Telemedicine Triple Play With Dr. Alvin Wells Save

Hi, I'm Doctor. Jack Cush from RheumNow. I'm here with Doctor. Alvin Wells. This past weekend, Alvin gave a fabulous telemedicine short, unbelievably short, but a really helpful talk on telemedicine in a TED format.

And this generated a lot of questions about telemedicine, which is very important in this time. So we asked Alvin to come on so I could ask him a few more questions. This piece is meant to be supplementary to his TED Talk, which will be on the room now for everyone to view, just check the website and you can watch the video. Alvin, good morning, how are you?

Good morning, Jack, good to see you.

All right, so let's get into it. Everything's changed with this new pandemic and not seeing patients live in the clinic. So normally I'd be asking you who's the ideal patient that you'd wanna do telemedicine. Right now, seems like everyone is the ideal patient, but who is the ideal patient? And then tell me how the switch over to seeing only patients remotely has changed your practice.

Yeah, Jack, anyway, as can imagine on this week, I've had more phone calls and emails and texts from all of our colleagues trying to see how they can get up and running. We've been doing telemedicine for over four years. And I think so some of the things which is exciting this week is that the rules have changed. My group as others, we've actually have Tuesday of this week, we've closed the clinic. So we only see an emergency patients.

I mean, means I had a guy who came with a gout flare or somebody who I think had a uveitis flare. Those are ones that were seen physically in the clinic and they're screened before coming in. You asked a question, who is an ideal patient to see for a telemedicine visit? And And you're right, I think it's all the patients. Let me take a step back.

So before the pandemic, I would say, hey, we could do that to screen new patient referrals. So I have a lot of my colleagues, they'll take the time to go through these notes and say, ten, twenty, fifteen minutes to review notes and say, don't want to see the patient. And you're not getting reimbursed for that. So now you can have, let's say, if somebody who's had back pain for seven years, they have a positive ANA, they want to be seen by you. So don't say no to that patient.

You say, hey, let's do a telemedicine visit for fifteen minutes and I can screen. You can ask the appropriate questions. And indeed, this might be somebody you don't need to see in the practice. On the other hand, taking about our most stable patient in the practice are rheumatoid patients. They're coming in, they're doing fine.

They just need to eat okay to keep their methotrexate, to keep their biologic. Those are my quickest and my easiest patients. And then of course we have other patients that are more of the challenging ones. Those patients with the osteoarthritis nodules, they want those to go away. The fibromyalgia patient who wants their life to be completely healed.

And I think the nice thing about those patients when a telemedicine visit is that it limits their length of discussion. Those patients can go on for thirty or forty minutes. And on telemedicine visit, they're forced to actually get it into fifteen minutes or for thirty minutes. And actually Dee, what I tell them, I say, hey, you write down the two things you want to talk about before your visit. So when they connect, we have three minutes to go through the niceties.

I take about five minutes to do a virtual exam and we can talk some about that. Three and a half minutes to do a summary and then three and half minutes to finish up my fifteen minutes, you can get a good feel for things along those lines. So to answer the question, all patients I think now are candidates and in some I think it'll be more suitable than others.

So a lot of people are interested in this. How are they gonna get up to speed quickly? Of course they could, we talked at the meeting about maybe partnering with another company and whatnot, but that's gonna take a few months to get going. What can you advise people now about how to get up to speed on doing either a telemedicine or even a telephone consult with their patients?

So, yeah, so first of all, we had a conference call on Wednesday night with Seema Verma, the director of CMS and talked about now you could definitely do telephone calls. Telephone calls are reimbursed by CMS, meaning Medicare. And then she also said something interesting too, said that now that your practice is The US, that they've waived the requirements for having a state license. So for example, I'm here in Illinois, I can do a telemedicine visit and code for that with Medicare for a patient from California or from Texas. So my practice now is The US.

And why is that done? I'll give an example yesterday. So since we're not seeing patients, our group has got all the doctors together to say, Hey, can you fill some of these calls? So eighteen fifty calls in the line for pigs who had questions about the COVID-nineteen. And again, so this one young guy I talked to yesterday, 16 year old with a temperature of 100.3.

He hadn't been outside for a week. I asked a couple of questions, talked to his mom. He's had strep throat in the past. I said, this sounds like strep. You need to go to urgent care for a strep swab.

On the other hand, I talked to a young lady, 30 year old teacher. She's been doing homeschooling for the last week. She had some nasal congestions, a little stuff and is in a temperature of 99. I said, that's nothing to worry about. Call if you get a fever.

So you can see, you can stratify those people. Some you can take care of them, alleviate their concerns over the phone. Others you say, hey, you need to go to another facility to like that patient with a strep throat. So there's some free platforms that are out there. There's one now everybody's been talking about called doxy.

Me, D O X Y. Me. You can sign up for that today, Jack. You can go on their line. You can do that.

They have a platform that a patient can put their information in and it gives you the kind of a paradigm of what to kind of follow with your patients. That is free. They do have an upgrade for that where you got your pay a fee, think it's roughly $30 per month. And that allows you to do more stuff. So take a look at that.

You can log on now. And there are other paid platforms out there. I've mentioned in the TED talk, there's one called HealthTAP, H E A L T A P, and another one called American Well or AmWell. Those you pay a fee to the company, but they give you the whole platform. You don't need to recreate the wheel.

Now, what we've done in this with my group as of May, we have Epic now. And we use Zoom as a connection between me and the patient, but everything flows through Epic. So we have a template for a video visit and everything is there. So whether you're doing a paid platform that's already ready to go, you can sign up and get that information. You can get going today.

Whether you have a platform with your group using Zoom like we have with Epic, or doing simple telephone calls. There are telephone codes and everything around there. You can look up those. They are online and available, but I think now is it really is open for all of us to be able help these patients alleviate the concerns, but also to keep our patients on our diseases and our drugs, keep them stable and making sure there's no issues as we follow them.

So you mentioned that this is all reimbursable now. How do you get your visits to be a level four visit, can you not do that?

Yes, can, Jack. And so for most of my patients, so I'll give you an idea. So January, most of the insurance companies like Aetna, Humana, they start reimbursing for telemedicine visits. And that essentially means here that the patient doesn't get a cash payment fee like we do with these other platforms, where they have to pay a fee before they're seen. They actually log in with me and I send the bill to their insurance companies.

And most of those are level three or level four. So think about this, and this is what many doctors don't do. I'm connecting with you. So one part of my physical exam is a psychiatric exam. You're alert, you're oriented times three.

I mean, you know who you are, you know the president's not Ronald Reagan. So you know all those different things. That's a psychiatric exam. And then I say, hey, open your mouth. You have any sores in your mouth looking for stomatitis.

I say, show me your joints. Can you make up a fist? We do like this sweets. So I do a prayer pose. Lift the shoulders up.

All those things that get me to the musculoskeletal. I review labs. And if I prescribe like some Ambien to sleep or if I get Flexeril for muscle relaxants, that's a level four. So we document all those different things. I say a template I have, I say, hey, our virtual exam was performed, including physical exam to the oral mucosa, looking at joints, and looking at the skin, and all those different things.

Now you might have a patient who calls in for an acute visit. Hey, I'm on one of my biologic drugs and I got a rash while I put that needle in. I need to tell me what it is. Could it be cellulitis? Could it be shingles?

Could it be injection site reactions? So the patient puts the camera over the part of their chest, their leg, or where they have the area and that helps you do. So that can be like a level two or level three visit. So you see how you can do that and all based on the depth. But I tell my colleagues, don't forget the psychiatric exam, scan your joints and the oral mucosa.

That gets you to a level three, level four right there.

Very good. What do you do about patients who don't have a webcam and don't have access? Can they go somewhere? Can someone help them do it? What do you advise?

So that's the challenging part that we talked about. Think it's really kind of telling, know, Obama said, you know, it's easier for a kid in Chicago to get a gun than it is can get a computer. And one of the things we've learned this week with the kids not being at school that unfortunately, Jack, a lot of the kids don't have internet coverage at home. So Comcast and others now trying to find a way they can provide care for those patients given people to give them internet coverage at home. I'm trying to work on a project think about this with the local libraries.

So now the librarians have nothing to do anymore. So think about a patient could go in and say, I need to go to one of those study cubicles, get me online, and then they can connect with me in a private study room. So we're trying to work with the local libraries on that. So again, as you can know, there's all kind of hiccups and things about that. And this is why I think, the CMS said this week that you can do the telephone visits and you can go from there.

Very good. Do you need to make any adjustments to the front end? I know you're using Epic, patients can use a portal to communicate. Do you incorporate that into your visit questionnaires or the portal use prior to the visit?

So, yeah, so when patients have a portal, as you know, they have access to everything. Now, something called OpenChart, that everything you record and put into the notes, the patient has access to. And there's a question on that too, would you be interested in a virtual visit? And so they can sign up and have all that stuff there. And then when I have my schedule in the morning, it's putting up how many people, how many injections I'm doing, new patients follow-up, and how many virtual visits I have.

And we've been doing more new virtual visits now, fifteen minutes or thirty minutes to screen them, ask their questions, and then the nice thing, Jack, I can order my labs, I can order my x rays, and then another week we can get back on the line and say, Hey, good news, you don't have lupus, I'm gonna send your doctor some recommendations, you can go from there. So again, you see how easy it can be done and many people, like I said, now they're wasting their time, they go through all these records where you can't bill for your time just to reveal something. I can do that while I'm on the phone with them, you get to reimburse and I think that's the reality particularly with this pandemic.

So lastly, malpractice would be on everyone's mind. I know that before I was told that in Texas, could see only people within Texas, otherwise I'd need a license outside of Texas. You alluded to this issue at the top of the talk. Tell me how you handle malpractice and what the recent revision might be.

So a couple of things. So with the platform HealthTap, patient pays $1 and that covers your $3,000,000 $1,000,000 policy, Okay, and they say you can actually do stuff across the state lines, which is new for me and I'm trying to learn out. But as of this Wednesday, like I said, I can see a patient from California for Texas. Does that mean I'm covered by my Illinois and Wisconsin malpractice policy Or are the other issues off? So I don't know about those because this is a moving target right now.

So the other paradigm before now was say, hey, need to have a license in all those different states and maybe have some coverage in all those different states. So that's a little bit of issue that's up in the air. So for right now with HealthTAP, patient pays a fee, you're covered. But right now I tell people still stay within your guidelines of your current practice provider. And then reach out to them.

They might have a clause in there and some are going have to tweak the clauses because this is a new era now. But talk about telemedicine, and some of those things are not in the standard policies that most insurance carriers have put out there.

So you think CMS is going to allow us to see people across line for Medicare only patients?

So no, there'll be for Medicare and for Medicaid, of course. But I think what's gonna happen, that traditional insurance is gonna follow suit. So once CMS kind of sets that standard, that threshold, then other insurance companies say, yeah, we're gonna do the same thing. I got 2,000 patients who have a question, do they need to be screened for COVID? Because you know to get the swab, you need to have a recommendation from a doctor.

They just can't go to one of these drive throughs and get swabbed. They got to be seen, they got to be filled by a doctor. I have to then order that test, they get a number, and then they go to the doctors to get the swab and everything done. So whether you're talking about COVID-nineteen, somebody who thinks they might have lupus, somebody who wants to be on a different type of drug or want a second opinion, all of those things are gonna change how we're practicing medicine in 2020 and moving forward.

Alvin, this is always amazing. You are a fountain of knowledge this Thank topic and you so much for this time, these questions. I'll encourage everyone to watch your video on RoomNow Live and RoomNow. Thanks Alvin.

Right, thank you very much.

Hi, I'm Doctor. Jack Cush with RheumNow. I'm here with Alvin Wells. Again, Alvin, we need you to help us get through these difficult times dealing with patients remotely. So, how are you handling the, introduction of remote visits with your patients?

What do you, how do you get them to consent to do it? Do you do a formal consent?

So that's a good question, Jack, and I think you know starting off with you know as simple as doing telephone calls and we do first have to document the patient, get their document, the identity that it is the one that we're talking to. We ask them birthdays. I don't usually ask their social security numbers, all those things need to be documented. And also my major practice in Wisconsin, I need to know what state they're calling from. And as I mentioned last week, we've been filling calls mainly from Illinois and from Wisconsin.

So I have to document what state that I'm actually conversing with that patient on. And as you know, the rules now open we can practice in all the different stages document hey I got a call from someone from Texas. This is what they did and these are what we discussed and we can talk about the documentation and the coding as we go through this.

Okay, so you do get a consent of verbal consent and you document that in your note. What kind of information are you collecting on your patients? Do have a template that you're working off of or what are your three or four main objectives and what data you document?

Yeah, so first of all, and again, this is why I think people start off with everybody's work one last week. Hey, do I need to rush out and get these programs? You can start first with simple as doing a telephone call. Now to document a telephone call, it has to be between me and a patient, not my nurse or my medical assistant. Now my nurse practitioner, my PA can actually fill those calls and we can actually bill for that.

I just made some cheat sheet here of the things I want to talk about that should be documented on the telephone call. What medical issue was discussed? Did they have rheumatoid arthritis? Is it PMR flare? What pertinent findings?

Hey, I'm having a headache. Hey, I feel short of breath. Hey, my joints are swollen. Assessment and diagnosis. So based on what they've told me, yes, this could be a gout flare.

This could be PMR. You talk about all those different things. Any medications or adjustments that refills were made, any labs that were ordered, and then what your follow-up recommendations would be. And again, the guidelines had been before this week is that, hey, that I do a telephone call or a virtual visit, it could not result in an office visit within seven or within twenty four hours. So if I have somebody today, it's a gout flare, here's a Medrol DosePak, call me back in six days if you're not better or come in for cortisone injection.

So to recap medical issues documented discussed, pertinent findings, the assessment or diagnosis, any medications, labs ordered, and what your follow-up recommendations would be. And then the codes are for again for a healthcare provider, a physician, physician assistant, or nurse practitioner, the codes are 99441, 442 and 443 for Are 5 to 10

those for telephone or televisit?

Those are for the telephone codes, okay? And again, because many people say, hey, don't have, I'm not up and running. It's gonna take me time to get the patient signed up on their end. I'm signed up, but the patient's not ready to go. I say, well guys, you can still do this by the telephone.

Pick up the phone call, pick up telephone and have a conversation with that patient. And that's what those codes are. 99441, 442 and 443.

Okay, what about an E visit code and a telehealth or televideo code? Are they different?

So yes, they are a little bit different, but here's the rule now, Jack. So we've actually even stopped using those. Now we'll use like the regular follow-up visit calls on 99213, 214215 for what you would document and bill for your regular visit. And most of my electronic visits now are level three and maybe in some cases a level four. You can still do those e visits, those other e codes, there's some g codes that are out there, but right now they're reimbursing for those regular, like your regular office visit codes.

So you don't need to make things more complicated by putting those other codes, putting in modifiers and all those things. We don't even do that anymore. And it definitely got sent for the telephone calls you just document that and you can go. At one point I need to make too Jack, remember some patients with Medicare and Medicaid they have a copay that to make. Now CMS has waived those co pays.

So hey, the patient does have a $10 copay or whatever to do a telephone call, that's all been waived, you still can charge for your codes and get reimbursed for that.

Yeah, we just, put up a secondary tweet about this. The office, the inspector general came out and said they're not going to pursue any any issues regarding collection of co pays and whatnot for federally funded programs like Medicare and Medicaid. So the last issue is how are you connecting remotely? There's telephone versus video. You're wired for video.

Where would telephone make more sense though?

Yeah, so the telephone is gonna make more sense. And again, it's really sadness in The US. We still have some people who are not computer literate, don't feel comfortable with a smartphone or what they are with a computer and don't even have internet access at home. That's the number one place that I'm finding that we are that we're using the telephone. And again what they do while I'm on the in the room in my office then my staff are connecting.

They actually queueing these calls for me. Say, hey Doctor. Wells at 01:00 Mrs. Smith, 01:15 is going Mrs. Jones.

And they're having those calls in the queue for me. I hang up on one phone and I pick up on and I hit the button on another one. They're holding on. My MA is now, they're doing my verification. I say, hey, this is Mrs.

Smith. She's got gout. She hear the medications. Everything's up to date. Boom, I pick up the line.

I go to the next one. So I have my team to kind of queue those calls for me and I can go really pretty quickly wrap it through those. I have Epic on there and I click on her name and then go to the next one from there. Having your team working with your medical assistants and your nurses to kind of help fill those calls, see what the issues are first, and then you can kind of go through those pretty quickly.

Okay, and then there are patients, visits that you can do by video. If you're not wired with an EHR setup that will do that, there are obviously other formats to connect face to face with patients. I'm gonna just mention a few of them here. Everyone knows about FaceTime, but it has to be Apple to Apple. If you don't have one Apple phone, then you could use the Google application Duo, which you can download and you can have both on Apple phone and Android.

You can also use WhatsApp for televideo conferencing. And then there's another application called doxy.me, which is a service but pretty easy to sign on to and you can use that. Again, that's just a phone or a camera on either end. Do you have any other tips or tricks here?

Yes, as I've been doing all those stuff, a lot of things come into this new one I'll call Vidyo, V I D Y O, Vidyo, that's another one. They have a platform that you can use. They can talk to some electronic medical records. And a nice thing about that, some of the universities are using those across the board. It can actually talk to Epic and I'll talk to others as well.

And as I mentioned before, the doxy.me, that's a free service. But if you want to have more utility of what that'd be able to do more things, can actually pay I think it's rough like a $30 per month charge that allows you to get more access and do more things. But those platforms require that a patient has something on their end. They need to be they need to be enrolled in that. They need to put their diagnoses.

They need to put in where you put the diagnosis, they need to put their medications, their allergies, all those different things. They need to create a health record on that and that takes a little bit of time. So those you can get rolling while you're doing your telephone calls. And I think you're really right to mention things like WhatsApp and doing a FaceTime, all those things and just to document you, you dare. And that's the most important thing.

So be able to collect and to bill for these things, have to show there was documentation and how long you're on the connection with that patient. Was it five minutes or ten minutes and what procedure? Yeah, we use FaceTime to connect at ten. I finished up the call at 10:15 and this is what we talked about. And you put that in at the beginning of your note.

So documentation is the key.

You're our fountain of knowledge as usual. Thanks so much for this input. We will connect with you soon for more good Alvin tips. Take care.

Thank you.

Okay, so we're gonna stop that. Hi, I'm Jack Cush with roomnow.com. We have on the line two experts in the field of telemedicine, Dan Albert from, Hitchcock Medical Center in New Hampshire and, Alvin Wells from Rheumatology and Immunotherapy Center in Franklin, Wisconsin. Good afternoon, gentlemen. Hi, Jack.

Hi, Jack. Okay. So, both of you have been using, telemedicine for quite a while. Alvin in practice, private practice, and Dan in an academic center at Dartmouth. I'd like to start by, Dan telling us how you're using, telemedicine in your practice, especially this week.

So, Jack, it's been a very eventful week. As you can see, I'm home, and I'm home because my fellow is being tested for COVID-nineteen, whom I rounded with for the last two weeks, and I've been sent home to do all of my encounters remotely. And this is not a new thing for me, but doing it exclusively from home is quite new. There's been a lot of changes with the COVID-nineteen epidemic. And most of them in my mind have been for the good.

They have relaxed a lot of the restrictions. You no longer have to have the patient at an academic or clinic setting. They can be at home. There's no restriction on the way in which you encounter the patient. In other words, HIPAA regulations have been relaxed.

They've changed some of the billing so that it's a little bit more transparent. And by and large, it's been quite a bit easier to do this, Even if you're stuck in quarantine, as I think I'm going to be. And the only restrictions that remain are the state restrictions where you have to be licensed in the state that the patient is at. And that hasn't changed at all. Other than that, there's a little bit different format and epic for doing these virtual encounters, but it's not a huge deal.

I think that by and large, most of the changes have been quite in line with what we had hoped telemedicine would achieve in the future. So I think if there's a silver lining to this particular one for telemedicine, it's definitely a plus.

Alvin, how are you using it and what's changed as far as your practice of telemedicine?

I think Dan is right on some things. I think you take a step back as a private physician. My goal was, hey, how can I increase revenue? And I've evolved over the years. We've doing about five or six years now going from platforms like HealthTap and American Well and Teladoc into now we use a platform with Epic where Zoom is our connection with the patient.

The one big change this week has been their use of telephones. Know, unfortunately a lot of older Americans and even some of the patients of, you know, a lower socioeconomic status don't have a computer, they don't have internet access, but a telephone call has been really, really been good to kind of fill those. And I can't tell you how many telephone calls we've had and I think a whole gamut of questions that we all have had. I think Dan is absolutely right that they've changed the rules now that we can actually bill and code for telephone calls. CMS has waived the co pays and deductible for all tele visits.

And again, the past where it had to be at one facility like a nursing home to a clinic or a hospital to a clinic, now they can be doing it at home which is very, very, very nice, which makes really good. Dan, I had a question for you. We've been struggling with some of my Medicaid patients. How do they get access? Like I said, if they don't have internet access at home, do you guys have a booth, a cubicle they can go to to kind of log on somewhere outside the university?

I mean, that's what we're struggling with. How do we get access for all of our patients?

Yeah, I think that is a generic difficult situation. We want to protect the providers and the patients from getting infected. And so we have to sort of keep them separate and isolated. But many patients don't have access to the sophisticated computer access that we require. As you've mentioned, some of these programs are quite difficult to manage.

So in general, we've been reverting to telephone encounters. Encounters. I don't think that there's an easy way around that. You can't send them to the library. The library has the computer facilities, but they're closed.

They're closed, right.

And that goes for almost every place that has public access. So, think we have to live with telephone calls.

I agree.

So Alvin, you mentioned that you're getting a lot of calls. I'm sure Dan is too. What are the two most common questions the both of you are getting? Let's start with Alvin. Two most common questions and what's your response?

Yeah, the number one thing is, of course, of all the biologic drugs and even methotrexate and the scenario goes, I just answered it once. Say, hey, my husband is a police officer and he might have been exposed by someone he arrested and I'm on one of these medications, do I need to hold my injections or my pills? No symptoms, no issues at all, no fever or anything even from the patient or from the police officer, but it still triggers a call. And that's been the number one I've seen. So, hey, I think I, as someone in my family has been exposed to whomever and what do I do with any of my 15 medication that we prescribe in Rheumatoid?

That's been my number one thing. And I tell them, hey, you wanna hold your medication because when the disease is active, the immune system is preoccupied causing havoc, you're less likely to fight an infection. So I think that's where we need more guidance from ACR and others to get the message out globally.

Dan, what's the most common question you're getting?

I agree. That's the most common question is whether I should continue my medications. They ask for very sometimes very sophisticated questions. Should I be taking ibuprofen? Should I Should I add hydroxychloroquine to my regimen?

You know, and variety of other nuance issues. But by and large, we've given them the same answer. If you're not sick and the person that you think has exposure, is not sick, then continue your biologics. So

I would refer our RheumNow audience to one tweet that I put out today from the American Academy of Dermatology. The ACR is coming out with its information any day now. The AAD came up with its guidance for patients and they say, do not stop your biologics unless of course the bottom line was if you are infected, yes, stop your biologics and contact your rheumatologist. And then for patients, did a video, I called it a PSA and it can be found on Facebook or on Twitter or on our website. It's called Managing Your Arthritis Medications, and it's like a six minute video.

It's sort of me to a patient about what to do about your medicines, including nonsteroidals, Tylenol, biologics, and all that sort of thing. It's a good resource to refer people to because again, we're getting these questions over and over again. Dan, you have a question for Alvin.

Yeah.

Alvin, you use Zoom for your, video portion of yours, and you've been able to integrate it into Epic. That's an interesting, I think we use Vidyo, V I D Y O, and the interface is a little bit cumbersome. And so Zoom might be a better option for us. Did you come upon that just by yourself or was that a recommendation?

So, no, one of the things we did, it's a learning. I always people that they're to dabble in telemedicine, they should really become a member of the American Telemedicine Association. So after going for a couple of meetings, you know, everybody's pitching their platform and then zoom came out. Of course, I got the T shirt that says zoom on it. But we looked at that and we really wanted something to integrate with the electronic medical record.

So in the past, I had Cerner and other ones, I would do like HealthTap or American Well, and I would have to print that visit out and then have one of my staff would have to scan that into the electronic records. So now I have Zoom on one side of my computer, I have Epic over here, I have my microphone and I'm talking and dictating as I go along, making sure the patient understands what we're saying. So it's really kind of seamless. We've created a template and if you have Care Everywhere you can reach out for those. We have a virtual visit template that we've created and we're trying to tweak that with the new guidelines.

But yeah, it's very, very in my mind kind of seamless. I think the challenge like you said is not all of our colleagues are going to have Epic or have the Zoom that's available. So some of these options that are ready to go out of the box, things like, you know, doxy.me or some other ones like even American Well that patient, physicians can use right off the bat.

So both of you have been doing this for a while, every one of us or the rest of us are struggling to catch up right now, and both of you have great lectures on the topic of telemedicine, telerheumatology, and you're really good at pitching the idea that this is maybe the future, this is important. This works because it's convenient, it's time efficient, it's cost efficient, and you maintain privacy, but there are downsides to this and I want you to discuss what the downside is of telemedicine besides the electronics. The fact that most older white haired, almost retiring rheumatologists, no haired rheumatologists, almost retired are not good at electronics and maybe this doesn't apply to all patients. What is the downside of telehealth? Daniel, you wanna start with that?

Go ahead, Daniel.

Well, think the downside for me is the inability to examine them carefully. I think that's been everyone's concern, and if you don't examine the patient physically in any detail, then there's an anxiety level on the provider side that you're missing something. That is a portion of the patients where the exam is a crucial factor. It may be, I mean, in our studies, it was more like twenty percent. It wasn't huge, but it was enough to say, I'm not comfortable, you need to come in.

And that's, I think the biggest limitation from my standpoint.

Calvin? So my thing is it's actually the patients. You know, we take a step back even when we have to introduce a patient, hey, have a nurse practitioner, I have a physician assistant, they're just as good as me. We still sometimes get some pushback from the patients. And I'm really surprised it's not always my older patients.

They love the time thirty minutes with the PA but some of my younger patients get the pushback. So my older patients are happy they can sit there on the phone, they can talk and they can go on and on and they love that kind of time. But I think it's one of getting buy in from the patient's side standpoint. I do think the good thing out of this is it's going to change how we practice in medicine in the future, that we will see this be a part of our medical care delivery system. I wish we get to the point that we did, that's interesting last year at ACR, I talked to some groups in Germany that the doctor now can prescribe these apps.

Can prescribe the watch that's covered by the German insurance. They have an app that leaks into the clinic and they can monitor the blood pressure and all those different things. So the tools are there. We just need to get sophisticated to see who can cover those things and making sure that across the country that the internet access should not be an option. It'd be something that's kind of standard.

Because again, you talk about medicine, but even in our area, Chicago and Milwaukee, there are kids who can't do the homeschool because they don't have the internet. So Comcast and others are trying to come up with ways to cover some of these inner cities where they don't have all the virtual access. So I think the biggest thing is a patient getting a buy in from them and then eventually getting more and more acceptance by standard insurance companies as well.

Let's end with the issue of new patients via telemedicine. Know, follow ups are easier. You know the patient, you know their stories or exams might change. You know what maybe you expect there, but it's new patient you don't know they come with, you know, it has its vasculitis, it's lupus, it's everything that it probably isn't. How do you handle telemedicine in new patients, Alvin?

So first of all, Jack, that's how I love it the most because I can tell you I roughly see nine new patients a day. My two PAC three each and I see three, but I see I stay staff all the patients with me. But I'm just overwhelmed by the number of patients I see that they really should not be in my clinic. So the patient who's had back pain for seven years, somebody does an ANA on them and say now that one to eighty ANA is lupus that calls you a back pain, you need to see Doctor. Wells.

I get them in, we've got them on the schedule for forty five minutes, and it turns out in five minutes I can say you do not have lupus, that doesn't cause your back pain. So instead of wasting my time where I don't get paid for, I don't screen patients visits, I say I have them come in, but now I love it for those new patients. So the scenario is I order my blood work, I get my x rays, if that set rate comes back at 80, the CRP comes back at ten, and then based on what they told me, say, wow, you need to come in tomorrow for a physical visit. Let's say this is some issues that's going on. So I love it instead of screening, taking the time to screen people, I love it for the new patients because we all know that many people that are referred to us probably shouldn't be seen by rheumatology.

Dan, what do you think?

So I have a very similar approach to it. If patients need to come down to our clinic, we pre screen them and we reject about 90% based on the same considerations that Alvin said. In telemedicine, I don't reject anybody. So I see all of them by telemedicine, and I do exactly what Alvin says. If they look like they have an inflammatory disease, if their labs are abnormal, I have them come down.

I think we have a very similar approach. It's just that we prescreen our in clinic visits to the point where I'm worried that we're missing things, you know. I'd rather do the telemedicine.

Exactly. So this could easily become an important part of the rheumatology evaluation model. Gentlemen, thank you very much for this insight and making us smarter in this time of COVID. Hopefully we'll continue the discussion.

Thank you, Jack.

Thank you, Jack. Thanks, Alvin.

Thank you, Dan.

Bye bye. Take care now.