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Free Telehealth Training

Allina Health is pleased to be partnering with the University of Minnesota’s Center for Practice Transformation on a free telehealth training this Friday, April 3rd, at 12 p.m. The webinar is an adaptation of trainings that John Sutherland, Ph.D., and I have been conducting at Allina in response to the Covid-19 pandemic.

I will cover a broad range of topics including the logistics of conducting a telehealth encounter. I will also address regulatory issues such as documentation requirements, exceptions to the Ryan Haight Act, deferred enforcement of HIPAA and waivers and modifications granted by the Minnesota Department of Human Services.

Please consider Zoom for Healthcare if you haven’t already landed on a telehealth platform. It is device and operating system agnostic, and many patients are already using it for other reasons (e.g., distance learning for their children). Solo practitioners and small groups are able to purchase licenses on a onesie-twosie basis through resellers. It is literally purchase and immediately practice.

Many thanks to Julie Rohovit, Ph.D., Joe Curtis and the whole gang at the Center for Practice Transformation for spinning up this webinar on very short notice. ✸

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! ✸

ECHO Wrap-Up

I appreciated the opportunity to discuss telehealth during today’s Project ECHO webinar. Here are some of the resources that I mentioned

Please contact me if you have any questions. ✸

Coronavirus Response

Our response to the novel coronavirus is based on recommendations from the Centers for Disease Control and Prevention and Minnesota Department of Health. Our primary strategies are:

A virtual visit is an online appointment that supports social distancing, that is, unnecessary, in-person contact with others. These visits occur via Zoom for Healthcare, a secure, HIPAA-compliant platform.

Please consider converting your existing in-office appointments to virtual visits. ✸

Going Dry

I recently participated in a panel discussion that explored how we talk about alcohol. It was a Sober Curious sequel, of sorts, that Peder Schweigert and Erin Kincheloe of Marvel Bar (cum Bachelor Farmer) pulled together.

Jana Shortal, the KARE 11 personality, moderated the discussion. The panelists were Julia Bainbridge, the acclaimed writer, Peder and me.

The event was professionally recorded and the resulting audio file is available here. ✸

Nicotine & Vaping WYNTK

I was in medical school when the Tobacco Master Settlement Agreement occurred. It was a major public health victory that was quickly eclipsed by the opioid epidemic.

But nicotine never really went away. If anything, it metastasized into more insidious social problems.

Teens have been trading traditional combustible cigarettes for “vaping.” Use of cigarettes and smokeless tobacco declined between 2011 and 2015. This was basically offset by a sharp increase in the use of e-cigarettes (1.5% to 16%) and hookahs (4.1% to 7.2%). The net net was no change in overall tobacco use (24.2% vs. 25.3%).

Severe vaping-related lung injury is just the latest wrinkle.

Top Right: Wes Thomsen (red shirt), Brad Hadsall (far camera) and Sylvia Juarez (near camera).

With this context in mind, I was in studio yesterday to shoot the third installment of Hazelden’s What You Need to Know series. Opioids and Meth packages are already available for purchase. Nicotine & Vaping, Alcohol and Cannabis packages can be preordered.

Many thanks to Wes Thomsen and his crew at Hazelden Publishing for involving me in this project. My previous appearances can be found here and here. ✸

Telehealth Suboxone

Methadone, the first evidence-based treatment for opioid addiction, appeared way back in 1965. In the years that followed, “methadone clinics” popped up in large cities that could financially support them. But most patients—especially those in greater Minnesota—were unable to access this potentially life-saving care.

The U.S. Food & Drug Administration attempted to remedy this health disparity by approving Suboxone in October 2002. The hope was that family physicians, internists and psychiatrists would prescribe it in their clinics, thereby creating broad access to addiction care.

Suboxone was originally available as a sublingual tablet. Source: CVS/pharmacy

Unfortunately, that idea was very slow to take off. Rural providers cited a range of barriers—time, risk, lack of ancillary mental health services—as reasons for not prescribing. As a result, Suboxone tends to be available through addiction medicine specialists (like me) who practice in large cities and are subject to federally-imposed patient limits.

About a year ago, Allina Health decided to take a different tack. We came up with a simple access strategy:

  • Addiction medicine specialists treat patients for opioid addiction via telehealth
  • Specialists transfer care to local primary care providers once patients are stable
  • Primary care providers can always consult with addiction medicine specialists or return patients to us if there are struggles
My telehealth studio (left). Laura Moldan, a nurse at New Ulm Medical Center, posing as a patient (top right). Provider interface (bottom right). Epic, the electronic health record, is running on the larger screen. Vidyo, the HIPAA-compliant audiovisual application, is active on the smaller screen. No protected health information (PHI) appears on the screens

The first provision addresses primary care providers’ concerns about treating active substance abusers. The second feature ensures that addiction medicine specialists always have capacity for new patients. The last design feature is how primary care interacts with every other medical specialty—cardiology, nephrology, endocrinology—when it comes to chronic disease management.

And it worked!

Our pilot program at New Ulm Medical Center, a critical access hospital, was a resounding success. We’re presently working to scale it to Allina’s entire service area. We’re also launching virtual visits next week, which will allow patients to be seen via their own smartphone or tablet.

All of this was a heavy lift by a committed team:

The view from my office on the 14th floor of the Medical Arts Building in downtown Minneapolis

The addiction medicine specialists are still located in a large city many hours from patients but distance is no longer a barrier to receiving care. ✸

✸ — ✸ — ✸

Postscript. I received a good question about the Ryan Haight Act. Our program is exempt from the in-person medical evaluation requirement as New Ulm Medical Center is a DEA-registered hospital. Please consult your compliance department or personal attorney about your particular clinical circumstances.

✸ — ✸ — ✸

Postscript. We launched virtual visits today (February 24th) as planned. The first patient lives near the Iowa border, two hours from both New Ulm Medical Center and the Twin Cities. The virtual visit saved him roughly four hours of driving for a 30 minute visit.

Sober Curious

I’m scheduled to appear on MPR News with Angela Davis this Friday, January 17th, at 11 a.m. I’ll be representing Allina Health in a live discussion about the sober curious movement (and here, here and here).

Peder Schweigert, the general manager of Marvel Bar, will also be in studio. He’s been a bartender for 15 years and about four years ago decided to stop drinking alcohol.

I’m occasionally asked if I have a personal history of addiction. I don’t but stopped drinking by my mid-30s before sober curious was a thing (I’m currently a week short of 50, so I’ve been “dry” for at least 15 years).

Some sober curious factoids appear below.

✸ ✸ ✸

“Would I be happier without booze? More productive? Would I feel more confident? What would it be like to never have to face another deadline half hungover? Would I be thinner if I didn’t drink? Look younger? Would I have less sex? More sex? Would the sex be better? Would I have anything to talk about at parties? Where would the glamour go? Would people think I was boring? Exactly how boring would I/life become? … I have termed this questioning as getting Sober Curious

  • Low-risk use: Consumption of alcohol or other drugs below the amount identified as hazardous, and use in circumstances not defined as hazardous
  • Hazardous use: Use that increases the risk for health consequences
  • Harmful use: Use with health consequences in the absence of addiction
  • Addiction: As per criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

According to the USDA, “If alcohol is consumed, it should be in moderation—up to one drink per day for women and up to two drinks per day for men—and only by adults of legal drinking age.” I think that recommendation is okay for women, however, the number should be one drink per day for men. Of note, “The level of consumption that minimises health loss is zero”

  • One U.S. Standard Drink contains 14 grams of alcohol. Examples include a 12-ounce can of beer, 5-ounce glass of table wine and 1.5 ounces of a distilled spirit like vodka
  • Alcohol provides 7 calories per gram. In contrast, carbohydrates (fiber, starch, sugar) and protein provide 4 calories, and fat 9
  • One 12-ounce bottle of beer provides 145 calories: 98 from alcohol and the rest from carbohydrates and protein

Drinking frequency (e.g., days per week) and intensity (e.g., drinks per day) has a “very small positive and marginally statistically significant effect” on body weight in men. There appears to be no relationship between alcohol consumption and body weight in women

Multiple studies have demonstrated that consuming alcohol in the evening “enhance[s] sleep onset but decrease[s] sleep continuity during the second half of the sleep period

“The available scientific research indicates that higher amounts of alcohol intake have an immediate short-term negative impact on the arousal and orgasm phases of the human sexual response cycle”

“Hangover symptoms are not just physical; they are cognitive as well. People with hangovers show delayed reaction times and difficulties with attention, concentration, and visual-spatial perception.” Veisalgia—the medical term for hangover—can be traced back to kvies (Norwegian), the “uneasiness following debauchery.” “Hangover is common and underdiagnosed and can have serious physical, psychiatric, and occupational consequences