Ask the Expert: Dr. Lewiecki Shares Invaluable Insight on Best Telemedicine Practices During the Pandemic
E. Michael Lewiecki, MD
Director, New Mexico Clinical Research & Osteoporosis Center
Director, Bone Health TeleECHO
Vice President, Board of Trustees, National Osteoporosis Foundation
The COVID-19 pandemic and mandated social distancing have forced healthcare providers to quickly determine how to use technology to provide patient care. A recent NOF survey revealed that more than 60 percent of healthcare providers are offering telemedicine visits by phone or videoconference. Since March 2020, more than one third (36%) of patient respondents have participated in technology-driven appointments. Overall, the feedback has been very positive with 77 percent indicating that their telemedicine appt was easy, convenient, a good quality visit and safe. NOF’s Dr. Lewiecki shares excellent insight and perspective on what patients can expect from this new form of healthcare.
Q: How should a patient prepare for a telemedicine appointment?
A: With restrictions imposed by the COVID-19 global pandemic, televisits have become commonplace as a replacement for the traditional office visit. As restrictions are lifted, more patients will be able to return to having face-to-face office visits, but some may still prefer televisits. Here are a few things to consider for a televisit:
a. Scheduling. Be sure you have the right date and time. With a televisit, you may be in a different time zone, so keep that in mind. Be certain you have provided the most current insurance information for billing purposes, along with all of your contact information details. For a televisit, it must be clear in advance whether it will be by phone or video.
b. Medical information. Please provide all necessary records and reports before the appointment. There may be forms to fill out with your medical history, list of medications, symptoms and concerns. Depending on circumstances, these may need to be mailed, emailed, faxed or hand delivered.
c. Technology. If the visit is by telephone, be certain you have a good connection. For a cell phone, ensure your phone is charged and that you have a strong signal. For a video visit, you should decide what device you will use – smartphone, computer or another device. If you have never done this before, conduct a test beforehand. If there is a link access to a website, be sure you have this available when you need it. If you need to download an app or program, complete this step-in advance and know how to use it. There are many different systems, so be sure you are using the right one for the appointment.
d. During the televisit. You must have the microphone, speaker and camera activated. If you are not sure how to do this, practice in advance and get help from someone who knows. Speak clearly and stay in front of the camera. If you want a family member or friend to participate, have them sit beside you. Be prepared with questions and important medical information and take notes, if needed. At the end, be certain you understand next steps such as whether a follow-up appointment is necessary; are lab tests needed; is a prescription necessary; etc. Be sure you are well aware of how next steps will be executed.
Q. What can a patient expect from an osteoporosis telemedicine appointment?
a. Initial consultation. There is some important medical information that is needed for the first visit. Please provide as much as you can in advance. The following lists some components of your medical history that could come up in discussion:
i. Previous evaluations for osteoporosis
ii. General health
iii. Falls – past falls, fear of falls, balance problems, physical therapy
iv. Fractures (broken bones) – which bone, what side, when and how
v. Surgery – especially for bones or intestines, organ transplant
vi. Family history – especially those with broken bones or bone problems
vii. Medications for osteoporosis – what, when, if you stopped why you stopped, side-effects
viii. Medications for other conditions – especially prednisone and anti-hormone medication for breast or prostate cancer
ix. Treatment for other conditions – especially radiation therapy for any reason
x. Bone density tests – when, where, reports, results
xi. Lab reports
xii. X-rays, CT scans, MRIs of bones – especially the spine
xiii. Intestinal problems – trouble swallowing, ulcers, heartburn, indigestion, food intolerances, digestion difficulties, diarrhea
xiv. Cardiovascular disease
xv. Kidney disease
xvi. Any special concerns
With a video visit, it is possible to have a limited physical examination. For example, balance testing can be done while someone watches on the screen. You may be able to show your teeth and any skin rashes of concern. At the end of the visit, be sure to discuss the plan for additional evaluation, treatment and follow-up.
b. Follow-up televisit. Be prepared to provide an update for all of the above, especially any new tests, falls, broken bones, difficulties with medications.
Q. What has your overall experience been conducting telemedicine with your patients?
A. I prefer a face-to-face office visit, especially for an initial consultation. When that is not possible, a video visit is my next best choice. As all of us have more experience with this type of televisit, it will probably become more comfortable and useful. A phone visit is my third choice but has the advantage that anyone can do it and no special computer skills are required.
Q. Do you have any top-line advice or key learnings to share?
A. Regardless of how you connect with a healthcare professional, effective communication skills are required on both sides. Be sure you are sharing all the information your provider needs and that your concerns have been expressed. Just as important, be sure you understand all that has been discussed. You and your provider should be working as a team to optimize the health of your bones.
Bone Health During COVID-19: Important Information for Patients and Caregivers
On June 10, NOF’s Board President and Chief Medical Officer reviewed important information via a live webinar about how to manage your bone health during the Novel Coronavirus (COVID-19) pandemic. NOF recently surveyed its patient and caregiver community to ask about access to care, availability of medication/treatment, and other healthcare concerns. Our experts shared highlights from the survey and responded to some questions and concerns raised during a Q&A session at the end.
Temporary Prolia® (denosumab) Injection, for subcutaneous use, Administration by Patient or Caregiver During COVID-19 Public Health Emergency
Dear Health Care Provider:
Following consultation with the U.S. Food and Drug Administration (FDA), Amgen is issuing this letter to provide you with safety information regarding temporary administration of Prolia during the COVID-19 pandemic. Prolia is intended for multiple osteoporosis indications.
The current U.S. prescribing information states that Prolia (denosumab) should be administered by a healthcare provider. At this time, self-administration of Prolia is not approved in the United States. However, administration by healthcare providers may be a challenge in the context of the current COVID-19 pandemic. FDA has informed Amgen that it does not intend to object to our dissemination of this letter or the accompanying temporary Instructions for Use and video only for the duration of the COVID-19 public health emergency declared by the Secretary of Health and Human Services on January 31, 2020.
Joint Guidance on Osteoporosis Management in the Era of COVID-19 from the American Society for Bone and Mineral Research (ASBMR), American Association of Clinical Endocrinologists (AACE), Endocrine Society, European Calcified Tissue Society (ECTS) and National Osteoporosis Foundation (NOF)
The guidance has been created to assist clinicians in the management of patients with osteoporosis in the era of COVID-19. The current pandemic has necessitated the implementation of social distancing strategies that have the potential to disrupt the medical care of patients with osteoporosis. We acknowledge that there is a paucity of data to provide clear guidance. Thus the below recommendations are based primarily on expert opinion.
Coalition of Bone Health Experts Issues Joint Guidance on Osteoporosis Management in the COVID-19 Era
Organizations responding to “paucity of data” to provide clear guidance for healthcare professionals treating millions of osteoporosis patients
WASHINGTON, D.C. – (7 May 2020) – The current COVID-19 global pandemic has necessitated the implementation of social distancing strategies that have the potential to disrupt the medical care of patients with osteoporosis.
In response to this disruption, the American Society for Bone and Mineral Research (ASBMR), American Association of Clinical Endocrinologists (AACE), Endocrine Society, European Calcified Tissue Society (ECTS) and the National Osteoporosis Foundation (NOF) today released guidance to help healthcare professionals treating osteoporosis patients in the era of COVID-19.
COVID-19 and Osteoporosis Treatment: Webinar for Healthcare Professionals
This webinar featured an expert panel that reviewed what new rules and legislation mean for clinicians caring for osteoporosis patients.
Due to the unprecedented healthcare crisis caused by the respiratory illness brought on by the Novel Coronavirus (COVID-19), Congress and the Centers for Medicare and Medicaid Services (CMS) have been releasing new resources and relaxing many rules to allow for flexibility in treating patients during this crisis period. This new information includes updates on telemedicine, reimbursement and delivery of treatment.
This webinar also called upon providers in all clinical settings to share how they have been adapting their practices during this crisis and what challenges they are encountering in their ability to provide the best patient care and keep their business intact.
Andrea J. Singer, MD, FACP, CCD, NOF Chief Medical Officer; Director, Women’s Primary Care, Director, Bone Densitometry Department of Obstetrics and Gynecology, MedStar Georgetown University Hospital, Washington, DC
Saira Sultan, JD, President & CEO, Connect 4 Strategies
M Kay Scanlon, JD, Senior Advisor, Connect 4 Strategies
Moderator: Claire Gill, Interim CEO, National Osteoporosis Foundation
ASBMR Webinar Panel on Treating Patients with Osteoporosis During the COVID-19 Pandemic
This webinar featured a panel of clinical experts in bone discussing timely topics related to osteoporosis treatment and the COVID-19 pandemic, including:
- Prolia® (denosumab) and the immune system
- Approaches to transitioning patients from Prolia® (denosumab)
- Timing of Evenity® (romosozumab) and possible transition to other treatments
- Transition from skeletal anabolics to antiresorptives
Panel of Clinical Experts:
Matthew Drake, MD, PhD, Mayo Clinic, Rochester, Minnesota
Doug Bauer, MD, University of California, San Francisco, California
Bart Clarke, MD, Mayo Clinic, Rochester, Minnesota
Elena Tsourdi, MD, Technische Universität Dresden, Germany,
Elaine Yu, MD, MMSc, Massachusetts General Hospital, Harvard Medical School, Boston
Amgen recommends the use of its products only in accordance with the Food and Drug Administration (FDA)-approved prescribing information. Please refer to the full prescribing information for approved product labeling and important safety information – https://www.amgenmedinfo.com/Home
Letter from NOF Interim CEO
March 20, 2020
As the coronavirus (COVID-19) continues to spread in communities across the country, we know that there is increasing uncertainty and anxiety as we are less able to plan and are worried about the health and well-being of ourselves, our loved ones and our communities. We must not panic, but instead practice patience and compassion.
The National Osteoporosis Foundation (NOF) has been monitoring the situation from a variety of sources and putting plans in place to address the ongoing needs, health and well-being of our NOF community. Following is information for patients/caregivers and healthcare providers that we hope will be helpful to you.
For Osteoporosis Patients and Caregivers
Osteoporosis Medications – It is recommended that you have at least a one-month supply of your current medications on hand during this time of social distancing and self-quarantine. This includes your osteoporosis medications.
- If you are taking the following oral medications or self-injectables to treat your osteoporosis, please check with your healthcare provider to make sure you have adequate amounts on hand:
- Alendronate (brand names: Fosamax®, Binosto®)
- Ibandronate (brand name: Boniva®
- Risedronate (brand names: Actonel®, Atelvia™)
- Raloxifene (brand name: Evista®)
- Calcitonin (brand names: Fortical®, Miacalcin® o Estrogen (multiple brands)
- Estrogen/Bazedoxifene (brand name Duavee®)
- Teriparatide (brand name: Forteo®) If you finish your 2 years of teriparatide or decide to discontinue the medication, please discuss an alternative medication so you do not have bone loss when you stop it.
- Abaloparatide (brand name: Tymlos®) If you finish your two years of abaloparatide or decide to discontinue the medication, please discuss an alternative medication so you do not have bone loss when you stop it.
- It is extremely important that patients taking the following medications administered by a healthcare provider stay on time for scheduled injections:
- Denosumab (brand name Prolia®) – If you skip or delay taking a dose, you have an increased risk for breaking a bone, especially if you already have a broken bone in your spine. Please discuss your schedule with your healthcare professional as soon as possible.
- Romosozumab (brand name Evenity®) – If you miss or delay a dose of EVENITY®, please contact your healthcare provider as soon as possible to schedule your next dose.
- Zoledronic acid (brand name: Reclast®): This is a once-a-year infusion and can be delayed for a short period of time since the medication lasts a long time. Please discuss the schedule with your healthcare professional.
- For all medications, if you have questions or concerns, be sure to discuss your osteoporosis management and treatment schedule with your healthcare provider.
Calcium and vitamin D – It is important to continue with the calcium (food FIRST and supplement for any shortfall in your diet) and vitamin D schedule and management that were established with your healthcare professional.
NOF recommends that all its Support Groups suspend in-person meetings as directed by local governments and health departments. NOF will be providing access to a teleconference phone line for any Support Group Leaders who wish to use teleconferencing as a substitute for in-person meetings. Please contact firstname.lastname@example.org for more information.
We also encourage patients and caregivers to utilize NOF’s free, peer-to-peer online support community to stay connected with others who are impacted by osteoporosis and low bone mass: https://www.nof.org/patients/patient-support/osteoporosis-support-community/.
For Healthcare Providers
We are carefully evaluating the potential impact on our upcoming annual clinical meeting, the Interdisciplinary Symposium on Osteoporosis (ISO), scheduled for May 27-30, 2020 in Washington, D.C. With just over two months until the start of the ISO, we continue to monitor the impact of COVID-19 and will make a decision that is in the best interest of our community. We will provide further updates on our conference website – https://interdisciplinarysymposiumosteoporosis.org/.
If you have questions about patient care, treatment or guidelines, please visit BoneSource®, our website for healthcare professionals – https://www.bonesource.org/. Or contact NOF at email@example.com.
Additional Information and Resources
According to the Center for Disease Control (CDC), the elderly and adults with underlying health issues are at greatest risk for severe disease due to COVID-19. The best way to protect against respiratory illness, including COVID-19, is to continue to practice good health habits:
- Avoid others who are sick. Separate yourself from all individuals by six (6) feet.
- Frequently wash hands with soap and water or use alcohol-based hand sanitizer.
- Avoid touching your eyes, nose and mouth.
- Cover coughs and sneezes with a tissue.
- Disinfect surfaces around your home and/or office regularly.
- Avoid shaking hands, hugging and kissing.
- Avoid large gatherings.
- If you become ill, stay home, call your doctor’s office to discuss symptoms. Go to a healthcare facility only if directed by your physician or if you are seriously ill.
Following are links to useful resources for accurate information regarding coronavirus and steps to take to avoid contracting the virus and what to do if you feel you may have been infected:
- CMS Clinician Info
NOF suggests that everyone in its community follow the recommendations of the CDC. If you have specific medical questions related to COVID-19 and your health, please contact your healthcare provider. We hope everyone in our community will remain safe and healthy.
Sincerely, Claire Gill Interim CEO