Telehealth provides options, convenience for medical visits     

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

One thing the pandemic did is accelerate the use of telehealth for medical appointments. To hear how this option has evolved since then and how it's used today. I'm talking with Margie Greenfield, a health information systems program manager at Upstate, and Dr. Ruth Weinstock, a distinguished service professor of medicine and the chief of endocrinology at Upstate.

Welcome to "The Informed Patient," both of you.

Ruth Weinstock, MD, PhD: Thank you.

Margie Greenfield: Thanks for having me.

Host Amber Smith: Ms. Greenfield, let's define what a telehealth visit is. Does it always include audio and video?

Margie Greenfield: The Health Resources and Services Administration's Office for Advancement of Telehealth defines telehealth as "the use of electronic information and telecommunication technologies to support long distance clinical health care, patient and professional health-related education, health administration and public health."

So from that definition, you can tell there are a lot of forms of telehealth. This includes what is most commonly thought of as telehealth: synchronous telehealth, where a patient and a provider are live in real time using audio and/or video for a virtual interaction. But this also includes asynchronous telehealth, where communication or information is shared between a practitioner and a patient, or maybe even two practitioners, that occur at different points in time.

So an example of that may be: You send a message to your practitioner, and they're sending you a message back at a later point in time.

Remote patient monitoring is another form of telehealth.

Host Amber Smith: So when would remote patient monitoring be used?

Margie Greenfield: This is a form of telehealth that's used most commonly in chronic conditions.

It allows health care professionals to monitor certain aspects of a patient's health and make adjustments to their treatment plans accordingly. So patients use medical devices, such as blood pressure cuffs and pulse oximetry, scales, glucose monitors, from their homes that transmit data electronically for their practitioner to review.

This is actually something that Dr. Weinstock and her patients utilize frequently.

Host Amber Smith: Now, some of us first heard about telehealth during the pandemic, but it's been around for a while. Do you know what year it started?

Margie Greenfield: Interestingly, there was, in 1924, a radio news magazine cover that displayed the idea of a doctor tending to a patient via video, showing what the future of medicine may look like.

And this was long before televisions were common. By the late 1940s, radiological images were sent to specialists via a telephone line. And by the late '50s, early '60s, Nebraska was using this for consultations, using closed-circuit TVs for psychiatric consultations as well as neurological exams. By the '60s and '70s, NASA was conducting remote monitoring in space with animals.

So what you'll see is that as technology evolves, so does telehealth.

Host Amber Smith: So Dr. Weinstock, have you found that your patients are receptive to telehealth?

Ruth Weinstock, MD, PhD: Yeah, I would say the majority are very receptive. There are some who are less familiar with technology, for example, some of our older patients may be less tech-savvy than some of our younger patients. But given the proper support in getting them started and training on how to do it, many of them become fans as well. So I would say that for the majority of patients that I see, it can work very well, but of course it's not for everyone, and we do respect people's preferences.

Host Amber Smith: How do you decide which visits should be in person and which ones can be done via telehealth? Because I assume you see patients in person and via telehealth, right?

Ruth Weinstock, MD, PhD: Yes, I do. And I let the patient decide which will work best for them, for the most part. I mean, there are certain times where an in-person visit is preferable.

For example, if we need to train someone to use a new, complicated device, such as an insulin pump, it's better for them to come in in person and have that hands-on experience with the trainer in that particular case. But for most of the visits that I do, particularly with diabetes, telemedicine could work extremely well.

Host Amber Smith: Are providers able to see more patients if they're all via telehealth than they would be in person, do you think?

Ruth Weinstock, MD, PhD: Not necessarily, it depends on the patient and on the situation, because I spend the majority of my visits talking to patients about their glucose and insulin levels.

So for example, in an in-person visit, many of my patients with diabetes are using devices such as continuous glucose monitors or insulin pumps or automated insulin delivery systems, and we can download their devices, meaning that we can look at their glucose levels, their blood sugar levels, also the amount of insulin being delivered, and that information goes to a cloud-based system.

So I can be looking at this and discussing it with them in person, or they can download it from home or be connected to this cloud-based system from home, and I can share my screen, and we can be looking at it together remotely. So in those cases, telemedicine works extremely well to do it remotely, and people like not having to take time off from work. There are transportation issues, trying to find child care or elder care, reasons why people find it convenient. Some travel quite a distance to see us. We have patients in Lake Placid, places that are not just right around the corner, so it is very convenient for some patients.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking about telehealth trends and usage with Dr. Ruth Weinstock, a distinguished service professor of medicine and the chief of endocrinology at Upstate, and Margie Greenfield, a health information systems program manager at Upstate.

So Ms. Greenfield, what are the telehealth initiatives that are underway at Upstate at this point?

Margie Greenfield: Very exciting time here at Upstate in regards to telehealth. Of course, we do our outpatient video visits, which is what we've kind of been discussing here thus far. But we've also started virtual nursing in the hospital, which is growing in popularity in hospitals as a way to mitigate some of the challenges that we've had with staffing shortages.

We've started by having virtual discharges on a couple of units to pilot the process, see how the workflow works, get feedback from our staff, our patients, and make adjustments accordingly. So that's a relatively new program we have here and are looking to expand into other parts of nursing tasks and nursing workflows.

We also have our telestroke and teleburn consults. Those programs have been running for quite some time now, and they partner with just over 10 hospitals in our region to provide telestroke and teleburn consultations. This is typically to rural hospitals that don't have those specialties available to them, and we are able to extend the expertise of our physicians to those hospitals to either determine that the patient can stay in their community hospital or whether it's best for them to be transferred to our center.

Host Amber Smith: So diabetes care, stroke care, burn unit care: It seems like there's a lot of specialties where this will work. Are there any where you just really are going to have to have hands on all the time?

Margie Greenfield: Yeah, I do think that there are some specialties that are less likely to use telehealth or certain forms of telehealth, maybe in the cardiology space, where you really need a stethoscope up to that patient's heart and listening to their lungs.

But there's also growth in telehealth in those specialties as well. They tend to use some of the remote patient monitoring pieces for someone, maybe with heart failure, who can use a pulse oximeter and a blood pressure cuff and a scale to help transmit that data to the specialist to determine if their status is changing and if an in-person visit is needed or maybe just a change of medication.

Host Amber Smith: Well, I'd like to ask both of you what the use of telehealth during the pandemic taught you about telehealth.

Ms. Greenfield, do you want to go first?

Margie Greenfield: Sure. From an IT (information technology) perspective, it really taught us that we needed a telehealth platform that could be integrated into our electronic health record. This would allow for practitioners to be more efficient, since they're really living in those health records.

Likewise, patients would have one platform that all Upstate providers would be utilizing. Prior to the pandemic, we had multiple platforms available, which could make it difficult for patients who were seeing multiple specialists, and they wouldn't necessarily know which platform they should be joining.

Now, with one enterprise-wide video visit solution that we have recently implemented, we've really improved both the patient and providers' workflows and experiences. Patients are now able to join a video visit from their patient portal. They can also be sent a text-messaged link or an email containing the link of the visit, really improving their experience.

And again, practitioners living in that electronic health record really improves their workflow for efficiency.

Host Amber Smith: And Dr. Weinstock?

Ruth Weinstock, MD, PhD: Before the pandemic, and when we switched over to telemedicine during the pandemic, people were concerned, and rightfully so, about what they would miss if they were not seeing the patient in person, particularly the physical exam.

So for example, podiatry, that's always going to need to be in person. You can't cut nails and debride (remove dead tissue from) wounds remotely. However, I think that it also showed us that many people who didn't think they could use technology, with the proper training, patients really could learn to use technology, and it ended up helping them in many ways, so that if they were connected when they were having a problem between visits, for example, we could see their glucose readings.

Also, there were some surprises to me. That when I started seeing everyone with telemedicine during the pandemic, for example, medication reconciliation, we always ask people what medications they're taking, we ask them to bring their pillboxes in, or bottles. Some do, but many times they forget, and so I've never actually seen their pillboxes. Well, when it's in telemedicine, I say, well, I'll wait a minute. Go get them. And then they'll show it to me with the camera, and I'll find out that the dose I thought they were taking, they were not taking, that the label on the bottle was different.

Also it enabled family members to join the visit who otherwise could not take time off from work or significant others or partners or caregivers. And that is also helpful, so that everyone's hearing the same thing and that they can help support the individual better, the patient better.

And in addition, it allows you to see the home environment a little bit, which also gives important insights into other challenges the individual may be having in the home and ways that we maybe need to help them in the psychosocial realm.

So, I'm a big fan of telemedicine, and I hope that reimbursement continues so we can continue to use it.

Host Amber Smith: It seems like there's a lot of pluses to it.

Ruth Weinstock, MD, PhD: Yeah, I believe it. Not in every specialty perhaps, but certainly in my specialty, there is. Individuals have to have the right equipment to be able to do it. Their hearing needs to be sufficient so that they can hear over the platform. but in general, for most individuals, it can work well.

I try to see people in person once a year, and other times, I'm more than happy to do telemedicine.

Host Amber Smith: Do you have any other advice for patients for how they can have the most success with telehealth appointments?

Ruth Weinstock, MD, PhD: Yeah, so I think it's really important that we instruct people how to prepare for a telehealth visit, which they now know about because they've been doing it, at least our patients.

But the first time, what are your expectations? To please be in a quiet area. If you want a family member there, or you need help setting up the visit, have the person be there on time, to bring their pillbox or their medications to the table where they're having the visit, so we can review it. I ask them if they have a scale at home to weigh themselves, and if they have a home blood pressure cuff to take a blood pressure. Make sure their devices are uploaded into these cloud-based systems I mentioned before.

So I think that those sorts of preparations really make for a very smooth visit. Have them write down any questions they want to ask, which, of course, is true for in-person visits as well.

Host Amber Smith: Ms. Greenfield, how can patients be sure that their appointment is private and stays private?

Margie Greenfield: Great question. From a technical aspect, we use HIPAA-compliant telehealth platforms. We also work with our cybersecurity team when selecting vendors to ensure that there are no security concerns and that standards are met.

We also have additional safeguards, such as patients needing to sign a consent to telehealth services. That's usually done at an annual time frame. And conducting visits in a private area or with headphones. Those are other ways that privacy can be maintained.

Host Amber Smith: So it's not being streamed live on the internet when someone connects with their doctor; it's safely between the two.

Margie Greenfield: Absolutely. And there are regulations that are required for us to meet in that way.

Host Amber Smith: And you mentioned HIPAA compliance, that's all about the privacy.

Margie Greenfield: Absolutely. Patients' health information as well as, the platforms that were required, to have the standards for HIPAA compliance.

Host Amber Smith: Well, I want to thank both of you for making time for this interview.

Ruth Weinstock, MD, PhD: Thank you so much.

Margie Greenfield: Thanks for having us.

Host Amber Smith: My guests have been Margie Greenfield, a health information systems program manager at Upstate, and Dr. Ruth Weinstock, a distinguished service professor of medicine and the chief of endocrinology at Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

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