Coronavirus in Context: Using Telehealth in a Pandemic

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Hello, I'm Dr. John Whyte, Chief Medical Officer WebMD. And welcome to Coronavirus in Context. Today, we're going to talk about the role of telemedicine in how we manage patients care in the era of coronavirus.

And my guest is Dr. Eric Wallace. He's the medical director of telemedicine at the University of Alabama at Birmingham. Dr. Wallace, thanks for joining me.

Thanks for having me.

You know, WHO, the World Health Organization, calls telemedicine healing by a distance. Is that really what telemedicine is? Can you explain it to our viewers?

No. I mean, I think that-- that there is a lot of things that are-- there's a lot of things in medicine that really need hands on care. And don't get me wrong. Even-- even physician needs hands on.

I mean, there's something about the human touch. I mean, I tell people, even though I'm-- I'm on the medical director of telehealth, I'd never give up my in-person care, because I like-- I like getting hugs from patients.

But that withstanding, at a time during COVID social distancing, and-- and this real risk of being in a physician's waiting room with other people that may have COVID, um, I-- I think that-- that we have to start evaluating different ways of-- of treating.

And not just evaluating. We have to implement these pretty immediately, which is what the University of Alabama at Birmingham has done, to not only protect our patients, but also to make sure that-- that they get the care they need.

And what are those ways that you're using telemedicine at telehealth?

ERIC WALLACE: The real implementation of telehealth and-- and what we call UABE medicine at UAB has been, is, for all of those patients who, uh, had care scheduled here at UAB.

So in March 13, when President Trump announced the-- the federal emergency, there was a real sense that not only did we have to protect our providers from patients, or providers from getting COVID, but also protecting the patients from coming into these really cramped areas.

And so what happened pretty much overnight, so on March 16, there was a change where we said, OK, well, only essential care needed to happen. And when you start-- start looking at only essential care needing to happen, there's all these-- these patients that still need care.

And-- and so there is really only two ways to take care of those patients. One way is to-- to reschedule them for a month from now. But all the-- or two months from now. But all the physician--

[INAUDIBLE]. We really don't know where we're at.

Right. But-- but all of those patients, I mean, let's say it was two, three months. I mean, at UAB, we're such a high volume institution that rescheduling people for a month from now, you would never catch up. Because all of the providers were already working at 100%, so they can't work at 200% to catch a backlog.

So-- so then it was-- it was, how do we change that so not only can we give the care that's needed, but minimize risk of exposure. And telehealth was really the only option for that.

So what can we see in telehealth and telemedicine? Are most appointments able to be converted?

Yeah. I mean, so currently, right now, part of this is-- is-- we had about 2,500 providers to train on-- on video conferencing and-- and remote care.

But currently in two weeks right now, about 50% of our ambulatory volume is actually handled over telehealth. And that-- that is just continuing to climb.

So what conditions can be seen through telemedicine and telehealth?

You'd be surprised. A-- a vast majority of conditions can be-- be seen over telehealth. And some of it needs a little bit of tweaking. So for instance, I'm a nephrologist, and I need labs. And I can't see anybody's kidney function over the video.

So what we needed to do was a way to actually be able to get lab work. But there's-- there's a difference in view which, is that, if I bring somebody into labs, they get their labs and immediately leave, their risk is far lower than getting-- than staying in a waiting room.

So, for instance, the usual was, I would get labs, they'd wait around for about an hour and a half or two hours until their appointment, the labs resulted. That was all within a health care setting. Then they'd be brought back, and then I'd see them.

But in this scenario, what we're having to do is send a patient to the lab. They go in and out very rapidly. And then they go home. At which point I'm able to use their video conferencing to do a full physical exam, with the only exception being, I don't have a stethoscope in everybody's-- everybody's home.

There are ways to do remote auscultatory exams, but provide-- operationally providing everybody a stethoscope is-- is difficult. So, but I can. I can look at-- I can look at how much swelling the patients have. I can look at their breathing. I can look at their eyes and mouth.

And then I can talk to them about all the labs that we just got. Same with imaging. So if-- if I really needed, for instance, a renal ultrasound, you can get the imaging and have the patient go in and out. So it's about minimizing the-- the exposure, the time spent with a lot of other people that may-- that may actually be sick.

How did patients prepare, though, for a visit?

That's a great-- a great question. Because when you look at the types of volumes that UAB does, um, you know, we were talking about anywhere from 6,000 to 7,000 ambulatory visits a day.

Wow.

And now all of a sudden we have to train all of the providers, but we have to train all the patients. Um, you know, video conferencing is not a-- a skill that one is born with. So we're starting to get out education material.

So what we had to do first was train our access center in-- in what information we needed to give the patients. So in our-- our version of videoconferencing. And in most videoconferencing solutions, the patient has to have something on their mobile phone that's able to interpret the video.

So they need to be able to download an app. So we tell them, you need to download the app. We tell them they need to be in a private environment. Um, I can't-- so when a patient comes to clinic, that clinic room is very private.

On the other hand, when I'm doing a video conference, if the patient is in a Walmart, then that's not a very private environment, and the provider has no control over that. They need to be in a place that has good internet.

And ideally, patients would either be on Wi-Fi or have unlimited, um, unlimited data. Because there is a risk of, if we transmit all this, uh, via video, which uses at least three to five megabytes per second download speed, that can chew through somebody's data very quickly who only has limited-- limited data.

So at the time of the visit, we have to train them. You know, you're going to get a link. You're going to click into the link, it will open a screen. Um, and so what's happening right now, although this is a very fast transition, is that right now, it's actually very difficult to-- to train all that-- those amounts of people.

But what will happen in the future is, when the first patient actually does their-- their visit, now they have a follow up appointment. Now there's a rapid learning curve that everybody will get better and better at this.

But when you're trying to transition an entire nation, uh, over the course of two to three weeks because of not only the health implications for the patient, but the financial implications for, uh, health systems and health care in general, it's-- it's a difficult transition.

So have they been happy with it? And I'll tell you, I did, uh, telemedicine visits the other day with patients I was seeing. And I wasn't sure they left the visit happy. But what's been your response?

I think-- I think you're going to have responses across the board. You know, I think that-- that just like education, there's people that-- that learn in different ways. And there's people that like their health care in different ways.

Primarily, you know, older adults in general have been-- you know, this was the transition from the-- the, you know, my dad's generation would disrobe every patient that came in. And now there are patients that feel like they haven't gotten a visit unless they've been completely disrobed.

But then the younger generation says, you know, if a doctor describes them, it's almost disrespectful. So-- so--

They're on their phone while we're trying.

That's right. And so I that-- that we have had different responses. We've had patients who don't want any video in their house, because of concerns of privacy, even though all that we are-- we are using it UAB is HIPAA compliant. There have been--

Thre's more rules now too, without going into regulatory. We've-- we've broadened it.

Absolutely. I think there's still a-- a distrust of video in their home, right? So there's-- there's that issue. We've had patients who have done it and say, uh, I never want to come back to UAB. I only want to get my care this way.

And, you know, some in-between. But-- but I think it's, you know, after this, nothing's really going to be the same, right? I mean, this is-- telehealth--

Has COVID-19 changed the way we deliver health to patients?

I think so. I think that what we're going to find and what's going to happen at the end of this is, people are going to realize there are-- there were things that we always could have done over video.

Specifically for the rural areas, um, that-- not just rural, the rural and what I call the super sub specialties, like transplant. That should have always been able to be done remotely.

Um, and so I think that there's definitely things that we're learning here. I think that what's going to happen at the end of this is, we're going to realize there's a mix of approaches. Um, and now we've suddenly added video, which is a very powerful way to deliver health care and increase access to care, um, in a time that we really needed it.

The other thing that I'm-- I'm hopeful that we will find is that the infinite amount of-- of regulations that we put, that we so easily tore away during the epidemic, which makes you wonder, why were they there to begin with, right?

Why did we put so many barriers to allowing people to access care? My hope is we realize that some of those were completely unnecessary, outdated, and were more to-- were not in the best interests of patients. That they were really put there, uh, from-- from business perspectives and things like that, and weren't really thinking about, how do I make sure that patients get the best access to care.

What's your prediction two years from now? What percentage of patients' visits will be telemedicine, telehealth?

I think we could very easily get to 40% and 50%. Um, I think that's a-- that's a very reasonable account, that it's going to be 40% and 50%. I also think, although my prediction, uh, much further from now, you know, before COVID, it was about 15 years from now.

I think what's happening is, is the generation that is-- is coming up will demand their health care in this way. And we should be able to meet them on that. I mean, we should be able to meet anybody on whatever terms they want to make sure that they're healthy.

I mean, that is-- that is what the-- although health care in general, but health care in the United States has had this ability. I mean, the first-- the first telehealth program was really in the '70s. Actually, it was the Mercury Mission that-- that was the first remote patient monitoring that was available.

And we just, for-- for reasons that I'm not sure were right, we've never operationalized it. And so now, I think we have the ability to say, look, I will meet you on whatever ground you want.

If you want to be seen in person, I'll see you in person. If you want to be seen remotely, I'll see you remotely. The most important thing is making sure people are healthy and they have access to care.

Well, that's a new perspective on-- on healing by a distance. And I want to thank you, Dr. Wallace, for taking the time.

Oh, my pleasure.

And I want to thank you for watching Coronavirus in Context. I'm Dr. John Whyte.