[MUSIC] In this lecture we wanted to talk about telemedicine. But it turns out that's kind of a narrow view of the technology. Telemedicine implies a medical encounter between a doctor and a patient. It doesn't encompass all the different aspects of care coordination and wellness counselling that can be conducted virtually. And so, we prefer the term telehealth. Really, telehealth without mHealth is limited because we're depriving ourselves of the data that can come from apps and wearables. So really, maybe the best term would be virtual care. And this we think might become the prevalent term to describe these kinds of digital interactions between consumers or patients, and providers or care coordinators, or specialists. But when we think about it, it's really a whole different way of delivering healthcare and wellness and health information to patients. If you think about your ideal medical encounter, it probably takes place in a spacious, well lit place, where you have all the time in the world to ask your doctor all the kinds of questions that are on your mind. And you get a lot of reassurance, you get to view a lot of information and you're sent home with all of your questions answered. The reality for most adults is that we go from one episode to another episode of emergent care or episodic care. When we're not feeling well, we seek relief, we get relief. But a lot of our biggest issues go unaddressed. And I work in an emergency department. I see a lot of patients that have many medical needs. But because the system is the way it is, I can only address the most acute issues. And sometimes when patients want to follow up, ask questions of their providers, they have to wait a long time, it's difficult to schedule appointments. And so opportunities get missed. Still, for most adults, episodic care is the way things are headed. And a lot of companies have sprung up to take advantage of this with fancy urgent care centers, where even vaccinations can be delivered and other aspects of kind of routine care can be conducted. Urgent care has really proliferated in recent years, but what's next in terms of convenient care? Well, when we look in virtual care, it's tempting to say that's where things are headed. It turns out virtual care and telemedicine go way back. This is image is from 1925, before televisions were even in widespread use. People imagined that doctors would be on one end of the TV and they'd be getting images from the sick patient. Maybe there'd be a nurse or a medical tech at the bedside kind of helping to evaluate the patient and the doctor would be making decisions remotely. Telemedicine as we recognize it now really was born in 1960s, and it was born in Boston. There was an acute need for international travelers arriving at Logan Airport. So sometimes they were getting off the plane and they were quite sick. There was an infirmary at the airport but it couldn't be staffed around the clock by physicians. And the doctors at Mass General hated driving to the airport because the traffic was really bad. This was before the project, the big dig. So, the solution that they came up on was to set up a camera crew. And you see here a nurse operating an old school TV camera to kind of film patients, and the doctors at Mass General delivered care remotely. Today, it's a lot easier to imagine telemedicine conducted through smartphones. They're ubiquitous. They have two-way communication and powerful image capabilities. So, you can imagine how we could conduct telemedicine visits today. But even thinking ahead, maybe even scheduling a video visit is not the most convenient form of healthcare imaginable. And some companies are springing up to take advantage of actual text message healthcare, or secure text messaging care. Where you simply chat your symptoms to a provider, who asks some questions, again, more or less synchronously, but more conveniently than a video visit. And you can get your answers and your diagnosis that way. For doctors that are reluctant to stop examining patients remotely, a lot of kiosks could be the solution. And some companies have sprung up to try to put kiosks in key facilities such as drugstores or hospital lobbies or other places. And these kiosks could serve as a private place for a doctor to examine a patient or to coach a patient and set their own self-examination. The kiosk can be outfitted with things like an otoscope or an ophthalmoscope. An operator can help facilitate an exam. And then as soon as the patient is done, the room can be cleaned and made available for the next patient. I've just mentioned a few of the different modes of telehealth delivery, but the truth is that there are many more. And they're all in various stages of development and implementation across the country in different healthcare institutions. When we're talking about provider-to-patients, the kind of classical, what we imagine is telemedicine. We imagine virtual primary care, where a doctor is checking up on a patient virtual urgent care where someone is seeking care for something relatively acute onset. And a pre-op and post-op follow up where a doctor can assess a patient's readiness for surgery, or how they tolerated the surgery and how they're healing after a procedure. But there's also asynchronous methods where a patient can communicate with a provider over the course of several days. And this is using text messaging, or even remote monitoring with Fitbits. Or even taking a picture of the rash and forwarding it to a dermatologist. Actually, this remote image management is often called storing forward and it's often used between providers as well. And finally, provided to provider synchronous communication can be used to facilitate consultations. We see this in strokes. We see this sometimes in the ICU when one intensivist is managing patients across several ICUs, and they're able to collect all this data from various patients. And because there are nurses and trainees and junior faculty present at these facilities, procedures can be performed, but supervised remotely. What's driving all this new interest in telemedicine? Well, it's largely about containing cost and delivering on convenience. As I said before, we all have smartphones now. So we there's an enormous temptation to use them to deliver care. And the legal environment is changing to now make this possible. In New York and other states, it is now mandated that private insurers actually be reimbursed for telemedicine services, just as some of the public insurance options are doing. More than just the legal environment changing though, the demographics of our population are changing. A huge fraction of the US is living with two or more chronic conditions. The population is aging. The largest growing segment of the population is those over 65. And these are the patients that tend to have the most chronic disease states. And so, it is difficult for them to get the kind of care and coordination that they need. And these are the last folks that you want schlepping across town and waiting for transportation to get to various appointments. If there was a convenient way to deliver that healthcare expertise to the patient where they are, that would obviously be preferred. And the wait-time to see a primary care doctor or a specialist continues to creep up. And while a patient is waiting, they can decompensate, they can get worse. So, obviously, huge motivation to promote telemedicine. Also, we're seeing increasing cost savings in various pilot projects for covered lives. So clinics that are setup just to monitor those that are at high risk for hospitalization, it turns out telemedicine is a cost-effective component to delivering good care. So, many insurers are now offering telehealth. You might be surprised if your own insurance company, if you check your benefits, it might include telehealth visits. Last year over 17 billion was reimbursed by CMS for telehealth. And that's expected to triple in the next few years. And we are seeing more and more pilots at single-centers or healthcare systems, where they are using telehealth to reduce readmissions for some chronic diseases, reduce cost or improve outcomes. And a lot of employers are dabbling in telehealth to keep their employees at their desks and away from losing time commuting or waiting in doctors offices. You can imagine that an employer would find that enormously attractive, and so many are adopting that. And a telehealth visit is a lot less expensive in the long run than an emergency department visit or even an urgent care or clinic visit. So employers are latching onto that. So how do patients feel about telehealth? It turns out, it often depends on age. Male and female preferences seems to be about equal, but when we look at folks in their 30s and 40s, that's the population that is most willing to try a telehealth encounter. And these are the highest utilizers at this point. Older patients, especially patients with more chronic diseases, they seem less likely to try telehealth. And that might just be because they know and trust their doctors, and they know what works for them. Where would patients have gone if they didn't have a telehealth option? It turns out a lot of the big vendors in telehealth will ask this question of their patients, and the vast majority would just wait for a primary care visit. But sometimes that visit is days away. And if their condition deteriorates, they might have ended up in an emergency department or an urgent care clinic. When do people actually use telehealth services? I have thought naively that this would be mostly in the weekends, in the evenings. Because that's when primary care doctors tend to be less available. However, utilization is pretty steady whether we're talking about weekday or weekend. And during the individual day, it turns out utilization is highest in the morning. I think a lot of people wake up sick, they decide that it's going to be difficult to go in and see their doctor and they initiate a telehealth visit in the morning. The overnight situation where someone is making a call at 2AM tends to be very rare in telehealth. How do clinicians feel about telehealth? This is a new speciality in many ways. And as with any new specialty there are a lack of standards, and there's some suspicion. The kind of folks that rush to fill this void are sometimes seen as opportunists. I remember reading an article a few years ago about a telehealth doctor that was taking calls from Mexico at the side of the beach, and this fit his schedule very well. But I remember reading it with some skepticism. And I think a lot of my colleagues would say that maybe the early telehealth providers are folks that weren't interested in working hard on a day-to-day basis in the US health care system. Or maybe they're older and using telehealth as bridge to retirement. Still, I think as the specialty develops and standards are put in place and we have better evidence that this is a mode of delivering care that works, I think it will start to be seen as very attractive among clinicians. Because they'll have the opportunity to set their own hours and work from home. So, I think it's very much a condition that's in flux. Also, we look very closely at our medical boards to see how they interpret telehealth. And right now, the situation is unsettled, with some major state medical board suing telehealth vendors for unsafe practices. So, whether this is really unsafe or not, I guess it’s up to the courts to decide. But, I think in the meantime, a lot of clinicians are sitting it out and waiting to see how things develop. And finally, you'll see some headline grabbing stories in the news based on some research where it looks like telehealth might be dangerous. For instance, there's this JAMA dermatology piece that came out earlier this year where they showed that a number of teledermatology vendors failed to properly identify rashes. Well, this turns out that the research that was conducted used a lot of vendors that were overseas. Vendors that were not even claiming to serve patients but rather they were setting themselves up as a service for pathology and so forth. So, counting them with regular telehealth vendors I think was a little bit disingenuous. But the point is though, that these headlines are grabbing attention and are making people think twice sometimes about devoting a career in telehealth. And there are still many open questions about what is safe, what kind of visits can be conducted by telehealth? I think most people would say if you are having chest pain or if you're having symptoms of a stroke, that's not appropriate for telehealth. It's best if you've seen in an emergency department. But other aspects, there's a broad spectrum and it's not clear who should go where just yet. It's also an open question about what drives patient satisfaction. Should doctors wear white coats when they're conducting a telehealth visit? Would it be better to schedule a telehealth visit right away and not get the doctor a choice? Or wait 30 minutes, 60 minutes, 90 minutes to see the doctor that you want to see or the doctor that's most qualified to see you? It's also not yet determined. And how will we measure quality of telehealth? Will we measure it in terms of Visits prevented, or in terms of diagnoses made appropriately, faster? It's an open question. I do want to touch upon mHealth because I do feel it is a good complement for telehealth. And as we mentioned elsewhere, the market for mHealth and wearables is growing. There's a lot of investment in these specialties, in these new devices and apps, and there are healthcare systems that are really leveraging this. For instance, at Oschner Health in Louisiana, when patients go to see a doctor, they can be given a prescription for the O Bar. The O Bar is kind of like a Genius bar, I like to borrow from the Apple term, where a patient can take their prescription for an app or wearable. They talk to a friendly technician behind the desk, and they are outfitted with a new device for tracking their blood pressure or their weight or blood sugar or various other things. And that app or device is then interfaced to their phone, and then interfaced to the healthcare system so their data starts flowing directly from their bodies to their doctors. And in this case, the doctor can then make decisions about changing medications or to the desired goal. Doctors are now being reimbursed and incentivized to monitor this data through some CCM codes. That stands for chronic care management services. So, if a doctor uses a new billing code and has consented a patient with two or more chronic conditions, that data can then start to flow to the doctor's electronic health record. And if they spend 20 minutes reviewing that data per month, they can send a Medicare bill for that. It's believed that this new service will actually spur the adoption of more and more O Bar type setups where doctors are prescribing apps and wearables as this data starts to flow. And then it's an open question about how doctors will make use of this data, and how care coordinators will process this data and decide where patients should best go. Can a medication be adjusted remotely? Should they come in for a clinic visit? Should they go right to? We're going to be really reliant on data scientists who process this data and tell us how to proceed. But ideally, we'll be able to keep patients out of the emergency department. Hopefully, we'll develop a resource like the Network of Digital Evidence, which I've mentioned in some of my earlier talks. This is an initiative led by Ashish Atreja and others, nodehealth.org, it's really a tool to evaluate apps and wearable devices in terms of their usability, but also in terms of the evidence behind them. So that when doctors are prescribing apps, they can be confident and ensure that the app will work as expected. And will keep the patient out of the emergency department if the right people are following the data. That's what I intended to talk about today with our telehealth and mHealth virtual care discussion. Thank you. [MUSIC]
