine option that is commonly used is AMD The authors of this article envision that organizations that invest in telehealth will have an advantage in 450 improving these quality metrics and outcomes in asthma care. This will enable these organizations to 451 show who really is providing the best care which will translate to the eventual acquisition of a greater 452 market share. Future research on the delivery of asthma care using TM is needed. Controlled studies are needed to 455 evaluate how the patient-provider relationship is altered when TM is used. In addition, we have 456 encountered that in the South Bronx that many asthma patients and/or their parents have poor digital 457 literacy and lack of technological infrastructure to perform an adequate telemedicine visit. Additional 458 investigation into ways of using different technologies to achieve these goals is important, keeping in 459 mind that access to the internet is now a social determinant of health. We must also determine what 460 happens to high utilizers of medical care during this Pandemic. In particular, it is important to determine 461 whether TM can provide care that is comparable to an in-person visit. After reviewing this information, 462 we will be able to answer the simple question of whether TM can meet the standard of care in the 463 management of asthmatic patients. You can use the free version and send the link via a 398 free text platform (. i.e. textfree.us) Patient does not need to download an App Telemedicine Association Home telemonitoring and remote feedback between clinic visits for asthma Telehealth delivery of adherence 518 and medication management system improves outcomes in inner-city children with asthma Telemedicine is as effective as in-person visits for patients 521 with asthma Do Patients of Subspecialist 523 Physicians Benefit from Written Asthma Action Plans? Real-world evaluation of a mobile 525 health application in children with asthma Written individualised management plans for asthma in children and adults The uses of telemedicine to improve asthma control The role of telemedicine in the care of children in under-served communities Use of interactive videoconferencing to deliver asthma education to inner-533 city immigrants Internet-based home 535 monitoring and education of children with asthma is comparable to ideal office-based care: results of a 1-year 536 asthma in-home monitoring trial A Telemedicine 538 Intervention to Ensure the Correct Usage of Inhaler Devices Health Care Outcomes for School-Age Children: A Systematic Review The "physician on call patient 543 engagement trial" (POPET): measuring the impact of a mobile patient engagement application on health 544 outcomes and quality of life in allergic rhinitis and asthma patients Information and Communication Technologies in Social 546 Work New Concepts and Technological Resources in Patient Education and Asthma 548 Self-Management Internet-based monitoring of asthma: a long-term, 550 randomized clinical study of 300 asthmatic subjects The Use Of Telemedicine By Physicians: Still The Exception Rather Than The Rule Telemedicine in the Era of COVID-19 Wearable Technology and How This Can Be Implemented into Clinical Practice Design and Benchmark Testing 558 for Open Architecture Reconfigurable Mobile Spirometer and Exhaled Breath Monitor with GPS and Data 559 Telemetry STAAR: a randomised controlled trial 561 of electronic adherence monitoring with reminder alarms and feedback to improve clinical outcomes for 562 children with asthma A tailored mobile health intervention 564 to improve adherence and asthma control in minority adolescents Propeller Health Asthma Platform: A Randomized Clinical Trial The Asthma Mobile Health Study, a 569 large-scale clinical observational study using ResearchKit Telehealth to improve asthma 571 control in pregnancy: A randomized controlled trial Impact of a digital health 573 intervention on asthma resource utilization Short-term effect of a smart nebulizing device on adherence to 575 inhaled corticosteroid therapy in Asthma Predictive Index-positive wheezing children Developing a Healthcare App in 2020: What Do Patients Really Want? : Imaginovation.net Mobile Health and Inhaler-Based Monitoring Devices 580 for Asthma Management Smartphone and tablet self management 582 apps for asthma Developing and pilot testing ASTHMAXcel, a 584 mobile app for adults with asthma Improvement in Asthma Control Using a Minimally Burdensome and 586 The use of mobile applications to support 588 self-management for people with asthma: a systematic review of controlled studies to identify features 589 associated with clinical effectiveness and adherence The feasibility of text reminders to 591 improve medication adherence in adolescents with asthma A mobile telephone-based interactive self-care 593 system improves asthma control Clinical and cost effectiveness of 595 mobile phone supported self monitoring of asthma: multicentre randomised controlled trial The Potential of Mobile Apps for Improving 598 Practice profile. A safety-net system gains efficiencies 601 through 'eReferrals' to specialists Credentialing and Privileging: Center for Connected Health Policy Joint Commission on Accreditation of Healthcare 607 Organizations Faster Pathway to Physician Licensure: Interstate Medical Licensure Compact Telemedicine Technology: a Review of Services, Equipment, and Other Aspects Tips for Seeing Patients via Telemedicine Update on COVID-19 for the Practicing Allergist/immunologist: American Academy of Allergy Advice Regarding COVID-19 For Pulmonary Function Laboratories: ATS 621 Proficiency Standards for Pulmonary Function Testing Committee Self-management education 625 and regular practitioner review for adults with asthma Physician Fee Schedule: CY 2020 Physician Fee Schedule Final Rule: Centers for Medicare & 627 Findings and 630 Recommendations 3. Provider is notified when the patient arrives in a virtual waiting room. If the provider is available, the patient 401 is allowed to enter the visit. If the provider is busy, the patient waits in the virtual waiting room. The 402provider or an assistant can send a chat to the patient letting them know the status of their visit. 4034. The patient is seen and a limited examination is performed as appropriate. 404 5. Documentation can be done in the electronic medical record at the same time as the patient is seen using 405 picture in picture or by using a double monitor. 4066. Prescriptions are sent to the patient's pharmacy and discharge instructions are sent to the patient. 407Example 2: Facilitated Virtual Visit-using a platform that supports digital exam equipment 408 Intouch Health/Teledoc has become a popular platform for facilitated virtual visits. The provider 409 interacts either with a stand-alone app or in some cases with an app that is integrated into their electronic