2. BIT by BIT
Outline of Talk
Building the
Basics
Workflow Process
Virtual MSK Exam
Identifying
Clues
Guiding your patients
Case examples
Targeting
Improvements
How can Med Students
improve Remote Consultations
3. Building the Basics
Private practicioner vs Teaching institutions
Alone, with Secretary, with Team Staff
New Patients vs Old Patients
Identify your workflow process:
EULA
Consent Form
Hardware and Software
Details
Chaet, D et al; Ethical Practice in Telehealth and Telemedicine; J Gen Intern Med 32(10):1136–40; 2017•
Indian Medical Council; Telemedicine Practice Guidelines: Enabling Registered Medical Practitioners to provide healthcare using Telemedicine; 25 March 2020
bit.ly/upmiutelemed2020
4. Which Patients?
Kulcsar Z, Albert D, Ercolano E, Mecchella J. Telerheumatology: A Technology Not Appropriate for All
[abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). https://acrabstracts.org/abstract/telerheumatology-a-
technology-not-appropriate-for-all/. Accessed July 15, 2020.
5. How do I go about doing this?
bit.ly/upmiutelemed2020
Dr. Iris Isip-Tan
#WISER-Physician
Convey value with your Welcome
Introduce the technology
Set an Agenda
Express Empathy
Listen Reflectively
Provide closure
6. What did I learn?
Zamora, L et al. Telemedicine for Filipino Lupus Patients during the COVID-19 pandemic: A single center experience. Presented at the Lupus Academy Conference 2020
Mendez, Elbert et a, Single Center Experience with Tele-Rheumatology During COVID-19 Pandemic in a Developing Country, Presented at the APLAR Virtual Congress 2020
Summarize
Narrow the differential
Analyze the differential
Probe the preceptor by asking
questions
Plan management
Select an issue for self learning
SNAPPS
7. The Virtual MSK Exam
Is it articular?
Is it acute or chronic?
Is inflammation present?
How many or which joints
are involved?
Heat?
Redness?
Swelling?
Pain?
Loss of Function?
1.
2.
3.
4.
5.
Dr Jack Cush, RheumNow.com
https://www.youtube.com/watch?v=gZ-NrMmz7as
Harrisons Principles of Internal Medicine
Translated from Lupus Inspired Advocacy RETFI Module
of Dr Sandra Navarra
8. The Virtual MSK Exam
May masakit po ba sa inyong
mga buto-buto o kalamnan?
Kaya po ba natin mag-bihis ng
walang tulong o alalay?
Kaya po ba natin umakyat o
bumaba ng hagdanan mag-
isa?
How/What/When?
(Paano/Saan/Kailan?)
Inspection
Range of Motion
Contralateral
Comparison
"Simon Says"
Dr Jack Cush, RheumNow.com
https://www.youtube.com/watch?v=gZ-NrMmz7as
Harrisons Principles of Internal Medicine
Translated from Lupus Inspired Advocacy RETFI Module
of Dr Sandra Navarra
10. Before Scheduled Consult
Ask patients to prepare or send ahead important lab
results or ancillary images if possible
Take photos using proper lighting and position
med records
To
D
oc
Lessa
M
y
M
ed
ical
Files
med records
med records
11. Taking Photos
Uzun, M., Bülbül, M., Toker, S. et al. Medical photography: principles for orthopedics. J Orthop Surg Res 9, 23 (2014). https://doi.org/10.1186/1749-799X-9-23
American Telemedicine Association (2016) Teledermatology Practice Guidelines.https://www.americantelemed.org/community/teledermatology/
Background: provide contrast. (Sky Blue, Solid)
The extremities should be presented without clothing or
accessories.
Anatomic markings should be visible
Cameras at least 3.2 megapixels (8 megapixels)
Diffuse, indirect, fluorescent (natural) daylight. (Outdoors
well lit or in shaded areas if sunny)
12. CASE 1
60 yo Female; Former Secretary
"Deformed hands"
Bilateral hand and writst pain
Fingers are stiff in the morning for 15 mins
Via Inspection,
what can you see?
Heberden's Nodes
Bouchards Nodes
Carpometacarpal joint squaring
13. CASE 2
Ask the patient if her right hand is
painful
Ask the patient to show the hands
to the camera one by one
Ask the patient to close her fists
and open them one by one
14. CASE 3
36 F, overweight; former dancer until 8 years ago when she had a right calf
muscle tear injury during a dance class.
3 years on-off right knee pain.
Father, brother, elderly aunt has a history of Gout
Osteoarthritis?
Gout?
Septic arthritis?
Rheumatoid arthritis?
15. CASE 3
Ask the patient to expose both knees so that you can
observe for swelling or redness
Ask the patient if the right knee is painful
Ask the patient to walk across the room
16. CASE 4
50 F with a history of rheumatoid arthritis video calls you due to bilateral knee pain with on-off swelling
since lockdown started. She says there is no improvement while she self medicated with pain relievers. In
the morning she feels stiff, usually for 10 mins. She can still do ROM of the knees but feels uncomfortable.
During the video consult, she has difficulty rising from the chair. There is a cane at the background which
you notice, and she confirms she has been using it more frequently. According to her daughter who is also
in the call, the knees are slightly warm, but they cannot confirm if she ever had fever.
DDX?
Osteoarthritis?
Crystal induced
arthritis?
Septic arthritis?
Active RA?
Physicians must be aware of
limitations of Telemedicine.
It will not be the right model
of care for ALL patients
Meant to enhance process,
not replace
Terminate remote consult
and advise patient to do
F2F consult for possible
arthrocentesis
Chaet, D et al; Ethical Practice in Telehealth and Telemedicine; J Gen Intern Med 32(10):1136–40; 2017
17. Item 1 Item 2 Item 3 Item 4 Item 5
100
75
50
25
0
Targeting
Improvements
How can Med Students improve Remote
Consultations?
RESEARCH
ADVOCACY
COLLABORATION
18. Research
Tech Savvy --> Tech Natives
What are your interests?
What are your ideas?
What are your thoughts?
20. providing
teaching beyond
the clinic setting
- Dr Eric Moral; PCCP 2021
Post consultation Materials / Internet Rx:
mobile apps!
infographics
bit.ly/impormasyon101
22. Collaboration
Data Scientists
Work with Bioinformatics,
Biostatisticians, Epidemiologists
Public Health
Preventive Medicine
Community Medicine
System Developers
Designing systems
Nursing & Pharmacy
Informatics
Patient care/therapy
Service and Supply delivery
23. Computer RHEUM
Building the Rheumatologist 2.0 BIT by BIT
Identify Clues
Target Improvements
Build the Basics
