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Cybernetic Care Blurring the Line Between Telehealth and In-Person Care

Author: Cait Shaw Illustrations by Bryan Beerman

Cybernetic Care: Blurring the Line Between Telehealth and In-Person Care by Cait Shaw Section 1

• Elimination of waiting rooms – period.

Cybernetics as Healthcare

• Point-of-Care taking place in homes

Efficient healthcare delivery respects the time, budgets, and risks taken by the patients and providers. Worldwide, healthcare is an everchanging, ever-debated topic with no single correct solution. Technology advances, and policy changes delay our path to efficient healthcare in the United States. The COVID-19 pandemic has led to devastating casualties, derailed multiple industries, and uncovered weaknesses in our economic structure. Amid the chaos, we have also unveiled broader capabilities of our technology and identified opportunities for improvement. Healthcare, in particular, has been pushed into the digital realm. Pre-pandemic, telehealth was a luxury in which few health systems were engaged; within days it became the preferred and most widely-use method for routine and outpatient care. This, too, revealed opportunities to use our digital tools in more efficient ways.

• Specimen collection in a drive-thru or in-home delivery and shipping system • Radiation-free imaging taking place in homes • Better access to healthcare in rural areas • Urgent care “where your feet are” – triage and in many cases, diagnosis, and treatment at your current location Cybernetics, defined in 1948 by Norbert Wiener as the science of communications and automatic control systems in both machines and living things (Conway 2005), refers to a continuous response and feedback loop in which a decision is made.

Telehealth as a response to the pandemic prompted us to our

Consequences for decisions occur,

next question: How can we use telehealth to more broadly impact

evaluation of the consequences ensues, and finally corrections are made

healthcare delivery during or even post-pandemic?

to inform the next decision. This loop is very similar to the Scientific

A “cybernetic care” model could dramatically improve the quality of healthcare. Cybernetics is the concept driving artificial intelligence; when

Method but refers to the ever-improving process naturally occurring within an organism’s biology or within a machine’s moving parts.

integrated with healthcare using the technology that Americans use daily,

This seemingly simple concept called cybernetics is the cornerstone

cybernetic care will not just be an addition to the medical practice but an

of electronics and artificial intelligence that we use today and

overhaul to the system entirely. This includes but is not limited to:

is therefore an ideal description for the telehealth of our future.

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Telehealth is a unique marriage of

With cybernetic care, the patient can stay in the comforts of their bed

communication that occurs within our

and avoid weather, transportation hurdles, waiting rooms filled with

technology (data mining and transfer),

other ill persons sharing recirculated air, exam rooms with sustained

within medical practice (books,

bright lighting and cold, hard surfaces, pulling out a credit card for

lectures, and case studies), and

the copay, transportation to the pharmacy (also filled with ill persons

between the technology and medical

awaiting prescriptions) before, finally, getting back home for some

practice. Decisions that impact health

overdue rest.

are made by either patient or provider, consequences follow, and analysis of those consequences using machines or human physicians informs the next decision. Wearables and other data-tracking devices can capture an overall look at an individual’s health and provide critical patient vitals to physicians

Current Healthcare Conditions | The Caregiver’s Experience From a caregiver’s perspective, the scenario is different, but no less challenging. When you arrive at work, you face another day of excessive handwashing and sanitizer use on your already dry hands

without using a caregiver’s time, facility, or risk of infection.

followed by disposable gloves (and the box already needs refilling

Can we develop a healthcare system that engages this cybernetic

it’s easier to eat quickly in the windowless locker room than in the

process incorporating both technology and medical expertise

spacious indoor/outdoor breakroom across the building.

to advance care quality, and to enhance patient and provider experience? Opportunities to integrate our current technology and medical processes abound, with the potential to rejuvenate healthcare delivery in the United States.

for the fifth time this week). Your workspace is likely harshly lit, and

If you’re an administrative professional, you serve as the first line of security between the public and your coworkers in the clinic or hospital. You wear personal protective equipment (PPE) all day, handle identification and insurance cards, answer phones, and

Section 2

touch patients’ phones and tablets to show how to use the health

Healthcare Then, Now, and Tomorrow

system app. You provide tissues, masks, specimen collection cups,

Current Healthcare Conditions | The Patient Experience We are all too familiar with this scenario: You have a fever now, but your primary care physician can’t see you for another week. The next step is to get in line at Urgent Care and wait in a room full of other sick or injured people while fighting through your own fever. You could be there for hours.

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pens, and maybe even a lollipop to the anxious child on the other side of your desk. Adding to your physical and emotional stress, you sit in the same waiting room as the ill patients for the majority of your day. If you’re an intake professional, you touch patients more directly. You wrap arms with blood pressure cuffs, weigh patients and place

thermometers in their mouths, and help them on and off tables or

The Cybernetic Care Experience

beds in the exam and procedure rooms. You ask them sensitive

Urgent Care Scene

health questions such as, “What’s your diet like? How often do you

Bria lives alone and cut her hand while cooking in the kitchen. It’s still

exercise? Do you drink alcohol or use drugs? Are you allergic to any

bleeding even though she has it wrapped and is applying pressure.

medications? When was the first date of your last period? Do you

She was able to call her doctor’s office or an Urgent Care by voice

have regular bowel movements? What ailments did your mother’s

command. She’s been on hold for six minutes and a nurse’s face

father have throughout his life?” Some patients are an open book;

appears on her cell phone screen.

others are shy and embarrassed to share such information. The muffled noise of voices coming from the next room doesn’t create a sense of privacy. You experience this routine for roughly 20-50 patients each day. If you’re a primary caregiver or doctor, you will be the one physically closest to your patient’s illness, injury, infected wound, or bodily fluid as you inspect and treat the area. Even though you practice good hygiene before and after each patient, you still touch many surfaces, use several disposable goods such as cotton swabs, otoscope covers, gowns, paper tissues and towels, gloves, sharps, topicals, adhesives, and more. You carefully document the details of the visit, either while with the patient or after you leave them to redress. The computer in this exam room is the slowest in the clinic, or the “j” key on the keyboard only works when you jab it hard. The swivel arm that the computer rests on doesn’t allow you to view the patient while you document, so you are constantly turning back and forth. You have roughly 12-15 patients to see today so you need to make

“Hi, I’m Carter and I’ll be your triage nurse today. Am I speaking with Bria?” “Yes.”

this visit as efficient as possible while maintaining a positive bedside manner.

“Hi Bria, please confirm your date of birth for me.”

All of these scenarios are a familiar part of the status quo, but there is

“November 9, 1997”

a better way.

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“The voice transmission says you are reporting a cut on your right

to your home so you can come in for stitches. Are you still at 1234

hand – is that right? Are you able to move your hand toward the

Apple Street? Do you authorize the driver to enter your home and

phone to show me?”

assist you, or will you be able to walk to the door yourself?”

Bria does her best. She isn’t going to pass out, but she also isn’t

Bria: “I’m feeling woozy – they should probably help me.”

okay watching her own blood flow.

Carter: “No problem Bria, will you confirm authorization that our

“Just take a seat, we are going to get through this just fine!” Carter

driver can digitally unlock and relock your door upon arrival and


departure? Also, can you confirm that the door we are using

Carter looks at the wound and the flashlight on her phone comes on. Carter adjusts the flashlight’s intensity and color and takes photos of

enters into the den and is on the left side of the home – near your driveway?”

the cut using Bria’s device.

Bria gives consent.

A typical dialogue to diagnose ensues: “How long has it been

Carter: “Ok, it looks like Kristy is just six minutes away and is

bleeding? Can you wiggle all your fingers? Do you feel any

available to come get you. She will be there soon and meet you in

numbness anywhere? I see that you are allergic to (enter medicine

your home. It will take 19 minutes to get to the doctor’s office when

name here), is that correct?”

you leave. Either Meg or Nick will take an in-person look when you

Bria’s smart watch vibrates and lights up with a loading screen. “I just got some info from your watch and it looks like your blood pressure is 125/74 – that’s good Bria. You are showing signs of stress though-, are you ok?” “Yes, I’m just a queasy about blood!” *breathy chuckles* Urgent Care Scenario 1 After five or so minutes of evaluation: Carter: “I think we need to get you some stitches and a blood coagulate. I expected clotting by now. I’m sending a medical Uber

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arrive.” Urgent Care Scenario 2 After five or so minutes of evaluation: Carter: “I think we need to get you some stitches and a blood coagulate. I expected clotting by now. I’m sending a medical Uber to your home so you can receive stitches at home. Are you still at 1234 Apple Street? Do you authorize the medic to enter your home and assist you, or will you be able to walk to the door to let them in?” Bria: “They can come in.” Carter: “Okay Bria, will you confirm authorization that our medic can

digitally unlock and relock your door upon arrival and departure? Also, can you confirm that the door we are using enters into the den and is on the left side of the home – near your driveway?”

Bria: “It can come in.” Carter: “Okay Bria, will you confirm authorization that our drone can digitally unlock and relock your door upon arrival and departure? Also, can you confirm that the door we are using enters into the den and is on the left side of the home – near your driveway?” Bria gives consent. Carter: “Ok, I’ve just launched Drone CR-8 “Charlie” to stitch your wound. It will be there in about 25 minutes and meet you in your home. One of our patient wellbeing advisers will stay on the phone with you until Charlie gets there. Dr. Talbot is on call and will talk to you through the drone while supervising your stitches.” Section 3

The Resources Exist The technology and strategic concepts to make healthcare more Bria gives consent. Carter: “Ok, it looks like Kristy is just nine minutes away and is available 20 minutes from now to stitch your wound. She will be

efficient for the end users have been around for decades. In short, what can the American healthcare system learn from Instagram, Chick-fil-a, Fitbit, and Amazon?

there soon and meet you in your home. Would you like to stay on the

Technology – Hardware, Software, & Connectivity

phone until Kristy gets there?”

96% of Americans own and use a cell phone – 81% of Americans

Urgent Care Scenario 3 After five or so minutes of evaluation: I’d like to send our DigiDoc Drone out to stitch you up. Are you still at 1234 Apple Street? Do you authorize the drone to enter your home and assist you or will you be able to walk to the door to let it in?”

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have a smart phone. (Pew Research 2019) Hardware Cell Phones (not “Smart” Phones) and Cybernetic Care: A simple phone call from an empathetic voice with health and diagnostic questions is a form of effective healthcare. Follow-up appointments or health management visits are often conversational

in nature, and don’t require a patient to navigate the stress of an in-

• Internet Connection via Wifi or Data plan

person visit.

• Flashlight • Pedometer

Smart Phones and Cybernetic Care:

• Data link(s) to Smart Home device (Alexa, Google Home, etc)

Smart Phones have opened the door for countless opportunities to

• Data link(s) to wearables

complete a task without requiring computer access. Healthy persons

» smart watch

with smart phones may never need to enter a healthcare facility for

» Necklace, anklet, etc

routine care. How’s that possible? Smart phones already include the

» glucose meter

following technology:

» heart monitor implants

• Image and Video recording

» Prosthetics

• Personal Data retainage (ideally with Password Protections)

» Augmented reality (AR) glasses

» Identity » Payment Methods » Insurance info • Audio recording

Smart phone technology has not yet reached its potential in terms of personal healthcare. To be fair, technology evolves at such a rate that all industries, including healthcare, may never be using its full potential at any given moment. However, healthcare efficiency in the United States could be greatly improved by better harnessing existing smart phone capabilities. Hardware and Connectivity in the Home: • ~29% of homeowners younger than 50 own a smart home device • ~19% of homeowner age 50 and older own a smart home device (Auxier 2019) Smart locks, readily available through retailers, give homeowners the ability to control door locks, cameras, or alarm settings remotely. Patients who are injured and alone can easily receive healthcare if they are in arm’s reach of their phones or within shouting distance of a smart home device. Integrating these systems to call for help

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and allow permissions for a caregiver to enter the home (without

patient’s surroundings and the ability of the patient to adequately

the patient having to crawl to the door or have the door broken

take legible images and/or videos. With patient consent, telehealth

into) is entirely possible. For extra security, access can be provided

software should allow the caregiver to remotely control the features

to a caregiver with an automatically generated unique code that is

of the patient’s smart phone to access information as adequately and

scanned by the front door lock, so not just anyone is coming through

reliably as possible. This means giving the caregiver access to the

your door.

phone’s image filters – much like Instagram filters – to view a wound,

Software Number 1: User Interface User Interface will be a critical success factor. Does the software audibly or visually guide someone to access the care they require with ease? Too much text, unclear language, and distracting imagery reduce user-friendliness. Beyond the in-the-moment hardship experienced while using software that isn’t intuitive, patients may lose confidence in the quality of care they will receive based on the telehealth software. The same applies to in-person visits; patients perceive the quality of care they will receive based on the look of the healthcare facility from the parking lot to the examination room before having seen a doctor at all (Arneill 2002). In other words, don’t underestimate the need for a graphic design professional, and possibly a writing consultant, for developing telehealth software. Number 2: Control (or Lack of) Caregivers have control of the examination environment when seeing patients in a healthcare facility. Doctors often move the stool, use the swivel arm for the computer, adjust lighting, adjust patient on the exam table, or adjust the exam table itself. In telehealth, the provider is at the mercy of the quality of lighting provided in the

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rash, inner ear, or throat, etc. With photo filters, the same RGB or CMYK values as every other patient’s phone-acquired imaging can be collected. This allows for an apples-to-apples comparison of healthy and unhealthy examples of the same body part in a health system’s database to be compared with each other more reliably. If the provider could also turn on the device’s flashlight and adjust its intensity to their liking, it wouldn’t much matter if the patient is in a poorly lit environment. Finally, the caregiver could control the patient’s camera for video or image retainage to help diagnose the case. This control doesn’t have to end with using the hardware capabilities of the smart phone, but can also facilitate health data collection. Apps which track heart rate, blood pressure, glucose levels, food intake, and activity could all be linked to a healthcare provider’s telehealth account and be uploaded for their viewing (with consent), offering a more holistic picture of patient wellbeing. Number 3: Electronic Consent Smart phones are very personal items with access to highly sensitive health, personal, and financial information. As such, phones may be password or biometrically protected. Six-digit passcodes, thumb prints, eye, face, or even voice recognition are all forms of electronic consent that can be easily used to verify a patient’s identity, permit diagnoses and treatment, agree to medications, or upload health data.

If any of those methods fail, voice consent via a phone call can serve

answer. Answers provided by a health system’s database can be

as a secondary option.

more credible than a general web search. Some questions about the

Number 4: Security The Health Insurance Portability and Accountability Act (HIPAA) aims to protect and secure personal health information. In a datadriven technology such as Cybernetic Care, sensitive information must be protected. Advances such as using artificial intelligence (AI) to auto-generate encrypted coding for each transaction of data were first widely provided to the public when purchasing goods via a cell phone’s virtual “wallet.” Regenerating a unique coding for each transaction of data greatly diminishes the ability for data to be stolen. This technology has found widespread use; in true cybernetic fashion, it is continually improved upon and eventually will evolve into something more complex and therefore more secure. A smart home device by Amazon earned HIPAA-compliance in 2019. “HIPAA-compliant” is a regulatory term used to describe healthcare organizations that embody a ”living culture that protects the privacy, security, and integrity of protected health information.” Amazon

mind and body are difficult for patients to ask; people don’t always know what language to use, may be uncomfortable asking a deeply personal question in a face-to-face conversation, or may fear being judged. A 2020 Clemson University study by student Courtney Linder researched the use of chat bots in healthcare databases. Her study suggests that chat bots could be an outlet for children and teens to find out important health information regarding sex, mental illness, or other topics they aren’t comfortable asking an adult (Linder 2020). Furthermore, healthcare systems could provide anonymous live chats with physicians to perhaps provide the same reliable information in a more personal way. Connectivity • Bandwidth: 73% percent of US homes have broadband connections (Mobile Face Sheet 2019) • 90% of Americans use the internet on a daily basis (Speedtest Global Index 2020).

achieved this milestone in its greater pursuit of becoming a cybernetic

A 2019 study by Harvard Medical School researchers examined

healthcare provider, and that process is still ongoing (Krasniansky

possible patterns in the use of telemedicine and the availability of


broadband connectivity. The study analyzed over 2,700 counties

In the spirit of using HIPAA-compliance and electronic consent, patients can provide necessary Electronic Medical Records (EMR), Insurance information, and payment directly to the provider. Other Software Opportunities: Chat Bots are robots with a database of healthcare information and the AI capabilities to dissect a question and respond with a relevant

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ranging from metropolitan to rural as the team tracked location and insurance coding for telemedicine “visits.” This study concluded that telemedicine was used more where broadband availability was highest, but only in rural communities (Wilcock, et al 2019). It is possible that this difference is explained by the fact that patients in rural communities must travel farther for in-person healthcare, and therefore have a greater incentive to use telemedicine.

In light of the current healthcare environment, however, telemedicine

now have strategic backgrounds in their homes or workspaces,

is highly encouraged, and the metropolitan areas have been altered

greenscreens for adding in digital backgrounds, or physical panels

significantly by the enforcement of social distancing. COVID-19 has

much like a photographer’s portrait studio to serve as backdrops.

reduced the use of public transit, and in-person visits pose new

These social media innovators have also developed an extensive

complexities due to infection risks. However, broadband availability is

database of the best microphones, cameras, and personal lighting

typically high in metropolitan areas. In rural communities broadband

devices for optimal audio and visual recording.

is perhaps less robust but still present, and the United States Federal Communications Commission’s (FCC) initiative of the “Connect America Fund” aims to increase broadband availability and strength in

The Telehealth Kit Telehealth owes the self-guided social media profession a great “thank

rural areas (Universal Service 2020).

you” for developing a kit of parts that physicians can use to present

The “elephant in the room” in the broadband discussion is this:

practitioners include:

different economic classes cannot all afford personal access to the latest and fastest internet technology. Healthcare systems could offer isolated hotspots to communities with less access to broadband connectivity. This is currently happening with public schools throughout the nation as students are using internet to attend classes from home in response to COVID-19. Public schools nationwide have provided hardware, software, and broadband connectivity (Willcox 2020). “Webside Manner” Charisma and good bedside manner are common (but not universal) skills of acclaimed healthcare providers. Unfortunately, these skills are not readily teachable, and do not necessarily translate well into the telehealth experience. In telehealth, bedside manner has mutated into “webside manner,” making charisma and personal connection harder to convey without in-person interaction. Luckily social media has provided a venue for innovation in improving onscreen personal appearance and relatability. YouTubers and Instagram professionals

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themselves to patients on-screen. Recommended accessories for

• A neutral, private clutter-free background with no passers-by » Solid wall color; light but not white » Soothing artwork (optional)

• Illumination of provider’s face

stages of development but is in the works (Isikdogan 2019). The best

» A “halo” light

practice until this software is widely available is to standardize where

» Natural daylight

the window of the patient’s face appears on the provider’s screen in

» Light surrounding computer screen that shines on provider’s

relation to the camera.

face • A working microphone » Separate plug-and-go microphone or built-in computer microphone, depending on sound quality • Acoustic Panel if in a shared space or exam room with hard

Behavioral Microexpression refers to subtle facial movements that occur in response to the brain’s current emotion. These quick, tiny movements are typically overlooked by conversation participants (Matsumoto 2011). Understanding a person’s emotional state during conversation is critical in medical care, particularly for psychological


evaluations. Conversing on video is a less intimate setting and can

» A foldable acoustic panel for hybrid exams rooms

cause the participants to miss emotional cues. Challenges include

» Soft surfaces to absorb sound (such as cloth seating, carpet

poor video quality, especially if the patient is using a cell phone or

flooring, and perhaps acoustic panels on the walls) • A working camera that auto-focuses on the speaker. » Built-in camera or plug-and-play, depending on quality • Two computer monitors, or curved monitor with large screen to maintain patient eye contact Equipment should be tested weekly or biweekly, depending on the frequency of use - and NOT while on calls with patients. A confident caregiver makes for a more secure patient. An unsure caregiver does not inspire patient confidence.

data connection; and inability to read full body language, as most video conversations only include the shoulders up. Electrodermal activity tracking software evaluates eye movement and other types of micromovements and categorizes them into certain emotions (Imotions 2020). This software could be used live during telehealth conversations to aid providers in their understanding of a patient’s mental health. Documentation Documenting a visit is paramount for healthcare providers to have an ongoing and holistic idea of a patient’s health. Some physicians prefer

Conveying and Observing Emotion

to document notes about a patient during the visit, and others like to

Other components of good webside manner include reading facial

wait until the visit is complete. In the former case, documenting during

expressions and making eye contact. True eye contact is elusive in

a telehealth visit is doable in a separate window on the computer,

video conversation, as the participants tend to look at the person on

as the patient’s EMR is likely open in a separate window on the

the screen and therefore not directly into the camera that is capturing

provider’s screen for reference anyway. In this scenario, it is important

their own face. Eye placement correctional software is in its early

to prioritize patient eye contact, not just documentation. As mentioned

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above, a standardization in the software or screen layout could allow

Responses received Tuesday, July 7, 2020 4:51 PM from

for the patient video to be nearest to the provider’s camera to maintain


best possible eye contact. The EMR or note-taking window shouldn’t be far away. Furthermore, the patient’s trust is gained simply by explaining the process: “This is good information that you are telling me, I’m going to be looking to my right so I can type this up while you speak.”

Question Have you used telephone calls, video conferencing, or both for therapy sessions? Answer I have used telephone calls and video for therapy. Question What technical difficulties have you experienced when trying to reach a patient? Was the problem on your (the provider’s) end or the patient’s? Answer First, the hospital system had not spent the money on a provider/ patient friendly software program for us to use. Insurance providers informed us what video conferencing software or apps they would allow HIPAA-wise. Problems include: internet down on provider side, internet down on patient side, I had to download different apps and systems on my phone to make it successful and if my internet was

Telepsychology Interview | Anonymous Therapist: The following questionnaire was conducted via email between Cait Shaw and Anonymous Therapist. Questions in black were written by Cait Shaw and were not peer reviewed prior to being sent. Responses in italics are from the Anonymous Therapist. Neither the questions nor the responses have been edited from the original conversation.

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not working right it would drop calls and would drop the video. My hospital system is getting Zoom Health set up for us but it won’t be ready for us until mid-July and they will have to train us. I doubt it will be hard. The other issue is that there were a few times that the Epic System was not working. We are dependent on technology. Patients also, despite the education on the front end of things still

answer while they are driving, in the car with family, stocking shelves

with a patient? How has this been affected by using

at work, at the cash register at work, etc. Not appropriate settings at


all. Spotty reception



I definitely use eye contact in teletherapy. In the videos meeting

If you have used video conferencing, do you feel you are

with someone you have to make a connection and eye contact is

consistently able to see the patients well enough to complete a

something I am mindful of. You have no idea what will be said in

successful session with them?

session. Although I did have a few patients who told me some pretty

Answer I think that video therapy has a place in this world. I think it is a

traumatic events and said that they would not have told me had they seen me in person or in video.

gamble. The risk is that you can’t pick up on nuances as easily. I had


a patient who I evaluated who was cutting on their arms and they

Do you feel that you or your patients are more likely to be

denied self-harm. I couldn’t assess for accuracy because I could

distracted during a session during a telemedicine session than

only see head and shoulders. I found out 3 sessions later.

they are in person? If so, why do you think that is?



Do you typically look for body language during your consultations

It is easy for them to get distracted from animals walking in the room

to help you assess a patient’s wellbeing? How has this been

or they think it is ok to be shirtless in the session. If they are set up in

affected by using telemedicine?

a high trafficked area that is a distraction. I set up expectations from

Answer You can only see what the video shows you so there is risk there.

minute 1 to help decrease the likelihood of distractions and have to redirect my patients from distractions.

Body language says a lot. It is imperative that you look at body

During COVID I have had a private place to practice therapy.

language in sessions. It is a part of the assessment. Some people

However, my 2 kids were at home and even with the sound machine

will do well with video therapy because they need help with a

you can hear the temper tantrums. Little kiddos are distracting.

stressful situation, and they are open and honest about how they are feeling and coping. That is not always the case.



(Anything that may be missing for you or for your patients’

Do you typically use eye contact as a strategy for communication

treatment experience).

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What shortcomings do you experience with telemedicine?


• Telepsychiatry — As defined by the American Psychiatric

With appropriate video software you can use a virtual whiteboard. I

Association, telepsychiatry is “a subset of telemedicine, can

like giving my patients homework and doing experiments in face to

involve providing a range of services including psychiatric

face sessions. Or go on mindfulness walks. You have to get savvy

evaluations, therapy (individual therapy, group therapy, family

and think outside the box. You have to upload all of the paperwork

therapy), patient education and medication management”

you may give a patient.

(Shore 2020). Especially for patients with severe anxiety or

Question Other than controlling the spread of infection, what benefits do you experience with telemedicine? (Anything that may be advantageous for you or for your patients’ treatment experience). Answer I suppose a benefit would be to help someone who is home bound until someone can enter into the home. The other issue is that not everyone has access to Wi-Fi and or high data plans. Studies in Indiana show that Medicaid kids are behind in virtual school for this very reason. No access to smart phones or Wi-Fi. It can benefit for those who are in need of something short term: smoking cessation, diabetes prevention, stressors at home, etc. I have found that it is also helpful for new moms that are battling with post-partum or people who need a bridge to seeing a long-term therapist. In-Home Care Types of Care Ready for Telehealth I. Visits that can be done using Telemedicine (Do Not Require inperson physical assessment) (Vanvuren 2019):

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physical limitations, being able to consult with a psychiatrist or psychologist using telemedicine technology can prove incredibly effective. • Teledermatology — Patients can utilize dermatology services remotely by sending a photo of a rash, mole, or other skin issue virtually, eliminating the need for an in-person visit. It is true that an in-person follow-up may be required if a biopsy is necessary but time and money can be saved by using telemedicine first. • Teleophthalmology — Through live video calling or “storeand-forward” technology (i.e. sending a picture to your ophthalmologist) patients can receive eye exams without leaving their home or office. Teleophthalmology is especially useful for diagnosing eye infections. • Teleoncology — Offering more convenient care to patients with cancer, teleoncology makes it easier to consult with specialists who may not be easily accessible from certain locations. Photo sharing and live video calling are used in this specialty. • Teleobstetrics — Pregnant patients can access prenatal care or urgent care for pregnancy-related health services, or get prenatal care using telemedicine. One example of this is recording the baby’s heartbeat in one place and having it reviewed by a physician in another. • Telerehabilitation — Patients who need physical therapy can receive video consultations instead of heading into an office

• Other applications: » Allergies

hurdles have been overcome, however, the door is open to use drones for all industries including healthcare.

» Arthritis » Asthma and respiratory and sinus infections » Bronchitis » Colds and flu » Diarrhea or constipation » Infections » Insect bites » Pharyngitis » Conjunctivitis (or pink eye) » Rashes » Skin rashes, infections, or inflammation » Sore throats » Sprained or strained bones » Bladder infections and UTIs » Sports injuries » Other physical injuries » Vomiting, heartburn, and nausea » Joint aches and pain » Headaches » Small wounds and cuts » Fever » Review medications, lab results, treatment follow-up Drone Healthcare The two largest markets for unmanned aerial vehicles – or “drones”

Medicated patients may need assistance for various reasons including but not limited to: • Some patients have difficulty remembering to take medication as prescribed. • Medications may be in the form of an injection or other non-oral method. • Some patients are susceptible to overdose and can only be given one dose of medication at a time.

- are the United States military and personal enjoyment. Few major

Time spent calling or physically attending to multiple patients for

shipping companies have done expansive studies and tests on using

medication management is prohibitively expensive. Therefore, patients

drones as delivery agents, but none are being used regularly as of

can often go improperly medicated for their condition and their health

2020 due to regulatory or feasibility concerns. Once the various


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Allowing drones to provide, remind, or even administer medication to

alternative solution. Emergency and non-emergency transportation

patients on a regular route daily or weekly could be a viable solution

employers can insure a medical aide to touch a patient and help them

to this challenge. Furthermore, in emergent situations drones have

to the healthcare facility.

the capability to perform some procedures such as suturing an open wound (Da Vinci Surgery 2020). Outfitting a drone with an ultraviolet

Section 4

(UV) light for disinfectant purposes, a robotic surgeon, and audio/

Cybernetic Care and the Healthcare Facility

visual capabilities for physician guidance allows for a quick response

At home or in the clinic: how do we ensure that providers have the

team to an injured person’s location.

right environment and tools to conduct telehealth visits with a few


basic finishes and accessories?

When patient needs require in-person care, transportation becomes a

Healthcare facility directors manage millions of square feet and often

critical issue. Lack of accessible transportation to a facility is a public

prefer to simplify their task with standardized mechanical, electrical,

health issue. Patients who do not have a vehicle, do not have access

and plumbing systems, standardized finishes, and standardized

to public transit, or are physically unable to access transportation

maintenance strategies. Since most healthcare systems have been

must rely on another person to transport them safely. Without a

around for decades and have acquired other systems or buildings

friend or family member to assist, patients would have to call for an

over time, these standardization goals are likely difficult or even

ambulance. According to the Healthcare Common Procedure Coding

impossible to uphold. It isn’t likely that telehealth will reduce how

System (HCPCS), an ambulance ride costs at least $215 minimum

much square footage any given healthcare system will use, but it may

per mile for any state in the US. The cost is increased if the transport

offer the opportunity for more efficient use of built space.

is considered “rural.” (2020 Ambulance Fee Schedule). Many cases requiring transportation don’t require an EMT team or ambulance

With telehealth, providers could work outside of the healthcare

assistance; non-emergent transport is available by some healthcare

facility as long as they are offering audio and visual security to the

systems or emergency transportation companies, but it isn’t widely

patient. In other words, you wouldn’t want your doctor looking at and

adopted (Lang 2019).

talking about your acne on their screen in the middle of a local coffee shop. However, a physician’s home may be an option, or any other

Calling an Uber or Lyft transportation service is certainly an option

location free from distraction, away from non-medical personnel, with

but isn’t ideal for a few reasons: Uber or Lyft drivers do not have

internet connection, and of course, with the proper “Telehealth Kit” as

the obligation to help someone into their car and have no medical

described previously. From various sources, anywhere from 19% to

training or first aid kit if needed. A non-emergent transport system

67% of outpatient medical care has shifted to telehealth in 2020 as

which includes a licensed driver with a medical aide certificate is an

a result of COVID-19. If all those care providers providing digital care

16 //

also shifted away from the facility, the void in office spaces, group

Once findings from the AI are reviewed by the healthcare team, the

workspaces, waiting rooms, exam rooms, supply rooms and parking

AI can be told if it was wrong or right and correct itself for the next

lots would be quite large. This “exodus” would also impact the loads


on mechanical, electrical, and plumbing systems. Before abandoning up to 67% of our built facilities, we should dive deeper into what

Finally, space will still be needed for in-person patient consultation.

opportunities this could allow.

When telehealth or home visits do not provide adequate care,

Dedicated Spaces for Cybernetic Care

healthcare transport to a facility for further testing, treatment, or

Each workstation for telehealth should be a one-person recording

recovery guidance. In outpatient care, these patient rooms should be

studio complete with the telehealth kit described previously.

spacious enough for procedures and mobile imaging equipment. Each

Background, lighting, camera angles and resolution, height of the

room should be equipped with telemedicine equipment in the instance

provider’s face within the telehealth screen, computer workstation,

that the local provider would like to access a specialist from anywhere

and acoustic isolations are imperative to each workspace. These

in the world to review the patient’s case. Much like telehealth at home,

studios should also have quick access to collaboration space with

the specialist could have remote control of the room’s lighting and

their health team.

imaging settings but would likely be speaking to the patient with the

Collaboration space is likely a digital wall where patients cases can be discussed and symptoms compared to one another for the sake of finding commonalities and, ultimately, treatment solutions. This software would not only allow for providers to see patients’ cases from that clinic, but also see similar cases throughout a health system-wide or even nationwide database. A larger study group sampling leads to more reliable diagnoses. This database would contain consistent imaging using standardized photo filters and lighting from either patient’s devices during telehealth sessions or from in-facility equipment. With consistent image quality the providers can take advantage of AI to compare the photos and find abnormalities, similarities, and categories of this ailment. This is especially helpful when the sample size of patients with the same condition is well into the thousands, and AI is inherently cybernetic.

17 //

patients will be transported either by themselves or via non-emergent

aid of the local provider.

No waiting rooms required; the patients that come to this facility have

Collaborative spaces that integrate telehealth visits are possible, but

already been triaged using telehealth and if the provider desires to

several environmental factors are key to its success:

check vitals once again, the patient room provides adequate tools and space for this. Lab testing would be completed hours in advance when the patient provided specimens either in a drive thru, homebased, or drone-initiated procedure. The lab in which testing occurred may or may not be attached to this facility.

1. Lighting: Rooms for telemedicine will benefit from bright but indirect lighting on the provider. Lighting should be in front of the provider’s face, not behind, and not glaring into the camera during a session. a. Glare from the screen onto a provider’s glasses is quite

Drone maintenance needs a place in healthcare under the Cybernetic

distracting; evolving video technology may help resolve this

Care model. Co-locating drone facilities with pharmacies or materials

issue over time.

management offices could be beneficial since drones will likely be administering medicines or performing minor procedures.

2. Background: Placing telehealth stations within the shared workspace, but in such a way that other team members are

Hybrid Spaces for Telehealth/Telemedicine & In-Person Care

not walking back and forth in the background, is best. A clean,

Cybernetic healthcare facilities can convert rooms from telehealth

non-distracting wall or panel with acoustic sensitivity behind the

to in-person care within minutes whether between visits or just for

telehealth providers is key to keeping a patient calm and assured

certain days of the week. This hybrid method of healthcare is already

that the provider is focused on them. The practice should avoid

active in many facilities because of COVID-19 adaptations. For the

clutter or paperwork on the walls behind the providers as well.

built environment to properly support this hybrid nature several guidelines must be met:

3. Interface: a. The provider will require multiple monitors – one for the video

Using an onstage / offstage care model allows clinical staff to work

of the patient and one for the EMR. (One large curved screen

collaboratively with each other whether the patient is physically in

is also an option). A current potential problem is lack of eye

the next room or on the computer screen. Communication among

contact between patient and provider. These two screens may

physicians and nurses, while benefitting from ease of access to the

be horizontally oriented with one above the other or vertically

exams/procedure rooms, has been linked to increased patient privacy

oriented side-by-side to avoid too much back and forth by

and increased staff happiness in recent decades (Freihoefer et al. 92).

the provider. Communicating with the patient is paramount

It’s no secret that private offices for clinicians are less prevalent today

to the patient’s assurance that the provider is focused on

than they were 20 years ago, but telehealth is best performed in a

them. For a provider to simply communicate why their eyes

private office setting.

on something other than the patient builds trust: “Bria, this is

18 //

really good information you are giving to me. I’m going to look

Converting Existing Space

at your record and add notes while I listen.”

Cybernetic hospitals and MOBs can use their empty waiting rooms,

b. The provider needs a means for sharing images such as lab

diagnostic exam rooms, and triage rooms for screening and treatment

results, imaging, or the EMR. with the patient. A whiteboard

spaces. Diagnostics and treatment within a cybernetic facility is for

for sketching and teaching may also be helpful.

use of specialized equipment and / or more acute medical cases since

c. The provider will need access to the database of similar medical cases previously described for a confident diagnosis. 4. Acoustics: Acoustic panels in addition to the wall/ceiling

common illness and injury can be diagnosed and treated off-site. Small exam rooms (80-120 SF) could be converted to much-needed psychiatry and therapy spaces, whether in-person or via telehealth.

enclosure may be required for better sound quality. Echoing of the

Less on-site visits from patients or the public means less parking

provider’s voice within the room can be off-putting to the patient,

on-site too. Where waiting is still necessary, outdoors provides the

especially if they are already in distress. In addition to actual

safest circulation of air and reduces risk for spreading infection better

wall panels, (such as the black panels common in radio booths),

than inside air. Beyond waiting, the healthcare facility could tout itself

cloth surfaces, flooring, furniture, and other soft furnishings

to be healthier from a holistic sense; outdoor recreation and physical

are encouraged. Furthermore, providers can use dedicated

therapy where there was once a parking lot is a success story if there

headsets to listen to their patients. This may add another level of

ever was one.

psychological security to the patient on the other end of the call. 5. Telepsychiatry: It is ideal for the provider and the patient to see each other in full body view. Setup for the doctor or therapist could be an uncluttered wall with a cloth seat that faces a camera several feet away. This relaxed setup is ideal for easing patients into difficult conversations. This is one medical category where a private office is critical for telehealth visits. No one has control over how a patient presents themselves on their end of a video

Where geographical locations are not conducive to outdoor waiting, parking lots could simply be converted to the trending biophilic landscape that acute care patients are often lacking in their environment. Section 5

Reaching Farther

call, but it may behoove the medical practice to ask patients to

Beyond the United States

show themselves full body even for just a portion of the session

LS3P’s impact on healthcare delivery now reaches beyond the United

and document whether the patient complied with this request or

States, with Kristie Nicoloff’s involvement in the WHO initiative to

not. A patient unwilling to show their body for a conversation or

provide COVID-19 response clinics – both temporary and permanent

even portion of a session may be practicing self-harm that will go

– throughout the globe. These response clinics are separate but


adjacent to main hospitals, and provide screening, testing, diagnoses,

19 //

and transport holding for infected persons. The WHO is working with

• Survey Psychiatry Care providers about Telehealth to measure

different architects on a pro-bono basis, and LS3P serves as advisors

its effectiveness in therapy and mental health treatment and

to those architecture firms.


While local outreach comes first, we encourage others to use their skills for global outreach as well. Using telemedicine with systems outside the United States is a simple progression of cybernetic care. If there is a need, specialists in Houston could provide diagnoses and medication to patients in Nepal. This kind of outreach is a financial obligation on the healthcare system since they would be providing

• Analyze what an in-person visit gives that cybernetics cannot: the psychosocial differences between in-person and telehealth conversations. • Use eye tracking and micro expression tracking software to evaluate how much time a provider is looking at patient versus at EMR or to evaluate patient emotions during conversation.

resources such as a built room with the equipment for telemedicine

Architectural design is needed now to support the efficient nature of

and an isolated hotspot for apt internet connectivity.

the cybernetic care model. Large quantities of unused square footage

What We Could Learn from Cybernetic Care Cybernetic care could inform where the needs are for physical diagnostic and treatment centers: Telehealth reveals where specialty care is used most and helps facilitate patient transfers (Stingley and Schultz 340). By using telehealth and telemedicine, data collected regarding how many patients are using specialists or are transported to a facility after initial diagnosis will inform the need for built treatment facilities in a given location. This is especially useful in rural areas where choosing locations for rural hospitals is often a financial gamble. Nineteen rural hospitals closed in the year 2019 for a total of 120 closures since 2010 (King 2020). Standalone studies suggested as a result of this literature review: • Evaluate which spaces in healthcare buildings are no longer needed, or no longer used for their original purpose, because of telehealth? What goes in their place? (Adaptive Reuse of built, vacant areas).

20 //

is inefficient and will be quickly addressed to ease health system’s budget and maintenance costs. While architectural and procedural simulation will be key and beneficial to studying the facility solution, actual trial and error from health systems renovating and using their space as part of cybernetic care delivery will ultimately provide us with answers. Medical practice is, after all, PRACTICE.

Cited Sources 2020 Ambulance Fee Schedule - A0428. (2020, September). Copyright Hcpcs.Codes - All Rights Reserved. Auxier, B. (2019, November 21). 5 things to know about Americans and their smart speakers. Pew Research Center. https://www. Conway, F., & Siegelman, J. (2009). Dark Hero of the Information Age: In Search of Norbert Wiener, The Father of Cybernetics. Basic Books. Da Vinci Surgery | Robotic Assisted Surgery for Patients. (n.d.). Da Vinci Surgery. Retrieved July 1, 2020, from https://www. Freihoefer, K., Kaiser, L., Vonasek, D., & Bayramzadeh, S. (2017).

King, R. (2020, February 19). 2019 broke record for most rural hospital closures: report. Fierce Healthcare. https://www. Krasniansky, A. (2019, October 11). Diving Deeper into Amazon Alexa’s HIPAA Compliance. Bill of Health. Lang, MD, FACEP, J. (2019, April 16). When-and When Not-to Call an Ambulance. American College of Emergency Physicians. https:// cases%2C%20treatment%20need,but%20there%20are%20 always%20exceptions Matsumoto, D., & Hwang, H. S. (2011, May). Reading Facial Expressions of Emotion. American Psychological Association.

Setting the Stage: A Comparative Analysis of an Onstage/

Offstage and a Linear Clinic Modules. HERD: Health


Environments Research & Design Journal, 11(2), 89–103. https:// Imotions. (2019). Eye Tracking: Screen Based. biosensor/eye-tracking-screen-based Isikdogan, L. F., Intel Corporation, Gerasimow, T., & Michael, G. (2019, December 26). Eye Contact Correction using Deep Neural Networks. Arxiv Cornell University. pdf/1906.05378.pdf

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Mobile Fact Sheet. (2019, June 12). Pew Research Center: Internet, Science & Tech. Shore, MD, MPH, J. H. (2020, August). What is Telepsychiatry? American Psychiatric Association. patients-families/what-is-telepsychiatry Speedtest Global Index – Monthly comparisons of internet speeds

from around the world. (2020). Speedtest Global Index. https:// Stingley, S., & Schultz, H. (2014). Helmsley Trust Support For Telehealth Improves Access To Care In Rural And Frontier Areas. Health Affairs, 33(2), 336–341. hlthaff.2013.1278 Universal Service for High Cost Areas - Connect America Fund. (2020, October 6). Federal Communications Commission. https://www. Vanvuren, C. (2019, January 22). Telemedicine in 2019: What is it, Who Needs it, and Why is it Important. Solvhealth.Com. https://www. Wilcock, A. D., Rose, S., Busch, A. B., Huskamp, H. A., Uscher-Pines, L., Landon, B., & Mehrotra, A. (2019). Association Between Broadband Internet Availability and Telemedicine Use. JAMA Internal Medicine, 179(11), 1580. jamainternmed.2019.2234 Willcox, J. K. (2020, August 18). Back-to-School Help for Students Without Internet. Consumer Reports. https://www.

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Profile for LS3P

Cybernetic Care: Blurring the Line Between Telehealth and In-Person Care  

Cybernetic Care: Blurring the Line Between Telehealth and In-Person Care  

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