Step 5

Conduct a Visit

• Schedule extra time for troubleshooting
• Prepare your patient’s expectations, before the visit, including the possibility of a technically unsuccessful visit and emphasize the ease of rescheduling and that whatever technical glitch prevents a visit, it is almost always a readily fixed issue and unlikely to recur next time
• Have a staff member perform a test connection or “trial run” visit with the patient prior to the scheduled visit, if at all possible. Some software platforms allow testing of connection prior to visit. If this is not possible, a telephone call reminder, with explanations of what to expect, how to be prepared, and reminders about room setup can be helpful.
• If you do not have available IT support and are not using video in your EMR, consider performing a mock visit as the patient to see the steps the patient will have to go through to connect
• Keep the patient’s telephone number handy – it is advised that a working phone connection is confirmed prior to visit
  • Have a plan in place if emergency occurs during visit or for troubleshooting if necessary
  • In certain circumstances a telephone visit may need to be used as a backup or triage mechanism for efficiency and for people who may not have immediate capabilities to participate in a telemedicine assessment
• The patient may have anxiety about the technological aspects of the visit – remember to start with a friendly introduction to help put him/her at ease.
• Explain the goal of the visit and the timeframe.
• Tell the patient to let you know if there is a problem if they are unable to hear you or see you well.
• Consider formally ascertaining any sound delay: count 1-2-3 and have the patient count back immediately. Remember to pause for this amount of delay before responding in conversation.
• Have your EMR open for documentation in real time
  • Having 2 monitors or 2 computers is ideal, but requires high bandwidth
• Enhance communication by increasing mimicry and variable intonation.
• Use the “share your screen” option if desired to share illustrations, instructions
• Send the patient the after-visit instructions via secure, encrypted email (within electronic medical record if available) or mail.
• During times of uncertainty (COVID-19), when follow up may be challenging provide recommendations with several steps ahead as well as disrobing “red alerts”
• Be sure to send the patient’s local provider a letter or copy of your office note, as you would for an in-office visit
• Text chatting during the visit is recommended in addition to the video connection, to allow synchronous and efficient exchange of text information, such as instructions (especially when containing technical language or difficult to spell medical terms), numbers, links, etc.  Many video apps allow simultaneous texting as well, but if that is not the case, consider a feasible separately added text option.
   

VALIDATION OF REMOTE RATING SCALES

UPDRS

The Unified Parkinson’s disease rating scale can be performed remotely with the exception of rigidity testing and postural instability testing. This modified UPDRS has been validated in the following publication: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666325/

Abdolahi A, Scoglio N, Killoran A, Dorsey ER, Biglan KM. Potential reliability and validity of a modified version of the Unified Parkinson's Disease Rating Scale that could be administered remotely. Parkinsonism Relat Disord 2013;19:218-221.
 

UHDRS

The remote UHDRS has not yet been validated. However, blinded rating for clinical trials and training/certification for the UHDRS are currently performed via asynchronous video, as in the following publication, suggesting that real-time evaluations can adequately assess motor function:

https://www.ncbi.nlm.nih.gov/pubmed?otool=upennlib&db=PubMed&term=A+pilot+study+of+virtual+visits+in+Huntington+disease

Bull MT, Darwin K, Venkataraman V, Wagner J, Beck CA, Dorsey ER, Biglan KM. A pilot study of virtual visits in Huntington disease. J Huntintons Dis. 2014;3(2):189-95. doi: 10.3233/JHD-140102.
 

MOCA

Performing the Montreal Cognitive Assessment (MoCA) remotely via telemedicine has been shown to be feasible in movement disorder populations in the following publication:

https://www.ncbi.nlm.nih.gov/pubmed/?term=A+feasibility+study+of+conducting+the+Montreal+Cognitive+Assessment+remotely+in+individuals+with+movement+disorders

Abdolahi A, Bull MT, Darwin KC, Venkataraman V, Grana M, Dorsey ER, Biglan KM. A feasibility study of conducting the Montreal Cognitive Assessment remotely in individuals with movement disorders. Health Informatics Journal 2016, Vol. 22(2) 304–311. DOI: 10.1177/1460458214556373 jhi.sagepub.com

Resources and References