Dr. Kathryn Dao - Transforming Your Rheum Clinic Save

Hi, this is Jack Cush with RheumNow. I'm here with my partner, Doctor. Catherine Dow. We're both from Dallas, Texas. We're both in practice.

Usually we sit about, one arm's length from each other, but right now we're sitting about 10 miles from each other because of the current circumstance. Good afternoon, Catherine.

Hi, how are you Jack?

Good, good. So did you have a busy morning running your clinic from home?

It's been crazy because I'm fielding phone calls from the nurse, I'm fielding phone calls from my medical assistant, my in basket is full, I have like a whole full schedule of patients who've been converted to telehealth, telemedicine visits and you know I've been trying to get my earphones working and finally have. So what about you have you been?

Well we're, doing the same although it's been a more familiar environment in front of our, a few nurses and a lot of, empty desks. You know, the interesting thing about, this conversion in the time of COVID has been, to run our practice, it seems like we have to be very multimedia. We're getting, messages left and right, group messages, individual messages. We got emails from and to each other as co workers, from and to our, leadership and who, you know, the administration who runs the clinic, and then on top of that we're dealing with patients. So, you really have to be very facile in running both the phone, your cell phone, your email account, and any other messaging services you would have within your work.

Are you seeing it any different?

Yeah, I mean if this is where my mom skills come in because I'm used to multitasking and I have a cell phone and iPad and I also have here I'm gonna show you my setup right here. This is my laptop. Obviously, I'm holding my cell phone. I have another laptop sitting right next to me that I haven't necessarily activated yet. My kids are on elearning right now, so I'm getting, mom, mom, like, I can't work this.

And, you know, I'm pulled in all different directions. And then my absentee husband right now is up at work like you would be.

So having your kids saying, mom, mom, I can't work is the same like sitting next to me. Catherine, what do I do? I don't know how to work this. Because she helped me a lot on computer and and Epic as well so so what do you think has been the main challenge in converting over to remote sort of interactions with our patients?

For me the toughest thing is trying to keep in guidelines with our institution. And I think that you know they want us to do certain things like download the BlueJeans app and then have the patients download their chart onto their phone plus the BlueJeans app. But then the communication never gets quite through to the patient. So I finally just decided, this is an interaction between me and the patient. Nobody else is involved.

This is just me and the patient having a conversation as if they were in my office. The only difference is instead of me being able to touch them, their phone whether it's FaceTime which we're now allowed to do under the telehealth laws. They're also very descriptive in what they're saying. I'm having them tell me what their blood pressure is. They're able to check it at home.

I'm having them pre fill out their chart at home beforehand. And I ask them, there's three things that I want to get out of this and I want to hear your goals as well. Mean the three things I want to know is number one, how are you doing? Number two, do you need refills? And number three is when your last set of labs were and you know if they're on the medicines that need to be monitoring I'm going go ahead and order their labs.

I tell them to stay home from physical therapy right now because you know it's just one of those things to decrease exposure. What about you? Are you instructing your patients differently or what are your goals for your visit?

Well, we both have the same, directive in that, that, well, first that all patients are called ahead of time and told your usual visit has been changed to a remote visit. We will contact you by phone or by video depending on your setup and how ready you are. I agree, telephone might be the first thing to do until you figure out how to do televideo, telerheumatology. But every visit begins with the same. We'd like to do a telephone or televideo visit.

Do I have your consent? And when the patient consents then you can get into your visit. Is that how you're beginning?

That is. That is. You have to verify their ID. That's really important. So you can verify their ID by date of birth, by their address.

Some people even go as far as their social security number. There was one patient, she was pretty hoarse, so I couldn't really understand her and it could have been, I mean, she sounded like she was a man. I really had to say, could you actually show me your like, you know, because we didn't have, we didn't have like the video portion of it. So I asked her if she could actually just give me something that she and I only knew about or joked about in the past.

That's like, that's like, I want you to tell me what I'm thinking, know, I don't, you don't want to do that. So after you get consent then you need to document and that's what we're both doing and we're documenting within our EMR and whether it's a telephone or televisit video. My goals are first to quickly ascertain whether the patient what the patient status is. Are they okay with and is it okay with me for them to do a remote televisit or are they have things that they've said that make this an urgent visit where they have to come into the clinic, and again there might be circumstances where that's appropriate. And yes, have the same thing, what refills do you need?

What labs we're going to get? Let's schedule when your next appointment is. And then I spend a lot of the visit. I try to get those as quickly as possible. I spend a lot of the visit asking them what questions do they have about their illness and the coronavirus specifically.

And you know we go over things like, you know, should I get tested? Can I go to work? Can I be around my family members? How often do I go to my other doctor appointments? I have a dentist and I have a hairdresser appointment, you know, give them some advice on those things.

And most of this is what's out there in the public domain as far as instructions, but they need it in the context of their illness. Then of course we have to strongly review the need for them to maintain their medicine. But I think answering questions about COVID are really important.

So how are you refilling your patients' meds?

Well we use the EMR, and I think that, we're using it the same way. You're thinking about do we just give them one month or two months or three months or whatever.

Give them what I would

normally do, and I think, you know realize that in these times a lot of things are relaxed. HIPAA's been relaxed, CMS rules on co pays have been been relaxed, CMS rules on tele visits have been relaxed, the OIG, I put out a tweet today about the OIG, I also put out stuff about relaxing payments and especially for telehealth visits. So, know, the question is do you refill one month or three months? I'm doing this as I normally would, So I want them to, I'm going to give most of my patients three months with one refill. I'm either seeing patients back in general, most patients that they are coming back in three months or six months, and that applies to hydroxychloroquine, which you know is going to be in short supply and is going be gone in a matter of days.

So if they're asking hydroxychloroquine, I'm gonna give them three months. Now, someone could fault me and say that that's rude or crude or wrong in this time when hydroxychloroquine is gonna save everyone's life. It's not. There's no evidence that it works and you should watch the video I just did with Lenny and Cassie Calabrese talking about how hydroxychloroquine may be the solution, but it may not be. And we need data rather than anecdotes to know.

And on the other hand, we have patients who we know are doing great with those drugs and they need those drugs. So why should we stop, you know?