TELECLINIC

‍During the COVID-19 pandemic, all visits will be conducted via telehealth (phone or zoom). Our administrative assistants, Ashley Kaufman and Alexia Sexton, will contact patients beforehand to determine which platform they would like to use.

  • Initial visits- all initial visits should be conducted over zoom. The meeting ID for the zoom encounter will be in the “Notes” section of each appointment. If you do not see a meeting ID, please email Ashley for a zoom link.

    • Staffing: For PGY2s, attendings will join the entire zoom visit for new patients during your first 3 clinics. After this, the attending should be contacted towards the end of the visit to join the zoom meeting and staff the patient. The same applies to senior residents.

  • Follow up visits- these can be conducted over zoom or over the phone depending on patient preference which will be determined by the admin staff. This will be specified in the “Notes” section of your schedule. Again, you will receive zoom links from the admin staff prior to clinic.

    • Staffing:

      • For PGY2s- attendings should be contacted towards the end of your encounter to log on to zoom/join the phone call and staff the follow up visit.

      • For PGY3/4s- attendings can be contacted at the end of your clinic day to staff follow ups. If you have a complex follow up for whom you would like attending input, feel free to staff with the attending in real time.

  • After your clinic day, the administrative staff should be made aware of any orders or referrals that need to be sent to the patients as well as when you would like the patient to follow up. This can be done via email or you can route your encounter to Ashley after it is signed. If you choose to route the encounter, you must specify what needs to be done for the patient/follow up time frame in the Comments section.

ZOOM TROUBLESHOOTING

  • If you do not receive a zoom link for your upcoming clinic, please send an email to Ashley Kaufman.

  • If you log onto zoom and your patient is not there- try to call your patient and determine what the issue is. If they can’t find the link, you can provide them with the meeting ID to log in. If you are unable to reach your patient by phone, Doc Halo Alexia or Ashley and let them know.

  • If the patient is having trouble setting up video-

    • For follow-up: Call patient and convert to phone visit

    • For Initial: Check with the attending to determine if a phone visit would be appropriate or if patient should be rescheduled.

  • If the patient is having trouble setting up audio- use a phone call for audio

  • If the patient is not English speaking- see below for instructions on setting up a translator.

  • If the patient is unable to be reached by phone or by zoom - ask the admin staff to reschedule.

‍TELENEUROLOGY: TIPS ON DOING A VIRTUAL NEUROLOGY EXAM

THE ZOOM NEURO EXAM

Basic Neuro Exam

This is a basic neuro exam for basically every patient in every division/with every attending.

Mental Status:

  • A/O: Person, Place, Date

  • Repetition: Apple, Table, Penny

  • Naming: Pen, Knuckle, Earlobe

  • Attention/Concentration: spell WORLD (forward and backward), serial 7’s

    • If pt cannot do that, do days of the week backwards

  • Repeat: “no ifs ands or buts” or “I only know that John is the one to help today”

  • Commands:

    • Crossed – use your right thumb to touch your left ear

    • Grammatical – point at the ceiling after you stick out your tongue

  • Memory: what were those 3 words?

Cranial Nerves:

  • Eye movements (CN III, IV, VI)

    • The command that has worked best for me for zoom is: “keeping your head still, please look to the R/L/up/down”

  • Facial movements (CN VII) – I typically pick 2 of these, 1 for upper face and 1 for lower face

    • Raise eyebrows

    • Squeeze your eyes shut

      • Sometimes helps to say “like you have soap in them” if they’re not giving you enough effort to bury lashes

    • Big smile, show me your teeth

    • Puff out your cheeks

  • Mouth/tongue (CN X, XII)

    • Stick out your tongue

    • Open your mouth “ahhh”

      • I’m able to see the palate 50/50, depending on lighting and camera angle

  • SCM/Traps (CN XI)

    • Shrug your shoulders

    • Turn your head R/L

  • Facial sensation (CN V)

    • Touch your face on forehead (hands or a cold spoon) -> cheeks -> chin; does that feel the same to you on both sides?

      • If they’re zooming from a phone, can have them use just one hand thumb + middle finger for this task since they’ll be holding the phone in their other hand

Motor:

  • Pronator drift (works best when pt is on a laptop)

  • Proximal LE strength: with your arms crossed over your chest, can you stand up?

    • Best to do it in patients who are not on rolling chairs

Coordination:

  • Finger to nose with eyes closed

Sensation/Proprioception:

  • Heat/cold sensation: can have patient use a cold spoon/fork

  • Romberg

Gait:

  • Let’s see you walk

    • Usually I just do normal gait

    • Other options include tandem gait, tip toes, heels

Division Specifics:

Below are exam maneuvers specific to certain clinic subspecialties. This is more accessory to the above information and contains more details.

Stroke:

  • Stroke attendings tend to like more complicated words for repetition: Brown shoes, Number 55, Honesty

  • Arm rolling test to look for orbit

  • Lateral tongue movements as part of CN exam

  • Aphasia – word list in 60 seconds (“within 1 minute, please tell me all the unique words you can think of that start with the letter F”)

Neuromuscular:

  • Consider doing sharpened Romberg for more mobile patients because it’s a little harder

    • Sharpened Romberg = feet in tandem (like the sobriety test)

  • For MG, there’s a lot of muscle fatigue testing:

    • In history taking, consider emphasizing breathing, double vision, speaking, swallowing, symptoms in heat, and fatigue

    • During CN exam, have patient hold upward gaze

    • Arms outstretched out to the side, hold it for a long time

    • Single breath test to evaluate for breathing (breath hold + counting)

      • An example (starts at 00:45)

      • Note: she usually has her patients count a little slower than this video

    • Balancing on one foot

Movement:

  • This division sees a lot of Parkinson’s patients, so repetitive movements and tremor assessment is very important

  • Some activities for evaluation of static tremor:

    • The best position to look for resting tremor is hands in lap with medial/pinky side down and fingers spread apart

    • Hands to your nose, roughly like this:

Image courtesy of Evelyn Shifflett

o   Hands outstretched like for pronator drift

  • Some activities for evaluation of dynamic tremor:

    • Finger to nose to camera

      • I like going to the camera instead of to the patient’s other outstretched finger because you can really see an action tremor when their finger gets close to the webcam

  • Some activities for repetitive movements:

    • Finger taps

    • Hands open/close

    • Remember to tell patient to go big and fast for Parkinson’s

Headache:

  • Some perks for the history:

    • Last headache

    • Frequency of headaches

    • Duration of headaches

    • Location of headaches

    • Quality/Aura?

    • Headache meds used in the past, what works

    • Any SE from headache meds

  • Physical exam will more often than not be normal in these patients. We mostly did mental status, CNs and drift, plus sometimes she would look for clicking of jaw (looking for TMJ)

MS:

  • Not much of a physical exam for these patients, especially if they’re follow-ups

  • If anything, mostly focusing on where they had previous symptoms/where known lesions are

TELEHEALTH DOCUMENTATION AND BILLING

Elements that are required for telemedicine documentation:

  1. Chief complaint: need to have both the actual chief complaint (e.g. stroke, headache) AND “Social Distancing-Pandemic” listed. The latter will autopopulate once you complete the Express Lane.

  2. Consent and Documentation – either put in note or fill out in Express Lane (see below)

    1. “Telehealth Verbal Consent” – Paragraph of disclaimers regarding telehealth that you must either put in note (.TELEHEALTHVIDEOVERBALCONSENTCOVID19 )or select this section under “Express report” in “Express Lane”

    2. “Telehealth documentation” – A series of questions about your location, patient’s locations, who else was on call, any connection problems. Can either put in note (.TELEHEALTHPRELIMDOCUMENTATION) or select under “Express Report” in “Express Lane”

  3. Charges: Must select “COVID BILLING LOS CODE NC” – either in Express Lane or in Wrap up tab Charges section

  4. Level of Service:

    1. If attending does not join video: 88888

    2. If video with attending: Use New patient or Follow-up patient codes based on complexity.

      1. If billing high level, you must have all elements entered into Epic and included in the note (FH, SH, PMH, ROS)

    3. Make sure to add in “GC” modifier with any level of service

  5. Note must include:

    1. Type of visit: Telephone or Video visit

    2. Time: Exact start and stop time of call/video.

Using the Express Lane feature in EPIC:

  1. Select the appropriate “Lane” (e.g. video visit due to social distancing). You will then get the Express Lane documentation, which adds:

    1. “Social Distancing-Pandemic” to CC

2. “COVID BILLING LOS CODE NC” to Charges

2. Add the actual CC (e.g. stroke, headache, etc.) – link in Express Lane, or in Rooming tab

3. Complete the Telehealth Consent and Telehealth Documentation.  Scroll up in Express Lane to orange highlighted area.  You must select both of the below:

a.  The first item “Verbal Consent Form” opens the below

b.  The second item “Telehealth Consent Form” opens the Telehealth Documentation checklist to complete:

4. Level of Service: There is also a section in the Express Lane for LOS, but does not have 88888.  You can also enter LOS in the “Wrap Up” tab

5. Note must include:

a. Type of visit: Note must state Telephone or Video visit

b. Time: Exact start and stop time of call/video.