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Dr. W. Keith Barnhill of Iowa Anesthesia: “Telehealth makes it difficult to perform a physical examination”

An added benefit of telehealth with video is the ability to have insight into the patient’s home environment and collect a variety of information on their mental status, living environment, and interaction with other family members. One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and […]

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An added benefit of telehealth with video is the ability to have insight into the patient’s home environment and collect a variety of information on their mental status, living environment, and interaction with other family members.


One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?

In this interview series, called “Telehealth Best Practices; How to Best Care for Your Patients When They Are Not Physically in Front of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing W. Keith Barnhill, PhD, CRNA, ARNP.

Dr. Barnhill has practiced pain management and nurse anesthesiology for more than 30 years and has been a Registered Nurse since 1983. He is a graduate of the Texas Wesleyan/US Army Graduate Program in Nurse Anesthesia 6F-66F and earned his Doctorate in Nursing Education from Capella University. His primary work is clinical pain management and pain education. In addition to this work, Dr. Barnhill acts as an adjunct clinical professor and educator for the University of Southern Florida, University of Iowa, and the Minneapolis School of Anesthesia, and has authored several clinical practice manuals and an online radiation safety and clinical pain management program. He is a member of the American Association of Nurse Anesthetists (AANA).


Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?

I moved to Iowa in search of an autonomous advanced nursing clinical practice. This led me to the rural areas of Northeast Iowa, where I joined Iowa Anesthesia LC, a small but expanding certified registered nurse anesthetist (CRNA) group led by Mark Odden, MBA, CRNA, ARNP.

Life was fairly routine until the abrupt onset of the COVID-19 pandemic and social distancing policies, which closed all our pain clinics for six weeks. This was devastating to our rural community pain practice of ten pain clinics serviced by seven CRNA Nonsurgical Pain Management (NSPM) practitioners. Notably, CRNAs like myself are uniquely qualified to help alleviate the opioid crisis by using non-opioid or opioid-sparing healthcare techniques — so there was an added level of concern and complexity, as well as a sense of urgency, to keep serving our patients who continued to have pain during this timeframe and needed their medications refilled, while remaining protected from an infectious virus. Fortunately, telemedicine has helped us to continue to treat these patients in the same, holistic way.

We were aware of telemedicine and e-health practices but did not have experience with this type of novel advanced nursing practice. Fortunately, we were able to find a rich stream of research and evidence to support this practice quickly. So, after a few discussions with the various hospitals’ administrative staff, information technologists, nursing staff, as well as the access to care insurance rules, we developed protocols for telehealth. By transitioning to a deliberate combination of office visits (face-to-face) and telehealth conferencing with patients and their families, we were able to abide by social distancing and limit face-to-face interactions for high-risk individuals.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

“You cannot teach a man anything; you can only help him find it within himself.” (Galileo Galilei)

As an educator, my teaching and learning theory is grounded in constructivism, where learners construct knowledge by taking their own and others’ views to build new knowledge and construct understanding. Thus, learning and meaning arise from connecting others’ views to own knowledge.

None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?

Yes, I would love to! My dear friend and mentor, Father Jeremiah Loch, CRNA, D.O.M.T.P., PhD, is a Nurse Anesthetist and ordained Russian Orthodox priest with nearly 40 years of experience in comprehensive pain management. He holds a PhD in religion and health sciences and presently uses osteopathic, classical naturopathy, spirituality, and functional medicine to promote health and wellness. He continues to influence the way I view and approach advanced nursing practice and the holistic care I strive to provide. When I am faced with a new or challenging situation, I always ask myself “What would Jerry do?” If I cannot figure it alone, I can always call or text Jerry for his advice. I greatly appreciate the ability to have a continued relationship and immediate access to my professional mentor.

Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?

If the patient is in front of you, the ability to build rapport is much easier than trying to do so over the phone or video communication. You can observe motion, test strength, manually examine the body for structural changes, perform special testing, and do a comparison of one side/part of the body to another. You can also read the individual’s body language and determine if they are grasping ideas presented, acting stoic, or displaying nonverbal cues that could prevent a good relationship between the provider and patient. These in-person observations can greatly influence our goal of providing high quality patient care.

On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?

The difficulty of not having a patient in front of you will vary with the type of telemedicine technology incorporated. Is it telephone only or video and audio capable electronics? The telephone is more limited than the audio-visual technology. Many times, patients and their family are familiar with the telephone but not so oriented to the video capabilities of their phone. The collecting of a pain history, medical history, and other information related to current medications and treatments can be obtained over the telephone, however, the actual physical examination must be administered with video assistance. If the patient is in front of you, it is easy to assess their eye contact, mood, and body language, and collect physical responses such as a reflex, strength testing, and compare strength and motion from one side of the body to the other side. Not so easy when it a video presentation.

Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need to Know to Best Care for Your Patients When They Are Not Physically In Front Of You? (Please share a story or example for each.)

1. An added benefit of telehealth with video is the ability to have insight into the patient’s home environment and collect a variety of information on their mental status, living environment, and interaction with other family members.

2. Without video access, the telephone alone does not allow for observation of verbal cues that contribute to the patient-provider relationship that is so important in managing pain. It also does not allow the patient to see responses to their questions and makes it difficult to discuss complex issues involving their treatment and expected outcomes.

3. Telehealth makes it difficult to perform a physical examination. In person, it is often difficult to determine a differential diagnosis for a pain problem. Over the telephone and video this process is even more challenging.

4. A major negative to the telehealth process is in-home distractions like the television, computer, and younger children running around the interview room. The ability to have an uninterrupted appointment is diminished and can impact the conversation and evaluation with the patient.

5. Finally, while it is difficult to do an initial comprehensive evaluation via telehealth, it is more useful and appropriate for the follow up or continued care of an established patient in pain. Follow up care can be done more conveniently than scheduling in-person appointments and provide more frequent discussions about modifications to managing their pain.

Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?

Because of the telehealth platform, I was able to see and witness a homecare patient in her actual living environment. Her homecare assistants were reporting she was unable to get out of the bed without major pain and assistance. After seeing the bed on video, I was able to contact our occupational therapist, who performed a home assessment and made recommendations for a more ergonomic bed with special rails and assistive devices. The ability to see her living environment allowed for more personalized and intentional care which may not have been as clear if we had a conversation in the office.

Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?

The ability for patients to access their medical records and chart information via the computer in coordination with computer cameras have made telehealth conferencing an ideal solution.

Additionally, I have to include telehealth resources, such as the American Telemedicine Association which is a valuable resource for telehealth providers. It is at the forefront of telehealth education and use of telemedicine equipment that communicates with patient assistant devices (e.g., digital stethoscope, blood glucose and heart monitoring).

If you could design the perfect Telehealth feature or system to help your patients, what would it be?

I would recommend something that is user friendly for patients of all ages, including the telehealth practitioners, customizable to provider and patient needs, and capable of assessing vital signs and radiographs. I imagine a glass box similar to the old telephone booth systems with innate x-ray capability like those seen in airport screeners, so a patient can walk in and be scanned and able to submit their verbal responses simply by talking while in the telehealth box. It would also have a sit-down capability, a requirement for most of my patients.

Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?

Relying on remote technology for assessment of an individual’s pain is safe, minimally disruptive to their life, and an inexpensive and effective means of accessing healthcare. This improved access comes from the ability to use a variety of devices, like mobile telephone and computers, with and without camera for video-assisted conversations.

The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?

Virtual Reality (VR), as you know, is technology that tricks your senses into thinking you are in a different environment. Augmented Reality (AR) keeps you in the real world but enhances your senses with digital details altering your perception. These are commonly seen in virtual games. Mixed Reality brings the real world and digital components together. Mixed Reality (MR) would most likely play the greatest role in modern medicine and telehealth education.

I am unsure how MR would assist in the assessment of a patient for telehealth purposes, but it would be beneficial in training health educators from a distance. A virtual clinical environment that incorporates simulation is possible.

One piece of technology that is currently being applied is the Nuance Dragon ambient experience which allows the healthcare provider to focus on the patient on the video display while capturing documentation of the verbal exchanges and transferring this information to the electronic health record hands-free. This not only saves time but allows the practitioner to focus on the patient’s body movement and listen to every word spoken.

Is there a part of this future vision that concerns you? Can you explain?

Although advanced technology is growing, with it comes the risk of breeching patient-provider confidentiality. Patients need to know we prioritize their confidentiality by abstaining from sharing photos, comments, or details that have a potential to identify patients on social media or in casual conversations. Therefore, it is important that patients understand that we will keep their information private and protected.

Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂

This is a difficult question, but I will try and answer by incorporating some of the most advanced technology in the health and fitness world, such as wearable devices like watches with video access that can also monitor heart rhythms and blood glucose levels. This device should also include medication or pill-taking adherence to treatment schedules.

If the patient wears the device, clinical staff can monitor compliance and directly communicate with the patient, determine if they are non-compliant, or if other problems are identified. In my case, I could monitor the physiological effects of pain, compliance with non-opioid and opioid-sparing medication regimens, and review an electronic pain diary that lists the time of the painful experience and the patient’s activity.

If an emergency response is indicated, I could be notified immediately, otherwise, I could review that data at a later time. This is similar to what is currently done with the ECG holter monitoring system, which is often performed after checking a patient’s heart rhythm. The continued focus on providing patients a continuity of care would be further enhanced by this technology. I, in addition to the patient’s other providers, would all have access to and would coordinate care based on the same, most current data.

How can our readers further follow your work online?

While, I don’t have a website or information related to telehealth, I have a website for my pain management externship: www.premeirpained.com. Additionally, to learn more about the CRNA profession, readers can visit www.aana.com.

Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.

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