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Center for the Future of the Health Professions Feb. 2021 column: Virtual health in the COVID-19 era: The opportunity is here!

This month, The Center for the Future of the Health Professions will be posting our second monthly op-ed column for 2021. Our columns represent strong, informed, and focused opinions on issues that affect the future of the health professions. As mentioned in the past, the center was developed to provide state, local, and national policymakers and health system stakeholders with accurate, reliable, and comprehensive data and research about the healthcare workforce, so they can effectively plan for a sustainable future and make the best use of available resources.

This month features a discussion of Virtual health in the COVID-19 era: The opportunity is here! By Randy Danielsen, PhD, PA-C Emeritus, professor & director of the Doctor of Medical Science program at ATSU-ASHS and director of the Center for the Future of the Health Professions; and Amanda Weaver, MBA, program administrator for the Center for the Future of the Health Professions

We encourage readers to share their thoughts after reading this important piece.

The Coronavirus pandemic has significantly impacted medical and dental education. COVID-19 has constrained face-to-face provider-patient communication and has increased the utilization for virtual medical visits to support patient care in educational settings.1 Virtual health visits are not merely a stopgap measure during the pandemic. A recent survey reveals that 83% of patients questioned expect to use virtual appointments thereafter.2

Virtual healthcare opportunities come in two forms: audio-only (typically conducted via smartphone or traditional landline telephone), or synchronous two-way audio-video conferencing. Synchronous video conferencing adds the capability to perform limited visual assessments. A successful transition to virtual healthcare requires the joining of at least three key factors: access to broadband internet, and internet-capable devices, and sufficient technology literacy to take advantage of the first two factors.3

Virtual health (telehealth, telemedicine, teledentistry) has been on the rise for many years, but in 2020 not surprising, the usage has soared by 33% from the previous year. American Telemedicine Association defines telemedicine as “the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status.” Telehealth focuses on various healthcare services that promote health but does not explicitly discuss care delivery.1 There are multiple definitions of telehealth, teledentistry, and telemedicine. However, they all share the same modalities: synchronous, asynchronous, and remote patient monitoring. Synchronous is live interaction with patients using a face-to-face connection through a smartphone, tablet, or computer using platforms such as Zoom, Microsoft Teams, and many others.4,5 The first published use of telemedicine dates back to the 1970s. In the United States, the use of technology for medical purposes was applied for several years to specific populations such as inmates, people living in rural areas, or patients who had physical difficulties in getting to the health center. Globalization and the advent of new electronic and digital equipment made it essential that all clinicians participate actively in this new scenario.6,7

A 2017 study published in The Journal of the American Board of Family Medicine conducted a random survey of 5,000 family physicians to investigate whether or not they implement telehealth services within their practices. Only 1,557 providers responded to the study. It found that family physicians practicing in rural settings used telehealth three times more than family physicians located in an urban setting.8

What’s Happening at ATSU?

Telemedicine

Within A.T. Still University’s Arizona School of Health Sciences (ATSU-ASHS), telehealth is offered at the CarePLaCe clinic for caregivers. The service currently provided in occupational therapy (OT). Virtual evaluations using cell phone cameras is the primary technology used. It has worked very well. The OTs also evaluate the caregiving situation, interviewing the caregivers and care recipients. Family members out of town can join in via Zoom, which has led to some successful family conferences.

The ATSU-ASHS physician assistant (PA) program started teaching their students about telemedicine within their musculoskeletal (MSK) clinical medicine block by creating three cases for a mechanism of injury that would likely lead to a particular type of upper extremity fracture that once identified on X-ray and would prompt the student to desire a specific kind of splint. Unique and expected lessons learned by the students after this MSK testing included how to connect and display empathy/compassion virtually, how to roll with any technology hiccups and keep stress to a minimum for self and patient, how to verbalize desired MSK range of motion when it is challenging also to show a patient the moves you wish for them to achieve, how to stay organized in a virtual physical exam. PA students overall were quite pleased with the transition to virtual testing. They believed it would greatly benefit them as they moved into a clinical year where COVID restrictions would likely mean taking part in telehealth encounters. This process was then used successfully in the neurology and cardiology courses.

Teledentistry

Teledentistry is a combination of telecommunications and dentistry involving exchanging clinical information and images over remote distances for dental consultation and treatment planning. Teledentistry can improve oral healthcare access, enhance oral healthcare delivery, and lower its costs. It also can eliminate the disparities in oral health care between rural and urban communities.

In October 2015, ATSU-Arizona School of Dentistry and Oral Health (ATSU-ASDOH) hired Dr. Scott Howell, DMD, MPH, FSCD, ’14, assistant professor; and Colleen Trombly, RDH, MHSA, assistant professor of hygiene, to develop and implement its first teledentistry program. Consulting with critical players in teledentistry, such as Dr. Paul Glassman from UoP, Dr. Howell, and Trombly, developed both didactic and clinical programs for ATSU-ASDOH students. The didactic components have evolved over the years and now include four primary classes. The first two classes occur in the second year and allow students to learn more about what teledentistry is and how they can use digital records to diagnose their patients from a distance. The third class occurs in the third year and looks at the challenges with implementing a teledentistry program. Students are taught how to be advocates for teledentistry as many of them will go into clinics or go to states that don’t use teledentistry or even allow it to be used. The last class takes place during a one-week public health rotation. In small groups, the students work with Trombly to learn how to use the intraoral camera crucial to gathering clinical records used in teledentistry.

Students get to practice using teledentistry during the public health rotation mentioned previously. ATSU-ASDOH has partnered with multiple community agencies to provide oral health services. These locations include Maricopa County Juvenile Detention Center, Aster Aging in Mesa, and Maricopa Reentry Center, which is part of the state department of corrections. Third-year students will travel with faculty to these sites and meet with patients to collect the necessary clinical records. The second set of students, who have not physically met the patients, will take the data gathered in the field and develop a diagnosis and treatment plan for the patients. Patients will then present to one of the ATSU-ASDOH clinics for the necessary care. This method allows patients to eliminate one or more visits to the school, saving them both time and money. As COVID has required some of these partnerships to be put on hold, ATSU-ASDOH has been exploring new ways to connect with patients and is now using teledentistry with Zoom, allowing students and dental residents to conduct post-op visits, emergency exams, sedation consultations, and treatment plan presentations via live video conference. And soon, partnering with Catalytic Health Partners, nurse practitioners visiting with Medicaid recipients will be collecting clinical records using the intraoral camera so that care can be coordinated between the medical providers in the field and dental providers at ATSU-ASDOH.

Telehealth or teledentistry, of course, can’t replace a physical examination. If combined with in-person visits, patients can maximize the benefits of healthcare. Although the pandemic has led to an increased number of telehealth visits, the amount of research on these visits is still lacking. The medical community would benefit from more research within various disciplines. Regardless, virtual methods of delivering medicine and dentistry are here to stay. We would love to hear what you think.

References

1 Vidal-Alaball J, Acosta-Roja R, Pastor Hernández N, Sanchez Luque U, Morrison D, Narejos Pérez S, Perez-Llano J, Salvador Vèrges A, López Seguí F. Telemedicine in the face of the COVID-19 pandemic. Aten Primaria. 2020 Jun-Jul;52(6):418-422. doi: 10.1016/j.aprim.2020.04.003. Epub 2020 Apr 17. PMID: 32402477; PMCID: PMC7164871

2 Telemedicine Adoption in the Age of COVID-19 and Beyond. Doctor.com. https://cdn2.hubspot.net/hubfs/3053445/Doctor_Telemedicine_Survey_Infografic.pdf

3 Zimiles A. Four new statistics that prove that telemedicine isn’t just a pandemic fad. Medical Economics. https://www.medicaleconomics.com/view/four-new-statistics-that-prove-that-telemedicin e-isn-t-just-a-pandemic-fad. Published 2020.

4 Julien HM, Eberly LA, Adusumalli S. Telemedicine and the Forgotten America. Circulation. 2020;142(4):312-314. doi:10.1161/CIRCULATIONAHA.120.048535

5 Rheuban K, Shipman S. Workforce, Definitions, and Models. In: Rheuban K, Krupinski EA. eds. Understanding Telehealth. McGraw-Hill; Accessed October 23, 2020.

6 Coronavirus Disease 2019 (COVID-19). Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html. Published 2020. Accessed November 22, 2020.

7 Gómez E.J., Del Pozo F., Arredondo M.T. Telemedicine: a new model of healthcare. Int J Health Technol Manage. 1999; 1:374–390

8 Moore M, Coffman M, Jetty A, Klink K, Petterson S, Bazemore A. Family Physicians Report Considerable Interest in, but Limited Use of, Telehealth Services. The Journal of the American Board of Family Medicine. 2017;30(3):320-330. doi:10.3122/jabfm.2017.03.160201

Resource: Telehealth and the 2021 Arizona Legislative Session

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