Connecting With Your Patients Through Telehealth

Host: Christina J. Hanson, FNP, South Denver Gastroenterology
Featuring Kim Orleck, PA-C, Atlanta Gastroenterology Associates

Welcome to Clinical Conversations: Connecting With Your Patients Through Telehealth

Christina Hanson and Kimberly Orleck received payment from Salix Pharmaceuticals for their testimonies.

Christina: Hello, I’m Christina Hanson, and thanks for joining us for Clinical Conversations. We are going to be talking about telehealth, specifically about how to continue to connect with your patients with IBS-D when providing care virtually. Telehealth has rapidly become essential to providing patient care, and despite the challenges of adapting to its increasing use, its benefits become evident almost immediately.

Caring for patients through telehealth can help improve access to services for those who are unable to make it to the office in person because of physical distancing recommendations, because a patient lives in an area with limited access to healthcare, or other reasons that make an in-person visit not practical or feasible.

Kim Orleck is joining me today to talk more about this topic. Thanks for being here, Kim!

Kim: My pleasure, Christina.

Christina: So, I have to say, I feel kind of lucky because most, if not all, of the providers in our group had experience to some degree with telehealth prior to the physical distancing requirements that came with the COVID-19 pandemic. We had those practices in place, so, transitioning was a fluid process. When our offices and clinics had to temporarily close our doors to inpatient and office-based care, we were able to convert to telehealth visits quickly from our homes. What are your thoughts, Kim, about seeing IBS-D patients through telehealth?

Kim: You’re right, telehealth has been around for a while, even before the coronavirus pandemic, but less widely available, so it may be a new experience for many patients—and even many providers. Patients are more accustomed to seeing their healthcare providers in their offices and clinics and might not know what to expect with a telehealth visit.

It’s important for us to remember we can still set the same foundation that applies to in-office care when providing care virtually for IBS-D patients—and all of our patients. It’s just as important—if not more important—to ensure that patients feel heard, that they have confidence in us as their providers. We can accomplish this by continuing to focus on what is most bothersome to them and working with each patient to determine their specific goals.

Even though our time is evermore limited, and we are pulled in lots of directions, we still can dedicate the time, patience, and the empathy needed to establish and maintain a genuine connection with our patients.

Christina: So Kim, how do you prepare your IBS-D patients, specifically, for telehealth appointments?

Kim: Before an appointment, I encourage patients to write down any symptoms they’re experiencing—for example, abdominal pain or diarrhea—as well as any questions or concerns they may have, and place them near their computer or device so they remember to bring up all the things they wanna talk about. It’s also helpful to have a list of all the prescriptions, over-the-counter medications, herbs, vitamins, and supplements they take handy.

I also like to send my IBS-D patients materials to review before their appointment to help them prepare for our conversation. These can be educational materials that tell them more about their diagnosis or things that can help them to describe their symptoms to me. For instance, GastroHubAPP.com has a discussion guide for IBS-D symptoms that I find really helpful for my patients.

Even during virtual visits, there’s the opportunity to use educational materials with patients. During a live video appointment, providers can share anatomical graphics and educational material on-screen in place of an in-person interaction.

In fact, there are multiple ways we can provide resources virtually to help patients understand their IBS-D diagnosis and relevant information about any medications, including what symptoms the medication may help with, how it is thought to work, when and how it should be taken, and what to expect with treatment. For example, in addition to on-screen sharing, resources can be uploaded to a patient portal or sent directly to a patient prior to or as a follow-up to the telehealth visit.

GastroHubAPP.com has the discussion guide that I mentioned, as well as other resources that can be downloaded for sharing with patients. In addition, various resources are available on the site that provide more detailed information for clinicians.

Christina: Whether I’m caring for patients in person or through telehealth, it’s so important to understand how IBS-D symptoms may be exacerbated by chronic stress…and I don’t know about you, Kim, but the past few months have certainly been more stressful for me!

Kim: I definitely talk to my IBS-D patients about stress now more than ever. I think, with COVID-19, it is so important that we check in about chronic stress, anxiety, and how they’re coping with life. It’s really important that patients know and understand that it’s okay to have some level of anxiety and really check with them about how they’re doing emotionally, their mental health, and what they’re doing to take care of themselves.

I think that further emphasizes the continued importance of scheduling follow-up appointments with IBS-D patients, even if care is being conducted virtually, to ensure they’re getting the care they need to help relieve their symptoms. Like I said earlier, we need to understand what success means to our patients and what level of improvement is acceptable to them so that we can help get them there—we need to rely on the best practices that we’ve always used in the office.

Christina: You know, an important factor in the patient-provider relationship in telehealth is the quality of communication. Videoconferencing may have a tendency to impact the connection between the patient and the provider, and some may think of telehealth as being a kind of “hands-off” approach to patient care. Have you found that to be the case at all, Kim?

Kim: I agree, good communication between a patient and provider is particularly important when treating patients with chronic conditions such as IBS-D. I have found that I’ve had to work a little harder to overcome the “virtual disconnect,” so to speak, but it is doable and it’s so important that we try. It also helps that patients are becoming more accustomed to videoconferencing in other aspects of their lives, either for work or just to stay connected with friends and family.

We all need to make a conscious effort to employ affective techniques during virtual interactions with patients. This includes encouraging and reassuring the patient; showing friendliness, openness, and honesty; demonstrating approval and empathy; and offering verbal support. Affective communication is not only verbal. I actually have an interesting statistic on this: it’s estimated that only 7% of emotional communication takes place verbally; 22% is conveyed by the tone of voice and 55% by body posture, gaze, and eye contact. In particular, our tone of voice, posture, and facial expression are all forms of nonverbal affective behavior that can help reassure a patient during a telehealth visit. I also like to encourage patients to act just like they would if they were at an in-person visit in their doctor’s office—it is such a simple thing, one sentence, but it reminds the patient they can be at ease.

Christina: That’s a great point, Kim. With telehealth, it’s difficult for us to use all of our senses, particularly the so-called sixth sense, or that gut feeling many of us have experienced when we interact with our patients in person that tells us something isn’t right. I think some may worry about missing signs of trouble and losing that “human interest” aspect of their practice.

Kim: This can be a concern, but telehealth allows us the opportunity to sharpen observations and diagnostic skills and strengthen relationships with our patients. During telehealth visits, we can uncover clues in clinical assessment when we are invited—albeit virtually—into a patient’s home or workplace. The difference between “seeing patients” in person or via telehealth isn’t just in the number of senses we use. In these visits, we can ask a patient's family member to become our hands during an abdominal exam and describe what they feel. When we partner with our patients during these remote encounters and allow them to lead, we strengthen the provider-patient bond. In today’s healthcare environment, clinicians may lack the time and resources to fully vet the needs and desires of patients with complex non–life-threatening disorders, such as IBS-D. Nurse practitioners and physician assistants are well-suited to create a patient connection that fosters open communication and to establish trusting ongoing partnerships to effectively manage patients with IBS-D.

Christina: That’s a great way of putting it, Kim—and a great thought to end on. It has been so great speaking with you today. Thank you so much for sharing some of your insights around connecting with your patients through telehealth.

Kim: Happy to join you, Christina.

Christina: And thanks to our audience for tuning in to this episode. You can find more clinical conversations around IBS-D, available in both video and podcast format, on GastroHubAPP.com.

IBS-D, irritable bowel syndrome with diarrhea.

INDICATIONS

XIFAXAN® (rifaximin) 550 mg tablets are indicated for the reduction in risk of overt hepatic encephalopathy (HE) recurrence in adults and for the treatment of irritable bowel syndrome with diarrhea (IBS-D) in adults.

IMPORTANT SAFETY INFORMATION
  • XIFAXAN is contraindicated in patients with a hypersensitivity to rifaximin, rifamycin antimicrobial agents, or any of the components in XIFAXAN. Hypersensitivity reactions have included exfoliative dermatitis, angioneurotic edema, and anaphylaxis.
  • Clostridium difficile-associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including XIFAXAN, and may range in severity from mild diarrhea to fatal colitis. If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile may need to be discontinued.
  • There is an increased systemic exposure in patients with severe (Child-Pugh Class C) hepatic impairment. Caution should be exercised when administering XIFAXAN to these patients.
  • Caution should be exercised when concomitant use of XIFAXAN and P-glycoprotein (P-gp) and/or OATPs inhibitors is needed. Concomitant administration of cyclosporine, an inhibitor of P-gp and OATPs, significantly increased the systemic exposure of rifaximin. In patients with hepatic impairment, a potential additive effect of reduced metabolism and concomitant P-gp inhibitors may further increase the systemic exposure to rifaximin.
  • In clinical studies, the most common adverse reactions for XIFAXAN were:
    • HE (≥10%): Peripheral edema (15%), nausea (14%), dizziness (13%), fatigue (12%), and ascites (11%)
    • IBS-D (≥2%): Nausea (3%), ALT increased (2%)
  • INR changes have been reported in patients receiving rifaximin and warfarin concomitantly. Monitor INR and prothrombin time. Dose adjustment of warfarin may be required.
  • XIFAXAN may cause fetal harm. Advise pregnant women of the potential risk to a fetus.

To report SUSPECTED ADVERSE REACTIONS, contact Salix Pharmaceuticals at 1-800-321-4576 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

Please click here for full Prescribing Information.

INDICATIONS

XIFAXAN® (rifaximin) 550 mg tablets are indicated for the reduction in risk of overt hepatic encephalopathy (HE) recurrence in adults and for the treatment of irritable bowel syndrome with diarrhea (IBS-D) in adults.

IMPORTANT SAFETY INFORMATION

  • XIFAXAN is contraindicated in patients with a hypersensitivity to rifaximin, rifamycin antimicrobial agents, or any of the components in XIFAXAN. Hypersensitivity reactions have included exfoliative dermatitis, angioneurotic edema, and anaphylaxis.
  • Clostridium difficile-associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including XIFAXAN, and may range in severity from mild diarrhea to fatal colitis. If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile may need to be discontinued.