New kind of Pap test; mpox risks; telehealth update: Upstate Medical University's HealthLink on Air for Sunday, Oct. 27, 2024

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a gynecologist tells what you need to know about self-administered Pap tests that screen for cervical cancer.

Rinki Agarwal, MD: ... Pap smears have been around now for over 40 years, 50 years almost, and have been amongst the great success stories when used in screening for cancer. ...

Host Amber Smith: An infectious disease doctor discusses the mpox virus.

Elizabeth Asiago Reddy, MD: ... It's in the same family of viruses as smallpox, and it has some similar features in terms of how the rash appears. ...

Host Amber Smith: And, how to make the most of a telehealth visit.

Ruth Weinstock, MD, PhD: ... 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. ...

Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, we'll learn about the global emergency that is mpox. Then we'll hear how telehealth has evolved since the pandemic. But first, a new Pap test lets women do their own cervical cancer screening.

From Upstate Medical University in Syracuse, New York. I'm Amber Smith. This is "HealthLink on Air."

Alternatives to the traditional Pap smear at womens gynecologic exams are on the way, and I'm talking with an associate professor of obstetrics and gynecology at Upstate to find out more. Dr. Rinki Agarwal is also the medical director for the Upstate Cancer Center's gynecologic oncology program.Welcome back to "HealthLink on Air," Dr. Agarwal.

Rinki Agarwal, MD: Thank you for having me.

Host Amber Smith: Could you please describe how the traditional Pap smear is done?

Rinki Agarwal, MD: Sure. So, as Amber has said, I'm a gynecologic oncologist, so I see patients who have been diagnosed with either a cervical cancer or high grade dysplasia. And, that's typically that somebody has already identified a problem, and that's when they're coming to my office.

The Pap smears are done, typically, in a primary care setting, so that would be your OB-GYN or a primary care physician, APP (advanced practice provider), one of those providers, done in an office setting where you have an exam room, you're undressed from the waist down. An examination is performed, including a speculum examination, and cells are collected directly from the cervix by the health care provider, and then sent to the lab.

Host Amber Smith: Now, how reliable are Pap smears in detecting cancer cells?

Rinki Agarwal, MD: So, Pap smears have been around now for over 40 years, 50 years almost, and have been amongst the great success stories when used in screening for cancer. Cervical cancer has decreased dramatically in the U.S. population when cervical cancer screening is completed. And the idea is that the test was first developed to diagnose cervical cancer, but it has evolved into now being able to diagnose precancers so that patients are treated for the precancer, that's managed, and it's led to an overall decrease in the occurrence of cancers, and that's where a lot of the difference has been.

Host Amber Smith: Now you used the word dysplasia. Is that pre-cancer?

Rinki Agarwal, MD: That's pre-cancer, correct. There's different kinds of dysplasia. There is mild and severe dysplasia, and it's the severe dysplasia that gives you this potential of converting into cancer. And typically, there is a substantial amount of time from a person developing dysplasia to occurrence of cancer or transformation into cancer.

So if there was good screening technique used at the time, in that whole, several-year timeframe where somebody has dysplasia or pre-cancer because they went through a screening process, that would be a mechanism how you would prevent the occurrence of cancer.

Host Amber Smith: I see. Now during the Pap test, is the physician or the provider able to visualize dysplasia or something that looks abnormal, or is it only discovered once the specimen goes to the laboratory?

Rinki Agarwal, MD: So both are true, if if it is a substantial amount of dysplasia causing visible changes on the cervix, then that will be picked up by the examining individual, the physician or APP. But, otherwise the Pap smear is designed to capture a lot of the cellular structure as well as HPV (human papillomavirus) DNA. And the current screening protocols allow for testing with one or both of those techniques. And then it's picked up by the lab.

Host Amber Smith: So why has this self collection option been developed?

Rinki Agarwal, MD: That's a great question. if I can kind of describe, I've said that the cervical screening using a Pap smear is very effective. And I also emphasize the words "when used." So the problem right now is that when it's applied, it's great, but the majority of cervical cancers in the United States or in the world are occurring right now in populations or patients who have not gone through the screening process. And that can be because of a number of different barriers, but in addressing some of those barriers, you're trying to use other tools.

If self-administered Pap smears closes that gap and makes screening possible for patients who otherwise would have difficulty getting to it -- hesitation, access issues -- trying to solve a problem for what's an effective test when utilized.

Host Amber Smith: So how would this self collection method work? Is it a kit that would come to the home, or would you get them from the doctor's office?

Rinki Agarwal, MD: This has been used in other countries already, and it's approved in one of two ways right now, with the second being tested. What is approved, as of May of this year, by the FDA (Food and Drug Administration), is a Pap smear collection kit that is available at the doctor's office. So the patient goes in, self-administers the test in the physician's bathroom, and the collection is done right in the office, and the results come back to the physician.

So it's overcoming a certain barrier of going through the examination and the hesitation that people have going through the whole experience of having a Pap smear test.So I think it applies to a certain population that would not go through the screening because the exam is uncomfortable. I don't think it replaces the full examination and the benefits of the examination. Like I said, the cervix is visualized, a full examination is done. And there is information that the provider is able to utilize for the patient in that situation. But if there is a barrier to going through the examination because of the awkwardness of it, this particular format would help address that.

There is a second method that's in development, and the rollout and how it's going to be executed in the U.S. health system remains to be seen, where the kit could be sent to the patient. So the kit is sent to the patient, and they administer the test themselves, put it in a mailing kit, and it goes to the lab with the results coming to the provider. The idea there, the execution, there's a number of studies that have looked at how this could be executed. It is likely to be covered by insurance because it's an FDA-approved process. But how is it coming to individual patients or regions and practices is something that will evolve over the next few months to years as it becomes more widely available. Even as we're recording this today, the first set of test kits that would be available to physicians to use in their offices has just become available.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Rinki Agarwal. She's an associate professor of obstetrics and gynecology at Upstate and also the medical director for the Upstate Cancer Centers' gynecologic oncology program.

So for the self tests, are women going to be able to collect samples from their cervix? And if not, will they get a collection that will be able to be as reliable as the traditional Pap smear?

Rinki Agarwal, MD: To answer that question, the best way to proceed is to talk about what the test is testing for. Right now, Pap smears can be tested for cell abnormalities. So that's called cytology. It can be tested for HPV (human papillomavirus) DNA. And, some Pap smears are used with both testing for the cytology, the cells, as well as the DNA testing can be done.

The self-administered test is only going to test for HPV DNA, and therefore getting right at the cervix and being able to collect those specific cells is not important for this test. And because it cannot be reliably done, it was excluded from the development of the testing. Having said that, just the HPV testing alone is a perfectly viable method of doing cervical cancer or dysplasia screening because the HPV DNA presence is a harbinger or a factor that's going to provide information regarding risk of developing dysplasia or cancer. So it's a very effective test, and it's used even in settings where a health care provider is actually doing the examination.

Host Amber Smith: Do you think that women will be able to stick with the traditional method, or are they going to be asked to do the self exam?

Rinki Agarwal, MD: I think it remains to be seen because there are certain things that are attractive about being able to do a self-administered examination or a cervical cancer screening test, because if it takes the exam out of the time that the patient has with the physician, if it makes their time used for counseling and to address their issues that they want to bring to the physician, if it reduces the amount of commitment they have to make in order to come and see the physician for the visit -- because telemedicine is also available now as a format -- there are ways that this could basically have a bigger uptake. But for the moment, I think that the best place or the best use case for the self-administered test is for situations where people would otherwise not be able to access getting the Pap smear testing in the traditional manner at all.

Host Amber Smith: Well, how often is cervical cancer screening recommended?

Rinki Agarwal, MD: Right now, the exams are once a year for just general gynecologic exams, and then the Pap smear testing is for cytology or just the cells, looking at the cells in under the microscope, is once every three years. But if you did the HPV testing or HPV with looking at the cells or cytology testing, that would be once every five years.

Host Amber Smith: And what age do women begin this screening, and when does it end?

Rinki Agarwal, MD: So you would start screening at 21 and typically the end date is based on what the history for the individual has been, but it is either 65, or 20 years of basically having very normal Pap smears.

Host Amber Smith: Since this test is designed to discover cervical cancer in its early stages, can you walk us through what typically might happen if a woman's Pap test finds some unusual cells? What happens after that?

Rinki Agarwal, MD: So the Pap test that's done in a traditional manner has both HPV and cytology done on it typically. So that would give the provider information on both of those pieces of data. And based on what those results show, there could be additional exams in the office, things called a colposcopy (a type of cervical exam), additional biopsies or additional procedures dictated by having those two pieces of information.

Because the self-administered Pap smear is only going to have the HPV DNA tested, and cytology is not part of the test, there will be an intermediate step where the patient who has a positive test for HPV DNA presence of certain types. So the testing for HPV looks at numerous strains of HPV DNA, and they can find high risk HPV DNA. If that's present, then that patient is at increased risk of having cervical dysplasia, would be contacted, called back into the office and undergo an examination in the traditional manner with collection of cytology, with the visual assessment, additional biopsies, possibly the colposcopy. And what range that would take is based on the results that we're dealing with.

Host Amber Smith: It's very individualized, it sounds like.

Rinki Agarwal, MD: Yes.

Host Amber Smith: If cancer is discovered, though, what are the options for treatment these days for cervical cancer?

Rinki Agarwal, MD: So the treatment options range from surgery, chemotherapy and radiation, and combinations of those things. But the range and success of those is dependent on successful identification, hopefully at an early stage, and then very effective use and compliance with the treatment that is recommended at that time.

But the early stage, which is -- cervical cancer has the availability of screening techniques that we've already talked about, but it also has the availability of vaccinations for prevention of cancer.

So in the United States, our view, I'm an oncologist, and my view is that we have tremendous tools so that my practice of taking care of patients who have cervical cancer should be a shrinking demographic that should be very few far between or hopefully never see them again would be an ideal thing for us to see.

But if somebody still falls through the cracks and does develop cervical cancer, the ideal situation would be that they were screen detected, they were detected early. And screening does make it more possible for patients to have an earlier detection at an earlier stage for the cervical cancer. And those then are treated with curative intent. That means that you manage the cancer and the patient is cured and can move on in their life.

Host Amber Smith: So it sounds like the keys are the HPV vaccine and regular cervical cancer screening.

Rinki Agarwal, MD: Well summarized.

Host Amber Smith: Well, thank you so much for your time.

Rinki Agarwal, MD: It's a topic that obviously is really dear to me.

Host Amber Smith: My guest has been gynecologist Rinki Agarwal, who serves as medical director for the Upstate Cancer Center's gynecologic oncology program. I'm Amber Smith for Upstate's "HealthLink on Air."

What Central New Yorkers need to know about the mpox virus - next on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

The mpox virus has emerged as a global emergency. And here to tell us what Central New Yorkers need to know about this virus is Dr. Elizabeth Asiago Reddy. She's an associate professor of medicine and Upstate's chief of infectious disease.

Welcome back to "HealthLink on Air," Dr. Asiago Reddy.

Elizabeth Asiago Reddy, MD: Hello, Amber. Good to talk with you.

Host Amber Smith: Now I understand the first case of mpox outside of Africa this year was reported in Sweden. Are there cases in the United States?

Elizabeth Asiago Reddy, MD: So an important thing to understand about mpox is that there are two different variants of the virus. We call them "clades." There is Clade 1 and Clade 2. So there was a big outbreak of Clade 2 virus, which I know we'll talk about later in this interview. But the case that was reported in Sweden was of concern because of it being the Clade 1 type of the virus. And that one historically has been more severe, with a higher risk of death from infection.

Host Amber Smith: So Clade 1 is the more severe, but is Clade 2 still a concern?

Elizabeth Asiago Reddy, MD: It is a concern. Ever since the outbreak calmed down considerably after 2022 -- it actually has continued to percolate so that we've seen anywhere between one to 10 new infections in the U.S. on a daily basis. So it is still occurring.

Host Amber Smith: Is this mpox virus the same virus as monkeypox that infected, I think, about 100,000 people worldwide in 2022?

Elizabeth Asiago Reddy, MD: It is. Yeah. So the mpox virus was renamed because of a goal of trying to de-stigmatize the concept of it being associated with monkeys. So the reason why monkeypox virus was originally named monkey pox virus is that the first cases were identified in lab animals that were primates. It was identified in lab monkeys, essentially. But otherwise it is not specifically associated with monkeys in any particular way, aside from the fact that they can carry it. And so the thought was that people would have a concern about this ongoing feeling or sense that somehow this was associated with humans having contact with monkeys, which in most cases it's not.

Host Amber Smith: Is it related to smallpox?

Elizabeth Asiago Reddy, MD: It is. It's in the same family of viruses as smallpox, and it has some similar features in terms of how the rash appears.

Host Amber Smith: Now has it evolved, the virus, since 2022? Is this the same virus, or has it changed in a meaningful way?

Elizabeth Asiago Reddy, MD: This is actually a question that scientists are still looking at it. It hasn't, when you look at the structure of the virus, it does not appear to have drastically changed. So it seems more likely that what has changed is human behavior and the level of contact that people have with each other. So we're an increasingly global world with increasingly complex interconnections between us. And it seems likely that that is more the reason why the virus started to spread more than it had in the past.

Host Amber Smith: So the monkeypox in 2022 spread globally, mostly among gay and bisexual men. How was that kind of brought under control, and then it's now again out of control?

Elizabeth Asiago Reddy, MD: Excellent question. So the Clade 2 virus that was circulating throughout the globe in 2022 was, it appears that there were at least a couple of events including an international event in Europe that may have kind of generated a lot of spread, where a lot of people from different countries had convened.

And this was actually a unique feature that had not been previously well described of the virus spreading sexually. There have been cases where it was considered that it might have spread sexually, but nothing on this scale. And some of the features that made it a little bit difficult at first was that it was not clear that sometimes the lesions at the beginning may be very small or people might not even have clear symptoms when they're sick early on that would allow for some asymptomatic or presymptomatic transmission -- so meaning that somebody could spread it onto another person before they were clearly sick with anything.

And that also the rash associated with this Clade 2 outbreak in 2022 was oftentimes located only to one region of the body, especially the genital region or other regions that might have come into sexual contact. And that was unique from previous cases or outbreaks of mpox. It was not as easy to identify early on because people were not used to seeing something that was so localized, and so it was being mistaken for other sexually transmitted infections initially.

Host Amber Smith: So today, in 2024, is mpox a risk to the U.S. in general, in Central New York?

Elizabeth Asiago Reddy, MD: Yes. I'm going to say it is, and yet I'm going to temper that. OK. So I'll mention a little bit about what's going on in the Democratic Republic of Congo right now. So, in the DRC, there has been a huge number of cases compared to the typical number of cases. The typical number of cases in that country would run in the hundreds to thousands per year. And now, since January of 2024, they've documented at least 27,000 cases. And, that's just the ones they've documented. So for sure there are more cases that have not been documented.

And the unique features in this case, we're talking about the Clade 1 virus, which, like I said historically has been more severe. The previous case fatality rate that had been described for the Clade 1 virus was 10%, meaning that potentially 10% of people who were diagnosed with the illness would actually die of that illness. So it's one in 10. Fortunately during the course of this outbreak, it has been more like 3%. And I say fortunately, obviously with that being better than 10%, but still being a concerning number. The other version, the Clade 2 version of mpox ended up with a less than 1% case fatality rate. So it still appears to be more severe.

Again, a lot of the people who are unfortunately becoming infected in the Democratic Republic of Conco have a lot of underlying health risks that are putting them at risk for more severe disease. So that 3% number is likely to not be the case in somewhere like the U.S. where people have access to better health care.

Now, why am I concerned about this and why is my concern tempered? So I'm concerned because clearly the numbers that are occurring in Congo are very high. And a lot of the transmission there appears to be initially heterosexual transmission with, then, subsequent transmission to close household contacts. And so a lot of the impacted in this epidemic have been children who are living in these households. And children, unfortunately, are a high-risk group for more severe disease.

So I think the fact that close contact and children. Obviously that's something that we get very concerned about. Again, we don't really know whether or not there is something different about the virus or the way our immune systems are handling the virus. We suspect again that this is just something that got kicked off because of closer contact, larger populations and therefore larger ability to spread.

But one of my kids came home from school the other day and said, "Mom, did you hear that now there's a new COVID in the U.S.?"

And so I said, "No?"

And she said, "It's called mpox."

And so I said, "OK. No."

First of all, the one that we would be most concerned about has not yet arrived in the U.S. And second of all, yes, this is a contagious illness. Yes, we need to take it seriously. It is not like COVID because it really requires very close contact, skin to skin contact with others for spread. in the vast majority of cases. And so this is not like a situation where people are breathing in and breathing out and spreading COVID, as was the case obviously up until today. So, I'll pause there because I know I've said a lot all at once.

Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Dr. Elizabeth Asiago Reddy. She's the chief of infectious disease at Upstate, and we're talking about the threat of mpox.

So let's go over what this virus does to humans. What are the typical symptoms?

Elizabeth Asiago Reddy, MD: Initially about three days after an exposure -- could be as short as three days, could be as long as 10 days,could potentially be even more quick, but that three days is about an average -- you could start to get some systemic symptoms, which include things like fever, malaise, sore throat, headache, and swollen lymph nodes all over the body. And then within a few days after that, the rash appears.

As I kind of alluded to, the 2022 outbreak had some unique features, which included that some people were not clearly having prodrome (early) symptoms. They were just going straight to the rash. They didn't remember ever being sick prior to seeing a rash, or the rash was appearing more quickly, in close concert with the other symptoms. So it used to be that we had these very clear progression of symptoms, and now things seem a little bit more blended than what they used to be.

But the typical is still kind of the generalized bad feeling for a couple of days with fever, and then the rash appearing after that. The rash goes through some very classic stages, so it looks like kind of a smooth bump at first, and then it turns into what we call a pustule, which is where you could see some liquid and some pus underneath that bump. And then it gets this appearance that is very classic for the orthopoxvirus family, which we call umbilicated. So that is where you see a very round lesion with an indent in the middle of it. And oftentimes you can see some fluid underneath that. You may not always be able to see fluid underneath it at that stage.

Other features are that different rash lesions can appear at different times, so you may see multiple different types of rash lesions going on all at the same time. And so that kind of helps providers to understand what they might be dealing with when they see something like that. The rash classically will last about a week, but it can take two or even four weeks sometimes to resolve in severe cases.

Host Amber Smith: Is that how it's diagnosed, just by looking at the rash?

Elizabeth Asiago Reddy, MD: That's where we start to have an index of suspicion. So, of the cases I've seen, I would say once you're aware of this as a possibility, that's the biggest thing is keeping it on your list. Then, again, the cases I've seen have been classic. It may only be one, but when you see it, it just, the way that it looks is unique to other types of rashes. And so that's where you have the index of suspicion, and then you would go ahead and test. Sothe testing that is done is actually done by swabbing the rash lesions themselves.

Host Amber Smith: And then what is the course of the disease typically like?

Elizabeth Asiago Reddy, MD: A mild illness could be something that would maybe resolve over the course of seven to 10 days.But a more severe version could last as long as four weeks. And I have seen both of those happen.

Host Amber Smith: And are the people typically isolated, to stay away from others?

Elizabeth Asiago Reddy, MD: Yeah, so the biggest issue is contact with the rash lesions. During those first few days that I mentioned where people are having fever, maybe a sore throat, there is a small possibility of close droplet transmission. So if somebody were to have a cough or kiss somebody else in that stage, they could potentially transmit it that way. That appears to be more limited, with the vast majority of transmission occurring by actually skin-to-skin contact with the rash lesions.

So the most important thing once that initial phase of the illness, as we call the prodrome phrase, when people are just feeling generally ill, once that has passed and the rash has started, the most important way to protect others is to keep that rash covered and not come in contact with others.

Host Amber Smith: Now, what about vaccines?

Elizabeth Asiago Reddy, MD: There is, fortunately, a vaccine available, and there was a vaccine available, which is how the Clade 2 pandemic was brought under control to a great extent, both through vaccination and behavior change. But the vaccine was created to help protect lab workers and potentially others who might be at an elevated threat, say from even weaponization of the virus or something similar. So that vaccine was already available, and it protected against multiple members of the orthopox family, to include smallpox and mpox.

And so it is a two-vaccine course. The vaccines are given four weeks apart. And it looks like, as it relates to the Clade 2 virus, it was most certainly highly effective because once the vaccine started being available, we saw a very rapid drop in cases and entered into a situation where we're seeing, like I said, a handful of cases a day versus hundreds and hundreds of cases a day. From retrospectively, try to look at the data -- although it dropped off so quickly, it's a little hard to get all the information -- it looks like your first shot will maybe give you about a 50% protection, and then the second shot goes up to 70 to 85% protection against a another episode of illness.

Host Amber Smith: How much potential do you think this mpox outbreak has to become a global pandemic?

Elizabeth Asiago Reddy, MD: I admit, I'm concerned. I'm also happy that the WHO (World Health Organization) has identified this as an epidemic of global concern because that offers the ability of more resources to the Congo, where the cases are rapidly spreading.

And certainly, unfortunately, Congo has traditionally been a location that has suffered from a lot of health inequities and lack of access to health care. And so those are locations where something like this can really thrive and proliferate, and people can face more severe courses, et cetera. So, vaccines have been deployed. There is still going to be a challenge in getting those really moving on the ground. But things are definitely moving in the right direction with awareness.

And the U.S. has actually, since December of 2023, been providing surveillance to multiple areas. So for example, here in New York state, we have the New York State Wadsworth Laboratory, where specimens can be sent and are being evaluated regularly to see if these specimens belong to the Clade 1 group. So there are a lot of opportunities for us to test virus and try to see if something like this is starting to show up in the United States.

So I think, again, the level of awareness is where the key really is to keeping this under control. SoI think we are seeing an appropriate level of concern at the international level to avoid this becoming a very significant, severe pandemic.

Host Amber Smith: I want to thank you for making time to tell us about mpox.

Elizabeth Asiago Reddy, MD: Absolutely. Thank you for having me.

Host Amber Smith: My guest has been Dr. Elizabeth Asiago Reddy, the chief of infectious disease, and an associate professor of medicine, at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air" -- making the most of a telehealth visit.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

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 "HealthLink on Air," 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 "HealthLink on Air," with your host, Amber Smith.

I'm talking about telehealth trends in usage with Dr. Ruth Weinstock, a distinguished service professor of medicine and the chief of endocrinology at Upstate, and also 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. I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Annie Przypyszny is a student at American University and the assistant poetry editor at the Adirondack Review. She sent us an exuberant poem that celebrates the return to health, those first moments of felt healing. Here is "This Moment and the Next."

It's raining

but the clouds, mild as cows,

welcome the glow of the sun.

The trees are glossy, and the puddles dimple

with full,

healthy drops.

Today I discovered

I'm in love with my breath, and my blood,

and my brain.

I never want the world to stop spinning.

Satisfaction

settles into this house,

this body. I move

with the eagerness

of something beautiful,

an iridescent fish,

or something very young,

a kitten. I look

in the mirror and my eyes

are gems of luck. I open

the window and say

to every wonderful thing:

Don't kill me!

I'm not done

with playing,

and speaking,

and thanking,

and making good guesses,

and thinking,

and hoping,

and waiting

for the next moment,

the next nourishing and vital moment,

which could be much like today's moment,

which I live with ease,

my cupped palms filling

with a lambent elixir of rain

and sun. I sip,

and it tastes as pure

as a kind-hearted lie,

a lie that says

you will never be punished for this.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

Next week on "HealthLink on Air," shingles is affecting more young adults, physical therapy for low back pain, and how cannabis use can reduce your pain threshold.

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.

This is your host, Amber Smith, thanking you for listening.