Podcast Episode Transcript: Telemedicine during the pandemic: Finding the right approach

With L. Gordon Moore, MD

Gordon Moore: Welcome to 3M’s Inside Angle Podcast. This is your host, Dr. Gordon Moore. And with me today is Dr. Andrew Robie, who is the chief medical information officer of Unity Health Care, and Dr. Angela Diop, who is the vice president of health information systems for Unity Health Care. Welcome to the both of you.

Angela Diop: Thank you.

Andrew Robie: Thank you very much.

Gordon: So first off, could one of you tell me a little bit about Unity Health Care?

Andrew: So Unity Health Care is a large federally qualified health center in the District of Columbia, one of the largest providers of health care for the underserved in the district. We care for about 100,000 unique patients, annually conduct about 500,000 visits caring for those patients. We have about 20 sites located throughout the city, a mix of traditional community, health care for the homeless sites, and school-based health centers. And we also provide all the care for folks in the DC Department of Corrections with the DC Jail.

Gordon: So that’s a pretty wide range of services. And you guys have obviously been doing this for a while. And I’m thinking when you do some school-based services, does that also mean that you had a history of use of telemedicine in the past because of the school-based services?

Andrew: So most of our school based services historically have been in person services, so providers located in the schools and the health centers there. Prior to this pandemic, we had a little bit of experience with telemedicine, mostly thanks to some grants that we were fortunate to receive. So we, for the past few years, had a research partnership with the Department of Emergency Medicine at George Washington University, providing some telemedicine-based specialty services for patients at one of our health centers. So we’re offered cardiology and nephrology and endocrinology, telemedicine visits with GW specialists for patients in their home primary care health center setting.

And then in addition to that, had a grant a couple of years back from the District Department of Health Care Finance, the district Medicaid office to provide some telemedicine services, mostly psychiatry services and a little bit of dermatology with Unity providers at one health center, providing telemedicine services for patients in a different Unity Health Center.

Gordon: That’s interesting. I was lucky enough to interview Dr. Peter Yellowlees in the past, he’s one of the researchers and past presidents of the American Telemedicine Association. And his work on using store and forward recordings in a primary care office and FQHCs actually, and so therefore able to provide psychiatric services in a way that kept the people in a familiar setting, not having to go in a referral where there was some attrition. What was your experience in telepsychiatry?

Andrew: I think we were skeptical at first. A lot of our interest in doing telepsychiatry is we had psychiatrists at centers who weren’t necessarily being very well utilized at that single center, but we knew if we could draw patients from, in this case, some of our homeless sites who also needed services, seeing psychiatrist in one of the health centers over telemedicine, we could hopefully better utilize that person. And a lot of the patients at first weren’t sure how they would take to it or respond to it, and had many patients say they actually liked the telepsychiatry than in-person psychiatry I think for whatever reason, that little bit of distance between the psychiatrist made it a little more comfortable for some reason for some of the patients.

As you said, patients were definitely—liked being in the familiar setting, the clinic that they were used to going to see their primary care provider and being able to see the psychiatrist in a place that was comfortable.

Gordon: I think about patients are more comfortable with that. Part of that also makes me a little bit nervous in the sense of in psychiatry, psychology, are we not getting to the real stuff? Is there a loss of fidelity in the interview or is there a loss of fidelity in the derm visit? Can you do everything you need to in that context?

Andrew: I don’t know that that’s something we’ve looked at in a methodical way, but I would say that anecdotally, I think the providers really felt that they were able to provide good care and get to the root of the problem and obtain the information they needed. And so I think in general, we felt that they were pretty high-quality visits and worthwhile.

Gordon: And so Dr. Diop, as the technology VP, were you in charge of figuring out how to put together the technology, and how did that work?

Angela: We like to approach technology collaboratively at Unity Health Care. And so it’s been a collaboration with myself and Dr. Robie in what we would do. And I think one of the beauties of the pre-COVID experience that we had with telehealth and the grant that we got, it allowed us to try a number of things. We were able to try different software. Technology really hasn’t been much of a limiting factor, I don’t feel, and in telehealth, it’s been more software driven. And we just partnered with him to try as much as he was willing to try or wanted to try as a clinician.

And I know that put us in a really good position when we went into COVID. We had a lot of experience with what was working and what wasn’t working, and we were able to jump in it. And we actually have some of our sister organizations that weren’t quite as quick to get involved. And in COVID, two or three weeks, it can mean life or death for people. So just having that really, I think, made a big difference.

Gordon: And I want to come back to the COVID experience just a minute, but back to your comments about the technology and really it’s about software, just today I was looking at my computer and I saw an e-mail from some vendor that has a standalone device that has integrated batteries that are part of something that goes up and down with cameras and this and that. And I was thinking, that looks pretty expensive, but it doesn’t sound like you needed to go down that pathway.

Angela: Yeah. Maybe it’s a little bit much to say it’s only about software. You do need the basics with hardware, you’re going to need a laptop, you’re going to need Internet, it needs to be reliable. So those are basics and not to be even taken for granted or lightly because, in the neighborhoods that we serve, there’s our patients and even businesses that might even struggle with that. But I think past that, we’ve found that at least for the applications we have, there’s no need for a big derm camera or anything like that, and I think maybe Dr. Robie might be able to comment a little bit more about that. But we’ve been able to use the equipment that’s right there and the computers that we have.

Gordon: That sounds super low threshold. And I remember them in the randomized controlled trial that Dr. Yellowlees performed with telepsychiatry stored forward. He was using $30 webcams and laptops, and then obviously married to secure capacity to transmit information without exposing PHI, so that’s where the software kicks in. So there’s not a massive cost threshold of getting engaged in trying that out. And I guess it comes down to figuring out what’s going to work in your environment and with the people you serve.

Angela: I think also what we are looking at is all of this is about expanding access for our patients. And so maybe you might—to Dr. Robie’s answer about the quality of the visits, if it’s a little bit less—you’re a little bit less able to see, or maybe it’s not exactly the same as an in-person, what if it’s the difference between not seeing the patient at all or the patient not getting that service? And so I think those are some of the things we’re also weighing along with the tools that we’re using to reach our patients.

Gordon: Yeah. So let me go back to that with Dr. Robie and thinking about, as I can imagine, I have an appointment with somebody on a televisit or something, and it might be phone or with video. And as we start getting into it, I realize this is not going to work, this is not going to happen. From before we get into COVID and it changed a lot, had you any experience in Unity with that kind of thing, and what happened at that point?

Andrew: So the telemedicine experience we had prior to COVID was always in our health centers, there was always somebody there to help troubleshoot. And so we certainly did occasionally have technical issues, trouble connecting or trouble with a camera not being recognized, the little things that come up with hardware and with software. But typically, there was somebody at the center who could jump in and troubleshoot and maybe get somebody on the other end, the distant site on the phone and work through things pretty quickly. And so I think for the most part, we weren’t always able to troubleshoot and complete those visits. And it becomes a real different ballgame when you’re conducting a telemedicine visit with a patient at their home. And I think we can certainly talk more about that as we go on.

Gordon: Well, yeah, let’s pivot to that now. Obviously with COVID, it changes so much because access becomes a huge barrier for people who are justifiably afraid of going into a health center where they may be exposed to sick people with COVID. And so a lot of people held back very appropriately, but sometimes not in their best interest. So tell me about your experience with that, what was it like? What happened?

Andrew: Yeah. So I think in March, as everybody began to recognize that this really was going to be a big deal and affect a lot of people and potentially put a lot of our patients and a lot of our staff in danger, we moved really quickly to shift as many of our visits as possible to telemedicine. So initially, we saw our visit volume really plummet. I mean, we dropped to about a third of our usual in-person volume in mid-March, and rapidly started to move towards doing telemedicine. I think we were able to do that largely thanks to the district department of health care finance, our Medicaid policymakers and putting some emergency rules into place.

So prior to the pandemic, direct-to-patient telemedicine, so telemedicine from a provider to a patient in their home or with her, wherever the patient was located was not a reimbursable service. So pretty quickly, they moved to allow direct-to-patient services, which was great. And then, as we started to think about how we could do direct-to-patient telemedicine, we started to realize that a lot of our patients didn’t have the technology to do video visits. A lot of them had a flip phone or even a landline phone in their house. And so policy was implemented shortly after that to permit audio-only telemedicine visits. And so we were able to really transition a lot of our already scheduled in-person visits to either video or audio telemedicine visits.

Really quickly, we got our visit volume almost back to where it had been historically, prior to the pandemic. And we’re doing all these visits. Really, almost a hundred percent of our visits or probably, I guess, more around eighty percent of our visits for quite some time via telemedicine rather than in-person.

Gordon: One of the things you mentioned, I think, was the reimbursement rates. One of the problems in the past was that the reimbursement for the work is very different for televisits than face-to-face visits. And even if the work is commensurate, the differential and payment could make it unsustainable from a provider perspective. How is that working with you guys?

Andrew: Sure. So the district has had a telemedicine parity law for a number of years, so that means that telemedicine services within the rules that are laid out have to be reimbursed at the same rate as an in-person visit. So as long as we’re providing the same level of service that we do in person via telemedicine, then we get reimbursed at the same rates. We’re really fortunate to be one of the jurisdictions that has a telemedicine parity law in place. So reimbursement from that perspective hadn’t been a big deal for us.

I think what really had kept us historically from expanding our telemedicine offering was the inability to do direct-to-patient telemedicine. Telemedicine gets a lot more complicated when you have to have the patient in a health center and the provider in a health center, providing services or a patient in a health center and a specialist at another institution where they’re receiving actually all the reimbursement for the visit and the health centers receiving very little or no reimbursement. So the ability to do direct-to-patient telemedicine, I think we’ve always felt was where a lot of the promise of telemedicine was, and we’ve been really fortunate and pleased that we’ve been able to expand that service.

Gordon: So I’m thinking, I’m going to Dr. Diop about the policy around opening the doors to direct-to-patient telemedicine, and what a breath of fresh air that is in the sense of allowing access to this new portal of care delivery. What do you think is going to happen as the COVID pandemic begins to wind down? Are we going to roll back to the old way?

Angela: That’s a great question. We’re actually in talks or have—I mean, we’re fortunate the district has reached out to us to understand our experience with telemedicine. We’re advocating to continue some of the laws that have been put into place. I don’t have a crystal ball, but I would say we think that the genie’s a little bit out of the bottle and that at least the televideo visits will remain, and we’re hoping for that. The teleaudio visits, I think, is a little bit different. And we’ve gotten a recent extension in those, the district cast extended out through law. But I could see if we would have something to not survive after this pandemic, it could be the teleaudio.

I do think we at Unity are working really hard now to do what we can to work with patients, to get them converted to video visits. With the pandemic, we didn’t have a lot of time for patient education and all that. And so we are using this time to try to get—increase our number of televideo visits, because we do think that that’ll be around.

Gordon: So when I think about that in terms of connecting to patients where they are, does that mean purchasing and distributing video devices?

Angela: Yeah. So I think everybody is looking at that from all sides. We are advocating in various venues that we can with support for the patients. I mentioned things like even broadband, Internet access. What is the district really doing to make sure that there’s parity in—neighborhoods actually have Internet, things like that. So I do believe there’ll have to be some building of capacity at the patient end. And that Unity can’t do it alone, we’d actually have to do it with our district partners to be able to do that.

Gordon: That’s interesting.

Andrew: I think that’s a really important point. I think as we do our best to conduct video visits with patients, there certainly is a group that don’t have smartphones, don’t have a laptop, don’t have a computer with a camera, and just off the bat, we know we’re not going to be able to do a video visit with those folks unless we can get, in the future, some other hardware into their hands. But of the people who do have the hardware and have the technology, the network access ends up being a big problem for, I would say, maybe even half of those patients. It’s not uncommon to connect with a patient and start the video visit and then realize that their data signal isn’t fast enough to continue the visit and you end up with choppy video or choppy audio, and and have to end up switching over to audio-only visit.

Gordon: I’ve heard some—and I’m trying to put my finger on it in my brain and I can’t, but I remember hearing something about working collaboratively with a carrier, a signal carrier, device maker, and a Medicaid agency to say, can we create a technology solution that uses these services for health care, which is not billed directly to the consumer or the patient, which becomes—it has either some other system or is a donated service or something like that. Have you heard of anything like that?

Angela: No, I actually have not heard of anything like that. I mean, we’re going down this path of—and this is a concern that I do have, is that amongst our patients, we see a lot of disparities and I can see a growing technology disparity that can lead to disparities in health. And so I think being able to address it at all levels, the federal level, the district level, and it’s going to take for these patients not to get left in this gap. There was an FCC grant that was released to help with telemedicine and bringing people more capacity for telemedicine, that was really still along with COVID. And actually, Unity is fortunately and thankfully, a recipient of that.

And besides being able to use it to get equipment and software and things like that, we’re also looking at—we can’t really put Internet services in patients’ homes, but what we can do is put monitoring devices and do more with the patient engagement part in that way. And so that’s one of the things we’re—paths we’re taking.

Gordon: So let me now pivot to another aspect of this, which is, I think about in the past, in my practice, having a phone call with somebody could solve the problem, could be the necessary vehicle for taking care of the issue. Here’s your lab result, let’s talk about that. Let’s go through shared decision making about you, you don’t want to do this test kind of thing. And just I’m hoping in the future, we can continue that audio encounters are a real thing, they provide a real service, and they take time, and it’s work and therefore ought to be compensated. And I hope we don’t close the door on that. We may think of them as different from video visits for other reasons, and maybe there’s a hierarchical reimbursement for that, but I hope it doesn’t go away.

So when I think about the audio visit and then the video visit, Dr. Robie, have you have you run it to some things that are clinically inappropriate? What about the clinical aspect of that? How much do you think you can do in a given day through audio, not face-to-face encounters?

Andrew: When we think about most primary care encounters, there are numbers and people have quantified this, but I think I’ve heard somewhere in the range of like 80 percent of what we do even in the office is talking in a much smaller portion, does actual physical exam, and often I think our medical decision making can be done even without some of the physical exam, some of the physical exam we do just to have a physical connection with a person because it’s what’s expected. So I think a very large portion of the care that we provide can be provided certainly via video telemedicine and then I think via audio telemedicine as well.

Video telemedicine, I think, is a little bit more personal connection with somebody. Patients like to be able to see my face when they have a video visit, especially if it’s somebody I am used to seeing every month maybe, and haven’t seen for a few months. I mean, that’s meaningful to people. And there certainly is some—there are observations you can make, is the patient breathing comfortably, does their skin look normal? Do they have a rash? And you can look at the rash if you’re doing a video visit, but I think most of what we do on video, we also can do on audio, just on the phone.

So my experience has been that we can offer a lot of really high quality care on the telephone, and those encounters have value. And I think, as you said, providers historically have spent lots of time with patients on the phone and that has almost exclusively been time that wasn’t recognized and wasn’t reimbursed, it’s always the evening after-clinic phone calls or lunchtime phone calls that we’re unfortunately not getting paid for. And I think providers really felt vindicated being able to finally get paid for and get recognized for that work with the audio telemedicine visits.

Gordon: And since we’re talking about providers, let me—you guys had hinted at acceptance. And Dr. Diop, what is it that it took to ramp this up when the pandemic hit and you needed to pivot so quickly?

Angela: It’s actually pretty—it’s pretty amazing, it just happened. We sent everybody out and sent everybody home, and even our providers actually went home empty handed. We didn’t even hand them a laptop or a device, which that’s just the amount of resources that we had, we just simply didn’t want to give everyone. We fortunately had done a lot to strengthen our infrastructure and our EMR and make it really stable. And we actually had a longer term plan of being able to work from anywhere, we just didn’t know it was going to show up like this, so we were ready for that.

And honestly, Dr. Robie worked really hard with the providers, just making sure they understood the software and how to get connected. And within two weeks we were up and going. I’m actually—I mean, it feels like a little bit of a miracle to me that we were able to do that. But it’s a lot of hard work, I think, especially on Dr. Robie’s part that we were able to do that with providers and have them be engaged. And I mean, they’re really devoted to the patients and making sure our patients, as much as possible, stayed in care, we’re caring for vulnerable population, a population that’s being highly impacted by coronavirus and then a lot of chronic disease and being able to keep them in care, making sure they’re getting their medications. That’s what we need to do to give them the best chances to surviving corona if they get exposed to it.

Gordon: And change is not easy especially when pandemic is coming and things are crazy and all that. So what was it that got the clinicians to accept this new way of doing things?

Andrew: Honestly, I think it was just the situation. I think everybody recognized what a serious situation we were in, the gravity of this pandemic, and the importance of being able to maintain physical distance and keep our patients safe at home and off of buses and trains and places where they could potentially be exposed on their way to the clinic. And then, secondarily, out of the clinic waiting room and away from exposing staff and providers and things at the clinics. And also, we’re dealing with a PPE shortage nationwide at the time, and so I think people were naturally afraid of the prospect of having to go to work and not having appropriate protective gear.

And I think at Unity, we’ve been pretty fortunate in being able to, for the most part, obtain the N95 masks and PPE that we needed, but it’s been limited and at times uncertain. So it didn’t take a lot of convincing for people. I think our providers and staff recognized how serious this was, I think most of our patients did, and everybody really realized we needed to roll with this and do it together and make it work.

Angela: We did do a lot of communications and set up a lot of things to try to address people’s questions and problems quickly. Dr. Robie has a users group for the version of our electronic medical record that allows us to work from anywhere and just trying to help them to make sure they could chat with each other and have their computer set up that they were using our telehealth application. If they were running into problems, they could actually chat with that. So that got set up. We did have to do a number of little workshops where we just had open office hours for technology. So people could just pop in and get their questions answered or get their problems solved.

And then I think all of us in the technology realm, Dr. Robie, he’s a physician but also he works a lot with our team. We all try to be really, really responsive to people. So people wouldn’t get frustrated as they were trying to deal with this really heavy lift really quickly.

Gordon: Interesting. That sounds like forethought and planning and having some prior experience was really helpful. And then the crisis in a sense made it obvious that change was essential. One thing that occurs to me though, I’m thinking, all right, I need as a health system, as you guys are a primary care delivery, want to be able to capture everything and take care of not necessarily just the prima facie problem, just the chief complaint, but sometimes you may need to be capturing chronic conditions and preventive care and other things like that, and make sure that’s all captured in the record and documented so that the next person who works with that patient sees what’s going on. Do you feel that moving to tele has in any way degraded the accuracy and completeness of documentation?

Andrew: I think possibly in the beginning, it may have as everybody got used to new systems and a new way of doing things and a new way of conducting visits. But I think as we’ve settled into telemedicine and gotten used to it, and patients have also gotten used to it and come to understand that this is your visit and this is the time to make sure we’re addressing all your chronic issues as well as your acute problems. I think we really are offering pretty comprehensive care at this point. We’re still a little bit limited in our ability to do labs. Obviously, we know we do have that opportunity for patients to come into the clinic to get blood drawn when they needed or have other lab testing done, but obviously can’t do it right at the time of the visit.

During the beginning of the pandemic, there was a move, I think, really nationwide to put a pause on things, like cancer screenings that were going to consume lab resources and consume PPE, and so we certainly weren’t doing some of those screenings as much as we would otherwise. But I think at this point really, resume doing colon cancer screenings and mailing fit tests out to people and ordering mammograms for people and things like that, so I think really are providing pretty good chronic disease management and good preventive care via telemedicine.

The other thing, opportunity I think that’s arisen from this shift to telemedicine is some staff who are maybe not being utilized as much as they were previously, our registration clerks who were super busy interacting with patients at the front desk all day, previously are still doing registration tasks, but I think maybe not as busy as they had been in the past. And so we’ve been able to utilize some of those folks and other staff members to do some population health efforts. We’ve developed a list of, for example, patients who would benefit from statin treatment.

We’ve had staff calling them and talking with them about statins and scheduling telemedicine visits with their providers to do some statin counseling and had really good success, getting people on the right treatment for cardiovascular risk reduction that way. So there have been I think opportunities really, to even in some ways, do a better job of providing preventive care and chronic disease management.

Gordon: That’s neat. It’s so much change in policies and procedures that you think about, well, this work is less, but I can do that stuff and shift people around and accomplish resource allocation, in a sense, to meet the needs of the people who come to you. That’s fantastic. When you think back through this, and let me start with Dr. Diop and then Dr. Robie, what have you—when you think about all the changes you’ve gone through, what would you do different and what do you think you’re going to do with this going forward?

Angela: Wow. That’s a great question. I can’t think of anything off the top of my head that I would do differently. But I think one of the things we actually have been talking about, we actually, Unity, we identified this about a year ago as our risk, and we called it a technology innovation risk. And that was really the risk that we would miss an opportunity in our business, or we wouldn’t keep up with the industry or something like that because we weren’t keeping up with technology and applying technology to our business. And what this has really taught me, I don’t know that we were really all that intentional about it.

Andy and I sit down annually and just try to plot out what technologies out there are on the horizon, what should we be watching, what should we be piloting and all that. And we do a pretty good job of that on the EMR level, but this really illustrated to me how valuable that work could be. And so going forward, we’re working to make that more intentional and that it just doesn’t happen, well, we got a grant on this, let’s just try to see what we can do with it and drive things that in that way. So that’s my thought about it.

I actually did want to say one other thing and maybe Andy might be able to speak to this a little bit better than I, and that’s the—we were talking about access in telehealth and the impact on our no-show rates. And so we normally have a pretty high no-show rate in our health centers, maybe around 30 percent. And we’ve seen a reduction in the no-show rates with the telehealth visits. I don’t know, Dr. Robie, if you want to say anything more about that. I think that’s pretty important.

Andrew: Sure. No, I agree. I think there are a lot of barriers to patients getting from their home to a health center. Even in a city where there’s pretty good public transportation and things like that, there are child care, and elder care, and jobs, and car breaks down or you miss the bus or whatever. And so telemedicine, I think, has a real opportunity to help reduce some of those barriers for patients. And we have seen that, I think, in the past few months, looking at our no-show rate historically for in-person visits, is probably, as Angela said, 30 percent maybe even pushing 35 percent. We ran a report the other day and it looks like the no-show rate for telemedicine visits was more in the range of 10 to 15 percent. So I think a lot lower, which is really meaningful.

So I think moving into the future, we anticipate that there will be permanent policy changes made to allow us to continue to offer direct-to-patient telemedicine services at least via video telemedicine. And so I think seeing a mix of in-person and telemedicine services is a permanent part of how we offer access to patients moving forward.

Angela: One thing, we were talking about the future, so we are really working on a number of things, one of them is to more—recreate the virtual visit. So now it’s mostly like a one-to-one with a provider or the staff member and the patient, but how do we create an entire virtual visit where we’re—the patient’s being checked in by a virtual patient registration clerk, maybe they’re being seen by the MA in taking their chief complaint or whatever, and before the provider to help have a more fuller and more replication of the actual visit, but virtually.

Gordon: That’s nice. It makes me also think as you are so thoughtful about technology and being very intentional about how you look forward to that. Some of the research I’m hearing about in tele and video visits that looks into things like paralinguistics and the signals that are coming and how to be very mindful of those signals and understand that as part of diagnostic information that can be useful. And also then, that lends into some interesting research around training and communication styles for clinicians and how that is useful.

I was talking to a psychologist who’s doing, obviously, a lot of telemedicine, and he said the social requirements for eye contact can be absolutely exhausting for constant video visits all day long, but to look away and a video visit is out of bounds. In a face-to-face visit, I can look to the side, I can look out the door and it’s not seen as abnormal unless I’m looking at my watch. And so I’m hearing about techniques, legitimate techniques, “Hello, Mr. Smith, you and I will be interacting today. By the way, I’m taking notes so I can make sure that I capture all the information and meet your needs today. And so I may be looking away to take those notes, would that be okay with you?” Then give me permission to maybe avoid some of the exhausting staring at the camera the whole time.

Angela: That’s really interesting. Very good.

Gordon: Yeah. So Dr. Diop and Dr. Robie, I want to thank you for your time today and for the discussion about telemedicine and how it is working with you guys and where the future may be going. Thank you so much.

Andrew: Thank you. It’s been a pleasure.

Angela: Thank you.

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