Podcast Episode Transcript: Telemedicine: Enhancing access to improve outcomes

With L. Gordon Moore, MD

Gordon Moore: Hello and welcome to 3M’s Inside Angle podcast. This is your host Dr. Gordon Moore. Today, we are going to revisit a previous podcast with Barbara Johnston, who is the CEO of HealthLinkNow, a telemedicine company. In the times of COVID-19, we have seen a striking increase in the use of telemedicine services. Barbara Johnston’s experience writing regulations and supporting the initiation and startup of telemedicine companies and telemedicine services provides insight into how this is done and done well.

And so welcome, Barb.

Barb Johnston: Good morning. Delighted to be here.

Gordon: Thank you so much for coming on today. What I would love for you to do for our audiences, describe your backgrounds to give people a taste, and then we can take the conversation from there.

Barb: Well, I started as a nurse at Kaiser Permanente many years ago, worked intensive care for some time and then transferred over to home care, which is where I got my start in the world of telemedicine. Was actually to solve a very practical problem, we didn’t have enough nurses to cover the caseloads that were coming in, and the acuity level of the patients being referred out to home care nursing was becoming increasingly severe. So I looked towards technology to see if there was some way to support patients who needed access to the care and services of home care nursing mainly for after hours and weekends.

So I did the first randomized clinical trial using telemedicine in home care. We did a study for a couple of years, and out of that discovered that not only did it save a lot of money, which is important to all of us, but that the quality of care was actually improved. The main reason was because patients could access timely care. Following that, I became much more involved with the American Telemedicine Association, started working with developing the idea of telemedicine networks.

I started working for an organization called the California Telemedicine and eHealth Center, and during that time, raised money in California to establish 10 telemedicine networks. Following that, I was recruited to work for a startup telepsychiatry company in Australia. During that time, I learned a lot about the barriers to expanding telemedicine in the international world. Following that, I came back to the States and started working for the Medical Board of California, which was quite an experience, very different than actually being engaged solely in telemedicine. But I learned a lot about some of the things that actually affect how telemedicine works. So I learned about the barriers, the rules and regulations, and a lot of the legal barriers to expanding this industry, which was very helpful to me.

I started a company of my own, a telepsychiatry company back in 2010 called HealthLinkNow. It has been a huge success. We have been able to provide telepsychiatry services across many states and hospitals, emergency rooms, clinics, and direct to consumer. I sold that company two years ago to Universal Health who have taken it to the next level and are using it to support psychiatric hospitals across the entire country.

Gordon: That is a storied career you’ve been in, as I mentioned before, just in the forefront of all this war. One thing that’s interesting to me is how you brought science to bear doing randomized control trials and being very scientific and data driven on this. Tell me what’s your understanding of how the telemedicine reduces costs?

Barb: Telemedicine actually reduces costs in many ways, because it affects quite a few people on the food chain when you look at health care. Let me give you an example. When we provide psychiatric services into primary care facilities in rural America, what you do is bring the psychiatrist to a primary care office so that patients in that community don’t have to travel. That cost of travel is significant when you look at the entire country. When we did a study for CMS between 2012 and 2015, we did a deep dive into what does it really cost people when they have to leave a community, and how does that affect the community itself?

If you look at a person, say someone owns the local supermarket in a small rural community, for example. They leave the community, they shut down their store, so they’re losing not only their wages, all the people who work for them are losing their wages. They also take the patient, travel maybe a hundred or two hundred miles to the closest specialist, and they’re taking their dollars with them. They may have to stay overnight, they may buy food out of the community. So there’s a huge cost there.

When you look at the health system and the insurance people who pay for the health services, if people have to be transported by ambulance because they’re leaving to go find a specialist, that’s a lot of wasted money. If they can see a psychiatrist right in their own primary care doc’s office, they’re not spending that money, there’s no cost for the ambulance transport. The other problem is many people put off leaving their community and traveling. That means their situation gets worse, they may end up being hospitalized, very expensive hospitalizations that probably never needed to happen if they could have had timely access to care in their own community.

Gordon: That’s an interesting aspect of this. I think with health systems going at risk, for instance, for total cost of care, they might be interested in reducing unnecessary emergency room use and hospitalization. And it seems to me that the early application of appropriate telepsychiatry for instance, as you’re describing it, would potentially reduce that. Is that something that you’ve seen?

Barb: Yes. We have—let me give you an example. We had set up telepsychiatry services into several nursing homes in areas where they just can’t get psychiatrists. Their only answer to seeking psychiatric services and evaluations primarily for seniors is by putting them in an ambulance, transporting them. They go to a hospital, usually about a hundred or more miles away. The patients would sit for days, sometimes weeks waiting for a psychiatrist to be available to come evaluate them. Those overall costs are very, very significant. The humanity part of it is significant also because the patient should be seen more timely. Everybody would like them to be seeing more timely. Just if there’s somebody available, that that makes it impossible.

So what we did at the request of the geriatricians in the communities was bring the psychiatrist directly into the nursing homes. So they had timely access. And what we discovered, which is well documented in the literature, if a psychiatrist does an evaluation of seniors in nursing homes, they frequently, if not, most of the time can discover that it’s medication management, they need to decrease or change the meds, get them filtered out so that the patients have the right medication, and the quality of life for that person is significantly improved. So you have a quality issue and a cost issue, which go hand in hand. And you see that whether it’s psychiatry, dermatology, cardiology, in the world of telemedicine, this comes up over and over again.

There’s tremendous amount of research that has been done. It’s well documented that in the world to telemedicine, you look at both of those things like the country is looking at, how do we make sure that we continue to strive for access to quality care, and at the same time decrease the overall cost of care?

Gordon: I remember, I think coming across some studies, looking at how telemedicine can change the way care is delivered as well, in a way that’s beneficial to people. So we have a nationwide lack of supply or an inadequate supply of psychiatrists, for instance, because of a lot of work for the DOD and not enough funding necessarily for the number of psychiatrists we need. With a typical face to face visit being an hour with the documentation, I’m aware, I think there are models with a store and forward that can potentially have a psychiatrist review three to four people within an hour, which is a significant dramatic increase in capacity. Are you aware of that work? Is that something that you’ve taken into consideration?

Barb: Actually, that work has been spearheaded by Peter Yellowlees who’s been doing asynchronous telepsychiatry for about eight years. He’s done a series of NIH funded grants to look into that. And the data is pretty solid, he’s published quite a bit on this. What they do is they have people who are trained in a clinic so that patients who come in who need to be evaluated by a psychiatrist are interviewed. They have a standardized interview survey tool that is used by people who are not psychiatrists, but who are trained to ask the questions to the patient, the patient gives the responses.

The whole session is videotaped. Those videotapes then can be looked at by psychiatrists at a later time, so that you have a psychiatrist who maybe has a full schedule and maybe somebody doesn’t show up or they have a lunch break, or even after hours, if that’s a convenient time for the psychiatrist, they can go in through a secure portal, view that consultation, that interview, and they can determine the diagnosis and suggest a treatment plan back to the primary care provider of that patient. They have been doing that for so many years now, and there’s enough data to support that. It not only works, it’s a much more efficient way to use the psychiatrists’ time.

In psychiatric practices, it’s pretty common that there will be a time during the day where there’s a no show or they may have a time of the day where they set aside—that they’re just going to do a review of those video surveyed consults. And that makes it a much more efficient use of their time, and it makes the whole process of doing at least the initial diagnosis and suggestion of a treatment plan, more efficient. Now, they do not do that, they do not use a synchronous telepsych for ongoing treatment, it really is to get the original diagnosis and suggest a treatment plan.

Gordon: It’s interesting though when I think about the book of work in a typical primary care practice and dealing with a population of people that there’s a small cohort of individuals who really need to be engaged with behaviorists and psychiatrists closely because they need that level of care on an ongoing basis. But there’s also a larger group of people where there’s ambiguity around the diagnosis or ambiguity around the treatment plan, or some need for input from a behaviorist or psychiatrist to help accelerate treatment appropriately. And there’s a voltage drop when PCP makes a referral and maybe a patient doesn’t go or it takes a while to get in. And what you’re describing here in the store and forward is a way to eliminate that voltage drop, provide immediacy, and to do it in a way that brings massively increased capacity to bear.

Because when you mentioned Peter Yellowlees, I remember reading a randomized control trial, the work of stored forward done in federally qualified health centers that demonstrated these results. And so we’ll post a link to that article online for the podcast. But it’s just so impressive. ? Here, we have a major capacity problem, and we have a process that is highly effective, very satisfying to those who are engaged in it, including the patients obviously. And that increases service delivery, not only no voltage drop, but it seems that it’s setup for much better care.

Barb: There’s two things that your comment just reminded me. One of the real benefits that’s come out of that work with asynchronous is there’s a direct communication between patient, primary care, and the psychiatrist, which is very different than what normally happens. If somebody goes in to see their primary care physician who identifies that they probably need an evaluation, the patient’s sent, and they go somewhere and they see a psychiatrist. It’s pretty rare that the psychiatrist communicate back or provide the consultation notes to primary care. Sometimes that happens, but it’s rare.

What happens in the way the asynchronous has been set up, with patient informed consent, after the consult is done, that is sent direct to primary care. So the primary care doctor and the psychiatrist have a way to communicate with each other, which has a wonderful benefit to that patient.

Gordon: That sounds so straightforward and logical, that it would be—you think it would just rapidly be adopted across the health care continuum. Everybody would look at that and say, “Terrific increase in capacity, much better outcomes, much more satisfying.” What are the barriers for adoption?

Barb: Main barrier is there currently is no reimbursement set up to do it. So that means that under Medicare or Medicaid, there’s no way to get this out there and going. And they would be the most likely to benefit the most, especially when you look at the economics of it. So the CMS should really look at this from an economic perspective. There’s enough data that’s proven, it’s been going on for eight years. We already know it works, the studies are well done. It’s a matter of getting CMS to pay attention and go, “This makes sense, we should be doing this,” but what we’ll see if that happens.

There’s one other aspect about it that recently, what they’re doing is looking at the issue of people who speak a different language. If English is not your primary language, that becomes a nightmare. Say in California, we have a lot of people who speak Spanish primarily, or maybe that’s their only language, what they can do with the store and forward, they can have the patient interviewed by someone who speaks their language, because that process happens in a local community and most of the time they have staff adequately set up to communicate with their patients in the most appropriate language.

Then when they send this out to physicians to do the review, they can send it to people who speak the appropriate language to make sure that you have quality care for that patient. So there’s a lot of things I think that will continue to grow out of this that will make it more practical, more efficient, and lower their overall cost of care.

Gordon: I had not even considered the idea of the language, and I’m sure cultural competency as well that comes from the ability to tap into a much larger pool of specialists. That’s a terrific insight. Aside from—so the payment’s not lined up right, and that that’s an issue, we need to work on that. What about, is there a policy beyond just payment that needs to line up?

Barb: Yeah. There are several things that still need to be done. And I think there’s hope because I do feel like when you look at the legislation that’s been coming up over the last two to four years in congress, it has bipartisan support. Both the Democrats and the Republicans see that this makes a lot of sense. So I think there’s hope that something will happen in congress to get the barriers that need to be addressed and to be resolved. One thing that sticks out in my mind significantly is that for a Medicare program, they require that patients be located in a very narrow definition of rural America. That has been what they put in place back in the early 90s.

Medicaid doesn’t have that requirement. I don’t know of any other insurance company in any state that has that requirement. It doesn’t make sense to me, it never has. It would be really helpful. Because by having Medicare limit people to only being able to access a specialist by telemedicine who happen to live in a very tiny part of this country, that mean it excludes about 90 percent of the country. That affects a lot of people.

Let me give you an example. If you have someone who lives in a small town, most of California, and they’re in a nursing home or they’re in a hospital or a clinic, if they don’t meet that rural definition, even if they desperately need to be seen by an infectious disease doctor or a dermatologist, maybe a second opinion from a surgeon, they cannot access them through telemedicine. That just doesn’t make sense to me. It never has. And it’s something that congress really needs to address. I do think that more of us keep begging them to make a change on that.

Gordon: It sounds to me like the idea of using a unique new approach to cover a gap in services is logical, but the proxy of rural versus urban is very inexact. And it really has to do with supply and demands and other barriers, which may be as present in an urban setting as a rural setting.

Barb: That’s correct. There’s another thing that needs to be addressed, and that is to have the DEA modify the requirements that were inadvertently established through the Ryan Haight Act. And that DEA rule prevents physicians who are caring for people through telemedicine to provide prescriptions for controlled substances. And in this day and age, as an example, we have an opioid epidemic in this country. We need to provide care to these people to help get them off of these opioids, but the psychiatrists and the specialists who need to provide the care, even a general practitioner, cannot prescribe the medications that they need to help them get off the opioid drugs.

The veterans, they’re scattered across the country. They need to receive care for different problems like PTSD and traumatic brain injury. The telepsychiatrists or the teleproviders are not allowed to provide medications that are controlled substance if it’s care provided by telemedicine. And the final group that comes to mind are children with ADHD. We have children who need those prescriptions, and the specialist is required to write those prescriptions frequently as far away. And the doctors are not allowed to do prescribing because of the Ryan Haight Act. And the DEA was requested to make that correction, I believe in 2015, and they have not done it. That would make a significant improvement to health care to a large part of our population that’s pretty desperate for access to care.

Gordon: Okay. So there are a bunch of barriers in the way, making it difficult to roll this out. Obviously, we might be able to find psychiatrists or other providers who are licensed within a state who can do that. But if we’re going to really take advantage of this, we need to change more policies and do it in a way that’s beneficial to Medicare beneficiaries and others. I’m going to pivot a little bit to thinking about what it takes to implement something like this. I’ve seen, when I walk out the trade show of American Telemedicine Association meeting, I see incredibly cool devices, but they look super expensive. These big machines, these fancy cameras and stuff like that, what does it take to do what you’re describing? Do I have to buy one of these machines and put it in place in every setting?

Barb: It actually depends on what the problem is you’re trying to address. So that if you have a hospital and you need to have a telestroke program put in place, you may look for technology that’s very specific to telestroke, and that may be a system that is more expensive than almost any other practice. When you’re doing telepsychiatry, it’s negligible. The technology that’s available nowadays, it’s cloud based, it’s on the internet, you can connect to any computer, iPad, you can use your iPhone. It’s really, really inexpensive and very simple to implement the systems that are available for most telemedicine programs. You will always have to have some peripheral devices to attach if you’re going to be looking at somebody’s ears or throat, but you have that in any clinic anyway.

Gordon: Got you. But in some of these, in what you’re describing before with the store and forward, as long as I have a secure way of capturing information and sending it, I could potentially record an interview on my iPhone and use that as the simple device.

Barb: You can. And they are doing that. And in fact, the research is going on right now, they’re using the same technology for in-person consults and for store and forward. It’s just a matter of another button on your computer. It’s pretty simple. But it does all have to be using HIPAA compliant technology systems. You cannot use video conferencing just because it’s available. You don’t want to use just commercial products, you’ve got to be sure that everything you’re using for communicating any work with patients has to be HIPAA compliant. And the guidelines are available at the American Telemedicine Association, on their website. There’s tremendous information that’s freely available to anyone.

So you don’t really have an excuse not to do it correct, it’s available for you to download and make sure we’re doing that correctly to protect the safety and privacy of our patients.

Gordon: And as you mentioned, the safety and security, is technology caught up enough that that sort of security is available?

Barb: Yes, it is. And in fact, probably the best place to go look, as what you had mentioned, the vendor showroom at the American Telemedicine Association really includes all the companies that are pretty much doing it now. They’re there, it’s a great place to talk to the people who do it that know how to use these systems. And you can really see everybody under one roof.

Gordon: Is that also a resource if people are listening when wanting to learn more about the policies and payment? Can they go to the ATA as a website for instance?

Barb: Right. There’s tremendous amount of information at the American Telemedicine Association website. The conferences every year really brings together not just people in the United States, but people from around the world that are very much involved in this. And it’s a nice group of people because you have people who build these technologies, the systems, and you see the new things, and you meet people from academia who do the research and who study this and who get up there on the stage and share that knowledge and answer the questions you really want to ask, and you have the companies. So it’s a really nice grouping of academics, industry, and the technology people themselves.

Gordon: Well, that’s phenomenal. We’ll provide a link to the ATA website also to congressional testimony that you’ve given, talking about the benefits of telemedicine. As I think about concluding, are there any things that you would like to leave with?

Barb: I think it’s just a wonderful time to be working in the telemedicine world. It’s been 20 years of a commitment to seeing how we can do this better, and being part of a community that is so focused on the future, the people that you meet and you work with, and especially the patients that give you back their gratitude. I must say, in all these years, what really keeps me going is when a patient says, “Thank you. Thank you so much. There was no other way we could have received this care.”

Gordon: That’s terrific. And I’m hoping that the gap right now in policy and payments may be—we may have an opportunity to close it. Just reading this morning about Berkshire Hathaway and Warren Buffett, Jamie Dimon from JPMorgan, and Jeff Bezos from Amazon have come together and say that they are going to rock the health care industry in the United States. And one of the things I hope they may do is change the complacency, which can sometimes slow down process improvement.

Barb: I have to tell you, when I saw that headline this morning, I just was so excited. Those are the right people. They want to do it, they’ve got a track record, and they’re doing it for the right reasons.

Gordon: I look forward to seeing where that goes and how it can help us all move.

Barb: Yeah. Very exciting.

Gordon: Barb, thank you so much for your time today.

Barb: You’re welcome. Thank you.

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