Anatomy of a virtual visit (VV)

Although I started offering virtual visits in January of 2019, when I was "between offices", I did not fully appreciate the utility of them until they became more widely used during the current public health emergency (PHE). For many of you, they may still seem a bit mysterious, so I'd like to break them down for you.

A virtual visit is an encounter between a healthcare provider and a patient through a telecommunication device, generally involving the use of either an electronic medical record (EMR) or a dedicated telehealth platform (THP). My EHR is Modernizing Medicine (ModMed for short), and the associated app is PocketPatient, and my THP is Spruce Health (an app). The communication channels vary: telephone, text messaging, emailing, faxing, sending store-and-forward photos, and/or video-chatting/video-examination. The visits can be in real time (phone, video) or they can be taking place over time--a period of hours or days--using "store-and-forward" images.

For insurance to consider covering a virtual visit, it generally must be initiated by the patient. The patient generally must be in state, although there is now some leeway in treating out-of-state patients. Historically, the patient needed to be "established", but this rule has been relaxed for the PHE.

The patient can call, text, email, or fax a request for a VV with me as follows:

Office landline phone--voice calls only: 914-422-3376 (during the PHE, we answer this phone weekdays from 1-5pm, but you can leave a voicemail anytime)

Spruce "after-hours" cell phone--voice calls or non-private text messaging: 914-768-4474

Email: this can either be secure through our EMR (you must contact us to enable your portal if you have not already activated it), or non-private through our website www.goldwasserderm.com or through info@jennifergoldwassermd.sprucecare.com.

Spruce fax: 914-259-5431

It should be noted that for urgent matters, you should call by phone.

Once we have connected, we can easily invite you to download the Spruce Health app to establish a PRIVATE/SECURE connection, through which we can: speak, text, fax, email, send photos/videos, and/or videochat/video-examine.

We recognize this is new to most of you, so we do our best to walk you through the process in the most efficient way. If privacy is not an issue for you, you can simply waive your right to a HIPAA-secure channel, and that simplifies the process. We are obligated to inform each patient that these services generate a fee, and we will collect the fee by credit card, either on the phone or by patient online payment, at or soon after the time of service. Medicare now generally covers telehealth services, and many private insurers have followed suit. We will submit the claim(s) for you to be reimbursed. The fee is generally similar to office visit fees.

After the visit, the follow-up varies. I may recommend an in-person visit, I may advise that you send a follow-up photo, I may schedule another virtual visit, I may send in a prescription (electronically), or I may just offer advice. When necessary, I can easily send you a summary of the diagnosis and plan via text or email.

I do want to mention a new technology that may prove useful: it is a kit for sampling (with tape) a skin lesion that is suspicious for melanoma. The test is produced by DermTech. It can be performed in office, or by a patient at home. This video tutorial explains how:

https://youtu.be/NhhX4SNygPg

Virtual visits typically take about 20 minutes. For new patients, more time is involved because we need to collect contact information, insurance information, medical and surgical history (including vaccine history), a list of medications and allergies, family history, social history, and pharmacy information.

You can facilitate your virtual visit by having all relevant information handy. I will want to know what the problem is, where it is located, how long it has been present, what symptoms are associated, what treatments have been tried, and what response you have had. You can improve the quality of photos if you (or someone in your household) can take the photo by "flipping" the phone and using the flashlight on the phone to illuminate the problem area. It is helpful to have both a close-up photo, and one taken at a bit of a distance. Place a coin or ruler in the photo for scale.

I hope this has demystified the process for you, and has answered some FAQ's! I am delighted that virtual care has gained acceptance by patients, physicians, and insurers. Even after the PHE passes, this option will remain useful in many situations.