NUR 752 Discussion 2.1: Electronic Visits (e-Visits)

The patient population I work with is mostly low income, underinsured, uninsured or migrant. Many of these patients are Medicaid recipients and work blue collar jobs with minimal benefits and limited time off from work. The implementation of telehealth for my patient population has been incredibly positive. Patients can take a quick break from work, use their lunch hour, or discuss their health on their commute during a telehealth visit without having to take time off. They can still receive medical advice, have lab work ordered, and even obtain referrals for specialty visits. I respond to asynchronous requests, but I usually like to have a quick telehealth call for a check-in to ensure I meet all patient needs and answer questions. Synchronous visits are the best way to ensure you understand what the patient is asking for. I usually have follow-up questions to advice requests and I often like to check-in on chronic condition management. If a patient could video a skin, eye or other condition that needs to be seen in person asynchronously that would prove useful as well. A barrier to this would be the patients who low or poor access to phones and internet. The population I work with has limited phone minutes and reduced access to quality internet which is a barrier to this visit method (Dhaliwal et al., 2022). There are several benefits and limitations to the use of telehealth in the primary care setting.

For this population it seems like a mix of providers and patients drive the demand for telehealth visits. Providers who might need a remote day, or who are in a facility that is short staffed and cannot support additional in-clinic visits would also benefit from the telehealth option. Patient barriers to care can be removed by adding the option of telehealth, chronic pain or mobility impairment is one-way telehealth can benefit home bound patients (Gajarawala & Pelkowski, 2021). Patients who are dependent on public transportation during the pandemic can drive demand for telehealth visits, or those who walk during inclement weather. Many of our patients have transportation barriers which would also benefit from the option of a telehealth visit.

Consent is always a big issue for any type of medical treatment, advise, or testing. We had to develop a telehealth consent option for patients to give us verbal consent over the phone. Some barriers would be ensuring the person on the phone is the actual patient (Balestra, 2018). Parents often like to complete visits for adult children, which is not allowed. Spouses who have appointments together are often not in the same location so visits cannot be completed without the patient being present. Prescribing controlled substances via these telehealth visits is also a risk because it can be difficult to track when the prescription was last filled. There is a potential for abuse with CS being prescribed over the phone or during a video visit, especially in states where the PMP cannot be reviewed.

Other technologies that can benefit telehealth or remote visits are the implantable glucose monitors. These devices can provide real time data to a clinician and touchpoints can be based on this data. At home BP monitors with docking stations that can upload the readings into the chart can also support an at home approach to BP monitoring. If the readings are good then the patient can forgo an in-office visit which can be easier on elderly, mobility impaired or patient with transportation barriers. Patient engagement and support are always a potential barrier considering a small percentage of the population utilizes free online resources concerning their healthcare (McBride & Tietze, 2018). We have a Mychart or direct connect option to further encourage patient engagement. With this program patients can see their results, request appointments, obtain letters, ask their healthcare team questions and access previous and current prescription information.

Balestra, M. (2018). Telehealth and legal implications for nurse practitioners. The Journal for Nurse Practitioners, 14(1), 33-39.

Dhaliwal, J. K., Hall, T. D., LaRue, J. L., Maynard, S. E., Pierre, P. E., & Bransby, K. A. (2022). Expansion of telehealth in primary care during the COVID-19 pandemic: Benefits and barriers. Journal of the American Association of Nurse Practitioners, 34(2), 224-229.

Gajarawala, S. N., & Pelkowski, J. N. (2021). Telehealth benefits and barriers. The Journal for Nurse Practitioners, 17(2), 218-221.

McBride, S., & Tietze, M. (2018). Nursing informatics for the advanced practice nurse (2nd ed.). New York: Springer Publishing Company. ISBN: 9780826140456

Good morning Lauren,

I love reading and responding to your discussions because I find your job fascinating. I have never worked in a clinic and find the material exciting. With the paragraph about using asynchronous or synchronous, you discuss how providers might need a remote day. Is this where a provider has one day dedicated to telehealth visits? This seems like a great idea because many providers’ days are filled start to finish with in-house appointments where if they could have a single day for only telehealth visits, more patients could be seen. I am curious if this is a common practice in your clinic and other clinics. I would have loved to hear more on how the healthcare team at your clinic prescribes controlled substances via the phone or virtual visits. What additional consents, verifications, and paperwork needs to be done? In Washington State where I work, for most opioid prescription, a provider can only give out a seven day supply for acute prescriptions and a 14 day supply for acute operative pain (Prescription Monitoring Program, n.d.). I agree that diabetic management through telehealth and remote visits would be beneficial for that patient population. Even the heart failure patients having their heart rate, blood pressure, and diet monitored via telehealth can change the course of their treatment positively (Washington State Medical Association, n.d.). I loved your discussion and it brought up some excellent points.

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References

Prescription Monitoring Program (PMP). DOH. (n.d.). Retrieved March 1, 2022, from https://doh.wa.gov/public-health-healthcare-providers/healthcare-professions-and-facilities/prescription-monitoring-program-pmp (Links to an external site.)

Washington State Medical Association (WSMA) (n.d.). Prescribing rules and Guidelines. Retrieved March 1, 2022, from https://wsma.org/WSMA/Resources/Opioids/Prescribing_Rules_And_Guidelines/prescribing_rules_and_guidelines.aspx

Thank you for your response. I really like hearing about how other states operate their visits and the rules that govern providers. We do have rotating telehealth days at some clinics for providers to help alleviate the strain on the health centers and to give providers time to get non-essential patient care work completed. This helps to reduce burnout for providers and ensure ancillary staff isn’t overwhelmed with our fax requests. We try to make it 1-2 days a week so there aren’t as many staff members or patients in the health centers to mitigate the spread of covid. This is a newer practice that started in December with the Omicron variant which ravaged patients and staff alike.

We needed to develop a telehealth consent that would cover our existing patients, but also new patients who were just looking for covid testing/ vaccines. Our network of clinics is part of the Illinois testing site and vaccination initiative and we needed to find a way to serve patients who’s care we wouldn’t be continuing to manage. Our telehealth platform was developed and specific visits types are just for covid related testing, treatment and advice in order to separate them from our standard visits with our patients. This was done for reimbursement purposes to show how covid has impacted our communities.

For controlled substances, we can do up to a 30 day supply of some medications via telehealth. We have a new system in place that has a duo authentication to protect misuse and ensure providers are aware of what they are prescribing. We have the patient’s PMP imbedded in our EMR to further alert the providers to potential for abuse or drug seeking behavior. I don’t love the idea of electronically prescribing controlled substances, but for class IV and lower it seems like it eliminates some pressure points for patients.

Hi Lauren,

I am happy to hear that tele-health is a vital role and one that works well in your clinic. At least you are not trapped with a system from (I’m not joking) the 70’s. The most experience I have with current health information technologies is just the My Chart app that I have through my primary care provider and it really only benefits me for seeing lab test results and vaccination reports. I feel as though I am one of those people that does not fully utilize the benefits and support of online tele-health, but then again I have never really felt the need to for myself and I do not have a family of my own yet and I am no longer married so I don’t have a spose that has to be there for a visit (McBride & Tietze, 2018). That being said, I have always, at least by my doctor’s office to have in in-person visit, even during COVID. I think though hat in general for just a check-up, the telehealth is a great resource for people to utilize to keep up with their health at least to some extant. Do you think that the lack of in person, face to face communication would truly inhibit patient interaction? Do you think that a doctor or health care provider being physically present truly makes a difference, or is a screen call enough? Also a downside which can get tricky is especially with prescription that involve pain medication, there are many people who do not get prescribed enough, due to past patients abuse of them and now there are many limits with that. Doctors have it harder, now more than ever to be able to decipher what is truly needed over these tele-health calls in that regard. Anyway, good post!

Gajarawala, S. N., & Pelkowski, J. N. (2021). Telehealth benefits and barriers. The Journal for Nurse Practitioners, 17(2), 218-221.

McBride, S., & Tietze, M. (2018). Nursing informatics for the advanced practice nurse (2nd ed.). New York: Springer Publishing Company. ISBN: 9780826140456

Hi Brittany,

I think sometimes the lack of pressure of a face-to-face meeting can put patients at ease and actually allow a conversation to develop. Sometimes we do use video visits so we can still get a visual component. I do think there are visits that need to be conducted in person, there are for sure complaints that require an assessment. At the same time, does a stable diabetic need to come in physically to the clinic to be evaluated every 3 months? Could they maybe switch to a 6 month in clinic schedule and do a 3 month follow-up on the phone with lab orders they go and complete on their own schedule? Would that really decrease the quality of care they receive? Pain medication is a great example of an in-clinic visit. These patients have very specific schedules and pain contracts with providers. We do not routinely prescribe controlled substances for pain since we are a SUD clinic and treat opioid abuse with medication and therapy. This is not a common issue I run into as I do not have my CS 2 license. I luckily can tell patients I cannot legally prescribe that for you and it pretty much ends the conversation about opioids. Thanks for the questions!

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NUR 752 Discussion 2.1: Electronic Visits (e-Visits)