Telehealth — How To

I’ve been doing telehealth for a few years. Now everyone wants in due to the coronavirus pandemic. My partner, John Sutherland, Ph.D., and I have been furiously spinning up mental health and addiction clinicians at Allina Health. We transitioned at least 75 providers this week and more will soon follow.

This post will provide some practical advice for those new to telehealth. It comes straight from the trainings that John and I have delivered in recent days.

Keep it Simple
I use a number of telehealth platforms including Vidyo, Epic Warp Drive and Zoom for Healthcare. I recommend Zoom for Healthcare if you need to get up fast and don’t have an IT department supporting you. It’s literally purchase and practice. Patients just need the Zoom app, which is device and operating system agnostic (and free!). Make sure you get a Business Associate Agreement to achieve HIPAA compliance (although a safe harbor [waiver] exists during the current public health emergency).

Be Professional
I remind providers that they are health professionals, not creepy basement YouTubers. The following are small touches that make a big difference

  • Use good lighting. Cheap solutions are readily available on Amazon
  • Place your camera at eye level. Options include putting your laptop on a few reams of paper
  • Use a headset microphone. I like Sennheiser gaming headsets with noise-cancelling microphones
  • Select a bland background. If none is readily available, blow in a virtual background
  • Minimize environmental distractions. Under the current circumstances, that might include your kids and dog
  • Look into your camera often. That’s where your patient is, not elsewhere on your screen (even if that’s where they appear to be)

Documentation
Payment for telehealth requires that certain elements appear in your visit documentation. The following is the header of my charting templates, where *** are elements that are populated for each encounter

  • Date of Service: ***
  • Start Time: ***
  • End Time: ***
  • Type of Service: Evaluation and management (E/M)
  • Type of Encounter: Telehealth [or: Virtual health]
  • Mode of Transmission: Secure, synchronous, real-time audio and video communication via Vidyo
  • Originating Site: *** [patient location — city and state]
  • Distant Site: Minneapolis, Minn.
  • Basis for Service: Virtual health, in my judgment, is an appropriate and effective means for providing this service secondary to the current COVID-19 pandemic and the need for social distancing. I have previously seen the patient for traditional in-office care and consider their mental status, including the absence of imminent danger, amenable to virtual care

Good luck! ✸

Think Like a Health Plan

In one of my lives (I have a few), I serve as the medical director for a commercial health plan. My duties involve developing policies and reviewing claims. It’s the greatest job on earth if you love evidence-based medicine (which I do!). And it connects perfectly to another life: teaching EBM at the University of Minnesota, which I’ve been doing since 2004.

I’m pleased to return to St. Joseph’s Hospital, my former employer and postgraduate alma mater, on August 20th to discuss health insurance with the family residents.

This post contains my key teaching points and didactic materials.

Suggested Thought Process

  1. Is the health care service a covered benefit? (cf. benefit plan)
  2. Does the carrier have a policy concerning the health care service?
  3. In the absence of a specific policy, is the health care service medically necessary?
  4. Does the member (patient) and/or evidence meet criteria?

Benefit Plan

At a very high level, benefits are determined by the member’s benefit plan. Eligible services are subject to the plan’s terms, as often summarized in medical policies. Excluded services are not eligible for coverage and cannot be funded by the plan (doing so would violate a contact with the plan’s owner).

Medical Policies

Medical Necessity

Group Exercise

# # #

Demystifying Suboxone

Suboxone was approved by the FDA way back in October 2002. Nearly 17 years on, there’s finally growing interest in its use. Primary care providers are prescribing it. And some emergency medicine physicians. Hospital medicine seems to be the next frontier.

I’m pleased to be partnering with Allina Health’s hospitalists on education and order set creation. The latter includes a presentation at their annual CME conference, offered on a repeating basis on April 5th, April 10th, April 26th and May 2nd.

Hospitalists frequently care for patients following overdoses and other opioid-related misadventures—trauma, endocarditis, and so on. Buprenorphine is a very nifty widget in these circumstances.

Another common scenario is acute pain management for patients who take buprenorphine in the community. Pain control is neither hard nor complicated, so long as you follow a few simple rules.

Special thanks to Drs. Saul Singh and David Beddow for their partnership on this.

Additional Resources
Suboxone Dosing Guide [pocket reference]
Buprenorphine Therapy for Opioid Use Disorder [journal article]
Use of Medications in the Treatment of Addiction Involving Opioid Use  [pocket reference]
Buprenorphine: How to Use It Right [journal article]

Drinking Less = Longer Life

How much alcohol is too much? For years, we’ve been using numbers from the National Institute on Alcohol Abuse and Alcoholism (NIAAA). It defines low-risk drinking as:

  • Women
    No more than 3 drinks per day; and
    No more than 7 drinks per week
  • Men
    No more than 4 drinks per day; and
    No more than 14 drinks per week

where 1 drink = 14 grams of absolute or “pure” alcohol. This corresponds to 12 ounces of beer, 5 ounces of table wine or 1.5 ounces of distilled spirits (e.g., vodka).

us.standard_drinks
National Institute on Alcohol Abuse and Alcoholism

All that is about to change. A new study involving about 600,000 people found that drinking targets should be a lot lower—probably no more than 100 grams of alcohol per week. This corresponds to just 7 standard drinks.

The study found that people who consume more than 100 grams of alcohol per week had a higher risk of dying. They also had more heart attacks, strokes and other cardiovascular diseases.

Here’s the flip side: drinking less appears to add years to your life. For example, 40-year-olds increase their life expectancy by at least 1 year when they reduce alcohol intake from NIAAA’s current upper limits to no more than 100 grams per week.

I’ve loaded these data into my longest running PowerPoint slide deck (Slides 14–16) and am encouraging my students to change the advice they give to patients. Please pitch in and start spreading the word!

The Accidental Psychiatrist

I’m honored to be the keynote speaker at the Minnesota Academy of Family Physicians’ Spring Refresher. Here’s a fairly final version of my PowerPoint.

mafp_spring_refresher_2018_title_slide

The bulk of my presentation will be devoted to the systematic management of major depressive disorder. The STAR*D Study, which has only become more relevant over time, will provide the overall framework.

I’ll also be discussing suicide assessment and how to monitor various psychotropic medications.

SBIRT

I attended Hazelden Betty Ford’s Professionals in Residence (PIR) program in 2002. I started the week thinking I was going to be a family physician—I was a resident at the time—but was hooked on addiction (bad pun intended) by the end of the experience. And so began my odyssey to an eventual career in addiction medicine.

I returned to PIR as faculty in 2009 and have been teaching for the program ever since. I lecture on Screening, Brief Intervention & Referral to Treatment (SBIRT—not to be confused with Ernie and Bert!).

My slide set has evolved considerably over the years. This blog post contains the latest and arguably greatest.

sbirt_title_slide

The Medicine of Place

I recently stumbled upon The Medicine of Place in a coffee shop in St. Cloud, Minn. The authors, Jerry Hansen and Chuck Norwood, are local guys. In fact, Chuck works a few doors down at the Paramount Center for the Arts, where I connected with him a few days later. (I see patients at the Stearns County Jail, which is right around the corner.)

The book contains perennial wisdom and beautiful photographs, and is a reminder that there are still mystics among us. Consider the following page (click to enlarge):

Easy Essay CXCIV

The title is published by North Star Press, also in St. Cloud.

Many thanks to Curtis Weinrich, with North Star Press, and Chuck Norwood for permission to post the page above.

Predicting Death

I’ve been teaching evidence-based medicine at the University of Minnesota since 2004. I have a particular interest in evidence-based physical diagnosis; that is, the relative value of history and physical exam data for establishing and excluding disease. This is the realm of pretest probability, likelihood ratios and Bayes’ Theorem.

I reviewed the National Early Warning Score (NEWS) in my December 2017 column in Today’s Hospitalist (where I contribute a numbers-oriented piece every other months). NEWS is a deceptively simple mash-up of vital signs that accurately predicts 24-hour mortality. Low scores—which is where my interest lies—have exceedingly high negative predictive value (translation: very few people with low scores die).

Nerdy footnote: Please check out JAMA’s Rational Clinical Examination and Stephen McGee’s Evidence-Based Physical Diagnosis for more numbers for doctors.