Telerheumatology- Dr. Alvin Wells At 2020 RheumNow Live Save

This is gonna be a TED talk and TED talks I like to kind of make it a little bit more dynamic and kind of move as we go through as well. So many of you are here to learn new information that you can take back to your clinic or to your hospital. We're getting close to the second quarter of the year, right? I'd make a fact that right up front that as you go into February, as you're developing your health care strategies for your practice, your academic centers, wherever you are, if telemedicine is not part of that practice of your strategy, then you don't have a strategy. Now in the words of our famous songwriter Halsey, let that sink in.

So you think about that. Again, use my kids as an example. I have a born girl twin. My son is a singer songwriter. He lives in Nashville, Tennessee.

He's a pilot now. Now, when they turned 26 years old had to get their own insurance. My daughter, she works at a private boy schools in Manhattan and she's lamenting that every two weeks she has $800 that comes out of her check to pay for her health insurance. And that's just that's the reality. So let me give you a couple scenarios and how will we see telemedicine how that kind of fits in.

Here's example. So 26 year old kid just got their health insurance. Young lady, she has a mother who had deformed rheumatoid arthritis. Now that she has her own insurance, she doesn't want to end up like her mother. She doesn't want to wait to come in those forty eight weeks to see somebody.

So she calls you up and say, hey, I want to be seen. Your nurse who screens the call say, what are your symptoms? What do you have? No swollen joints, no painful joints, nothing at all. I just want to be screened.

And they put the brakes on the system right there. So if I had the polling questions come up, what would you tell her? You say, one, don't call me. Call back if you have some symptoms. Two, go to University of North Texas.

They'll see anybody. Right? Number three, or you do a virtual visit with her. Now, here in that lady reminds me of another story. You heard about the two guys on the park bench just sitting there.

One was a widow, one had been divorced. You know, watching people jog and going throughout the to the park throughout the day. And the one guy who was divorced, he turns over his friends and said, no, I'm thinking about getting married again. And the guy said, really? He said, but this time I do a little different.

I'm gonna have almost like a prenuptial. He looks at his friends, okay, what would you do? He said, I'm gonna request that she has three things. That my next wife, I wanted to have this. I wanted to have this.

I wanted to have this. Alright? The guy looked at him and said, wait, wait, I get this story. You wanted to have a brain, you wanted to have a heart, but why would you want her to have rheumatoid arthritis? So I tell that story.

Here's a good example. We'll talk about another case and this is a true story of mine. I have a lady who's a teacher, 56 years old. She works at a school. I'm open from 07:30 to 04:30.

04:30, the phones go off and the doors are locked. We have another hour, hour and a half to get the messages done, go through my inbox, and get everything done. This lady is finishing up school at 03:45 and then after school, she's a counselor for the student counselor. She does all these different things. She cannot make it to the office.

She's missed three appointments. She's going on nine months out. Now she needs some methotrexate, she needs everything else, so she calls me up. What do we do? My staff for my first line of defense, they put the brakes on the system.

So she calls in for her refills and no, you must be seen. That's my first answer. Second answer, hey, I'm not open but go to urgent care, they're open all night. Or the third option is to go to see me virtually and that's what we talk about. So what is telemedicine?

Telehealth, virtual medicine, whatever term you want to use. It simply says that it is exchange of medical information from one site to another by electronic means. And here's a caveat, the goal is to improve or to enhance patient care. It's not to replace a physician or patient relationship, it's not to replace a relationship between a healthcare provider and that patient, it's only to enhance well operating procedures that are in place. And in fact, when we talk about telemedicine, telehealth, 80% of it is all of you guys.

It's the physician, the nurse practitioner, that physician assistant together with your MAs and everybody else. 15% is the logistics. How often will you see them? What kind of platform are you using? All of those different things.

And then I will pull up one slide, then the next one is all the technology. What are you using the scans like you see in the Air Force now with a clear? What do you have in the Google Glass? I know two of my colleagues in Charlotte and Miami who use this for the management of their patients. Whether they use an electronic device like their smartphones or all the different things that we see.

This is where the technology is. We used to have in our lobby at one of these kiosks where patients could either put their thumbprint in or actually log in to freeze your system, do the hack score, they could do all those things before they're even seen by me. So all these procedures that are there in place. That's what telemedicine is. And again, like I started out this the the talk is, if you don't have that as part of your paradigm of your health care program, you don't have that.

And what I should give a little snapshot about what we do, it makes it very simple. I can tell you the number one from emails and texts I've been getting this week is a what platform you do, how to get set it up, do I need a license, what about malpractice insurance, all of those different things. So we make a sample. I have Epic as my electronic medical system. Now you see that on the right.

And then we actually use Zoom teleconferencing. And connect with Zoom, the patient has a video, the virtual practice that visitor set up, I click on that in Epic and then I'll able to dock and do all my documentation. And now if you use Epic, they have everything, they have something now called OpenChart, right? Patient can see everything, they can communicate with you and now they can take a picture of their joints. They can actually send that to me.

They can take a picture of the skin. They can send all those different things to me and that could be done electronically, it's secured. Now, was good to see all the couches and the pillows in the background, the piano and the fireplace and everything. We make it very nice. We have this little bubble that goes in the back of the chair and when the patient sees me, all they see is that little blue screen or you can get a green screen, whatever color that you want.

So they won't see the dust on my shelf. They won't see everything that's in my office and that little bubble is there. I do a bit of wide screen to kind of show you what looks like. When I'm online with them, all they see is me and that little screen back behind there. So here's what we do.

So we talk about seeing those patients who need to get in quickly. Like I say, I see nine new patients a day and thirty percent of those who have never been in my clinic. It's a patient with back pain for seven years and a positive ANA, I would have done the screening up line. I would talk about, hey, who has alopecia? I pull up pictures.

This is a real deal alopecia. We're not talking about little hair on your pillows. We're talking about scarring alopecia Because a positive ANA and back pain that's not lupus, you go through all the criteria. And right up front, we can tell people who don't need to be seen by us, and we can actually screen those patients out. And indeed, most of the new patient I see on a daily basis, some I don't see back in my practice, because we tell them, hey, we try to focus on the disease that we can treat.

I'll give a couple examples of everything. This is what do we do and how is it virtual itself. We have patients, we're using my follow-up patient, we do a fifteen minute appointment with them. And I love the virtual visit because you never run behind. So that patient who goes on for forty minutes in your clinic, you're looking at your watch, I'm like one of the guys, I have been up standing with my hand on the doorknob and the patient is still talking to me.

It's happened to all of us. Right? So the patient, let's say, make a 01:00 appointment with me. At 01:10, we get a five minute warning. We get a two minute warning and then the link is cut.

I'm dictating while I'm on the on virtual connection with the patient and they do everything. So three minutes, what do you want from me? I need my methotrexate refill, just what I want. I have a rash, is it coming from that injection? Is it coming from an infection?

Is it coming from shingles? We do the rapid three. I was called glib but one of my colleagues is not being glib, it's actually, hey, what can you do? Because again, virtual medicine is not replacing your relationship with the patient. We talk about that as well.

And then the biggest thing is capturing these images. I just learned about now looking to canthus and hey, who has DM versus lupus? Those little pearls are what you need to take back. A couple minutes to relay the plan and two minutes you're done. You're going in and out the door.

So if you look at a couple of cases here, think you I saw the one of the slides early on that say, hey, that you can see this is inflammatory arthritis. Is this coming from a rash? Is it lupus? Or again, is this somebody had uveitis? Is it pink eye?

All the different things of what we talk about and see. I give another good example, already can appreciate this one. A man with psoriatic arthritis, I can diagnose this in my sleep. Do I really need to see him in the clinic? Having those images, talking with the patient a couple minutes on the by video chat, I get my blood work, I get my x rays, I get my QuantiFERON, I get all those results, I have those back in a couple days, we connect on the phone and say this is what we're gonna do, can you come in tomorrow for an exam, a big teaching to start them on a drug and get from there.

The other big question I've gotten the last couple weeks, how do you do as far as follow-up? Like all of you patients call in, I don't want to take my drug, I'm worried it's gonna make this coronavirus flare, it's gonna make all my disease flare. We say, and they don't even want to come to the clinic. I had two patients cancel this week because they're afraid to be exposed to everything. Now, I don't have to worry about canceling.

You might say, Hey, let's do a connection virtually with me as well. And the way I do mine, again, people say I'm kind of crazy, but from 07:30 to eight is when my virtual clinic goes off. If I haven't followed up within twenty four hours with a virtual appointment, we schedule a follow-up patient with that. And then we do another set from 04:30 to five in the afternoon. That's why my doors are closed.

We don't see live patient, we see the virtual patients there as well. And for doing this for four years, we've never gone without filling that slot. But indeed, I can tell you somebody who wants to be seen, they want to be seen immediately. And now having Epic is really good because I got students who travel like the University of Michigan, they're at Vanderbilt, they're at Duke, and we can see them all now virtually. So I tell you, as you think about telemedicine and doing virtual medicine, doing virtual rheumatology, that this is where the future is gonna be.

Not every single patient would be ideal for, but I think those patients with osteoarthritis who we can't do a whole lot for, the five year old mild who just want to be seen, they want to be listened to, they want to be heard, and we can do that in real time. And the key thing is staying on time. And again, in January, the insurance companies raised the antes. Anthem, Blue Cross, and now your knowledge begin to follow suit that they're actually covering these things. So, I say what telemedicine codes you use, we don't use the telemedicine codes.

I do this, I do my documentation and most of them doing a level three or level four type visit. My new patients are usually a level five because reviewing records, I'm talking about labs and everything like that, this is all as well. That's telemedicine. So, doing like we said, so if you don't have a telemedicine as part of your healthcare strategy, look at this. This is a good example what's going on with this coronavirus now.

You can still sit at home, you could be in the clinic with your doors closed and still deliver patient care. There are some people, yes, need to do a lymph node exam, I need to listen to their lungs and their heart, but for the bulk majority of our patients, you're gonna see that hey, we can deliver great care. And again, the goal is not to replace what you're doing, it's to enhance the active lead process that you have in place. Thank you very much.