Patient Advocacy 101 : Tips on Getting the Most out your Virtual Rheumatology Visit [VRV]

Telehealth / Virtual visits are NOT  a novelty and existed even prior to the pandemic.

However, the accelerated adoption in 2020 -2021  and its ongoing support at the policy level with proven safety and comparable outcomes to in-person visits have kept it center stage.  

The future of telehealth is bright. It is also practical.

YOU, the patient,  can now foreseeably travel with your virtual provider across  State -lines and maintain provider-patient continuity regardless of your nomadic and contemporary lifestyle. The neighborhood, house-call physician is now in your laptop bag so long as you remain on US territory. 

You are now unhindered in your choice of physicians who will remain your trusted advocates for life. Your specialists will know you through your lifespan and will be able to coordinate your care with top academic research departments in the world. 

Your information can now flow between health information exchanges [HIEs] and you do not feel obliged to a single provider within a defined narrow network mandated by a payor /insurance or a physician group. 

This could be your and [hopefully also my]  future someday. You and your provider are now both finally on the same team. 

So how do you prepare for this future and your much-anticipated upcoming visit with the Rheumatologist? 

Some of the advice I offer here is considered general housekeeping for 'any' telehealth visit with any virtual provider. However, some of it is specific to a Rheumatology visit. 

 I appreciate the 5, 10 or even 15 minutes you might spend reviewing this today. I promise it will help us both have a delightful and productive encounter. Human potential and technology is boundless and even though we do not share the same 'space' , we are still bound by the same limits on our precious Time. So lets respect each other's time and prepare for the most productive visits ahead.

Now that we have re-imagined health-care , lets re-create it TOGETHER: 

Here is how I would break this down ....

SAFETY: Distractions are Dangerous !  

Avoid taking your appointment in a car while driving.  I will likely re-schedule your appointment if I find you behind a wheel  OR request you to pull over to a safe location which will delay appointments. 

Treat your virtual visit with the same respect that you would an In-person visit.

After all, you are going to get the same level of attention as you would for an in-person visit and your virtual provider is definitely equally qualified regardless of the healthcare setting! 

The convenience is great but the risks are likely not worth it. Most patients that are scheduled during their 'work break' find a hallway or break -room in their office. A vehicle especially one that is on the move should be last resort ! 

This article Telehealth's Newest Safety Risk : Distracted Patients offers great advice for physicians' in setting expectations with patients. I think patients would find this to be useful as well insofar as seeing it from the perspective of their physician and risk management. 

COMPANY : more the merrier !

One significant advantage of virtual visits is that you can bring your 'loved' one along to the visit. So if you need a parent, child, spouse, neighbor or friend present at the visit then by all means let the scheduler know in advance so we can expect more people to join. There can be several advantages to having a companion.

Shared -Space Companion [ present with you in same room] 

- Your companion may be more 'tech savvy' and can help troubleshoot any wifi or device issues. 

- Your companion can also hold your phone, laptop or computer during your virtual physical exam. I find this particularly helpful when I assess for gait. 

- Your companion can also help you transfer from seated to standing or vice-versa if you suffer from arthritis and need help with transference to and from a wheelchair or assistive device. In -the fact your functional limitations and ergonomics can often be more easily and accurately appreciated in your home virtual visit than in an office setting where your physician is likely running to and from all day long. So take advantage of this ease. 

Non-Shared Space Companion  [ Joining virtual visit from different location]

- This companion could be your adult child [caregiver] or even a concerned parent. It is great to get their perspective on your health especially if they are your designated power of attorney. 

- This companion can help understand your plan-of-care and can take notes during the visit. They can also prompt and ask questions that you may not have thought of asking. 

EFFICIENCY:

Wifi:

-Verify that the room, hallway, parking -lot or office you intend to be visiting from has good wi-fi connection. Otherwise either your audio or visual may fail mid-visit. I suggest you view this infographic: 

Frequently Asked Questions by Patients - Spanish Infogram

Frequently Asked Questions by Patients - English Infogram

Interpreter: 

-Make sure you mention to scheduler [ ahead of your appointment day] that you may need an interpreter.  

-Most health care plans are MANDATED to provide interpreter services. Look at the back of your insurance card! Your provider will have interpreter arrangements as well but these ought to be planned in advance for optimal visit experience and patients can definitely advocate for themselves here.

Rheumatology Specific:

Records :  Most Electronic Medical Records [EMRs] and Health Systems now speak to each other through a feature of Health Information Exchanges [HIEs] called 'Interoperability'. In -fact for better or worse there are legal, compliance, and regulatory requirements to freely exchange health records so that no single system can [or should] claim ownership of a patient's personal health records. Gone are the days when health systems would attempt to monetize or monopolize data. However, YOU as a patient are STILL your best advocate. You are a walking living memory of your own health history. While most data is usually a click away inside Inter-Operability Wells, we are still a few years away from a perfectly seamless exchange. There is also now the threat of " note bloat" which is actually endangering patient lives since getting to the right information is like looking for a needle in the haystack of over-zealous documentation. 

As a rheumatologist, the single piece of data that could alter the outcome of a virtual visit would be the availability of 'histology reports'. These are reports written by trained histo-pathologists upon review of a 'piece of your tissue' from a 'biopsy'. I am sometimes bemused and occasionally disturbed when patients affirm history of an invasive procedure [such as skin or kidney biopsy] but either never received a copy of the report or perhaps did not think to ask for it. These are usually chock-full of data and if nothing else, I would advocate for patients to always retain a copy of these histo-pathologies. These are usually the 'missing ' items even in inter-operable systems although I have seen better exchange of data in this regard from academic centers than HMOs. 

Specialized Immune or Genetic tests run by reputable national central labs are also useful to have on hand. However, this is often tricky terrain for patients to decipher as  'special' tests run the gamut from expensive, excessive, and pseudoscientific reams of useless tests for conditions dubbed 'adrenal fatigue', 'leaky gut' etc... to actually validated lab markers that carry true diagnostic or prognostic value.  Since it is unrealistic to expect patients to keep a record of lab tests in the age of information, I might advise that patients start 'asking' their specialists to provide them copies of any 'special ' testing and a brief review of what the implications of those tests might be. If your provider does not have a good explanation for testing then it is unlikely one that you would need to lose sleep over. 

Physical Exam

- IT is good practice to keep a blood pressure cuff at home. It is likely the next best investment in your health after quitting smoking [if you do]. Keep your blood pressure log in the days leading up to the visit. Most patients have better blood pressure reads during virtual visits than in-office settings [ white coat hypertension]. Inform your rheumatologist if you have experienced noticeable weight gain or loss in the 6-12 weeks prior to the visit. 

- It helps to keep your device against a self-propped system or get a companion [see above].You should be 'hands-free' as rheumatologists like to visualize  'range of motion' at the joints. You need at least a full arm's length of space around your body for proper assessment. 

- Postural Exam. Prepare to stand and turn around to the camera if needed or asked to. 

- Take pictures of skin rash[es] under direct lighting PRIOR to the appointment. In fact you can also use your 'screen share' feature to show pictures of the rashes if you are prepared in advance. 

- Keep a Diary of your most painful or swollen joints in the days and weeks leading up to the visit so that you can use your notes to jog your memory. 

- Keep notes on the pain medications and non-pharmacological modalities such as heat, cold, massage, acupuncture etc.. that you have tried. It helps to know what works and does not work for you and could save unnecessary workup and delays in treatment. 

Cyber-Hygiene: 

- Make sure you introduce any other personnel in the vicinity during the visit who may be in ear-shot

- Remember to ask your provider, if there is anyone else in their office

- Come up with a follow-up plan and remember to set up a follow-up visit. Given the pressures on health care providers these days, most of have resolved to 'out of sight - out of mind' so the onus of getting on the physician schedule falls to the patient. Physician reimbursements are still greatly tied to the 'fee-for-service' model but there is hope that this is evolving and changing towards value-based care. 

- Activate the EMR portal for secure communications. This usually requires either a cell [mobile] phone number or an email. If YOU do not have one, then see if a family member is willing to be your 'tech' surrogate. Embracing new technologies and adapting to new health cultures could be the safer route to better health outcomes than resisting change. 

- Think ahead to the pharmacy you prefer. Request refills through your pharmacy FIRST rather than the provider office. Almost all pharmacies in the United States are linked to EMRs through 'Surescripts'. So unless your provider is still surrounded by paper -charts , there is a very good chance that they are linked to SureScripts

- Lastly check out these 'security' tips : Virtual Care Security Tips for Patients

Carpe Diem ! 

Farah Salahuddin MD

I accept feedback on my posts  through website or email: clinic@rheumwithoutwalls.com 

Author

Farah Salahuddin MD Farah Salahuddin MD [ pronounced Salah'din] is the founder at Tele-Rheumatology Medical Associates [dba 'Rheum Without Walls'] where digital health is leveraged to bring Rheumatology closer to the patient's home and with a view to raising the value of specialist care while curtailing burgeoning health care costs. She resides in California and has an Inter-State License [IMLCC] to practice in several US territories. She serves as Rheumatology Consultant for Ochsner Health System and Telemed -2U driving change in rural health settings and serving vulnerable and underserved populations across state lines and across health care systems.