tv The Communicators Dr. Joseph Kvedar American Telemedicine Association CSPAN November 9, 2020 8:00pm-8:31pm EST
tv. connolly: thank you peter. >> if you're interested in hearing more about the books, members of congress are reading these books, booktv.org and search what are you reading. at the top of the page. >> tonight is expensive, the communicators is next with a look at the role of telemedicine during the coronavirus pandemic ... ... >> this week on "the communicators" a discussion about a growing form of telecommute occasions and that is telemedicine.
joining us are doctor joseph kvedar of the american telemedicine association and harvard medical school along with our desk reporter kimberly leonard of business insider. doctor kay, how long is telemedicine been around and what has been the growth or use of it in the past couple of months? >> it's been around since some people say the early 1920s and there was a lovely picture in one of the magazines now popular science they had a different name for it but shows a family huddled around the radio having a visit with the doctor on the other side. the concept has been around for a while and since the late 60s is when it got going and it puttered along for the next several decades until a couple of months ago when the push we told everyone in the u.s. that they had to stay in their home and we as clinicians had to take care of them so it blossomed overnight at that point. >> host: how can it be used
today? >> guest: in a number of ways. i think the best uses, first of all, mental health is the number one probably used and god knows it's a growing need so that is wonderful. a lot of urgent care type things such as sore throats, earaches and actually screening for the coronavirus is quite handily done using this technology so virtual urgent care and then chronic illness management follow-up visit for patients with diseases like hypertension, diabetes, heart failure and the lights are very handily done. during the pandemic we really did everything this way. i'm a dermatologist and we did a lot of dermatology this way. i think we are we're headed now is some kind of what i would call hybrid and most people are pretty confident that we will continue to have telehealth as part of our care going forward and there are a lot of reasons
perhaps we can get into them later but and most of those things, even more. i would finish off by saying that everything and that is important. really the conversation that you need to have is with your doctor and for us as clinicians to be able to think through the information we need to make either a diagnosis or change of care plan and if we can do that without touching the patient then we can do it via teleheal telehealth. >> host: let's bring kimberly leonard of business insider into this conversation to explore some of those issues. >> guest, doctor kvedar thank you for being available for this interview. my understanding is that the trump administration had to make a lot of changes to rules to allow telehealth to be used and more doctors offices. could you tell us what some of those changes were for those who might not be as familiar? >> guest: i was told the other
day i testified in front of a senate panel and i was informed that there are 31, to be exact. i can only refresh the highlights. the biggest one is that the federal government and most private payers came on board with this in a other clinicians in the same amount of reimbursement for telehealth patients as they would if someone came into the office and that was a critical one. the second one was allowing us as clinicians to see our patients wherever they were in medical care used to be limited to rural and health fashion shortage areas and at one away so i can be where i am right now which is my home and you could be where you are and we could have a visit and we could go for that. the second tier regulatory relaxation was in the area of technology and hepa. hepa is our privacy standard
rule that many people know about and it went away overnight. people could use facetime and you zoom in google hangouts and skype to do these calls or the telephone. so we could talk about whether that is a good idea but the third area was licensure and 49 out of 50 states now have loosened their licensure requirements so that you can practice across state lines. i'm in the boston area and eastern massachusetts. if you happen to come visit me let's say you live in new hampshire which is about half hour drive north and you came to visit me in the office and wanted to do a follow-up while you were in your home we couldn't do that before because i wasn't licensed in the state of new hampshire but we now can do that because of the so it's really those three areas that are highlights. >> this week president trump said he thought a lot of the telemedicine changes that the menstruation had made might become permanent and we heard
the administrator on the centers for medicare and medicaid services say the same and if you were to look at the landscape which is the most important factors that each remain in a post pandemic america? >> thank you for asking. >> guest: i testified in front of the senate health committee and there was really strong bipartisan support for this so we are very hopeful but to be specific to answer your question number one, this is what we call the site concept and i should care for you wherever you are, not just in a health profession shortage area or rural area. that is number one on her list and the second one being that federally qualified centers and rural health center should be able to get reimbursed for providing these services that was not the case before. importantly the secretary of health and human services should be able to defy -- decide which
services are reimbursable or not as part of their mandate. those are three areas that are very important and there are many others but you're trying to be [inaudible] >> it sounds look some of the changes may be able to have them for rulemaking but other will probably require a decision from congress, is that right? >> guest: i believe so. originating site rule and mentioned it was a rule and i would have to be as i understand it that would have to be a new statute to change that. >> host: doctor kvedar, congress doesn't usually move this quickly and these things are happening pretty fast, aren't they? rule changes. >> guest: this is a bit of a new world for me and i'm not been directly involved in government before but i was so impressed the other day when i was on the hill virtually and i testified in this very same room in front of them but how committed the senators were at that hearing to
move as fast as possible. we have a term that telemedicine cliff and what that means is this is it an abstract notion. i am back now seeing patients in the office at 40% of our previous volume and when we get back more cranked up we will be at 75% and we won't go higher than that. in order for us to meet the demand for patient care we have to have telehealth embedded in our workflows and if we can't do that and then all of a sudden the public emergency goes away and there are no ways to fix some of these regulatory restrictions and we will be in trouble in our patients will be in even more trouble. >> host: as a dermatologist how do you diagnose? >> guest: that's an interesting question. the way we do it as it turns out in this is research that i did
almost 30 years ago now but your smart phone camera is quite adequate and good quality images. when we do this we have our patients submit those images over the patient's portal which is of course secure and they wind up in my in basket and my electronic record and then we can do a video call or phone call with him to go over and review the images. for dermatology a single lesion is bothering you or a rash and this is a great thing. a lot of my patients need their patients who had skin cancers and need a six-month or one-year full body skin check and that has to be done in the office so that is why again, i said the idea of a hybrid environment is the way we are going with this in critical we are able to do both. >> host: kimberly leonard. >> my understanding is money and this is from talking hospital ceos and doctors is that the amount of care the telemedicine has increased so drastically in
the past few months and for a lot of hospitals it was something that they wanted to do for a really long time and plan to roll out in the next two years but instead they did it within two weeks or two months even. what percentage now would you say doctor visits are happening over telehealth and what are some of the biggest lessons that have come out of this? anything unexpected with the volume that we've seen of telemedicine visits? >> guest: thank you for that. one thing i will say i am not always proud to be in my profession and i think sometimes we must handle things as a profession but this is one where i'm incredibly proud because doctors were previously skeptical or thought of this as a curiosity or i'm too busy and i can't get involved that everyone jumped in with both feet and we really haven't had a bad patient outcome. of course, patients have already loved it and patients are realld
give patients this what i call magical triad of access quality and convenience everyone is happy and everyone knows the patient knows it and the doctors know it so i say that's the biggest surprise. it went so well. when i work at in boston the delivery system called mast general we did 1600 virtual encounters in february and we are now up to 60000 a week and it has gone pretty smoothly. everywhere i talked to in all the delivery systems and all care providers are experiencing similar growth. you asked about what sort of or how we will settle up because we run from only seen people in the office overnight to only seen people virtually essentially and except for emergencies. we know that that is not right either in most people it is too
early to tell the most people are thinking between 30-50% of their activities will be virtual going forward. we will see how that turns out. some people have said 70% they think that's a probably a little aggressive but i think between 30 and 50% and it does depend on your specialty. my wife is an ophthalmologist and they can do things religiously and you have to go to the office and do things with gadgets to make the diagnosis of your condition. >> one thing i'm curious about is for people who might be uncomfortable using the technology, maybe because they aren't used to it or they might live in a part of country where there isn't very good high-speed internet so how do you get around some of those obstacles to make sure that this is something that patients can use or try or have as an option for them? >> guest: thank you for that. again, one pleasant surprise from this and there have been a few but one was that health plans in the government started paying us for [inaudible] up
until the pandemic that was just never done. it was always felt like they would say if you call your patient after a visit then it's bundled in with the fee for the visit and now that is not the case. the reason i bring it up is because for our patients that are in areas where they don't have broadband or for those patients that can't afford a tablet or smart phone the telephone works and we've spent a lot of research to show that a lot can be done, not everything in there are things we miss if we don't have video, especially as we alluded to earlier in mental health but there are things that can be done. in my case, as the i said, if you send me images i'm perfectly comfortable calling you to talk about the results of that and we can formulate a care plan quite well so telephone is an anchor point to solving that problem. of course, we would love it and this is a me speaking as an eta
official but we would love it if there were more broadband. we would love it if the government put some stimulus funds and crating more broadband and i think there would be great for everyone, not just for healthcare but for all kinds of things. broadband would be great, telephone visits are good. finally, one of the things we all own is making these interactions more patient friendly. god knows some of the thoughts that people have trouble downloading an app and we have to find ways to make it easy. there is one telemedicine platform that has the workflow you send the patient a text message when you are ready for the visit and they just click on the text and open up into their video and they chat with you. we have to find ways to make it easier like that. >> host: doctor kvedar, at the beginning of this discussion you mentioned that hipaa has gone out the window. could you expand on that a little bit?
>> guest: well, yes. i didn't mean it that way but yes, for the pandemic the federal government relaxed of the requirements that your video platform had to be hipaa compliant so that we could again, use any number of things and doctors do not have to, you know, before to get something in you had to hire an it consultant and do an rst and they made it difficult for people but this is a great thing because we care so much about patient privacy and take that seriously but if you are a practice of two or three doctors and have to go through that it was an excuse to not be that involved trade the federal government and the wisdom was trying to let people overcome that in a time when, as i said before, the only way we can provide care was to do this by telehealth. as we see the pandemic start to wane and get back to some level of in person care i think we
will probably see that they will reinstate hepa and i think that's a good thing because for vendors to supply us with videoconferencing and other types of patient engagement technologies they should be willing to hold your information secure and that should be part of their argument and they should be able to do that and if they can't do that we probably shouldn't be using their technology. >> how can patients be confident that her health information, when done over video conference or over the phone, can be confidential? i think of instances where perhaps position might take a call from a patient in a public place such as a grocery store or if, you know, information or to get hacked somehow as a patient was having a conversation so how can you make sure that patients are and feel comfortable and know their health information is secure and won't be leaked for everyone to see. >> guest: sure, i'm glad you brought that up because everyone
is concerned about that. we certainly are concerned about that at aca. number one, it turns out that even though we allowed these various non- hipaa compliance platforms, most of them are secure. for instance, skype is very secure. what's app is very secure. there are many of them and so i think the likelihood and this is important for patients watching this, the likelihood that you would get your information compromised during a video call is infinitesimally low. it is very small. could happen? yes and it's very unlikely so that is one thing. again, as we move forward we will get back to a state of normalcy where we are demanding that technologies are secure before we use them and so we are headed in that direction again, i'm sure.
with regards to your question about the clinician and making sure the clinician is in a private place we are training people as fast as we can. one of the other activities i'm involved with is the association of american medical colleges creating training competency for residents and metals go student so we can teach a whole number of things about being a good telehealth provider and one of them is being or keeping your video chat private from the point of view from where you have it. we are getting that word out as fast as we can and there aren't many people who are foolish enough to take it in the car or public place. we are already, i think, pretty well on the way to that. >> host: are you getting resistance from physicians at all for this? >> guest: surprisingly it may be a little. i don't know if it's surprising or not because the one thing that if you get into a public health emergency like this and
people true stripes come out and as i said earlier everyone came to the party and jumped in with both feet and use whatever analogy you would like and participated so they are resistant and i think honestly if you would've asked me this in january and said here's a scenario i would've said there would have been more but there wasn't and i think it's because people fundamentally want to take care of our patients and that is really our calling as clinicians. that's a good thing and again, very little. some specialties need to do a procedure and need to use a piece of equipment and they just can't do this. for them that's not resistant but just quality of care. >> post pandemic should telehealth visits be paid the same amount as a brick-and-mortar in person visit? is that something you're advocating for specifically? >> guest: that's a complicated answer and it's very highly
nuanced actually so i will try to break it down without sounding too nerdy but clinician compensation comes in three buckets, complexity of thinking, time spent limitations and practice, we would argue that the complexity of thinking is what it is no matter what vehicle we are using to care for you and so should always be cared for compensated by the same way. it is possible and this is not been proven yet at all but it is possible that when we scaled telehealth we will find the practice may be less and that may be a way to differentiate between what is possible and what the specific or official apa policy is is that for the federal government yes, we believe these things should be compensated for at parity and we
also recognize that in private markets health plans will inevitably want to negotiate with pears as they always do we don't feel like it's our place to get in the way of that. >> we heard from different health insurers that telehealth became much more prominent toward the beginning of the pandemic and a lot of them said that they would provide telehealth at no co-pay to patients and as a reporter as a business insider at her patients that have surprised medical bills from telehealth visits and understood them to be included in their benefits but then ended up with that surprise bill. how do you prevent something from like that happening and make sure patients know what exactly their benefits are supposed to cover? >> guest: we all probably would benefit from more transparency and complicity in our industry, let's face it. it is convoluted and difficult sometimes to communicate the nuances of their plans and various coverage termination to plan members and i would say
that during this time i'm not making the excuse for anyone but i would say we've thrown a lot at our health colleagues and payer colleagues and we found a lot at them and said pay for all of this and they are doing the best they can and so it's a long-winded way of saying i would cut them a break and any member has the opportunity to go back in question any of that. right? we all do. it's been a tough time for everyone and i think they're leading into it in a very careful way so some of those things may have slipped through the cracks. >> it sounds like you think it's more about speed bumps than any particular -- >> guest: i do. again, this is another thing i would not have predicted but i talked to a lot of health and many are on board with continuing this and there is a
belief and it is only a belief and i should not say that because there are some data to support it but there is a belief that if we could keep people healthy in their home that we can lower cost at keeping people out of the emergency room and inpatient service. if we do it right we will actually save premium dollars. >> host: doctor joseph kvedar is president of the american telemedicine association. he's a harvard medical school professor as well and a practicing dermatologist and kimberly leonard covers healthcare for business insider and doctor kvedar, is there a chance that these sessions could start to be recorded thus increasing the privacy concerns? >> guest: well, now as we are currently doing this and it as we alluded to earlier there are people using every kind of platform and some of those allow you to press the record button for sure.
we strongly advise clinicians never to do that. it doesn't make any sense whatsoever unless perhaps you are recording part of a neurology exam for the record or something like that. but patients, again, they have the option of doing that as well and i don't think that should be part of our futures and right now it could happen. >> what if a patient wants that recording to be able to listen back and say okay, maybe during a visit with ecologist or psychologist and want to listen back and try to embed it in the brains and hear the advice they received. is that permitted if a patient wants that information and wants to report it? >> i believe it is but i would have to double check on that but i believe it is permitted. i'm not so sure it's the best practice going forward but i think it is okay. >> host: had there been liability concerns with this? >> guest: thank you for asking.
there always has been. but there has been very little [inaudible] almost all our malpractice failures, even before the pandemic were covering physicians from a malpractice perspective and like any other malpractice conversation or any other negligence conversation common sense is really important and i said at another point in this interview that doctors need to decide what they need to make a decision and if they can get that information and if they can't get that information they shouldn't make the decision and you know, if you have to come into a brick-and-mortar facility to get something done well that is the best way to get your ca care. we have to be thoughtful and we came to be a sloppy and we are getting to a point now very quickly where, as i alluded to earlier they are, we no longer
have to say the only way you can get care is by this. it will even out and people will start to say no, i'd rather come in for acts but i think it is okay with that we do wide by telemedicine. as we do more and more that those liability concerns will naturally be -- >> host: how has 5g advanced or changed telemedicine? >> guest: 5g should be an amazing thing for us. i would have to say i was underwhelmed by 4g some a little bit of a skeptic naturally but if it works as advertised it should be an amazing thing. how many of us and i'm guessing people watching both of you have probably been on failed zoom calls during this crisis and the bandwidth is restricted and we found out just how restrictive it is. one of the promises of 5g is that it will be much more elastic, if i can use that term.
that is i think the main thing. not only faster but more available and so if we will start doing more and more of this video -based medications, not just in healthcare but in business people saying we will not go back to the office and be virtual then we need that bandwidth to be able to get it all done for sure. >> how do we prevent cases of fraud and abuse of the technology and i would think it might be fairly easy for some physicians to bill for many is it that they didn't actually conduct just to give an example -- does there need to be new legislation or guardrails passed by the trump administration to prevent those kinds of scenarios? >> guest: fraud is a terrible thing and it ata we are very committed to a world where there is minimal fraud and we would advocate for that. with that background, i guess i would say two things. one is another principle i lived by four almost 30 years of doing
this is that we shouldn't hold telemedicine to a higher standard than in person care. we know that there are unfortunately are plenty of fraud in the office visit realm as well. if fraud means people randomly sending bills for things they did not do there is no difference here except we may be even better off because as you know software can time and date stamp when you're having a conversation with a patient. we have, for instance, in my system we have [inaudible] embedded into our [inaudible]'s we can track whether people are having those video calls or not. that's part of the system. we can be pretty sure that we won't be committing any fraud in that regard. i think more and more systems that allow, again, not to record the content but to record that the visit happened and you could envision a future where this type of care shows us or results
in less fraud than in person care because you can't always document that someone came to the office. >> host: unfortunately we are out of time. joseph kvedar president of the american telemedicine association, harvard medical school professor as well and kimberly leonard covers healthcare for business insider. thank you both for being on "the communicators". >> guest: real pleasure. >> thank you. >> you are watching c-span2 your unfiltered view of government. created by america cable television companies as a public service and brought to you today by your television provider. >> the spam court hears oral arguments on the affordable care act and the consolidated cases of texas v california and california at the texas. on tuesday at 10:00 a.m. eastern on a c-span health care law was
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