How does telemedicine work? Esp as an NP

caliotter3 · Mar 5, 2021

One of my providers offers telemedicine visits however they require that every few visits be in person so they can "put the stethoscope on my chest" as they put it. I think it is a good idea. However, my opinion is that if I were a brand new NP, I would want to start out hands on only until I had my confidence built up. Then I would probably only offer tele visits to well established patients that I felt comfortable "seeing" in this manner. My opinion.

Noodle411, ADN, MSN, RN, NP · Mar 6, 2021

Yes, there are certainly limitations to not being able to do a physical exam on a patient and patients need to be made aware of this as well when making their appointment for telemedicine/telehealth/televisit.

Since I do not work with pediatric population, I can only speculate that if you were to work as an NP in Pediatric Primary Care, telehealth visits would be mostly talking to the parent, and some with the patient (depending on the child's age). Virtual video would be likely your main mode of telehealth visit since they likely are comfortable with using their smartphones and video-chatting. Non-urgent problems would likely be the most appropriate type for telemedicine visits... routine/common ailments, medication management, and health promotion.

Speaking as an Adult NP working in a privately MD-owned gastroenterology office, my experience in telemedicine has been this:

Most patients have already been "seen" by their PCP and are referred to our specialty office for further evaluation.
Telephone vs. "Virtual Video" conversations done in our office primarily due to having more elderly patients (also less likely to deal with tech issues or tech-knowledge deficits).
Primarily, the conversation goes much like an intake chart, minus the Objective findings: Chief Complaint, OLDCARTS, Assessment/Impression/Differential Diagnosis, and Plan.
The plan usually involves additional diagnostics such as imaging, labwork, endoscopy procedures, a prescription or a recommendation for alleviating current discomfort (example: May consider 1/2 dose of OTC Imodium BID PRN for diarrhea), and next follow-up.
For the imaging and labwork, we usually send scripts to their choice of imaging office (or hospital) or lab (ex: LabCorp, HealthQuest). When the results become available, we review them and discuss next steps with the patient.
For established patients for follow-up, the conversation is not that much different than if they were in the office. "How are you feeling today compared to... since you started...". The plan changes and you adjust accordingly. For example, "Per shared medical decision-making with patient, patient agreeable to trying... If his/her symptoms do not improve, I would consider increasing medication X to BID, or this XYZ diagnostic, or refer to specialty surgery for further evaluation."
Challenges with televisits: Calls dropping (if you or they are using a cell phone). Patients don't pick up the phone (because you're calling from a blocked number or secondary office line that is not recognized by their cell phone). They talk longer than the time you allotted for the appointment (which also happens with in-person visits).
Another challenge with using the telephone: Needing to get creative with your wording so that patients can better describe their problem. Example: Me-If I were to ask you to point to where in your body your pain is, where would you point to? Patients-Directly underneath my right ribs, the part of my stomach above my left hip bone, in the bottom of my throat between my collar bones.

Hope this was helpful. Best of luck in your future endeavors.

missdeevah, NP · Mar 16, 2021

I do pediatric telemedicine. The one thing I can't stress enough is that you need to have experience. You need to intuitively be able to tell when you should send them to an ER, and when you should send them to an in clinic evaluation.

DrCOVID, DNP · Mar 18, 2021

On 3/16/2021 at 9:31 AM, missdeevah said:

I do pediatric telemedicine. The one thing I can't stress enough is that you need to have experience. You need to intuitively be able to tell when you should send them to an ER, and when you should send them to an in clinic evaluation.

If you have a few years of nursing exp, shouldn't this be pretty intuitive? I know there are those online only, no exp needed programs but Sheesh!

Providers learn dx, meds, advance assment blah blah, but it is nursing basics to tell if someone really needs to go to the hospital, amirite?

missdeevah, NP · Mar 20, 2021

Being a nurse is different from being a provider. I'm not talking about the obvious person in distress that needs to go to the ER. I'm talking about treating someone that shows up on a virtual visit with a chief complaint of pink eye, and you deciding whether to treat or decide they need to be seen immediately for orbital vs periorbital cellulitis. A brand new provider may not know this. There's not much time in a virtual visit to research issues while the patient waits.

I'm not talking about the person that shows up with obviously low BP or SOB that any prudent nurse would say go to the ER/ call 911 stat.

Lastly a new provider may also feel uncomfortable with things that could be treated on a virtual visit with some precautions given, and instead send them to be seen in clinic. This could happen far too many times than is necessary.