My name is Carolyn Millett. I'm staff with the Academy, and I am your sort of staff liaison, staff host for the collaboration. Today is our first real collaborative meeting for the MSK Telehealth Practice Collaborative. I'm going to go through our agenda for today. As I think you know, the theme for today's meeting is physical exam. Our first component of today's meeting is going to be a review of the telehealth survey, and I'm just going to go over kind of quick, high-level response overview. Then we're going to move into a panel discussion with two physicians from the collaborative, Dr. Haley Robbins and Dr. Michael Weinberg. Then after they're done presenting, we'll go ahead and open a Q&A and collaborative sharing and kind of ask you all to ask questions, share similar learnings, things along those lines. Then the second half of our meeting, we're going to go into some breakout rooms. Those breakout rooms are going to be body area-specific, so we're hoping that each of you will kind of speak to issues related to specific body areas that were identified in the goal survey. Then we'll do a quick report back where you can share some of the key learnings from your breakout group discussion. Again, if everyone could mute their computers for at least the beginning of this session, that'll make sure we have minimal background noise. At the conclusion of this meeting, we are going to review a couple next steps. I'm going to talk through some FIS forum resources, and then we'll talk about our March collaborative meeting. So, just a reminder, I shared this slide in our December kickoff meeting. The green arrow suggests exactly where we are in our collaborative process. We kicked things off with our December kickoff and improvement selection survey, and then January is our first collaborative call. We'll have our second collaborative call on March 9th, and following that call a couple weeks later, probably around the end of March or early April, you'll receive an exit survey, which is similar to the baseline survey we did at the beginning of the pilot of the program. That exit survey is going to be a key part of what we send to ABPMR in order to make sure that you all can get credit for participation. Carolyn, your screen is not showing what you're talking about at the moment. Oh, I'm very sorry. Hang on one second. Thanks for letting me know. Let's try that again. All right. Are you all seeing a slide deck now? Yes. Wonderful. Okay. Thank you for letting me know. Okay. So that's just the timeline that I was referring to. So the first thing that I wanted to go over today is our goal selection survey. So this selection survey was something that was sent to you all in late December, and most of you completed it early in the year, and many of you selected more than one goal, but everybody was able to select the goals to work on during this project. So one of the main themes we identified, and this sort of speaks to why today we're talking about physical exam, is 45% of you selected one or more of your goals to be something related to improvement in physical exam. So many of you highlighted specific body parts, specifically shoulder, knee, cervical spine, and lumbar spine, whereas some of you were a little more general and selected just improvement in physical exam, for example, was common as well. The emphasis of all of your goals was really improving the exam, improving the ability to provide the exam, and then also improving the quality of the exam. The second sort of larger bucket of goals was program administration. So 34% of participants are seeking to either begin a telehealth program or increase the number of visits they offer via telehealth. So a common theme was, you know, more telehealth visits per week, more follow-up visits as telehealth, things like that. Nine participants identified what I'm calling sort of workflow issues or scheduling issues, things where you're trying to improve the sort of connection between you and your staff in terms of communication to patients or ensuring you have appropriate amounts of time in the schedule for the visit. Five participants are working to identify or implement a new telehealth platform in their practice. And then four participants identified goals related to coding and billing, and four identified patient education. So in March, we're going to be talking about a lot of these topics, but I do get the sense that we may not be able to touch on absolutely everything that was identified in the goals survey within the context of these calls. So one of the things that I'll talk about a little bit more at the end of this meeting is the FYS forum community and how staff is going to start sharing some resources that speak to these few issues on that FYS forum community. We're also going to encourage you to share similar resources if you encounter them. So hopefully that's going to be a way that you can start working on your improvement project as soon as possible using some of those resources. So to further refine what it is we're going to be looking for in those resources, we have a couple of polling questions that we're going to ask at this time. So Grace, can you put up the first polling question? And, Grace, I'm not seeing that come up. Maybe can one of the attendees? We're getting responses. Perfect. Should we not respond if we have an active telehealth program? Correct. Okay. Sorry, Grace. You're going to have to kind of, maybe you could just read what the percentages are or something, just because I'm not seeing those coming up. Yeah, sure. I'll give it maybe a couple more seconds. Great. Okay. Okay. So it looks like we have ten responses in here. Let me go ahead and end. Carolyn, are you seeing this at all? I'm not, unfortunately. So you can just move on to the next poll. And, obviously, I'll be able to see that on the back end. And we can adjust the resources that we're looking for based on your feedback. So, Grace, if you could just let me know when you've moved on to the next one. Sorry about this. No, I will launch the second poll. It's in progress. Again, if the question doesn't apply, we just don't answer it. Exactly. Okay. So these questions will apply to only a subset of people. And our goal is really to kind of narrow in on what resources are going to be most helpful to those people who are sort of struggling in that particular area. All right. I'm going to go ahead and end this poll. The majority, Carolyn, is in no. Okay. And then there's one more. And again, this is applicable to a subset of you. So if the poll doesn't apply to you, go ahead and just not respond. That's fine. All right, looks like we have about 24 responses, I'm going to close this one. And Moe said, yes, established by my practice, pandemic related. Great. Okay. Wonderful. All right, so I'm now going to move on to our panel discussion. We have Dr. Weinberg and Dr. Robbins. I believe Dr. Robbins is going to kick things off. I'm going to go ahead and stop sharing my screen so that we can see faces. And I know Dr. Weinberg and Dr. Robbins will be letting me know when they're ready to show a couple of videos. Hi, I'm Dr. Robbins, Dr. Hallie Robbins, and I'm delighted to be here. And tech wonders, you know how it goes. Dr. Weinberg, thanks for sending some videos over last night. Carolyn, instead of video clips, I did some screenshots. And because I wasn't able to do it, the computer crashed. So I have it on my iPad. And if you give me access to the screen, then I can just do a share from my iPad and make it work from here. Okay, I sent you the slides, but it's easier this way. We'll go ahead and make you a co-presenter, and I think that should give you access to screen sharing. Yep. Jose, can you? There. Perfect. Thank you. Great. Okay. Can you see? Let's see. I can't see you, so I'm hoping you can see me. I'm going to just take you through- Sorry, Dr. Robbins, we're not seeing the screen yet. All right. Let's see what I can do. Goodness. Okay. I'm not used to this, so share screen. There we go. Can you see it now? Unfortunately, no. Nothing like making everything work just right. Right? The night for it. Okay. So what I am trying to do- You're also welcome to try emailing them to me if that's- Already done, so check your inbox if you can, and otherwise, I will let Dr. Weinberg start, and then I can go after. All right. Sorry for the delay, everyone. All right. I had shut down my email, so just give me one second to re- We're all having fun. So while we're waiting, I am a doctor, rehab and physical medicine. My practice is based in Utah, and I'm currently in Massachusetts and New York. So the whole pandemic affected me incredibly because my practice had to shift entirely, and so I've had to go only on to telehealth, telemedicine, and my group that I'm with is newly starting a brain injury program, and my first patient with them is on Tuesday. So I'm really excited about how things are going, but it's going to be a challenge with translation on top of everything else. I've been doing musculoskeletal medicine for many years, and so- Good, you got them working. Thank you. Perfect. Okay. So my special focus in the academy, I have been interested in myofascial pain with David Simon and Jay Shaw and other people for many years, as well as myofascial pain and musculoskeletal medicine, emphasizing manual medicine with the osteopathic group. So I've taught at the academy since the 1990s off and on in a variety of subjects. So I'm delighted to be here today. If you can see my slides, I pulled the photos from the various videos, and Carolyn, feel free to share this as a slide set that people can have access to, so that way everyone can have access to the videos. Very instructive. Typical of a lot of online activities, though, there's only 100 to 600 at most views of most of these, and maybe three or four thumbs up if anyone has commented, has shown any preference for them, comments turned off. So any good online sources for instruction are going to be limited to how much the doctor or the providers are going to circulate this to their patients. That's my first comment, is that good materials are worthwhile. Dr. Laskowski did a great stripped down version, Dr. Weinberg, right, in terms of how to do a good presentation to your patients to get them enthusiastic and involved, but if you don't make it actively available to your staff to circulate or put onto your portal, then all the good production is not going to make that difference. So that's my first comment here. In terms of that first slide, translating medical ease, rehab doctors like us are specifically able, more than most of our colleagues, to put the jargon into vernacular, make big words fit to small. So if someone's talking about low back pain and lumbago, talking about an L5, S1 radiculopathy and different kinds of nucleus propulses, herniations, is not going to make sense to our patient. So we have to make sure that anything that we do for examination is going to be appropriate to the education and understanding level and always check on communication. How are you coming across, someone's not having audio here, if that can be helped. So being able to talk about it. In the slide set here, the two basic comments on this slide, localize your pain is great for us to be talking doctor to doctor speak. It's like business to business. It's not doctor to consumer patient. We don't ask patients to localize their pain so much as where do you hurt. So if you're going to be putting a lot of effort into any kind of presentation, use the terminology that is most understandable to the patients in a way that they feel you really are connecting on what they're going to tell you in turn. In terms of this great view of the back, does it really show the back landmarks? No. But also make sure that you're actually showing people what you want them to show you. Next please. Okay. So here's a great example of a one-time repetition of a squat on both legs. Really fast and easy, only five or so seconds in this great video. But you're not telling people keep your heels on the ground and we all know patients don't know to do that. That's going to be often a cheater's kind of exam result. If you don't tell people what you want them to do specifically, you're not going to get the results that are most elucidating, most helpful to what you're really trying to help them show you. So you want to be more clear about what instructions you're providing and how to ask them to succeed. Next please. Here's a great example. What's wrong with this one? All right. And no one's put anything in the chat. I welcome chats and responses. But just to say safety second, that leaning back pose is all well and good, but holding on to a rolling chair while doing so is not exactly the stability that we'd want people to be demonstrating safety when we're asking them to do instructions. So in the intro that Dr. Laskowski provided, he was talking about having a good walkway area and other safety or demonstration supported features. Make sure that you also tell people here's the equipment I want you to have on hand. If you're going to be asking them to do something, have an example on your side to demonstrate things. Make sure that you're clear in the instruction and make sure that the patient is safe, whatever you're asking them to perform. Next please. Range of motion is really easy. All of us know how to have an internal goniometric sense of movement and ranges. And we can see if someone's quality of motion goes along with the quantity. So you can see left, right, forward, back, all good. Next please. Here's the problem though. When we're getting too clear or confusing, the instruction is nice saying, okay, put your head back and now turn and rotate. That's going to be really confusing to a lot of patients. They're not necessarily going to understand what to do and your results are only so good as what you ask that patient to perform and demonstrate if you're not able to put a hand on and feel how and well they're doing it. So if you're saying tilt your head to the right, I often will say just like those instructions up top, look right and left, I might say point your nose over your right shoulder. Point it over your left shoulder. People are then very clear. If I say now tilt your right ear towards your right shoulder, do the same on your left, people will be much more clear about what they're being asked to perform and it's like an invitation of instructions rather than tricky to interpret. We all know one and two or more levels of instruction are tougher for patients to interpret and the results will show if we don't give them clear instructions. Next please. Same thing here. The reason I wanted to show this, most patients are doing the telemedicine visit on phone or laptop exactly. So this is definitely another problem Dr. Ramos agreed. So in terms of what I wanted to show you, all of the previous slides were taken from YouTube videos. Mayo Clinic might have a great channel. Most providers don't have the same expertise and production and access for a channel. Yet you also have to just look at it. If someone is going to be doing the video, the videos that follow from these few minute long instruction videos go to any number of things, to chiropractors, to your health food store or whatever else as well as your latest news feed. So just be conscious when you have someone doing production to take the whole view of production into account to make sure that the end result keeps the person focused on the material and not distracted to go to the next and the next. The website that is shown for the hand instruction, the hand clinic video that is at the bottom of the set that Dr. Weinberg provided from Mayo Clinic is a website video instead. It cuts off material up at the top on an iPad or an iPhone for instance. So a lot of people are going to be technology limited as Dr. Ramos was saying. And so we are always dealing with how well are people able to get what we want them to be getting from what we give. So if we're going to be asking someone to do this very detailed thing, like a quarter inch detail, first off you can see that I have a lot of websites that are still open up on the top. So how you select what media or platform you use will make a difference for how easily people will be able to access. Also, if you're going to be saying a quarter inch, that surely doesn't look like a quarter inch distance to me of that paper clip. So if you're going to be precise, make sure that you have people understand why or what you're really asking them to do, because otherwise you're just providing details that can be confusing rather than useful. Next, please. And there's only two more. So that the idea again, in terms of language, if we're going to say, spread your fingers apart, don't let your push their fingers together using your other hand. Is it inward the way that it's talking about? Or is that the words can be confusing? Are you talking about bringing your fingers inward to a fist? Are you talking about bringing them back towards each other? So the language that you use can make a big difference for how easily someone interprets what you're asking them to perform as well. And last one here. One of the things about an examination that goes into exercise instructions as well, when you are dealing with telemedicine, we're often dealing with people who are showing us real time, real life, what they're having a hard time doing. And because they are typically in their home setting, they might be showing a lot more than they could in your office. So make this a plus rather than a hindrance. Make it possible for people to feel like they're actually showing you what the tough stuff is. And they can take that device with them often to show you where it's a tough thing, if it's in their bedroom or in the bathroom as well. Maximize their sense of being able to take you into their life. They'll feel a lot more supported and responded to in turn. So the last thing I wanted to say, it's great to show opening the bottle versus opening the jar. For some elderly people in particular, though, or those with spinal cord injury or limited hand function, often it's not just opening the issue, but also closing it. So if you're going to be going from a full examination, consider the A to Z and not just the A to K effort that it takes to demonstrate the functions. So that's what I wanted to just share with you from a brief overview so that we can have time for the rest of tonight. Thank you. I'll welcome any questions. I know, Carolyn, you have an agenda for us. So I'll let it move over. Thank you. Yeah. Thanks so much, Dr. Robbins. I think that, you know, Dr. I know Dr. Weinberg is going to speak next and then we can open for conversation. And Dr. Weinberg, I think maybe you can give some additional context on the videos. I know he was generous enough to share those links, which, you know, if he's comfortable, we can distribute with the rest of the participants. And Dr. Weinberg, are you available to speak now? Yeah. And these, you know, when we all got shut down to varying degrees last February, March, April time, and there were a lot of challenges that were going on as far as how we could maintain contact with our patients, you know, whether it's our local patients, whether it's our patients at distance. And, you know, for our practice, you know, trying to develop some ways to reach out to our patients was really kind of our highest priority. Sorry about that. Let me see if this is better. That's, that was much better. How's that? Is that much better now? Perfect. Yeah. Okay. Thank you. Sorry about that, folks. And again, that's what, you know, again, the initial difficulties that Dr. Robbins was having getting connected up and something as simple as just this connectivity really underlines what those challenges are, you know, and we are allegedly a little more tech savvy than, than some might be, you know, and so, you know, these are all, all the challenges that came up along the way. Part of it was the actual connectivity. Part of it was, you know, the documentation part of it was, you know, what can we actually do through a, you know, a little or a small TV screen or video, excuse me, video screen that's going to actually be useful to our patients at helping us care for them. And so, you know, we, our, our group, we're blessed. We have a nice size group of people with a lot of expertise in different fields. And what we decided was that, you know, this, this telehealth thing that, you know, we had used fairly sparingly up to that point was probably going to be our savior in a lot of ways, but with a huge number of warts along the way as well. And so one of the things that we decided to do was, you know, in talking with patients who the, the few who are still coming in to see us. And then once we were talking on the phone, we realized that, you know, there, there had to be that somewhere in between activity. And that's where the virtual video visits came into play. And we understood that there were going to be some challenges in getting that set up. We ultimately decided to put together a few of these videos, and these were really kind of multi-purpose videos. The, the, the big benefit was, well, there were a few things. One of them was that we were able to start sending these out to patients. And so they knew what they were going to be more or less getting themselves into, at least giving them some expectation of what the interaction was going to be like. And some of the instructions included simple things such as make sure you're in a quiet room and, you know, and, and that there's good lighting. And if there's somebody nearby who can control your tablet, your smartphone, your laptop, whatever device you might be using, you know, in, in retrospect, we think about these things now, and we say, well, of course, you know, why wouldn't we want to have those things available? But, you know, at the time it was really kind of a matter of being, you know, going from the basic, most basic of building blocks. And so when we convened our group to, to try and figure out how, how could we examine things? What could we reasonably examine? And what things were really kind of not going to lend themselves to, to appropriate virtual examination. And so, you know, we came up with a couple of these different videos and, you know, as, as, as Dr. Robbins clearly pointed out, these aren't perfect devices by any means. But what they do is they do help orient the patient, okay, which is one really important piece to what the process is. And it's also been a really wonderful tool to help us educate our colleagues, our residents, our, our, our other learners in physical therapy, occupational therapy, nursing. You know, we've, we've encountered some challenges, of course, again, like anybody else would have some technological challenges. And so we have internal servers that we use for internal education. We have external servers. You know, we have the YouTube channel and YouTube comes with all the works that go with YouTube or anything else that's commercially controlled. And so, you know, no, no question, again, not perfect vehicles. But again, we're right now we're actually in the process of moving these videos up, edited it to some degree to, to, to, to a more consistent site. But, you know, with that said, our patients have been thrilled. The feedback we've gotten from the patients is that they've been thrilled that they had a bit of an idea what to expect, because they were, you know, a little questionable also. And, and to say, it probably has been generational, right? With, you know, the, those in, you know, in the, you know, the, the, the boomers and, and, you know, we're maybe a little more, you know, interested, but perhaps a little challenged with it. You know, those in their eighties and nineties, you know, this, this was much more of a challenge. Whereas, you know, the, the, the, you know, the, the Gen Xs and the, the other gens that I'm sorry, I have trouble keeping up with at this point for them, it was, it was, you know, smooth as silk. But the feedback that we've been really happy with is they said, we knew what to expect. We knew what it was going to be like. Now, I mean, at this point, we are looking into some other projects or ways to actually be able to quantify, quantify a variety of things. For example, there are technologies now that are available that allow us to measure and, and, and quantify wounds over a video. And so that's, that's been quite a boom for our wound care center, for our amputee service, that type of thing. We're looking at movement analysis, again, hooking up with gait labs who, you know, they're used to looking at camera images all the time. And so now can they get us good enough data that, that it's coming from, you know, that little screen that may be, you know, who knows how big that is. So, you know, again, a starting point and something that we've been pretty happy with how it's been able to, to, to help meet the needs of our patients, which ultimately that's, that's what we're all here for. And that's why everybody's here, you know, on a, on a Thursday night at whatever hour it is in your time zone trying to figure out how can we help our patients better. So with that, you know, the, the images that we have, again, you know, those videos right now, they all live on a YouTube channel. And, you know, we'd say, you know, somebody wants to go look at, please go look at them, decide if that's something that's useful for you. Can you learn something from it? Can you learn what you shouldn't do, what you should do? That's great either way. But again, you know, the starting points and, and as, as smart as we want to think we are, we're still probably at the baby steps of all this virtual care that, that we'll be developing over the next years. With that, I'll, I'll turn it back over to you, Carolyn. Great. We did have queued up the, that initial visit video. I know Dr. Robbins had some screenshots, but I think it might be nice for the group to see. It's like a five minute. Are you okay with that, Dr. Weinberg? Oh, absolutely. And, and what we would say is, you know, you'll, you'll recognize our colleague, Dr. Laskowski in there. And for those of you who know Dr. Laskowski, he is just an absolutely genuine, really brilliant gentleman and just engages with patients so well that you'll, you'll see. Great. I'm going to hope that my tech savvy abilities are a little bit better this time. So just bear with me while I share and, and hopefully press play. Hi, I'm Dr. Ed Laskowski and I'm a physician in physical medicine and rehabilitation and sports medicine at Mayo Clinic Rochester. I'd like to share just a few thoughts on your upcoming telehealth examination. Video examinations can give us a lot of information. They're not a substitute for your face-to-face exam, but we can still gain a lot of information to hopefully help you out and give you some suggestions to help you deal with your condition. I'll give you some tips on how to set yourself up for a successful telehealth examination. First of all, you want enough space. The doctor may ask you to walk to and from the camera, so you want enough space that you can be walking forward and backwards. And the camera can catch this. It's nice if you can have somebody else holding the camera. It's always easier. So if somebody else is available to help you, that would always be recommended and I think it would enable you to do more movements and feel less impeded by anything. So somebody else to hold the camera is a good thing. Enough space is a good thing. A room free of distractions. We love your pets and everything else, but it's kind of distracting if they're in the field of view. So kind of keeping the room clear of distractions and as little as possible in the room so we can see you well, that's a good thing. Proper lighting in the room is also good. It helps us to see things very well. And your doctor, when you see them in the video, they'll probably be dressed like this and they'll ask you some questions, they'll interview you, but this is an examination. So your doctor will be dressed like this, but we want you to be able to show us the areas of the problem. So if you have a problem in your neck or your shoulders, your doctor is probably going to want to see those areas. So what we can do is have on something that will permit the doctor to see as much as possible. This could be a t-shirt, this could be a tank top, this could be a shirt that's easily movable and liftable so we can see as many areas as possible. But if we have a neck problem or a shoulder problem, we're going to want to see those areas. Make sure you have enough room to move your limbs during the examination. We're going to have you move and not hit things in the ceiling like I just did. You want to have enough room to move around so the doctor can see the range of motion about your joints. You want to be able to make sure that the doctor can see the areas that are problematic for you. So if it's a neck problem, you want to be able to show him all the areas of the neck that are troublesome to you. If it's a shoulder problem, you want to be able to show him all the areas of the shoulder that might be troublesome to you. Same thing goes for the elbow and for the wrists. If you have a back problem, you want to make sure that you have a shirt that you can pull up so that the doctor can get a view of the low back. And this could be, again, a loose fitting shirt or anything that just lets him get a good view and that will permit good and easy motion. If you have a problem in the hips or the legs or in the back because the nerves in the back go in the legs, the doctors are going to want to see a little bit more. So you want to make sure that you have exposure of the joints that the doctor is looking at. And lots of times it's nice to have just bare feet because sometimes shoes we can't assess as we want to with shoes and socks on. So if you have a hip problem, you're going to want to wear shorts. If you have a knee problem, if you have an ankle problem, we're going to want to see those joints. So make sure you wear something comfortable to enable us to see those. It's nice if you have a table nearby and if some of these maneuvers may have you do on the floor, so a mat that you can put on the floor so we can have you lie on your back and do some maneuvers, that's helpful as well. If you do have an additional person besides the camera person, sometimes to assist with some of these maneuvers, that's a good thing as well. But overall, we want as much information as possible and by looking at you and having you do some maneuvers, again we may have you walk, go up on your toes, go up on your heels, move your joints around. Those all are helpful movements that give us information about what's going on with you. So I hope this was helpful for you and we look forward to seeing you on your telehealth examination. Excellent. So, like I said, Dr. Weinberg was generous enough to share links to several videos. That was the first one and then there are sort of more body part specific videos that go through the elements of those exams. So I can absolutely make those, share those with the audience as well. So at this point, I'd love to turn this over to the group to ask any questions that you might have of Dr. Robbins or Dr. Weinberg and then also please feel free to share your own, you know, your own takeaways, your own sort of expert opinions on things so that we can make this more of a collaborative discussion. And you can feel free to just unmute yourself and share your video when you want to speak. Yes, hi. This is Dr. Julio Martinez from Massachusetts. Actually, we need to keep in mind that some patients may not have any family members that will be available. And there may be other options like, for example, they may have a cell phone stand. And I had a patient, for example, that she had a laptop and I was going to do a full examination. So I just told her to put the computer in the floor and we were able to do the exam. So these are, there are some other things we sometimes we need to kind of think out of the box to, because that finding that the patient not necessarily may have the space or the props or the resources that we ideally would like to have available. If I can respond to that, Dr. Martinez agreed. I had worked in a facility that wanted to develop a telemedicine program last summer. I am so sorry. I cannot tell what that is. I'm very sorry. That was not. It sounds like it's playing the start of your recording. It was playing the start of another telemedicine YouTube video. Very sorry. I did not close that window. Dr. Martinez, please continue. Thank you. So just to respond. So part of the problem that I ran into is that a Wi-Fi signal was able to reach the left shoulder, but I was checking for a subluxation of a right shoulder post stroke hemiparesis and the signal would cut out. So often we're running into the problems of Wi-Fi strength, and even in a staffing situation, if someone is not familiar with how to position or how to set things up or how to schedule, all of the niceties that make our visits work don't happen as easily. So that's always the accommodations. And in the foot video, it shows a camera based on the floor. So be creative and help your patients feel like they're the ingenious ones who make the visit successful. Is there anyone else? Yes, hi. This is Angela Ryan. I'm in Connecticut and I was just wondering as I was watching some of those, the video and the presentations, I was curious in your experiences, how much time do these take as compared to a regular visit where you just kind of whip through everything and have the person do it? I feel like these are much more time consuming. I don't know if that's something that you've been experiencing. That's a really good question. Part of the objective of having video type things was to try and help get honed in on what really is the main issue. Timing wise, I've actually found it interesting that from the perspective of time efficiency, once the patient understands and starts to take some direction, they seem to do fairly well with it. Part of it is that I think they tend to be fairly pleased with mastering the technological experience. I know that people that we've had subsequent visits with, they start to get kind of like, hey, okay, let's move. I got stuff to do. Certainly, there's a lot of challenges getting somebody up and running. A lot of it depends on, I think Dr. Martinez said it very accurately, is when patients can quickly think outside of the box on what is it that you're trying to accomplish. When you say, can you turn around so I can see the back of your shoulder blade? Then they start to have to sort of figure out what is this position that they're trying to get into. Some of the three-dimensional stuff is very challenging when you have to try and verbally describe it. It's certainly not a panacea by any means. To get back to the issue of time, it really, any effort that can be put in ahead of time or educating the patient ahead of time, I think really does pay off an awful lot in helping your time efficiency. Yeah. Dr. Ryan, it's sort of like when you are from the Queen's Gambit, when you're playing multiple chess sports, making it possible to have visits lined up in a block of time, and you're really going from one room to the next virtually, makes it a lot more efficient. Actually, it can be very time efficient. Patients tend to like once they're in the groove and they know what to expect, they also really like that it's focused and targeted. It can also be very one-on-one specific because they know you are totally present and aware for their needs in that time. The satisfaction can actually be very high instead of wondering because we all know patients hate when we're looking at our computer screen. Well, in this case, we actually are, but they're the ones who are the beneficiaries from our full attention with and on them and in turn day with us. I feel like those videos ahead of time, I think you can send out, how that could really help so much. That's a good tip. Well, I have a few comments. Number one, depending on where you are, you may have a more restrictive or more lax institution. At least in my hospital, I have the flexibility of doing a basic exam. If I think that someone really needs a more comprehensive evaluation, then I can make another appointment to bring them to the office. So, that actually helps. Number two, I need to recognize that the technology limits me. I cannot check reflexes. I cannot really assess tone or rigidity. So, I'm trying to use the time on the best maneuvers I can do reliably considering the distance. And the last one that I find personally very helpful for any new patients, I have our staff call the patient one day in advance and fill a questionnaire. That way, I'm very targeted and the patient also knows exactly what we're talking about on the visit. And that actually helps focus the visit. So, make it a little bit shorter. I agree. The visit tends to be longer if it's a new patient visit. But if it's a follow-up that you can really target, it tends to be faster than a face-to-face visit. Yeah. So, Dr. Corraltes is bringing up that it can be taking quite a bit longer time to do the equivalent of a face-to-face. Some people, especially when COVID is a high risk in their area, have adopted a practice of doing the interview, the history taking, with staff as well as themselves in advance and then maximizing the face-to-face in-office time for the visit in order to cut down the amount of time altogether for the encounter that's in person. So, with all the accommodations and adjustments, there are ways to use this rectangular world to our advantage, but then to optimize for what we needed for in the face-to-face as well. There's a couple of questions in the chat here. Dr. Corraltes makes a comment that new patients tend to take somewhat longer and then established patients tend to sometimes be able to actually even stream through a lot faster. And that makes the very accurate comment, on the plus side, patients are almost always on time. And that can make a big difference. Dr. Robbins made the comment also about the scheduling. And what we've discovered is that it makes a lot more sense, at least the vast majority of our physicians, feel it makes a lot more sense to try to block together the virtual visits altogether rather than bouncing from a face-to-face to a virtual. It just seems like that your flow or your rhythm doesn't seem to be quite as good. And it may be a little more challenging to keep on time like that. One of the things that we've also been doing is, and a lot of it depends on what your electronic medical record is like, but we have exam checklists and we use Epic. And so we have a lot of smart blocks and smart forms that let us sort of have a lot of click boxes for examination findings. And so it lets us really, again, be focused on what the patient is showing us on the screen. But as part of the orientation, when I get onto a video visit with somebody for the first time, one of the first things I'll say to them is, you're going to see that I may not be making eye contact with you. Because I'll always point up and say, because the camera's up there, but where I see your picture on my screen is over here. And then your record, your chart is on my screen over here. So if I'm looking like this, it's not that I'm not paying attention to you. And if you were next to me, you'd see exactly what I was doing, but it's just part of the process. So again, letting them know that, I think it was Dr. Martinez said, you have my attention, I'm all there for you. And there's a great point in terms of needing to figure out in advance, to suss out the situation is really helpful. And being able to have a better understanding of the person's technology before the visit. So I've been in touch with AI developers and answering two of the questions here in terms of consistency and standardization of the exam, as well as the features. That's what Dr. Weinberg was talking about in this sea change operation that we're all in, to arrive at standards of examination. Going back to the start of PM&R, Jerry Herbertson from Philadelphia was one of my teachers for a good MSK exam. He had one non-functioning arm from being a polio survivor, and yet he was extremely able. And so going back to kinesiology and figuring out which muscles are most particular is why I was emphasizing, how do you ask someone to do it? If you're saying, turn your head to the right versus tilt versus touch and turn. We are the doctors who know the kinesiology and know the functional requirements that it takes to distinguish SCM from scalenes from whatever else we want to examine. If we're asking for biceps versus brachioradialis, we know corkscrew maneuver. We can ask someone to demonstrate it, and they don't need to know all of the details that we do. So part of the challenge is giving, that's why I use that third time now tonight, the word success. Patients get frustrated if they don't understand what they are being asked to do. And so part of the speeding up of time is precision in our language and also knowing what to interpret based on what they show us, and every moment then becomes a learning experience for us to do it better. Yeah, I think that sometimes we can even use ourselves as a model. You can just demonstrate a maneuver, do this, and then they can do it. Regarding technology, I really think that it's helpful to have that call in advance because if someone doesn't have a smartphone, guess what? You can just call and do a telephone visit, which will be very, very limited compared to video, but at least you get some information. And I'll tell you, I actually diagnosed a cervical radiculopathy, which ended up going to surgery over the phone. And we were very, very hot with the COVID, very hot here in Massachusetts, and I knew the pain doctors in my hospital were seeing patients in the office. So I said, you need to call, let's call them, let's have you an appointment to confirm, and indeed she had a radiculopathy. Another thing to keep in mind is, and this is unfortunately something that I learned, please, if you're going to send a notification to a patient about an appointment, be sure that you don't do it by email on the day of the appointment because guess what? How many emails have we received since we are here in the call? We're not in front of the call, but if you send a text, that's a real-time notification. An email, and unfortunately my institution decided to do invitations by email, is really a disaster. You won't believe how many appointment a patient have missed just because they didn't see the email in a timely manner. In that vein, I'd be curious, maybe, I don't know, maybe with a reaction vote or something, how many people use, or their practices use, you know, a text notification or, or maybe just a text notification because I agree with Dr. Martinez, the email notification sometimes is nowhere near as helpful, but, or any type of appointment notification. The challenge always is how many people have HIPAA protected, or portals, or other things, because all of these changes have really been taking us by storm. And even, you need a BAA even to use Zoom for HIPAA, it's not just getting signed up, you have to have agreements in place that make your technologies work for you safely and securely. So even the text used to be frowned on, now we accept them. How has that changed it? Maybe if, if everybody could use the reaction button to do either a raise hand or a whatever that might be, just to indicate if, if you do use text notifications. When I when I do emails for different purposes, I will ask the person to email me back So that way I can confirm that they have received it and I'll do it a few days in advance So that's one way that I've worked through because some things do need to be emailed or faxed or other things and no one uses Except office's faxes anymore Or text back as people are saying to Yeah, it looks like there's people who are in their practice are using some text notifications or some links to to Either to their portal or to the virtual waiting room. So again not necessarily straight-up email, but things that are Theoretically perhaps but not entirely Totally HIPAA compliant Right, I'm on the phone a lot with with Medicare lately For setting up some new programs and The sea change is also felt very clearly there Their site visits are not yet set up for telemedicine in terms of evaluating programs they expect people to have at least offices set up in place and that's not always practical right now and similarly the challenges of Coding billing and reimbursement are changing so radically that staying on top of the game is in itself an adventure Anyone else want to make any comments on this topic before we move into the breakout discussions Thank you so much, dr. Robbins and dr. Weinberg for Volunteering as our first panel speakers. We really appreciate it. I know it was very helpful information So I'm once again gonna try sharing my screen Okay, so we are going to go into some breakout discussions. I know if you joined us in December, you participated in some smaller breakout groups. This time we're going to do four breakout groups, so you'll have a larger group of folks in your room. The breakouts are going to be based on body area. Like I said, we really did try to put people in the room that most fit with their goals as indicated in the goal survey. I don't think we were able to get that 100% perfectly, but I think a lot of the information should still feel very relevant. I did send some discussion questions ahead of this call. We're also going to put those discussion questions in the chat box. So, Grace or Jose, maybe you could do that now while we're chatting. So, you should be able to refer back to those. The discussion questions are really just that. They are not something that you absolutely need to answer all five questions. It's more a prompt for you to kind of get the conversation going in your group. We're going to be in these breakout rooms for about 25 minutes, 20 to 25 minutes, just because we may have a little time on the front end assigning some of the phone numbers to the groups. If you're a phone line participant, you can press star six to speak in your room. And then what we're going to do in terms of report back is just note three takeaways from your discussion that you feel like might translate to an action that you're going to take in your practice. And if you could designate a speaker, that person can report back to the larger group. So, the questions that we have to prompt these conversations are what are the biggest challenges you've encountered in conducting a physical exam on this patient population? So, a physical exam for a patient presenting with a knee problem, for example. Is there information the patient should know ahead of time to improve the chances of a successful virtual exam? So, obviously, we've been talking a lot about pre-education via video or additional information you might want to discuss with the patient by a phone before the exam, but maybe something that's specific to that body area. How would you conduct an in-person assessment of a patient with a problem in this body area? And then what workarounds could you implement to achieve a similarly successful exam via telehealth? And then following treatment, could these patients reasonably be seen via telehealth for a follow-up encounter? So, we're going to go ahead and break out into those groups. You should be assigned to your group momentarily, and then we'll come back in about 20 to 25 minutes, okay? All right, thanks so much for participating in the breakouts. So, I think the next thing we're going to do, like I mentioned, is just I know you hopefully designated someone in your smaller group to speak. No? So, we'll see if we can get at least a couple people to report back. Does anyone from the knee group want to speak to a couple of takeaways? It doesn't even need to be three, just a few things you'd like to share with the rest of the group. Okay, well, we didn't designate anybody. We just spent a whole lot of time talking about what we thought was helpful there, what was less beneficial. I think we all tended to concur that we needed to do some of that old-fashioned stuff like listening to the patient really to help direct how we could best help them. We recognized that the virtual physical examination for the knee has a lot of limitations, but that we felt we could probably identify a lot of the red flag concerning issues that would need sooner rather than later care, and otherwise, the emphasis really needed to be on taking care of the patient and their function rather than coming up with some big fancy diagnosis that would make us feel very smart, but may not necessarily help the patient very much. We also agreed that we are sorely lacking in adequate investigatory styles and that we need to have a better way to meet the patient's needs where they are, and to check on the technologies before the visit can be very helpful to make sure that their comfort with the exam is going to be optimized, too. Great, and I think, obviously, those takeaways in large part can be stretched across a lot of different body areas. Does someone from the shoulder group want to speak to a couple highlights? We didn't designate anyone either, but we were trying to recap some of our highlights. I think one thing that, and anyone can jump in because now I'm forgetting, but I think one of the things that we felt, we all felt very confident about was that it would be very useful to do a virtual shoulder exam post-injection to follow up on therapy. We were a little bit feeling less sure and less confident about a new patient and a new diagnosis for a new problem. I feel like a lot of our people are not really doing that so much. The other thing we talked about was we kind of felt maybe it would be useful instead of going through the traditional physical exam the way that we know with palpation and range of motion and manual muscle, ways that we can functionally assess the shoulder. And were there ways to standardize like a weight, like a at-home weight, you know, to have to have people use the, you know, lift a can and see that to try to get some sort of muscle testing exam. So we were kind of looking at it more functionally. I think we were still a little bit daunted about the idea of going through the whole exam and sensory and all of that. I forget what our other point was. Somebody want to jump in? And we also were talking about not specific to the shoulder, but just the, I think the setting up, like I was discussed in the beginning of the group, the setting up the preparation practice, preparing the patient ahead of time and just the logistics of how your staff does it and how you communicate with the patient ahead of time. We were just kind of sharing how we do that. Some of us don't do it at all and some of us do it. And, you know, whether it's best to lump them all together, all the virtuals and just still a little unsure about how to make it most efficient, I think. Great, how about the cervical spine? Anyone from that group? Carolyn, I'll speak and certainly if anybody else has any thoughts from our group, go right ahead. I think we discussed this broadly, and I think one of the major areas we talked about was compliant, HIPAA compliance and how that might turn in time. And of course, we don't have any real answers, but I think we decided that we'd probably need to have some system in place that we could feel comfortable was compliant. We also talked a little bit about who might be appropriate to see as a televisit. And we're a bit split about whether we would see new patients or not. I think several of us felt you could do at least some components of a new patient exam, maybe even a limited patient exam, but that if it came down to a neurologic exam would be very challenging, if not difficult to give an accurate diagnosis or to feel comfortable with it. So in my setting, I could bring somebody in and I would opt to do that. And I think some in our group agreed. I think we also decided that in terms of follow-ups, particularly simple follow-ups that were of known patients, it could be very practical. And especially if they were further away and this was easier for them to do. So I think we got to the point where we had an idea when we might use a telehealth visit and when we probably would prefer not to. And then our concern, of course, was doing it in a way that was safe and secure. Great. That's, yeah, that's really helpful. I think starting from that initial point of decision-making is a really interesting way to start thinking about it. Anyone from the lumbar spine want to report that? The cervical spine group, same as you, we talked a lot about patients we felt comfortable seeing and not seeing. I think to add to what you said about the setup, we should recommend or make a recommendation, usually probably by your office would be serving this role, but making sure the patient understand what the role of the telehealth visit is, set the expectation, particularly those of us on the spine group felt there are real limitations and we should expect to be able to accomplish the same thing we can in person as in telehealth and setting that expectation with the patient. So if you've got a progressive problem, you don't need, we shouldn't be dealing this with telehealth, that should be something that should be seen in a more urgent manner. You have a new problem with no progressive issues of neurological by history, that's something you could start with telehealth, but it likely is going to require an exam at some point. And then a chronic pain patient, obviously those are going to differentiate based on what their symptoms are. So we felt setting it up in ways just like everyone talked about here, the internet works, the camera's right, the person's hands free, maybe they have the right clothes on, but also set up the expectation of the visit. I thought that was a really important takeaway. We were also, we talked about how in the lumbar spine, we think range of motion and directional preference you can still get from telehealth. Strength, you can figure out if they have a really gross motor problem, but you can't really figure subtleties out from it. And being aware of that, and then you can do a straight leg raise or a neural tension sign can be helpful, but still we're missing a lot of things, which includes the gait, touch, palpation, sensory exam, and particularly hyperreflexia. So those need to be noted as we would never expect to be able to accomplish those with a telehealth and should be, you know, an aspect this person has to be seen in person at some point. We talked also in depth a little bit about ordering procedures based on a telehealth visit, and pretty much the group agreed that anybody new or new symptomatology, they would never consider ordering an invasive test without an in-person physical exam. That's an important thing we should add to what's going on in the greater discussions, even outside of physiatry, which a community can't do. We think telehealth was actually very helpful for follow-up patients that are well established in your practice that you know well. And again, just like the cervical spine group kind of split on would you actually see a new patient, the problem is there's so many people with spine issues that, you know, I think we can categorize them into or triage them into a progressive problem that needs to get seen. That's better than not seeing them at all, but at least getting them to the place they need to be, maybe the way we should take it. And we also talked about, you know, invasive procedures on people that we haven't seen, as well as opioids. I'm not comfortable with that via telehealth. Did I miss anything, group? Everyone is Zoom fatigued. Certainly understandable. So we do have a couple of extra minutes, so if anyone has any last things they want to share, I'll move on to the next couple slides. I just wanted to say something that I'm really impressed by our work group and very appreciative for this chance for us to come together in this think tank fashion that's also an action tank. And that's what I wanted to just recommend from the academy on through. We have to be the advocates, not just for our patients and our profession, but also for just advancing the ball down the field in terms of what telemedicine provides. We talked in our group in terms of how we are falling through the cracks where people think of telemedicine for primary care, hospitals for interventionists and hospitalists, and telerehab for the therapists. We are not, and teletherapy for behavioral. We are all of us falling through these cracks and not at our peak performance for ourselves as a profession. We are the ones who have to educate and advocate and lobby for how to change the dynamics and understanding of what telemedicine can offer to all the people, spine, sports, cancer, burn, spinal injury, you name it. They need us to be the ones who are here for when they're suffering and the people we talked about who are dealing with workers comp, with personal injury, with medical legal, with all sorts of time elapsed situations cannot wait for us to figure this out and let them sit at home and vegetate. They are often suffering in silence or dwindling and we need to continue to advance where telemedicine is what rehab doctors can provide for all the people with post-COVID, with long hauler, with stroke, everything else that we know about. We cannot let primary care put baby in the corner when it comes to rehab either. Any other final comments? Hi, how are you doing? I just hope that we could establish a standardized telehealth MSK exam with this forum. And it's so important because we could get so much information, especially with functional tasks. You get a lot of information from that. So, you know, I mean, I don't know if anyone has considered writing a manual on telehealth MSK exam, cervical spine, and then what, you know, how would you go about it? What, what specific words would you use to ask the patient in order to achieve what you want out of the exam? So has there, Dr. Robbins, has anyone, has there been talks about that or? I would love to talk with you more about it because I, I've been talking with people in the AI world and the algorithmic approaches, part of what we're all trying to figure out, like Dr. Prather was saying, being able to winnow out the best selection process for who needs to come in, when do they come in? What are the outcomes, the follow-up after whatever the procedure, whether it's shoulder or knee injections or after the spasticity evaluation and the pump, we need to know how they're doing. We need to be able to track and our field specializes in outcomes. Let's put it to the task. Right. Has there been discussion about developing like a tier system for like each specialty saying, all right, for, let's just say for pain management, ideal candidates for telehealth are one post injections, right? Second would be focal ailment to a certain body, to, to like a peripheral joint, like, like a tier system in a way to say which one's high yield for telehealth and which one is not so high yield. I agree. That's a point well taken that I'm sure Carolyn, you're thinking about that in the academy level, because all of us want to see our profession, just as we're reading about the our profession, just as we're redefining what is physiatry, not psychiatry, not this, not that we need to find who we are. And as I said, not to let others define us, and that goes for our patient advocacy and care and outcomes. So I can share just from a academy perspective, some of the actions that we're taking this year, we do have a tele telehealth innovation work group that's meeting for the first time a little bit later next month. So a lot of the information that we're collecting from this group is really giving a sense to that work group of what the baseline is sort of where, where our members currently and what can the academy do to better serve our members in terms of telehealth. So exactly what you're describing is information that I can share with that group, as they're starting to prioritize what what's really needed for the field. So it's definitely a priority for the academy. A lot of the coding changes came in a really timely way for 2021. Sorry, Dr. Ahmed, can you speak into the microphone just a little bit? Sorry, got an earpiece in. I was gonna say the coding changes for 2021 came at a really good time. It really allows you to not have to focus on the billing aspect of it, and then just focus your MSK exam for telehealth with where it needs to be. Yeah, absolutely. And so our understanding at this point is that those flexibilities are going to be in place for probably the duration of the year. But obviously, that doesn't help us in 2024. So in terms of reimbursement, and sort of the legislation that's needed to kind of broaden things, that's definitely a priority of some of our existing committees. So I work with our Reimbursement and Policy Review Committee, but we also have a Health Policy and Legislation Committee that's sort of actively looking at telehealth legislation that would hopefully expand some of the coverage to be more consistent with kind of how things are in the pandemic, which has really helped accelerate implementation of telehealth. All right, I'm just gonna move into some next steps, just because we are about 15 minutes away from the end of our time, and I do know Zoom fatigue is real. So I want to be cognizant of that. Just one second. Okay, so hopefully you're seeing my slides. So in terms of next steps, as I mentioned early on in the call, we are going to start actively sharing some resources via FYS Forum next week. So all of you are a part of this practice collaborative community on FYS Forum. If you go to our Academy website and click on FYS Forum, under the Communities tab, you should see a My Communities link, which should take you to a list of the communities that you're a part of, and this will be one of them. If you have any trouble accessing it, please feel free to email me directly, and I can make sure that you're a part of the group and make sure that you know exactly where to go to get it. One thing, sort of a takeaway to do from today, if you did learn something in your small group discussions or in the panel discussions at the beginning of the meeting that you want to implement right away, we'd love to hear about your experience and how you're kind of changing how you are conducting your telehealth visits. So go ahead and share any experiences you'd like to share on FYS Forum. You can also share resources or post-discussion questions, whatever you feel like will be helpful to make that forum more actively part of the collaborative. It's really the way that we're hoping you all stay in touch in the couple of weeks between now and our March call. So speaking of, our March call is scheduled for March 9th. It's going to be an hour later, just to better accommodate some of our West Coast participants, and the focus, like I said, is going to be some of the platform integration, workflows, and scheduling. There were a couple of participants in the goal survey who indicated that they are willing to share and be a part of that panel discussion. So hopefully they're still comfortable with doing that, and I'll be reaching out to them before March. But if you're also interested in sharing on some of these topics, please feel free to just email me, and we can expand that panel as needed. And really, it's five minutes. I know Dr. Weinberg had those amazing videos, and it doesn't need to be an elaborate presentation. It can be just sharing some insights from your own practice, some challenges, some successes. So yeah, feel free to email me if you're interested in participating that way. I wanted to just once again thank Dr. Robbins and Dr. Weinberg for so graciously sharing their experiences. It makes for a much more exciting, collaborative discussion when someone can share what they've been doing. So that is all of the content I have for today. Definitely feel free to email me over the next few weeks if you're running into any issues or if you have any trouble accessing that FYS forum. But otherwise, early next week, I will get an invite out to everybody with a link for the March 9th meeting, and that'll be at 7 o'clock Central Time, 7 to 9. Okay? So with that, I think, does anyone have any questions? Otherwise, we will end the meeting just a few minutes early, and the recording for this meeting will be available on our online learning platform. I'll send everyone a link once it's available. All right. Thank you all so much for joining.

telehealth

physical exams

musculoskeletal conditions

limitations

pre-education

realistic expectations

standardized approaches

in-person exams

functional tasks

HIPAA regulations

patient populations

comprehensive care