Transitioning to Telemedicine - UNC Neurosurgery

Telemedicine has not been a method of health care delivery widely used in surgical subspecialties. However, the COVID-19 pandemic has caused all health care providers to rethink care and transition non emergent patients to virtual appointments when possible.

At the beginning of the pandemic, neurosurgery resident Dr. Randaline Barnett and pediatric neurosurgeon Dr. Carolyn Quinsey published an article on Virtual Care for Surgical Subspecialties on Kevin MD outlining several issues that they have encountered with the transition to telemedicine and how they were able to overcome these difficulties:

Include a resident, nurse practitioner, or scribe on the call to document the visit and place orders to allow for the provider to be fully engaged with the patient.

When necessary, coordinate interpreters prior to the start of the appointment. Make sure that the interpreter has joined the call and is ready to go before the patient joins the appointment.

For patients without access to a computer, tablet, or phone with video capability, providers should arrange the visit through a family member if possible, to ensure that the patient and provider are able to connect over video.

Consider setting up a back-up platform option, such as a regular phone call to ensure that the patient and provider are still able to meet if there are technical difficulties.

Providers can also utilize online videos for patients who will require post op instructions or further instructions on how to check measurements or vitals from home. Recently, our pediatric nurse practitioner Kristi Hildebrand created a video demonstrating how to accurately measure an infant’s head circumference for parents of pediatric hydrocephalus patients. Taking measurements from home saves parents an unnecessary trip to the clinic.

Now that Telemedicine appointments have been going on in our department for several weeks, Dr. Randaline Barnett further expanded on the successes and challenges of virtual appointments:

 

  1.  Now that these appointments have been going on for a couple of months, how have you been able to improve the process?

One of the major problems we experienced in the beginning was the difficulty that patients initially had with accessing their video visits. There were several patient history questionnaires and surveys they were required to complete on their own prior to the visit, and this was something that we and our patients were unaware of in the beginning. Some of these questionnaires took 10-20 minutes to complete, which caused significant delays in starting the visits. We quickly obtained feedback from patients regarding these experiences, and we worked on a system within our department to help address these issues more efficiently.

Our outpatient schedulers and nursing staff (the real MVPs behind our Telemedicine initiative) began calling patients several days prior to their appointments to virtually “room” our patients and go through the patient history questionnaires and surveys with them. They also provided education on how to access the video visits in order to be prepared for their appointments. Once we implemented this process, our video visits ran much more smoothly and efficiently, and we were able to remain on time. Patient satisfaction greatly improved as well once we implemented these measures.

 

  1. How are patients reacting to the change to virtual appointments?

Since we have worked out a lot of the kinks we had in the beginning, most patients have expressed that they liked having the option to do virtual appointments. We’ve had plenty of people say that they were happy being able to see their provider from the comfort of their own home, and they appreciated not having to drive far distances to get to their appointments.

There have been some appointments, in which we’ve been able to conduct multidisciplinary visits on the same video chat with providers from other specialties such as oncology and ENT, and patients have expressed satisfaction in being able to discuss a more comprehensive approach to their care with their healthcare team instead of having to attend several different appointments, sometimes on different days in different locations.

 

  1. What are the benefits of Telemedicine?

The most substantial benefits include maintaining a safe method to evaluate our patients during the coronavirus pandemic that keeps both patients and providers safe while maintaining close relationships with our patients. Patients have the luxury to talk with their provider from the comfort of their own homes, and this saves valuable time and money since they don’t have to travel, sometimes for hours, to their appointments.

As I said before, we’ve also been able to conduct multidisciplinary visits with other providers that we co-manage patients with, and this allows the patient to have a conversation with their healthcare team in one location rather than attending several different appointments. We, as providers, have really enjoyed this aspect of telemedicine as well since it makes it much easier and more efficient to collaborate with our colleagues in other departments to ultimately provide our patients with the best care. Another benefit for providers is having the luxury to conduct these visits from our own homes, offices, or clinic spaces, and it allows us to have more flexibility in our schedules.

 

  1. What are the greatest challenges with Telemedicine? 

We miss seeing our patients in person and being able to comfort them when we sometimes have to discuss bad news or emotionally difficult topics. It’s harder to do that sometimes through a video. Another challenge is that technology barriers can certainly hinder visits. It does require reliable technology and internet access. There have been times that we have had to convert video visits to phone visits when either the patient or we experienced audio and/or video failure due to technology issues.

Another challenge that we noticed early on is that this could possibly create further health disparities in populations that do not have access to reliable technology and internet due to socioeconomic or geographic reasons in addition to populations in which English is not their first language. Populations who primarily speak or read in other languages, in our experience within our neurosurgical department, have had more difficulty accessing their video visits even with the assistance of an interpreter. The reasons for this are still being investigated. In order to make sure we are still delivering optimal care, we often have had to convert to phone or in person visits. I’m currently conducting research on barriers to care in our vulnerable populations, so that we can continue to improve this process and ensure that all our patients are receiving the highest quality and safest care.

 

  1. You discussed how you want to implement Telemedicine into your future practice. Can you elaborate on that?

Growing up in a rural area of eastern Kentucky, I was accustomed to witnessing health disparities that occurred due to socioeconomic reasons, and this was something I had always been passionate about addressing throughout my medical education and journey to becoming a physician. Where I grew up, most people had difficulty accessing specialty care since most specialists practiced in the larger cities in Kentucky. This meant, for some folks, having to drive hours for their care, and for populations who require frequent follow ups and management, this can be very challenging. You have to take into account the time missed from work, travel expenses, access to child care, etc. This can be financially straining for families who already are experiencing financial hardships, which often forces people to forgo necessary medical care.

As a rising neurosurgeon, I want to be able to provide my patients and referring providers with viable alternatives that can increase access to high quality care and limit the burdens imposed on families who live in geographically underserved areas and/or challenging socioeconomic circumstances. It’s important to me to give back to those who supported me for so long and helped me get to where I am in my career. One of the ways I’ll be able to do that is through implementation of Telemedicine into my future practice, and I’m really fortunate that I have had the opportunity to learn how to navigate this world as a resident.