When PAs and NPs first encounter telehospitalist Dana Giarrizzi, DO, it’s on the screen of a wireless robot she controls with a joystick from hundreds or thousands of miles away.

At first, many clinicians look at her like a “deer in headlights,” she told Clinical Advisor. Patients sometimes look a little unsure or skeptical, as well.

“But now, nurses just introduce me to patients as their doctor,” Giarrizzi, the national medical director of telemedicine for Eagle Hospital Physicians in Dallas, Texas, said in an interview. “It’s been an amazing transition. The most common question I get now, is, ‘Where are you?’ and that opens the door to a conversation.”

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The robot displays her face on screen and Giarrizzi sees the hospital or clinic through the robot’s video “eyes.” She can pull up electronic medical records (EMR) on her computer in real time, as she talks to patients and on-site clinicians.

“It’s amazing how far telemedicine has come in a few years,” she said. “I’ve done it so long now, I forget sometimes that I’m on a computer.”

Her first assignment was working with NPs as a supervising physician on the night shift at a small hospital. “Before that, they were working alone, with a physician an hour away, who they didn’t want to call at night if they didn’t have to,” Giarrizzi said.

Telemedicine encourages a more team-oriented approach to medicine, which can help speed up admissions during intake surges. “There are times where we have multiple patient admissions at once, so instead of my telling the PAs, ‘Call me when you’re done with those six,’ we divide and conquer.”

She predicts that as telemedicine becomes more commonplace, NPs and PAs will use it to stay in touch with both supervising physicians and patients alike. Due to the shortage in hospitalists and primary care physicians, there’s an increasingly acute need for telemedicine-competent clinicians who can cover more than one hospital or clinic. In the future, activities ranging from admissions to post-op conversations to DNR discussions may all be done via telemedicine, Giarrizzi noted.

Another area were telemedicine will be particularly useful is for NPs and PAs working in rural hospitals, where it’s often difficult for patients to travel long distances to receive care. “Rural hospitals are paying a ton of money for locum tenens employees. They need an alternative or they’re not going to survive,” Giarrizzi said.

Pairing NPs and PAs with telemedicine will help reduce access-to-care disparities between America’s rural and urban, impoverished and affluent communities, Giarrizzi and other experts predict.

“NPs and PAs are increasingly taking on some of the tasks previously performed by primary care physicians. We utilize both PAs and NPs in various roles, ranging from primary care to specialty care, to high-risk care, to senior management,” William Chin, MD, chief medical officer of HealthCare Partners in Torrance, Calif., said in an interview, adding that clinicians who are technologically savvy are in highest demand.

Technological evolution

Although telemedicine may seem intimidating at first, in a sense it’s no different from traditional medicine, according to Giarrizzi. Essentially, the only thing that’s different is the use of telecommunications and computer equipment to allow real-time videoconferencing and image sharing between health-care providers and their patients.

If one takes telephone consultations into account, telemedicine has been around for decades, but the recent rapid proliferation of new technology is now enabling clinicians to monitor, diagnose and treat patients thousands of miles away.

Although many telemedicine consults and hospital rounds are currently conducted with a push-cart system, wireless robot systems will become more widespread in the near future. The robot that Giarrizzi uses is part of the InTouch Health remote presence system (Santa Barbara, Calif.) and is FDA-approved.

“I can drive it around the hallways, go down to nurse’s station or patients’ rooms,” Giarrizzi says. “The vendor makes sure the wiring is correct, and that the robot and wireless signal are working.”

She said that most hospitals already have the required T1 wiring necessary to implement such systems, The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) also performs regular inspections to make sure patients are receiving appropriate care.

“I’m able to pull up every patient’s chart, anyone’s x-rays because of picture archiving and communication system (PACS) imaging technology. I have two computer screens – one to look at the patient, and another to look at their records. I can even pull records and x-rays over to their screen so they can see it, and circle things for them while I’m talking,” Giarrizzi said.

In addition to being able to communicate with electronic medical records (EMRs) telemedicine, many systems are compatible with smaller hospitals and clinics that still use paper charts. In practices without computerized physician order entry, web-based portals are used to bring in orders. If a clinician makes a new note in a patient’s paper chart, Giarrizzi can ask on-site staff to hold up the patient’s chart to the camera so that she can zoom in on it.

Increasingly, telemedicine also supports post-hospitalization monitoring of patients. “Currently, we are significantly expanding our use of video teleconferencing for NPs and PAs in home settings, especially with chronically-ill patients,” Chin says.

Successful implementation

As telemedicine continues to expand ensuring student exposure in NP and PA training programs will be vital to their success.

Some nurses, even recent graduates, confide that despite frequent mentions in nursing and physician assistant school they do not understand exactly how to use the technology. “There are real, ‘What do I do now’ moments,” Giarrizzi said.

Certain personality types will be more inclined to adapt to telemedicine than others, she added. Clinicians that are successful in telemedicine are generally good at communicating, like thinking on their feet and are comfortable with evolving technologies.

In addition to making sure staff is properly trained to use telemedicine programs, Giarrizzi recommends using FDA-approved telemedicine systems, which have important patient privacy features and are better protected against security breaches.

Although there are currently very few rules and regulations in telemedicine, government agencies will likely start regulating the industry more closely in coming years, particularly in matters concerning the Health Information Portability and Accountability Act (HIPAA).

“There is a shortage of health care providers and we have many challenges ahead of us,” Giarrizzi said. “Telemedicine is not the one answer for everything, but it’s going to be part of the solution, no doubt about it.”

Bryant Furlow is a freelance medical writer in Albuquerque, New Mexico.


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