On this last episode, we look back on 23 years of joyous, difficult and always informative conversation.
The pandemic has created new challenges for patients seeking access to non-coronavirus related healthcare. As the medical community works to meet the healthcare demands of the coronavirus, telemedicine has become increasingly vital in the treatment of patients.
How is the local medical community adjusting to telehealth? Is telemedicine the future of healthcare in the region? And what are the advantages and disadvantages of practicing medicine remotely?
Produced by Kayla Hewitt
- Ranit Mishori Professor of Family Medicine, Georgetown University School of Medicine, @ranitmd
- Megan Hollis Medical Director, Conway Health and Resource Center, Community of Hope, @cohdc
- Jason Hallock Chief Medical Director, SOC Telemed, @SOCTelemed
- Eleni Boosalis Co-owner, Del Ray Psych and Wellness
KOJO NNAMDIWelcome back. Although the notion of telemedicine is by no means a new concept, the coronavirus pandemic has forced healthcare providers across the region to practice medicine remotely. So, what does telemedicine look like, and is telehealth here to stay even after the coronavirus pandemic is over?
KOJO NNAMDIWe've got guests from a ranch of practice areas to help us with this conversation, but we'd also like to hear from you. Have you had a virtual appointment with your physician? Tell us what that experience was like for you. Joining us now is Dr. Ranit Mishori, a professor of family medicine at the Georgetown University School of Medicine. Dr. Mishori, thank you for joining us.
RANIT MISHORIHi, Kojo. Thanks for having me.
NNAMDIDr. Mishori, patients have become hesitant about seeking out medical care since this pandemic began. What do you think is the reason that is keeping people from seeking care? Fear of contracting COVID-19?
MISHORII think you're absolutely right. That is the number-one reason that I hear from patients who have all kinds of medical issues or that need to get a mammogram or some diagnostic testing. And the number one thing that they say is, I don't want to go to a healthcare facility right now, because I don't want to get coronavirus. So, this fear of infection is certainly what's driving people to not showing up in person, not seeking out care, not going for diagnostic testing.
NNAMDIAlso joining us is Dr. Jason Hallock, chief medical director of SOC Telemed. Dr. Hallock, thank you for joining us.
JASON HALLOCKOh, thank you, Kojo.
NNAMDIFirst, what is SOC Telemed, and in what kind of settings are your services usually requested?
HALLOCKSure. Well, we're actually a large physician group that started in telemedicine, oh, over 15 years ago, mostly focused on tele-psychiatry, tele-neurology and tele-ICU care. And we provide a little different side of telemedicine, more on the acute care side, providing these specialists in hospitals where they wouldn't ordinarily be able to be. Even in urban areas, there's a shortage of specialists or specialists when you need them.
HALLOCKSo, we started the practice 15 years ago and developed a technology platform to actually service our own needs. But now we power a number of other healthcare institutions nationwide, including in the D.C. area, to empower them to get their doctors where they need to be quickly and efficiently.
NNAMDIDr. Hallock, what is acute care, for those who are not aware, and how is telemedicine usually practiced in that area?
HALLOCKWell, sure. Acute care focuses on hospitals and healthcare facilities like skilled nursing homes and rehab, but also can be any form when a patient needs it on demand, and particularly needs a specialist. And so that that's been our mission now, for well over a decade, is to bring, you know, the clinicians and patients together, you know, with an appropriate, you know, technology piece or technology enhancement that allows that to happen very rapidly.
NNAMDIJoining us now is Dr. Megan Hollis, medical director of the Conway Health and Resource Center for Community of Hope. Dr. Hollis, thank you for joining us.
MEGAN HOLLISThanks, Kojo. Nice to be here.
NNAMDIDr. Hollis, what is Community of Hope, and who does your health center serve?
HOLLISSo, Community of Hope is an organization that has three medical sites throughout the city. I work at the Conway Health and Resource Center that is in the Ward 8 neighborhood of Bellevue. We're right across from the Bellevue Library. In addition to providing medical care, we also provide behavioral health services, dental care. And we also work with housing for families, as well.
NNAMDIWhat kind of medicine does your center offer, and what did your daily operation look like before this pandemic hit?
HOLLISWe we're a practice of family medical providers, so we're made up of family doctors and nurse practitioners. So, we basically see everyone from birth to death, and everything that comes in between, whether that's prenatal care or care for chronic illnesses like hypertension and diabetes, to physicals for children and adults. And we're also seeing patients for acute visits on a walk-in basis to try and prevent them from having to go to an urgent care or emergency room.
HOLLISAnd before the pandemic, we did everything in the traditional, old, in-person appointment-based system. We had a pretty bustling clinic with seven fulltime providers seeing patients scheduled at 20-minute intervals throughout the day. So, we had a pretty busy waiting room most of the time.
NNAMDIYou suddenly had to quickly pivot to telehealth. What were some of the challenges in making that transition?
HOLLISYeah, we did. So, basically, overnight end of March we converted all of our already scheduled appointments over to telehealth visits that initially were over the phone, for the most part, because of some struggles we had with our video-based system, that we've since worked out. But basically, overnight, we transitioned everything to telehealth. And since then have been kind of navigating balancing the safety of our patients and our providers with the care that may still need to be done in-person.
HOLLISSo, I think some of the major challenges that we've had was really to do with our patients' access to the resources for being able to do telehealth visits, whether that was reliable internet access or access to the devices to do things like video visits, whether that be smartphones or tablets or computers. So just kind of navigating how we get through some of those barriers through this process. And over the last few weeks, we've kind of transitioned to trying to reopen a little bit more access to in-person appointments, while still maintaining some of those telehealth appointments, as well.
NNAMDIAlso joining us now is Dr. Eleni Boosalis, who is the co-owner of Del Ray Psych and Wellness. Dr. Boosalis, thank you for joining us.
ELENI BOOSALISThank you for having me, Kojo.
NNAMDIYou're a practicing psychologist, and you've seen a spike in the number of patients seeking mental health support since the start of this pandemic. How has your practice adapted to accommodate the surge in demand for your services?
BOOSALISSo thankfully our platform that we use for billing already had the option of video therapy. It was set for compliance. So, some of the practices locally here had to figure it out overnight. But thankfully, we had that option. We had used it once in a while for clients or patients that had a difficult time getting in. Maybe they had a problem with mobility or, you know, panic disorders, something like that.
BOOSALISAnd so, overnight, we moved from seeing clients face-to-face, to all virtual. And I think, initially, the first month some people hesitated, I think. Some people cancelled and they said, well, let's just wait until the pandemic dies down. And then I think once everyone realized that this is the way of life for a long time, we got a surge in probably about May in calls. And we have a long wait list now, where people that had ended therapy before, some old clients, they're all returning, along with new clients that are having significant symptoms of depression and anxiety. So, it's all virtual now, and it will be, at least until September.
NNAMDIAs I said before, if you've called, stay on the line. We will be taking a short break soon, but we'll come back to you and your calls. Dr. Boosalis, how well does telemedicine work in mental health services? We only have about a minute left in this segment.
BOOSALISIt works really well. I think that people initially thought it wouldn't, because you can't read body language. You're seeing someone on a screen, versus 3D, you know, feeling the energy in the room, the nonverbal communication. But some studies that have been done show some strong empirical evidence that there's little difference between face-to-face versus remote sessions. So, that's what we have found, especially for people -- the younger folks that are used to communicating in this way, that it's really effective.
NNAMDIWe're going to be taking a short break. When we come back, if you are on the line, we'll be getting to your calls, 800-433-8850. I'm Kojo Nnamdi.
NNAMDIWelcome back. We're talking about telemedicine and its possible and probable future in the field of healthcare. Let's go to Karen in Bowie, Maryland. Karen, you're on the air. Go ahead, please.
KARENHi. Thank you, Kojo, for taking my phone call. I just wanted to share two experiences, both as someone receiving telehealth medicine, and then as a provider. Just very quickly, my children, we've had to pediatrician appointments via telehealth. And while they've been efficient and quick and very easy, it's also -- it can be very distracting given that you have, you know, multiple kids in the room and everybody wants to be on the camera. And so it becomes more of control management than actually being able to be present with the provider and to hear, you know, what they have to say.
KARENSo, that's just as an experience receiving telemedicine. And then, as a provider, I work part time as a behavioral healthcare manager in a county clinic, and primarily with the Spanish-speaking immigrant community. And so what we're seeing is that it's very difficult to do telehealth, because, first of all, most individuals don't always have access to computers, don't always have access to the programs that are needed to make sure that it's a secure network. And so that can be very challenging.
KARENOften, it can produce even more anxiety to think about having to download, having to get onboard with that. So, that's been challenging. My senses and what I'm seeing is that people are very eager to get back into the clinic, back to seeing their providers face-to-face, particularly, like I said, with the community that I work with, which is the Hispanic immigrant community and working in Spanish.
NNAMDIOkay. Thank you very much for sharing those stories with us. Dr. Mishori, I'd like you to address the first part -- no, I mean the second part of it, where people -- there are people who do not have access to certain kinds of visual equipment online, and how do you handle that?
MISHORIYeah, well, first of all, what Karen was talking about is something that is very well known in the field. It's called the digital divide. It's the reality that certain groups of people, they tend to be older, immigrants or non-English speakers, females, people in urban and rural areas and those with low tech literacy are having a very difficult time accessing and adopting telehealth.
MISHORIAnd as she was describing, part of it is related to the fact that people like that in those groups don't necessarily have access to the devices and the technology that enables telehealth. Parts of it is because people who live in certain areas don't have access to Wi-Fi or broadband, and the connectivity is an issue.
MISHORISo there are different ways of addressing such issues. In practice, you know, every once in a while we bring people in. If the telehealth platforms don't work, we can do phone. Most people have a phone. It's also important to know that people who are older, for example, there's a study that shows that half of households where people are over the age of 65 don't have a smartphone. So, in those situations you need to know that ahead of time and create a -- and not use telehealth or video platforms, but use a regular voice call.
MISHORII also wanted to very briefly say that, you know, the issue that she was -- the first issue that she was addressing, I've had people...
NNAMDI(overlapping) A lot of kids in the room, yes. (laugh)
MISHORIYeah, but I've had people take telehealth visits, you know, from the park or from Walmart. That is really not conducive to having an efficient and useful medical visit. So, there needs to be a balance, but on the whole, I think it's a great and promising platform that allows people to access healthcare from anywhere and at anytime. And I can tell you that where I practice, we've noticed that the no-show rate has decreased dramatically. It's anecdotal, of course, but I don't have people not showing up. Because wherever they are, where they're in the car, hopefully not driving, or at home or in their office, they can see me from there.
NNAMDIOkay. Thank you very much. Here now is Jeannie in Mitchellville, Maryland. Jeannie, you're on the air. Go ahead, please.
JEANNIEHello. Good morning. Or actually I guess it's the afternoon. I use telehealth to speak with my oncologist. And I find that helpful in a couple ways. I don't drive, so if I didn't -- he's in Bethesda, and I'm in Mitchellville, which are about 25 minutes apart -- I'd have to take Uber or Lyft which would expose me possible to COVID. So, I'm avoiding that by speaking to him with telehealth.
NNAMDIHow's it been working out?
JEANNIEIt's been working out well, very well. And I also get blood tests that he needs, that the oncologist needs, I get them locally. So...
NNAMDIWhat do you mean when you say you get them locally?
JEANNIEOh, in other words, I live in a retirement community, a wonderful retirement community, and lucky, too, we have MedStar. And I can get the blood tests that my oncologist needs here at our MedStar clinic.
JEANNIEAnd they send him the results in Bethesda.
NNAMDIThank you very much for sharing your story with us. Care to comment at all on that, Dr. Hollis?
HOLLISYeah, definitely. I think it's great that that's one thing we've noticed for some of our patients, as well, is increased access to some of the specialty services because of the option for telehealth. I think, for the most part, it's only been for patients who had already been connected to those specialty services. But, you know -- and I think the same thing that Jeannie was talking about is sometimes an issue for lots of people. Just access to transportation to appointments can be a challenge, whether that's your specialist or your primary care doctor's office.
HOLLISAnd like Dr. Mishori was mentioning, the decrease in, you know, kind of the, quote-unquote, "no shows." We've noticed that as well with, you know, our patients not having to get transportation to an in-person appointment. And so I think that's been a great advantage of the telehealth option for patients.
HALLOCKWell, yeah, I would definitely agree. I mean, I think what we're hearing in the industry is a resounding that it makes patients feel safe. There are, you know, hiccups with, you know, the digital divide, as mentioned, but patients definitely feel safe. And I think, you know, we hadn't really -- before COVID, we hadn't really thought that that was going to be such a focus in the industry, but certainly, it is. And patients certainly can access by phone, also, and that's even more effective when you have a preexisting relationship, for sure.
NNAMDIDr. Boosalis, we got an email from Will, who wants to ask: I heard that last week there was a notice for Medicaid psychiatric patients in Maryland, that they're psychiatric telemedicine care will no longer be covered as of August, 2020. I haven't been able to check on that, but can you comment on that, Dr. Boosalis?
BOOSALISActually, we don't have any Medicaid or Medicare patients in our practice. But I know that the laws, they vary from state to state and from insurance to insurance. So, I can't speak directly to Medicaid.
BOOSALISBut in terms...
NNAMDIGo ahead, go ahead.
BOOSALISIn terms of the previous question about practicing at home, I have found that people are more comfortable having sessions in their home, sitting on their couch with their blanket. But I have also found that it's difficult to have privacy. So, I have had many psychotherapy sessions where people are locked in their bathroom or their closet or their vehicle, (laugh) so they're not interrupted.
NNAMDIOkay. Can you answer that question, Dr. Hollis, about the Medicaid?
HOLLISI could -- maybe I can. I don't know that I have the specifics. Most of our patient population at Community of Hope is D.C. Medicaid insured, so I don't know that I can speak directly to Maryland Medicaid. And a little bit of this is informed by our experience prior to the pandemic, because we were providing some behavioral health services in a telehealth fashion prior to that. But because of the restrictions on billing for telehealth, it had to be from a clinic to another clinic.
HOLLISSo, essentially, we had a psychiatrist at one clinic who would have a video visit with one of our patients who was primarily seen at one of our other clinics. So, it wasn't like from the doctor to the patient's home or, you know, both in a remote basis. And the public health emergency, you know, I think with the D.C. Healthcare Finance, they helped to, you know, definitely fund or allow for phone telehealth be available during this public health emergency.
HOLLISBut definitely one of the things we're concerned about is if those measures go away when the public health emergency ends, will our patients still have access to these services? So, my guess is that there may be something with Maryland Medicaid where they might be kind of reverting back to previous practices with limiting the capabilities for billing for those services after a certain time.
NNAMDIDr. Boosalis, restrictions on the practice of medicine across state lines have also been loosened during this pandemic. What changes were made in Virginia, and how has it affected your practice?
BOOSALISSo, initially, in Virginia, we had to practice within our state, be in our state and the patient be in the state. So, they couldn't be in their home in D.C. or Maryland. But now, after COVID, they've allowed psychotherapists to see their clients that are out of state. And I believe they're also allowing out-of-state clinicians that have to travel to treat Virginia clients through September 8th.
BOOSALISSome states are requiring that psychologists and psychotherapists apply for a temporary license in a different state if they're going to be there for a while. But, as of now, they're allowing out of state clients. But we are also encouraging new clients to seek therapists that are residents of their state, because this will not last forever. And so, you know, just to have continuity of services, we're encouraging new clients to seek therapists in their own state.
NNAMDIAnd since the start of the pandemic, Dr. Boosalis, many insurance companies have changed their policies with regard to covering telehealth. Have those changes impacted your practice as you've turned to virtual therapy appointments?
BOOSALISThey haven't impacted it. I mean, I think that it has helped, because they have covered many of the co-pays. That's something new. So, a lot of the clients, they have covered their deductible, their co-pay. And so that's made it easier for people that have lost their job or, you know, are not working.
NNAMDIOkay. On now to John in Adams Morgan. John, you're on the air. Go ahead, please.
JOHNHey, hi, Kojo. I just wanted to share that I'm over 60, I have a chronic health condition. I've had a couple of tele-appointments since this whole thing has started, and I find it very convenient. Very happy with my provider who's down in George Washington. And I encourage other people to try it. It works very well.
NNAMDIOkay. Thank you very much for sharing that with us. On now to Sandra in Washington, D.C. Sandra, you're on the air. Go ahead, please.
SANDRAThank you. Hi, Kojo. I have done the appointment over the phone, the telehost, and it is wonderful. What it does do, though, is show up the privilege of having -- and I heard your guest talk about this -- the ability to have the phone, the smartphone or the computer, all of the things that a lot of people don't have. We see it with our students in the computer divide. And so while it is a privilege and it is great, it does cause for concern about older individuals -- and I'm over 65, as well -- who don't have that. And is there any outreach -- is there a plan or any kind of policy or way to reach individuals who are put off by the coronavirus and don't have the devices? What is it that they're going to be able to do? And thank you.
NNAMDICare to deal with that, Dr. Hallock?
HALLOCKSure. You know, there's a lot of talk going on, and certainly a lot of this will reside with state and national legislators about how we address, you know, more vulnerable groups via telemedicine. And certainly, you know, older people that, you know, may not have or be as comfortable with the technology, and younger also in other groups, you know, it can be a problem.
HALLOCKSo, really, I think the way to address that is through somewhat facilitated care. You know, family members can assist, even visiting nurses or technicians or paramedics. You know, it will have some personal interaction, but that can help access groups that would be challenged otherwise.
HALLOCKAnd then, you know, I think, as we address this, you know, clearly, there needs to be more technology access with the actual technology and broadband, which even some hospitals struggle with. So, I would encourage everyone to write their state and national legislators about how they feel on these issues. We're encouraging our entire practice of doctors to do so, because, in the end, it's going to be decided by them. And I think they do respond when they hear the voice of the people.
NNAMDIDr. Hollis, what changes with regard to insurance are needed in order for telemedicine to be accessible for all communities?
HOLLISI mean, I think this pandemic has kind of been an experiment in how we do that. And, you know, with the public health emergency, we were kind of given free rein with the ability to provide telehealth services on any platform, whether that be over the phone or, you know, through video. So, that was very helpful, that it just sort of, you know, kind of allowed for all of these options for us to be able to access our patients in ways that we hadn't before.
HOLLISSo, I think the changes that maybe need to happen are the ones that we have put in place for the pandemic and just being able to figure out ways to continue to still be able to bill for those services going forward, so that we can maintain this as an option for patients.
NNAMDIAnd how do you deal with this situation? Penny emailed: I recently had a thoroughly unsatisfactory experience using telemedicine for my appointment with an internist who knew me, but had no patience with my difficulty in using the telemedicine portal she used. I'm a blind person, and although I know there are accessible portals, my doctor used one that was not accessible. I had to ask a family member to get me in and to accompany me with every aspect of the appointment, which I felt violated my privacy. Dr. Hallock, what do you advise in a situation like that?
HALLOCKWell, I think, you know, you should go through the regular mechanisms to give feedback about the interaction. It's interesting, even on my team, we've all used telemedicine where we haven't before, for ourselves. And I've actually heard that story now more than once. I think, you know, clearly there's a learning curve for the doctors and other practitioners. You have to be more animated via telemedicine, because otherwise, you don't look, you know, kind of on video, as being as empathetic. And also you've got to be patient, as there's a learning curve for everyone. So, you know, again, I think that everyone deserves the feedback of how the patients felt.
NNAMDIDr. Mishori, talk about that learning curve, because it's a learning curve not only for patients, but it's a learning curve for medical professionals, too, isn't it?
MISHORIAbsolutely. And as Dr. Hallock was mentioning, it's a different kind of an encounter in terms of relating and building rapport, building trust with the patient, being able to pick up on certain cues that are not necessarily facial. If you're only seeing the face, you can't pick up on other cues that are more physical. So, yes, it takes time. It takes time for the patients. It takes time for the physicians. It takes time for the technologists to adjust the technology so it's patient-centered.
MISHORIOf course there need to be technological designs and creations that are useable to the patients. In the end, it's about the patient. It needs to be patient-centered and not just physician-centered. It's about teaching people to use the technologies. So we're not going to close the digital divide or even work with patients who don't have a problem with the technology, but unless we teach people how to use the technology efficiently and train other physicians in the more sensitive aspects.
MISHORISo, for example, can you address a gynecological issue on a telehealth visit? I would say absolutely not. When patient is reporting intimate partner violence, that's not a visit that I want to practice on tele-health, especially if there's no security or safety in the home. So, there's certain things that probably will never become 100 percent telehealth enabled, or that I would recommend to my colleagues and my patients to use telehealth for. But we're learning as we go along.
MISHORIThis is new for a lot of people. I think a lot of people have been using telehealth, but for many of us, this is new, and it's happened almost overnight. So, there's a lot to learn from the patients. And I think this is why the patient perspective and feedback, as Dr. Hallock was mentioning, is really, really critical.
NNAMDIDr. Hollis, were you ever trained to practice telehealth?
HOLLISNo, I was not. And none of our providers at Community of Hope, I think, except for one, have any experience doing telehealth prior to this. So, it was a massive learning curve at the beginning, and a challenge. And I think a lot of us are still kind of struggling with the frustrations of maybe feeling like we're not kind of providing the care, the level of service that we have been able to provide in the past and found that kind of frustrating. And so I definitely think there are days when I feel like I haven't been able to use all of my expertise to be able to serve my patients, because telehealth is sometimes a little bit lacking in that.
HOLLISAnd I definitely just think, you know, for that, for training for physicians for this type of care in the future, definitely I would love to see, you know, more research into best practices for, you know, certain types of telehealth appointments so that we can, you know, try and confidently serve our patients an evidence-based strategy, the same way we would try to practice medicine in person in an evidence-based way, as well.
NNAMDIHere is Faze in McClain, Virginia. Faze, you're on the air. Go ahead, please.
FAZEHello, Kojo. I have been an emergency physician for the past 30 years. And emergency medicine, especially neurology, the telemedicine is very, very helpful. We see patients with a stroke and, as you guys know, it's a very time-sensitive situation. And also there's a thin line between treating and not treating the patient.
FAZEAnd, for that reason, we bring a neurologist. And while I'm examining the patient, the neurologist watches me and sees the patient's reaction, and all those things. And we both make the decision where this patient goes, how do we treat it. And also, there are some centers that they have invasive procedure and somewhere they have neurologists, but they don't have that facility. So, we make the decision where this patient goes. As I said, this is time-sensitive.
FAZEAnd the second thing in emergency medicine is psych patients. They bring patient, I clear the patient medically, and the psychologist interviews the patient. And then we both make the decision if this patient requires admission, or a patient be followed up by a psychologist or psychiatrist the next day or after.
FAZEAnd the third thing that somebody mentioned about the translation. We do have a system that any language in the world a patient comes, we used to rely on a family member. Now we have that system that translates for us. And the last one, is telemedicine probably helped save lots of lives patients did not come to emergency room. And they rely on their primary physician.
NNAMDIThank you very much for your call. And I'm afraid that's about all the time we have. Dr. Ranit Mishori, thank you so much for joining us.
MISHORIThank you so much for having me, Kojo.
NNAMDIDr. Eleni Boosalis, thank you for joining us.
BOOSALISThank you for having me, Kojo.
NNAMDIDr. Megan Hollis, thank you for joining us.
NNAMDIAnd Dr. Jason Hallock, thank you for joining us.
HALLOCKThanks, Kojo. It was my pleasure.
NNAMDIThis segment on telemedicine was produced by Kayla Hewitt. And our conversation on the D.C. jail during the pandemic was produced by Kurt Gardinier. I also want to note the passing of Alan Lieu, whose service to the District as a city planning executive is imprinted on landmarks from the convention center to National Stadium, as well as the rehabilitation of the city's public schools. He also served as the city administrator. He died today of complications from the COVID-19. Our condolences to his family.
NNAMDIComing up tomorrow, Sandy Greenberg is an inventor and philanthropist who went blind in college. He credits his roommate Art Garfunkel with helping him to regain his sense of purpose. Greenberg joins us to talk about his memoir. It's called "Hello Darkness, My Old Friend." Plus, the Black Lives Matter Movement has seen significant gains in engagement through social media. How have activists used the platform to spread their message? That all starts tomorrow, at noon. Until then, thank you for listening, and stay safe. I'm Kojo Nnamdi.
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