1. Final Presentation MMI-402 GROUP #3: William Marella Lena Matternas Rishi Ohri Daniel Runt

2. Introduction  Clinical scenario (before)  Role of technology in facilitating clinical encounters  Clinical scenario (after)  Implications

3. Clinical Scenario (before)  45 year-old male patient presents with chief complaint of pain in right hand of 2 weeks’ duration  History of lumbar disc compression but no subsequent history of neurological problems  No family history of neurological problems  Other standing items on his problem list include: seasonal allergies and insomnia  Employed, married, ex-smoker

4. Clinical Scenario (before)  Physical exam shows normal color, temperature, no perspiration.  No sign of acute injury or trauma  Unilateral symptoms  Symptoms isolated to area innervated by median nerve  No pain or paresthesia in arm  Weakness also reported, but no atrophy of the thenar eminence

5. Phalen maneuver

6. Subsequent clinical course  Patient is referred for nerve conduction studies and electromyography  Not hearing results more than a week after testing, David S. calls the office for results. Dr. Miller reports the results are positive for moderate CTS and recommends surgical consult.  David S. has surgery for carpal tunnel release with resolution of CTS symptoms, but with surgical site infection which resolves after treatment.

7. Opportunities for improvement  Initial visit could have been virtual  Nerve conduction and electromyography probably unnecessary for diagnosis  Poor follow-up of test results  No conservative treatment tried  Complication of treatment: surgical site infection

8. Physician/Organization Impacts  Remote Visits (Telepresence)  Removes geographical conflicts  Time savings  Cost savings  Increase number of patients serviced.

9. Physician/Organization Impacts  Remote Monitoring  Allows for resources to be spent in other places  Time savings  Cost savings  Increase number of patients serviced

10. Physician/Organization Impacts  Clinical Decision Support  Allows for inclusion of most recent evidence based medicine results  Prevents diagnosing errors  Improves physician performance  Best return on investment

11. Physician/Organization Impacts  Patient Portal  Better communication Answer questions Send lab results Appointment reminders  Replaces need for some visits  Time savings

12. Clinical Scenario (after)  David S. logs into scheduled video-chat via secure patient portal  Nurse triage via video chat  Patient sees documentation entered in real time.  Nurse transfers video chat to physician, who conducts initial discussion as in initial scenario.  Physical exam is modified to accommodate technology limitations.

13. Clinical Scenario (after)  Clinical decision support (CDS) queues algorithm for CTS evaluation and treatment based on preliminary diagnosis  Information on disease prevalence and etiology  CDS estimates probability of disease, with MD over- ride  Tests presented showing modified PPV/NPV for different tests available, with preferred tests prioritized.

14. Clinical Scenario (after)  CDS presents treatment options  Conservative treatment recommended, with plan for escalation if symptoms persist  Patient receives visit summary, checklist, and information  Follow-up at scheduled intervals facilitated by system  Conservative treatment success verified and adjusted by mid-level practitioner