Delivering Better Virtual Care: Improving Your Telehealth Skills

Hey, everybody. Thank you so much for being here and welcome. Thank you for joining us for our Osmosis webinar on delivering better virtual care, improving your telehealth skills. I'm Doctor Jessica Geida. I'm a Senior content Manager at Osmosis by Elsevier and clinically work as a board certified OBG. I'm located in the suburbs of Philadelphia and very excited to have you out here today. Well, go ahead and jump in as this is an important topic. As we all know or are learning since you're here today, telehealth is a core part of how we deliver care, but a lot of us don't receive formal training and how to do it well. So we'll learn how to build stronger patient connections, how to communicate more clearly and efficiently on video and how to avoid some of the more common mistakes that can impact the quality of care. And I think probably a lot of us have experience being on the patient end of delivering or of receiving telehealth care, but possibly less so on the delivering it. So if that is you, you're in the right place and we'll go ahead and get started. So, all right, so first and foremost, delivery or why this matters, telehealth patients expect a virtual option. So virtual care for good, better and different how you feel about it. It is here to stay. During COVID, actually during the pandemic, there was a 4330% increase in the use of telemedicine. And I think that COVID just kind of broke open that telemedicine world for for better for all of us. That being said, clinicians need to learn and practice to use telemedicine as a skill set. And these skills are teachable. Nobody's innately better at telehealth. They probably just have more experience with it. So today we'll focus on the skills that make telehealth effective from preparation and connection to adaptation and follow through and great virtual care. Just so everybody knows, it's less about the technology and more about how you connect with your patient and follow through that. All right. So before the visit, the most important thing before the visit is just setting yourself up so that the technology disappears and that excellent level of care that you provide comes through. All right. So first and foremost, you want camera lighting and posture these at least. Like when I was in training, if someone had said these things to me, I probably would have just brushed them off because at that point you're very much more focused on providing good clinical care. But hopefully you've got that part down and now you can focus on on these things that seem very surface level, but actually make a huge difference as you're delivering quality virtual care. So first and foremost, you want to have excellent camera and lighting. The best place to actually put a light is behind your computer. So as you can see here on the slide, the light is on the side of the desk and that's going to illuminate your face for your patient so that they can see you very clearly. If the light ends up behind you or even next to you, sometimes it can create an odd shadow. And while that's still going to give good care to your patient, just showing them who you are really does make a big difference in in my experience. Second, you want to make sure that your face and your head are in screen. Make sure that your face is centered and your shoulders are in screen too. And then in terms of posture, it's very important to have good posture and protect yourself. Otherwise long term you're going to be uncomfortable, possibly develop, muscular skeletal changes and that may prevent you from providing that excellent level of care. We've all been in situations where you're in the hospital or in the office and you put yourself in a weird position. I know me clinically as an OBGYN, I'm always in odd positions trying to get my speculum to work. But the good news, we don't do the speculum exam on telemedicine. So I can sit in a good posture where I'm sitting back fully. I actually have a little cushion for my low back here and then putting my feet flat on the ground. You can buy yourself a fancy chair so that if you're short me as well, your feet actually touch the ground. You also want to make sure that your screen is at eye level about an arm's length away and your shoulders are relaxed. Here I'm breaking my own rule. My elbows are not 90?, so I probably need a desk that's lower, but keeping my wrist neutral is helpful too. So all of those things you want to try and encompass and then really important. And I'm going to dive into that a little bit more in a few slides to stand, stretch and look away between visits. We'll, we'll get to that though. And if it seems something that you do or something that you're learning, go ahead and drop a heart. That's always good to know. All right, so next we have our tech and environment set up. Feel free to go ahead and screenshot this checklist for the future. I know if I'm watching webinars on my phone or something that I always to screenshot and save it to a a folder that I pin so I can go back and revisit it. Now for this first you want to focus on the audio and the connection so you can use a headset or headphones to cut echo. Again, breaking my rule here, but I created a nice little office space space for myself when I started virtual work and it has doors so the echo is in isn't very perceivable. But if you're in a big room or a shared space, using that audio, using that headset or headphones can be really helpful. Also great to run a quick mic and camera check before you get started with your telehealth session for the day. And you can either use wired or very strong Wi-Fi. I took my oral board exams virtually and took them on our second floor where I had my office at the time. So actually bought a 70 foot wired cable for my Wi-Fi because I was absolutely not going to drop it in the middle of my exam and have to restart. So I have it now and I can use it when needed for telemedicine purposes. 2nd, be sure that you understand the platform, know where mute is, where the video is, and the screen share. It's also good to practice with some practice patients just setting up the invite and the waiting room flow in advance. So that way you're not struggling in real time with your patient on the telemedicine platform trying to figure out where's that button and how do I do this? How do I do that? Taking just that extra 3 minutes to get familiar with it is very helpful. And then always have a backup plan in place. You want to keep your patient's phone number handy and continue by phone if for some reason the video does drop. The goal again is for the patient to notice you and not the technology. So here again is that connection checklist. Can they see me? Can they hear me? Can they use the platform? And then what's the backup plan? All right, next we want to make sure that this video is or this video, this visit is right for video. So how you can do that is by going through this checklist and seeing, why they made the appointment and if their history of present illness is accessible. But this is probably one of the most important safety topics for beginners. The number one new provider mistake is forcing something onto video that needs actually hand on, hands on care. So really good examples of what's appropriate for telehealth are medication refills and management going over results, behavioral health follow-ups, routine follow-ups, and then minor issues a skin rash or insect bites, things that you can really see well on camera in the middle here in yellow, we have cautionary ones. So maybe new or worsening symptoms, pain that really goes out of that, mild, I would even say into the moderate where you want to get a hands on exam is probably not appropriate for telemedicine if either for the patient or for yourself. It's hard to visualize or understand one another. And if your patient needs vitals, labs or hands on exam, they should come in for that. Always, always, always to if you're uncertain about something and you think the diagnosis, but you want to run, one or two in person tests or whatever it is, never be afraid to convert to an in person visit. Telemedicine is great in that it's very accessible for people and convenient, but it should never replace that hands on relationship, which brings us to things that should absolutely stop you from doing a telemedicine visit. And these are things chest pain, abdominal pain, severe symptoms respiratory distress or neurologic distress. And always in an unstable or severely I'll patient, it's always good to make sure that where your patient is. So for instance, I'm in Pennsylvania, I'm licensed in Pennsylvania. So my patients that I'm providing care for need to be in Pennsylvania. And the reason for that is if there is one of these emergencies where you log on to a telehealth visit and your patient is having unstable symptoms, it's the worst headache of their life. You can go quickly and know where the correct location to advise them to go is, wherever that nearest emergency room is. You might be able to call ahead and give a report to the, accepting emergency room physician or something that. Versus if your patient is on vacation, say, and they're in Colorado. I don't, I don't know where any of the hospitals are in Colorado. So it's, it's probably not a great idea for me to, well, legally I can't. And it's also not a great idea for me to be providing care for someone out of state. But those are things nobody really tells you when you start out. So I'm gonna, I'm telling you now. So now And again, I hinted too, we want to route patients to the right care. So screening for where your patients are scheduled and what they're scheduled for actually starts at the scheduling. If you have a good office manager and front office staff, they're going to be able to know red flag symptoms. And maybe that's something you come up with together for a checklist of things that should and shouldn't be scheduled for telemedicine so that these urgent cases are routed to in person or emergency care. When in doubt, again, convert. It is always acceptable to start virtual and then refer the patient if your exam, your diagnosis, just your gut feeling feels off. The goal is to give every patient the right level of care. All right, let's move on to the visit itself. So here we are. During the visit again. We want to connect, examine, and document, but we want to do it while maintaining the heart of virtual care. OK, this is probably my, my favorite slide because the 1st 30 seconds of connection with a patient, especially a new patient on a telemedicine platform are so important. In that first 30 seconds, you want to welcome them. You want to introduce yourself and then greet the patient by name. I personally to just in the beginning of the day, go through my, senses of patience that I have right down Mrs. Smith, Mr. Smith. That way I know their name as soon as we log on. And I'll even put it in a little post it note on my laptop, an actual post it note and stick it on that way I have it. And I'm not searching through the chart and being, oh gosh, who am I seeing today? Like, oh, it's so nice to meet you. We all know how that feels and we've certainly all done that to patients when you're in a rush and just pulled in. But if you have the time and you can make it, knowing who you're seeing, knowing their name and introducing yourself and greeting them truly makes a big difference. Next, you want to explain the steps of the visit. A lot of times, when you're in person, patients can pick up on those body language and subconscious cues, but sometimes that doesn't come across on telemedicine. So actually walking them through that verbally is very helpful. And then another thing that I found is helpful too is checking with your patient that the video is working and the audio is working. There is almost nothing more awkward than when you're the patient and your providers just going on and you can't hear them or you can't see them. And it's so a, such a weird position to be in to be, I'm so sorry. I just missed the last five minutes of what you said because the technology wasn't working. So I find that on the provider side, being the one to call that out and saying, Misses Smith, can you, can you reassure me? The video is working, the audio is working. That takes that awkwardness away and just confirms that you can put your, your full attention and your focus on this patient interaction, which brings us to focus. So behind the patient interaction, which you guys can't see on my screen, but I have two monitors up. I only have our presentation up. I don't have my messaging browser up. I don't have, the patient chat up. I don't have anything else that I need or that I don't need up because if I can get distracted, I will. So I want to make sure that focus is right where it needs to be, which for today is on you guys. So when I start the appointment, I always smile, I always make eye contact. Also, you want to try and make eye contact with the camera. And it's, it's kind of funny because if you're charting on another monitor, which I said, I have two over here. If I'm charting over here and I'm looking at my patient, which my video might be over here, but to them it kind of looks I'm looking off into space. Like is she paying attention to me? I don't know. Is she looking at something else going on and totally distracted? So if I'm looking right at this video camera, I'm paying attention to you and it's just a little subtle shift that can really make a big difference. Always greet and introduce yourself, explain the appointment, check your technology, things that you want to try to avoid doing, looking down or away from the patient, being distracted, not greeting them or introducing yourself, not giving clear direction and then focusing on the patient complaint instead of the entire picture of the patient. And just remember, that warm human connection matters even more on video. So really taking that time to go ahead and be fully present is key. And it's really what's going to make your telehealth skills stand out to your patients. On to the the privacy, the consent and the documentation. So you always want to make sure you're in a private space, A quiet space, using a HIPAA compliant platform, that you've reviewed consent and that you've documented it, and that all the key visit details are documented too. It's OK to ask patients to use headphones if you can't hear them well. Make sure that you have a backup plan in case the video crashes. Remind patients always too, that they're in control. They can stop the video anytime and then make a specific note of consent to continue. I always love to share the story of when I first started out with telemedicine. We were in a a rental and I had a door behind me and I was doing a mental health check in with a postpartum patient and all of a sudden the door on the camera, the video screen just started creaking open. It was my cat. She came in, but my patient couldn't see that from the view. And so I was mortified that she thought another person was entering this sacred space that we had created. And so ever since then, I always make sure I face the doors so I know what's happening behind me. Having, one last thing that could go wrong is is really important and also not breaking that special place of a provider patient relationship. So just certain things to keep in mind as you are providing excellent telehealth. Also make sure that you document it because you always want to make sure if you look back, this was a telehealth visit and not an in person one in case certain things are different on your documentation or you need that for reference. And then, oh, the last thing I wanted to mention too was for the backup plan, make sure with your office manager and your patient knows who's going to call the patient back. Like if this video closes and you have 15 other patients scheduled and it shuts down 5 minutes before the video or before the appointment ends, you might not have time to call the patient back and do your final wrap up because your next patient is waiting. So make sure that's ironed out with your office manager or front office desk staff, whomever that is, that would be calling the patient back instead of you if it's not going to be you. All right, next we're going to move on to website manner and specifically website manner that translates. So you want to face and look the camera, create that sense of eye contact, use warm kind of tones and facial expressions. I tend to over exaggerate my tones a little bit on camera just so it really does come through. Again, patients aren't able to see your whole body. They can't perceive your non verbal communication. Am I facing the patient? Am I facing away? All of those things kind of fall to the wayside on telemedicine. So being a little bit extra in the things that you can control never hurts. Be present. You can lean in and then just keep an attentive expression, acknowledge that they're a human being on the other side of the screen and keep, if you can a neutral background, quiet and uncluttered without any movement, a cat coming in. Interestingly, I always to show this, if I were to tilt my camera this way, you can see that I have a very clean picture behind me and it comes across as a very professional put together background versus if I tilt it this way, you can see my junk corner with my my printer and all the, the different stuff that I have going on. So finding that nice neutral that lets your patient know this is a professional service. For me does make a big difference. Things to avoid if you can, looking at another screen, typing or checking messages, using a big a busy background and rushing the conversation. One thing I do want to shout out here is if you are typing, which you do have to document and patients know that or you have to look something up, just let them know that because the pause when you're on camera, A, it can sometimes be a little bit of a lag, and then B, it just feels so much longer than it actually is. So just let your patient know. Be, hey, Misses Smith, I'm going to take a second to look up this drug interaction. I'm not ignoring you. I'm just looking at this other screen over here. And that kind of takes away that awkwardness of it. You want that empathy, clarity and being present to really come through because ultimately, patients are going to remember how you made them feel, but they might not remember exactly what you said. And then just listening actively to nodding, using verbal affirmations, pausing a beat before replying. These are all these little subtle imperceptible differences that really make providing telehealth and providing telemedicine care go from average to exceptional. And what's going to bring your patients back for more. Another key part of telemedicine is adaptation and adapting the clinical exam to fit telemedicine environment. So what you can do virtually, you can always look at your patient. You can note the appearance of any rashes, swelling, wounds. For me as an OBGYNI might be able to evaluate somebody's C-section scar for any infection. Alternatively, if I don't have good lighting, the patient doesn't have someone to help show that scar or I need to evaluate for systemic signs or symptoms of infection. Rule out anything going on that needs a internal pelvic exam. Sam, I'm OK to transition that and have my patient come in and tell them this isn't appropriate, but if I can do it on camera, I'm I would love to try. So you can always listen to to how your patient's breathing sounds, what their cough might sound and how their speech sounds. Those can be really big cues into what's going on. You can also ask the patient to reposition or press to guide you. I'm breaking my own rule and checking a slack message. But Nope that was an old one so sorry about that. See I should turn that off. That's why you should get rid of all distractions. I actually usually leave my phone in the other room, so I'm completely focused on what I'm doing. But getting back to listening, you can listen. You can hear their breathing, their coughs, how their speech sounds. You can also ask the patient to reposition or press to guide you. If you're evaluating someone for sinusitis, you might say take your two fingers and put them under your eyes here. And then just give a little bit of soft pressure and ask them, does that hurt? Do you feel pain radiating anywhere else? Does it feel better when you do this and things that to assess? If you were assessing the abdomen for guarding or rebound, those are things that you probably want to do in person. And so you'd redirect them to an urgent care or the emergency room or your office if if appropriate. It's also OK to use home tech. So blood pressure cuffs, thermometers, pulse oximeters. We do a lot of virtual care in OBGYN that way. So blood pressure management, preeclampsia, things that. We can have our patients trend their blood pressures and then go over those readings virtually. So we can adjust medications and things that. And it's really nice because it saves the patient from having to come into the office, possibly with a newborn, maybe with a newborn in other children instead, they can just log on from the comfort of their couch while hopefully baby's sleeping. Ultimately, though, you want to make sure that the telemedicine setting is appropriate. So always know the limits, know when to escalate. And again, just to reiterate it, it's never a failure if you start virtual and then convert to in person. It's actually really good clinical judgement. OK, and then on to troubleshooting, specifically troubleshooting in real time. So first prepare. Know the call back number for your patient. Let them know too. If we lose video, I'm either going to call you back or if it's the last 10 minutes of the appointment, my office manager will call you back to reschedule or close the loop in communication. . Also make sure that you communicate. So stay calm. You set the tone for how the visits going to go. If you're panicked and frantic, your patients going to pick up on that and they may kind of mirror that or they might lose confidence in you as a provider on telemedicine and not want to do that in the future. So just staying calm kind of troubleshooting in, in real time is very helpful. You can also let the patient just know what's happening. If they can't see you, but they can hear you, you can say, OK, Misses Smith, I, I, I can't see you either, but I'm working on it right now. I'm so glad we can at least hear each other. Let's give it two or three more minutes. If this doesn't resolve, then I'm going to actually end the call and call you and we'll just go over the rest of the visit from here and reschedule. Reassure them everybody knows technology is glitchy. Those glitches are normal. Just name the next step so that the patient isn't left guessing. If you freeze, let them know they can end the video and they can try and come back into the waiting room or however it works. Just I feel communication and that closed loop communication really, really shows that you're going the extra mile in telemedicine specifically if there's any quick fixes to so that audio switch to the phone, frozen video refresh or rejoin and a lag, just pause and simplify it. And then if tech blocks safe care, always, always, always move to in person visit. All right, that's perfect. And I said, to make sure you let let the office know what the plan is for moving forward because chances are you probably have a bunch of visits in a row. One thing too, a lot of telemedicine doesn't really take into account is adapting for accessibility. So that's one of the actual coolest things that you can do in a telemedicine atmosphere is adapt for it. If your patient needs any access or accommodation, make sure that that's done before the appointment and how to access it. You can prepare accessible elements and provide those documentations too. So for hearing, you can use captions. If they maybe read lips and they're a little bit hard of hearing, you can face the camera and just enunciate very clearly. Make sure you're keeping both sides in a quiet space too. For vision, you can describe what you're doing. You can also use high contrast visuals and large text. For instance, white text on a black screen is usually easier to see than black text on a white screen. So just even something so simple as switching those two. And then you can also provide accessible documents for patients to review after the visit's over in terms of language, using interpreter services, using plain languages or using plain language and short sentences and then using a teach back method of checking understanding is, is very important as well. For extra support patients, you can allow longer appointment times, include caregivers with consent from the patient and adjust the pace as needed. You may also just have to break a visit into or a problem into several different visits to adjust all of it if extra time is necessary, but you don't have that in your schedule. Ultimately, though, your patients may not appear to have disabilities or need adapting for accessibility, but you're not going to know if you don't ask them. So be sure that's on a screening questionnaire or something when they're getting started with you. All right now we're finally at after the visit. And as we all know, the care does not end when we close the visit. So let's jump in and see how we can wrap up. Well, first summarize the key decisions made. You can use that teach back method to verify your next steps. Let them know I'm going to book your next appointment or someone from the office will call you to schedule your next appointment. Tell them where to go for labs and imaging, all of that that your front office staff or your medical assistant might do in the office setting you're responsible for in a telemedicine setting. So just remembering how that teamwork works and then closing off those loops for yourself. Make sure that you complete documentation, try and finish your notes the same day. That way they don't pile up and then close out orders and make sure that you route results and communications. And also just let your patient know. Like a lot of times you might close out the visit and then be running to the next one, whether that's in, in real time running or running virtually on telemedicine. But your patient might be waiting for that antibiotic to go to the pharmacy, they might be expecting it. And then if you don't tell them I have three more visits and then I'm going to send it or I'll send it while I'm on the the video platform with you, they're not going to know. So just communicating that is is something that makes telemedicine run a bit more smoothly. You can also send the visit summary, share the instructions and educational materials, and then send referrals and prescriptions too. And then finally, you want to build a safety net. So any return precautions, be sure to review those offer when and where to seek urgent care and then schedule that follow up visit too. And we all know this part is kind of the least fun, but it is how you continue to make sure that that care is provided after the screen goes dark. So you just got to do it all right. Here we are for the that side to loop back into the posture and the camera in the very beginning. So caring for yourself on camera, something most of us probably ignore but need to be better at, myself included. First, you want to protect your eyes. So follow the 20/20/20 rule. Every 20 minutes, look 20 feet away for 20 seconds. If you can put your computer by a window, you might just turn your head every so often and look into the distance. That's really good for your eyes to kind of defocus from being so close up. You also want to protect your focus. So right now I'm presenting to you, all of you, and I actually have myself view hidden so that I'm not focusing on myself. I'm not analyzing myself. I'm just giving this presentation. You want to reduce distraction, silence your phone and close any tabs or apps. Also protect your body. Sitting is the new smoking and sitting and smoking are just not great for you. So stand up regularly, move and stretch to reset, give yourself time between appointments to do that. It it's hard because in telemedicine you think, oh, I'm going to have more time, but you actually still need to build in those 5 to 10 minute breaks so that you can go eat something, you can go to the bathroom, whatever it is that you need to do. Just make sure you're protecting your body and then also protect your boundaries. Start and stop each call with intention. Build that start and end of the day so that you're off work. When it's the weekend and I'm done working, I close the doors to my office. I don't keep that open. I don't want to accidentally wander in here and start working on a task on, on a Saturday and then my kids are, mommy, come play and I'm in here doing work just because it's convenient to me. And I know we've all done that. So really setting those boundaries is key. Take breaks, step away and rest when you can and don't work through lunch. Make sure you take a break and eat because even if you're not running in the hospital or running in clinic, you are still going and giving a lot of effort to your patients and care. And that requires nourishment for yourself as well. All right, So here are key takeaways. They range from preparing, connecting, and adapting to protecting, following through, and sustaining. Ultimately, though, telehealth is a skill. It can be learned. It can be practiced. It can be improved. Great virtual care is less about the technology and more about how you prepare, connect, adapt, protect and follow through. I won't go through each of these again just because we spent a lot of time on it and I want to leave room for the question and answer, but if you want to screenshot this slide as well, feel free. I'll give you a second to do that and then we'll move on to questions. So any question here is appropriate. There is no question that is too small. Our goal is to make virtual care work for you and your patients. And then I just want to do a little shout out here. Thank you to Osmosis for allowing me to present this topic that I'm passionate about. And thank you to all of you for taking the time to tune in and deliver better virtual care. As a thank you, we want to offer 15% off for Osmosis for a subscription for attending today's webinar. And then also you can find this recording at osmosis.org with a\ events. The recording will be available early next week and you'll you'll get that e-mail reminder when it's live. All right, I'm going to stop sharing my screen so I can get to your guys questions here. And I'm going to do these in somewhat of a rapid fire succession so that we can hopefully get through them all. All right. So first, do you have any advice on managing diagnostic uncertainty in telemedicine in particular relevant for our out of hours clinical assessment services which are usually delivered by phone or video call? So yes, if you have diagnostic uncertainty, if there is something that you are not sure on, it is always better to move that care from virtual to in person. If it's in off hours, the weekend when your clinic might not be open, it's OK to tell the patient listen, I think XY or Z is going on, but I want to make sure AB and C aren't also happening. I need you to go to the nearest urgent care or the nearest emergency room, whatever it is that that level of care you think they need, it is appropriate to do that. They might be upset by that. That's OK. Your job is to provide safe and sound evidence based care. If you can do it in this virtual platform, all the better. But it's OK to have those human limitations too. Are there any recommended AI tools for telehealth? So something I've been playing a lot with is playing around a lot with is using an AI scribe. I actually just learned that open evidence, which is free for anybody with NPI number, has an AI scribe tool which it listens in as long as you and your patient give consent for it and helps you write the note. But then I found out this extra cool part. It can actually give recommendations. So, say you're reviewing your patients family medical history and they come back and they have, yeah, I don't know, I'm just thinking of something off the top of my head family history of breast cancer. The AI can actually listen in and say this patient should go for advanced genetic screening and pull the recommendation for where that comes. So A, it's a great tool for speeding up documentation and B, it'll, it might introduce extra clinical things that in real time you might not think of while you're still in the visit with your patient. And this can help save sending those extra messages or having patients come back in for additional blood work, lab tests, referrals, whatever it is from happening again in the future. I also think there's some cool gadgets and gizmos and things that, which saying that makes me sound super old. But one of the ones I was thinking about was an aura ring which I wear. And from an OBGYN standpoint, it tracks your temperature, your heart rate, all kinds of things. It can actually be used to help track fertility too. And there's tons of different AI incorporated apps and things. So if your patients are utilizing those and there's one that you over another, you can always recommend that to them. And then they might even be able to hold up their phone and show you their cycle tracking, show you all that information. Of course, if these these apps integrated into our Emrs, that would be even better. A lot of times they don't. So you can just, copy and paste it into your note later, but always make sure you get that that consent from your patients too. But I think AI is, I mean, I think we can all agree it's here to stay. So we may as well learn to work with it and let it help us then kind of ignoring it. The next question here is can home healthcare assistance conduct telemedicine? I think they can be a part of telemedicine. I think that probably the goal of a home healthcare assistant is to actually go and assess the home environment that the patient is in, in which case they most likely need to be in person, but they can certainly help and participate in a telemedicine visit with your patient and you leading it. Again, in terms of OBGYN, we might have a home healthcare nurse go out and check a patient's blood pressure. If it's high, they're going to page us. And then if we set up a telemedicine appointment and they're still there, they can be there and help communicate any concerns to you as a provider. I don't know that they could independently do those types of visits. So if kind of that's where that was next question we have, we have a what strategies can clinicians use to build rapport and trust quickly during virtual visits, particularly with new patients. So that's where that first 30 seconds slide comes in. And something I to do or a lot is give 5 to 7 minutes in the beginning of a new patient interaction and just get to know your patient, find out where they're from, what their hobbies might be, what's bringing them in. Do you guys have anything in common to relate to? And then that kind of gives that personal feel. And it is personal. So that's why it gives that feel to the telemedicine space, if you think about it. Like an in person visit, they're going to interact with your the front office staff, they're going to interact with a medical assistant, maybe a nurse, maybe a medical student or resident, and then they're going to interact with you. So that warm up. For getting your patient comfortable and trusting and establishing that rapport isn't there on telemedicine. So building it in as best you can really does help to establish that trust quickly, especially for your new patients. Next question is, will virtual care ever replace real appointments? I don't know. I mean, I think that there's definitely room for virtual care to continue growing and it, it does improve accessibility to care, especially for people in rural areas that might not be able to get into the office. I think it's great for that one side that has all of the green areas that are, these are go to appointments for virtual care. For instance, I had a consult with a patient or I was the patient. I had a consult with a physician recently and they ordered a bunch of blood work for me and they were, I'll just call you after we can go over the results. And I told the the doc I was, why don't we do a telemedicine visit? That way you get reimbursed for your time and your expertise in explaining these results to me. And I feel that, but patient provider connection, it's not just a quick, your labs are normal send, it's not a quick phone call between patients. You actually get the dedicated time in your schedule and that's better for you as the provider and it's better for your patient too. So I don't think that, there's always I would never deliver a baby virtually, that's silly. But there's ways to incorporate telemedicine for every specialty, I think, and that's only going to increase access for patients. But I don't think it'll ever take the place of in person appointments and that, that type of care. But I don't know, we'll see. Can telemedicine work in an area where Internet connection is unstable? I think that that's probably tough because if your Internet or your patience is constantly going in and out, that's going to interrupt that patient provider relationship and probably not make for delivering the best care that you can on telemedicine. So in that case, it might be better to if your patient can travel to a place with stable Internet or if you have poor Internet where you are, get just a a hard plug in to ensure the highest quality of care possible. How can clinicians effectively manage virtual visit fatigue while maintaining patient engagement and clinical quality throughout the day? Schedule your breaks. Don't take those breaks as a nice to have or, let me just squeeze in one more patient, one more message, one more thing. Schedule those in, give yourself over lunch, 30 minutes, an hour, crazy. But taking that time and whether it's doing the 20/20/20, I have a window next to me looking out the window for 5 minutes, set the timer. Like really just do it. Let your brain kind of Daydream or whatever it is that you to do when you look out the window. But that's protecting your mental space. Maybe I stand up while I do it. I do some stretches while I'm doing it, protecting my body, protecting my brain, just all of it. So really, really make sure you prioritize your health. And that goes for virtual care as well as in person care. You can't perform a robot as a clinician. Like you are human. You're allowed to take these human breaks. Do that on telemedicine too. Next question, are there any healthcare specialities where telemedicine is not appropriate? I think it probably is less specialty dependent and more situation or clinical presentation dependent. So in things that you want or rather need to assess in real life or in real time person, those patients are not appropriate for telemedicine. If somebody calls me and says they have chest pain or the worst headache of their life, they lost vision, whatever it is a very serious high risk complaint, they need to go to the emergency room. I'm not going to evaluate that on telemedicine, A, because that's not appropriate for me. And then B, it's not appropriate for the patient either. They need to go get checked out by somebody in, in real time, not via the computer. And so those those specialties emergency medicine, labor and delivery, things that, probably not great for telemedicine, but we can extrapolate things from that and maybe do a follow up from the ER to go over your labs and imaging on telemedicine, maybe that blood pressure check for, your postpartum patient, things that. And I think the more creative and out-of-the-box we get as clinicians, the better care we're going to be able to deliver long term to our patients too. And then if you could change one aspect of current telehealth practices to most significantly improve patient outcomes, what would it be and why? Well, that's a good one. One aspect of it, I think probably it's a loaded one, but getting insurance companies on board with telemedicine if there are things that they don't currently cover for telemedicine, making that more of a streamlined standard process. Whether that's the patient needs to come in once a year for a visit and then the rest of the visits can be telemedicine if that is what works for you and them or something along those lines. But basically anything that makes delivering care easier and more efficient and better for you is going to make it better for your patients too. I know on the patient side, I just love being able to log on to a visit from my car or while I'm waiting for daycare, pick up, whatever it is that is so convenient for me. And it makes my follow through on things much better because nobody has time to go see their doctor and doctors especially don't have time to go see their doctor. So if you can do it on telemed, that's excellent. And if we can get insurance to pay for it, 100%, let's do it. All right, Ever. And that brings us to the end of this webinar. Thank you guys so much for joining and for your thoughtful questions and your comments. To watch this or other webinar recordings or register for future events, go to www.osmosis.org. Dash\ events. The recording of this event will be available to view early next week, and we'll e-mail you when it's live. Hi, thanks for having me helping current and future clinicians focus, learn, retain and thrive. Learn more.