Health care from home! Local Northern Michigan physicians share what you need to know to utilize telehealth services— from the technology required to best practices and protocols.
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While telehealth isn’t new, its uses and applications are constantly changing, and that can be, well, overwhelming at times. When should you call in versus walk into your clinic? What level of service can you expect remotely? It can be a lot to sort out, especially if you’re already under the weather.
We caught up with Dr. David Klee, MD, who specializes in family and emergency medicine at Munson Family Practice Center in Traverse City and the Emergency Physicians Medical Group in Cadillac, and Dr. Kelly Flynn, DO, a family medicine physician at McLaren Northern Michigan’s Mitchell Park Family Medicine in Petoskey, to hear about how they use telehealth in their practice.
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Most people see a primary care physician, whether it’s for an annual check-up or a symptom they’re concerned about. How are you using telehealth to manage that process in a way that works for both you and your patients?
Dr. Klee: Many of the patients we see through video have symptoms consistent with Covid, and to reduce potential risk of spreading that within our building, we’ll triage them and see them through video to decide whether they need Covid testing. Beyond that scenario, there are a lot of medical issues that can be managed very well through video connections, such as mental health issues. I think it works really nicely for this situation. We don’t have to wear masks. The patient can be in a place of comfort—whether it’s in their house or the car or wherever they feel like they can talk freely. I think that opens up better dialogues than it does sometimes within the office. We also do Medicare wellness exams and can manage a lot of preventive issues with our patients who are 65 and older and are at higher risk of getting infections coming into the office.
Dr. Flynn: It’s really helped connect people who wouldn’t typically come in for an appointment—people who have certain health conditions that make it hard for them to get in to the typical physical office space, people with transportation issues or mental health issues. It’s really just opened up the door for a lot of people. It’s great for things like doing a Medicare wellness exam, which is a yearly exam that patients over the age of 65 on Medicare are able to participate in that doesn’t require any sort of physical exam.
What’s your protocol for when a visit can/should be done via telehealth and when a patient should see a doctor in person?
Dr. Klee: I think the biggest question is how much of the physical exam is needed to make the diagnosis. You’re taught in medical school that 90 percent of your diagnosis comes from history, and you can obtain history just fine over video. There’s some good evidence that chronic medical care can be managed nicely through video, things like diabetes or hypertension. If patients have home blood pressure monitors—and we know that home readings are even more accurate than in-office readings—and we can have that data, then we can manage most of that through video. Musculoskeletal issues are harder to do over video though: Actually feeling somebody’s knee or examining their abdomen because they’re having acute belly pain—those are things that we need them to come into the office to do.
Dr. Flynn: At McLaren, we’re not having patients that are experiencing Covid symptoms come physically into the office. We always see them first in a telehealth appointment and assess them that way and then decide if they need an in-person evaluation or if they need testing, imaging labs or any sort of treatment. So that’s what telehealth is best used for—to assess. But there are so many limitations with it. If it’s something that requires a physical exam, like an injury or a skin rash or you fell and hurt yourself, you should be seen in person. We can’t always make, in my opinion, an appropriate diagnosis through video because you don’t have a physical exam component with telehealth. I still feel people should be seen physically in the office at least once a year; twice a year if you’re on any prescription medication.
Photo by Courtsey of Dr. Kelly Flynn
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How do you work with telehealth to create the same care and focus a patient would get in the office?
Dr. Klee: That’s a good question. One of the things that develops rapport with your provider is one-on-one time and connection. I think, right now, the fact that we have to wear masks, and the patient has to wear masks, that breaks down some of that normal communication we have through reading people’s facial expressions and body expressions. Over video, we’re able to maintain some of those more normal nonverbal communications. I also think it’s easier for us to stay on time when we’re seeing video patients, because we’re otherwise relying on our staff to have the patient roomed and they’re being pulled to get vaccines or run EKGs or do other things that sometimes delay us. So often my schedule runs more smoothly when I’m doing a full day of video patients than it does in the office.
Dr. Flynn: We all have training as far as keeping eye contact with the patient, where to look at the camera, that sort of thing. I think people feel less vulnerable
when they’re in their own home and they sometimes share different things. I’ve found it useful, too, that people will bring their medication bottles right up when I ask, “What are you taking?” “When are you due for a refill?” They can just grab their bottle really quick, which is nice.
What technology do patients need to properly utilize telehealth?
Dr. Klee: We use an app called Doxy.me that sends a link to a patient’s smartphone and all they have to do is click on the link and it connects directly to us—they don’t have to download anything else. We can also send [the link] to somebody’s home computer through email if their computer has video capabilities. One of the issues that we do run into in Northern Michi- gan is connectivity problems. If you’re in an area where you don’t have good cell coverage or you don’t have good internet coverage, that makes it more difficult. There are places like a public library parking lot where people can go and freely access the internet. So, there are ways to combat that, but that’s probably our biggest struggle. We do have some patients that don’t have those technology resources at home. We can accomplish some things over just a telephone visit, but otherwise we’ll bring patients into the office.
Dr. Flynn: McLaren has an app—McLaren- Now—that the patient downloads that’s internet-based and we go on and connect to them that way.
Photo by Courtesy of Dr. David Klee
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What kind of feedback have you received from patients about their telehealth experience?
Dr. Klee: We’ve actually done some research projects over the past year that we’ve presented regionally looking at providers, thoughts about how well this platform of video visits works, what type of patient or conditions it works best with, and then also on the patient side. Both have shown this is a positive—for patients, you can take your appointment from wherever you are. If you’re at work, you can step out. You don’t have to take a half-day off to come to the doctor. You don’t have to travel if you’re living 30 minutes away—you can just jump on right from your home. It’s convenient.
Dr. Flynn: I think it’s been good. But when there are connectivity issues, it’s very frustrating for patients. Some people who are not very comfortable with technology will have family members with them, which works really well actually, because then I can talk to the patient and the family at the same time. And then there’s not having to travel—we serve a wide area up here. There are people who were traveling from the U.P. to see us, so that they do not have to do that every time is nice.
Do you see the emergence and popularity of telehealth as a positive?
Dr. Klee: Yeah, I think it really is a positive. One of the things that we’re working at is becoming as patient-centered as we can. Typically, patients have had to follow whatever works best for the clinic and the provider and that’s how things are done. But with the patient-centered approach, if we have somebody that has anxiety and feels like they can’t leave home or they’re having difficulties with transportation, a video works really well in those situations.
Dr. Flynn: I think so. I think it’s here to stay. Patients like it, but there are definite downsides. A lot of insurance companies and pharmacies like Walgreens offer visits that are telehealth-based, and I think sometimes patients really should be seen in person. Like for urinary tract infections, they need their urine tested and that sort of thing. I’ve certainly had things that are not correctly managed, so there are just those components. But for the most part, I hope it stays because there are benefits to it.
Allison Jarrell is the managing editor of Traverse Magazine. You can reach her at allison@mynorth.com.
