TNR Telemedicine Next Steps Save

Hi everyone, welcome to Tuesday Night Rheumatology, the Grand Rounds series. We're going to continue what we started a few weeks ago. You've all survived March Madness, also known as COVID-nineteen. And we've put forward a few good lectures, a few good sessions so far. And now we're gonna go to our real key opinion leaders, our real educators in the area.

I don't know about you in the past week and how you've done, but what I'm seeing in clinic and in rheumatology is it's getting a little better. You know, I think I can remember hearing Alvin, our speaker, Alvin Wells, talking about this at, RWCS conference in February. And he gave this, you know, sort of brand new lecture on, telemedicine, telehealth and telerheumatology, and it seemed so far fetched. And we got into this, you know, by all the hard way and suddenly in March and it's getting easier as we go along. I think we're getting smarter as we manage difficult patients remotely.

We're getting smarter as we manage all that in the context of what is an epidemic that's greatly affected all of your lives and the lives of our patients. But we're gonna continue with this grand round series. It's also known as, rheumatologists with good haircuts. I got a good haircut this week. And I'm gonna introduce my good friend, Doctor.

Alvin Wells, who also doesn't have to worry about a good haircut. Hey, Alvin.

Hey, Jack, how are you?

Okay, Alvin is from the Aurora Rheumatology and Immunotherapy Center in Franklin, Wisconsin. He's got a lot of academic affiliations. He has a lot of expertise in a lot of areas. Alvin, I was just talking to you today about, I don't know what to do with pan uveitis and what it fails at TNF and they were called Alvin Wells. So that's another lecture another day, but right now you're wearing your your teller room with hotology hat.

I wanna inform the audience that if you haven't been following Alvin on RheumNow, you've been missing out. And this series is an extension of what we've done thus far. So at RheumNow Live, nearly a month ago, he gave a fifteen minute TED Talk about telemedicine and why it belongs in your arsenal and how far it's come. And it was really a bold invite for all of us to say, to take this on. And little did we know it really did happen like soon thereafter.

And then he's done, been really gracious in doing three other interviews with us to take us one step further, one step further. So he's got a series going and we're pretty much gonna give him his own website and channel soon. This lecture Alvin's gonna be telehealth and telemedicine and moving forward. I'm gonna turn the screen over to Alvin and let him take it from here. Stick around folks, we're gonna do Q and A at the end, okay?

Perfect, and thank you Jack for all those nice, kind words. I tell you, I think this is like you said, it's a whole new world for us in telemedicine. I go back until about six years ago, I started with a company called HealthTep. I was reading and stuff on what do I do to increase revenue of my clinic and I saw that, hey, you can sign up, you can see patients and do that remotely. Remotely.

I did that for a couple years and after that I joined with a group called American Well and learned how to do that and do these consults and then moved over to last year when we converted over to Epic with my group and began to use Zoom. So the purpose of tonight's talk, thought I'll hand you back and say, hey, about thirty minutes take us through to where we are now and where we headed. And I really would encourage people to stay to the end because we're gonna challenge you. I'm gonna give you some bold statements about where I think the future of not only rheumatology, but also what medicine would be, so moving forward with telemedicine. A couple of introductory slides, kind of see all these things.

So telemedicine, what is it? And again, whatever kind of view you want to have, medical records, these applications, remote access, personal medical records, all those things play into this. And this is a slide we do, and some of these things I'll come back to, we get from the American Telemedicine Association. But telemedicine, virtual medicine, telehealth, telerheumatology, whatever acronym you want to use, it says the same thing here. And essentially is the use of medical information that's exchanged from one site to another by electronic means.

And here's a caveat, everybody excited and got all concerned, hey, do I need to do those all the way? The take home message, this is to improve patient health. It's not to replace processes that are already in existence. There are some systems where are synchronous in real time like we do on tonight. I'm connected with the patient, I see them real time.

Others which is asynchronous, that's more for radiologists. Hey, somebody gets an MRI in Arizona, I can read that in my office in radiology in Chicago, so Stuart and Sheriff Ford. It is to enhance processes and not to replace them. Because at the end of the day, I like the breakdown here, 80% is you. It's the physician.

It's the physician assistant. It's your nurse practitioner. It's your medical assistants or your nurse. 15% logistics. Do my MA check them in first?

Do I have them scheduled in advance? Can I see them the same day? And only 5% is the technology. Am I using DoxyMe? Am I using American Well?

Am I using all those different things? So I want you to keep in mind to improve the patient health, because I can tell you that if you're using telehealth and telerheumatology, it's gonna be important for us to kind of show, hey, what the outcomes look like. I'm a member of the American Medical Association. They have another system they call Steps Forward. Also, if you're a member there, can look at their website.

And again, as you embrace telemedicine, again, to enhance wellness to chronic disease management, and that's rheumatology, 90% of what we do, enable access, and this is something that's been opened up with this whole COVID-nineteen crisis, improve efficiency, and at the end of day, look at talk about patient safety. So as you look at all these buzzwords, enhance, improve, increase, that's what we are. There's no such thing as replace. It's not gonna replace my day to day visits. It's not gonna replace my hands on visits.

And I think that's what some rheumatologists were concerned about that. And at the of end the day, we have data for the next talk. I won't talk about that, so maybe Jack will have me back when we can talk about outcomes. But telemedicine has definitely reduced morbidity and mortality. We're then looking at hypertension, congestive heart failure, diabetes.

Improved patient outcomes. A patient gets discharged from the hospital, somebody connects with them remotely, say, hey, Mrs. Smith, were you able to fill that medications? Did you indeed take your biologic medication? And not wait until they come back four months from now and say, well, I didn't get that medicine filled, and now they got deformities of their hands.

And at the end of day, overall it's gonna lower the overall cost. So you wanna keep people out of the hospitals, out of the emergency rooms, and we can see that's where the cost savings come in as well. Now moving forward, this is gonna be my buzzword tonight, it's gonna be moving forward, we will still need telemedicine. And these are some data we talk about, these are old, but going back for us a few years ago, looking at the shortage of The US. We talk about primary care doctors, and in some of these are numbers where there's over 30% of patients where there's a shortage, states rather, where there's shortage.

And over here on the right, we talk about, hey, where there's a greater demand, there is a supply. So right here, where I am, Illinois, Wisconsin, you look at all these parts of The US, again, we don't have enough doctors to cover the supply. One of the other things we say in moving forward is that again, we know that a lot of doctors here were thinking about retiring. And unfortunately, one of the things that's coming out of this COVID crisis is some doctors say, Hey, now it's time for me to hang up my shingles. This is just too overwhelming.

Unfortunately, some practice is not gonna survive even despite the aid that's coming from federal government. But look at doctors who think about retiring, those that say, I'm gonna keep where we are, I'm not gonna change any things. Maybe I retire a little bit early, I say, I wanna cut back my hours. And again, if you go around primary care, you can see people retiring, but look at the specialists. I have one other slide that kinda highlights even more.

Look at all the different specialists to talk about, hey, internal medicine is probably okay in pediatrics, but most of our specialties is rheumatology and pulmonary disease, you're gonna see a lot of people are gonna be retiring. We will still need telemedicine. That means that, hey, if I can't now see a patient in Illinois, well what about if somebody's retired, there's no access of patients, physician of rheumatology, whether in Wisconsin, Michigan, Indiana, surrounding states. I look at this slide and say, wow, thought this was years ago, but this is the workforce project that came out in 2015 by the ACR, the American Medical Association. And it's projected to say that 2015, that this year in 2020, that we would need up here at the top 6,796 rheumatologists, but we only have 4,400.

And not too far away guys, less than five years from now, we're going need 7,500 rheumatologists. We're going have about 3,600. So we're going to say what that need is going to be. So that means, hey, that now from your clinic, wherever you're practicing in California, you might say, hey, I can reach out to a patient indeed from another state and we'll talk about what those guidelines are. So now here's a very intriguing thing.

Like I said, I'm gonna be provocative tonight. So we talk about this, every patient need a physical exam. So I went through my database, I searched on Epic, I said, give me my 20 top diagnoses, and this was what came out. So I created this word slide, rheumatoid arthritis, osteoarthritis, you know, the things we hate to see, the Lyme disease, back pain, fibromyalgia, all those things come on the list. Now when you think about those disease entities, how many of those people need a physical exam?

So the question is who needs a physical exam? Everybody. There is everybody. So the big question is how frequently do they need to do the exam? Is it a Nixon exam?

Do I need to do just my follow-up? Or what about my urgent care or acute visits? As many of you know, I train in Sweden, I speak Swedish. I usually go to the hospital every year to Stockholm. This year my plans have been thwarted by the COVID-nineteen crisis.

They are struggling just like we are here in The US. But at Karolinska in Stockholm, they have whatever disease, if a patient's in low disease activity or remission, that patient's only seen once a year. They have a centralized lab, so labs are done. They have a centralized pharmacy, so drugs are dispensed. They have a way to track if somebody does get an infection while on the biologic, etcetera, etcetera.

So does everybody need a physical exam? Here's the challenging part. What about the disease state? So on my word slide, I had osteoarthritis. So that 80 year old lady with herbalism and Bouchard's nodules, I'm not gonna do a whole lot for that.

I'm gonna keep on some topical NSAIDs, maybe some Tylenol, maybe a little tramadol to have. A gout, unless a patient's having a flare, they are stable, only one flare a year, I might only need to see them once a year to making sure their labs and everything else are okay. Many of my colleagues hate fibromyalgia. We get stuck with the patients because we came up with the diagnostic criteria. There are indeed three FDA approved drugs that we can use, but the question is, hey, how often do we need to see them in the clinic?

If they had their way, they would want to be seen every month. And then the back pain. I work closely with the pain doctors, but again, they don't treat a managed pain. They only do the injections and procedures. So these are just four that I picked on to say, hey, indeed, if they're being seen by a rheumatology practice, and if you're not seeing these, again, I don't know many people are surviving because these are sometimes the bread and butter patients, but we push back and get through.

So they might only be seen once or twice a year for an examination. And then the question comes up, an examination by whom? Now many of might have seen this data that we did with the Treg group a few years ago for the ACR. I haven't seen it published, it still makes a good point. So they train physiotherapists, PT people, to pick up psoriatic arthritis.

So they had the rheumatologist say, hey, the patient did not have PSA, possible PSA, or definite psoriatic arthritis, and then everybody had an ultrasound. 1,100 patients were invited, about 100 did the assessment, and it turns out that the physical therapist was just as good at picking up who had disease as it was on ultrasound, it correlated with a topaz, one of the questionnaires has been validated for psoriatic arthritis and elevated C reactive protein. So it turns out that, hey, you don't need a physician to make that diagnosis. Moving forward, why this is important guys, look what's being talked about. Congress is already pressuring CMS Medicare to cover telehealth services.

Not only the office helps care providers, but physical therapists and occupational therapists. So again, the light at the end of this tunnel with the virus, you will see that just like we can do a telephone call and evaluation by Betty remotely, physical therapists, occupational therapists, and and others will be able do that, and they will be reimbursed for their time. So again, who needs a physical exam? This is one of my patients. We tell them, Hey, make a fist and show me what you see here.

They will ask the question, What do these joints are inflamed? I tell them, hey, you look for that little valley, that little groove on the MCP, you want this one, look at this, you can see the difference here. My kids could tell you that this little looks a little different than the others. Now, are the data to back up this when we talk about the physical exam? Indeed there are.

So a very article that came out last year in the analyst that said, hey, they took somebody who had clinically suspect arthralgia, not osteophyta, but really had they thought inflammatory disease symptoms for more than six weeks, but less than one year. And they did an MRI, the MCP joints and the wrist, and they said, What features that they saw on physical exam that correlated with the MRI features? And indeed, saw if a patient could not make a fist or they had a decreased grip, that correlated with tenosynovitis. And the one thing they saw, they did follow those patients longer than a year, and many people went on to develop full blown rheumatoid arthritis. And again, the incomplete ability, incomplete fist closure was the one that was predictive of making RA development.

So again, on the physical exam, the patient could not make a fist correlated to MRI changes, and those people could not do that indeed went on to develop rheumatoid arthritis. So there are things that are out there that's being tweaked as well. Moving forward, we still need some other tools. We talk about what tools can we use as physicians in lieu of a hands on exam. So what can help me do my virtual exam?

There's an article from New England Journal last year that say we all have these smart devices, everybody has a smartphone, we have the, okay, the Fitbit, we have the iWatch, there's another device out called Biofit. I didn't pick the slide here, but they also have a smart ring that's out. You can look at your emails, you can get John Tracings and things like that from there. And then they have these smart sensors. This little sensor that you swallow is a little bit bigger than a capsule, and it correlates and sends a signal to a patch on the surface of the skin.

Then that can be transmitted to the cell phone or to the computer, and then all this stuff is fed into electronic records where a physician, a nurse, or somebody's monitoring that data, hey, the DAS score comes back elevated or the CRP comes back elevated or alert goes out and that triggers some intervention by the healthcare provider. Last year at the ACR, as I went around looking at posters, we met a group from Germany, and they have telemedicine there, and they've taken it a step further. That is a rheumatologist in Germany, hey, I want to monitor my patient at home virtually. They can write a prescription for a virtual medical kit at home. And what does that look like?

A digital stethoscope here. You can see this gentleman has echo device that he puts over his heart. They can look at the training. I'm using my clinic on a daily basis. A digital thermometer, a young lady checking a temperature, it goes through the device here on the iPhone, and that can be fed to the physician.

We tell all of our patients on the biologic drugs, hey, before you do your injection, can you check your temperature? And if it's above a certain threshold, let us know. The same thing can be done with the COVID crisis. At home, if somebody has a temperature, that gets fed to a center to say, your temperature's over one hundred and point four, then hey, you might need to be seen or somebody calls them and say, what are the symptoms that are having? A digital sphygmomanometer, kind of look at these things, look at the blood pressure levels and see.

Glucometer, I think many of you seen these, a little device a patient puts on their skin. It can measure the blood sugar levels without them having to do a finger puncture. The smart scale, this is the one I have, one called RENFO. It not only measures my weight, I do my weight twice a day, but my BMI, my Present Body Protein, it tells me all of these different things and that can be fed to an app on my phone and I can download that and do other things. Then I would start to say, hey, what things are out there, what tools are out there for rheumatology?

Not a lot, we need to develop some. There are a couple of things, a dolorometer or an odometer that looks at pressure. We talked about putting enough pressure to move four kilograms per pound per square inch. We're looking at that to see, this is some devices that have been out there and they are available. The occupational therapists use this, for example, when they do a functional assessment on our patients.

So think about this, that you'll be able to order a virtual home kit for your patients to be able to monitor them and follow their symptoms down the road. Some of you have multiple clinics. You might have an MA at a clinic one day, a patient calls in and say, Hey, I have a sore in my throat or my ear or my mouth, what do we look at? Here's a medical device called the Auris. It's used to look at the ears and the nose, they have an attachment they can go on for looking in for the eyes as well.

I thought about this, I'll say, all my patients on methotrexate, I say, If you get a sword in your mouth, me know, but I can't see that. With this device, I can not only look into the ear, here's a mother looking at the ear and that is fed into a physician who can look at that. So if I got somebody who's on methotrexate, they might have stomatitis. I have a young lady who might, I think, hey, is she having a flare of her Behcet's disease? If I have a lady with lupus who has an ulcer in her nose, let me take a look at that to see if that's coming from the lupus ulcer.

And again, you think this is Star Trek, let's take it a step further. Again, we can look at this to monitor skin lesions. Many of our drugs like the TNF drugs, the JAK inhibitors, they say that the patients need to do a periodic skin exam. Sometimes the dermatologists push back, they don't like to do these patients, hey, I can take a picture of these lesions that I suspected and I can send that to my dermatologist and have to look at it. He says nothing to worry about.

Oh, come in, let me do a biopsy or let me freeze that off. So several devices out there, one called the Molescope. A little cautionary warning, was reading something in JAMA just today that the FDA, none of these devices, several devices on the market are not FDA approved and some have been banned to be used in The US because they are making false claims. And this reason just kind of blew me away. Think about this, guys.

Immediate access to care. So say you have a sore throat, earache, you can go online, do something called Oto Home, and you can click on the button. And then you can get this otoscope that's sent to you. Here's ET taken off and bringing it home. And if that image is sent to a physician, they think you have a middle infection, they can get antibiotic.

And it is, again, guaranteed this from one to three, this happens within three hours. If you don't have it and connect it with your doctor within three hours, you don't have to pay. So think about that for a patient with rheumatoid arthritis, think about that with a patient with gout who's having a flare. Can I see that patient today? Can I do it immediately?

And all those different things. I'll tell you how we manage it in our clinic as well. But this is where it is, so moving forward, telemedicine is here to stay. We need to get devices to help us monitor our patients with rheumatoid arthritis and other inflammatory diseases, and some of these things are in development as we speak. As you know, this year, the things that changed with the COVID crisis, on March 17, Seema Verma from CMS said, Hey, moving forward that we change the ports of care.

So one of the challenges I had before this crisis came up, I could only see patients to get reimbursed from it when I did it from a hospital to my clinic, or from a nursing home to my clinic. Fast forward after March 17, they've changed this, they said, thank you, you can do home to provider. So here I am sitting at my desktop and I could connect with a patient at their home. And you get reimbursed for that and that's why they changed all those different things. I don't think this will change moving forward.

I think this will be something that we'll still see coming up in place. A cautionary warning as you move forward telemedicine, debated Orin Fromm at RWCS in Maui this year, and he came up with some of these things that you still need to know the regulations. That, hey, I'm in Illinois and Wisconsin, I still need to say, can I indeed see a patient from Montana? I have a Montana license. Can I indeed see a patient from South Dakota with my South Dakota license?

So you need to know your regulations with your site of care. And part of that regulation is gonna be with the malpractice. So look at your malpractice carrier, look at that and see what kind of rider they have and then we can do a remote visits. Reimbursements, I'll share a little letter in a minute, but I think the reimbursements are here to stay. They probably will not be as same as an office visit, but they won't be down here where nothing, it's gonna tell me what we're thinking.

The American College of Physicians, again, not only for a new patient, established patient, but also for new. We still gonna have to deal with the licensure. I have five medical licenses. I thought I was doing good. And so I met an ophthalmologist last week who had 15 medical licenses and in 15 different states.

So I worked with the Federation of State Medical Boards to say, Hey, can I treat patients, get my licenses that I have, will that kinda carry me to other states here? Because that was one thing that changed with the COVID crisis as well, they say, hey, that now you can see patients across state lines because they can't get in to see somebody in Texas, then indeed that doctor in Florida or Louisiana can see that patient, connect with them remotely, prescribe, order drugs, order labs, etcetera, and that's what's gonna change. When I talked about reimbursement, look at the efforts coming from the American College of Physicians, I'm a member of that as well. So on April 8, the American College of Physicians sent out a letter to Seema Verma, and essentially says here that we don't wanna go back. That indeed as we do in our office visits and telephone calls, that it should be reimbursed at the same rate.

And again, they wanted for immediate guidance on this as well. And again, you look at all the different colleges and organizations that were signed off on this, here you see the American College of Rheumatology as well. There's a whole force behind us that said, and indeed, if I see a patient in real time in an office visit, if I connect with that patient and still spend fifteen minutes on the telephone or by way of the video, I still should be reimbursed for my time and their aggressive efforts with that. And like I showed you earlier, not only for us as physicians, but it's gonna be the same thing for physical therapies and others as well. So moving forward, this is a slide I saw, white paper that came out, it's on the healthit.gov site.

And I'll say at the end of this presentation, I have some resources for you. You can make a screenshot of those to kind of share with you. But moving forward, are be whether we talk about an integrated care or fractured care. Here's one thing I'll tease you with guys. You're gonna see rheumatologists play more of a role as a primary care doctor.

That indeed if I put a patient on a biologic drug that might make the cholesterol go up, I might have to be able to manage that. Indeed if I put a patient on a drug that might make them have inflammatory bowel disease, I need to remake that referral to a gastroenterologist and help to manage that care. So we will not be relying on the primary care doctor in many of our cases, it's gonna be us serving the roles of primary care doctor. We just need to be telehealth enabled, we need to have this extended integration, but if you're outside of this, this is where you're gonna bend into issues because we won't be to cross talk and the patient's gonna be disjointed and you're see this. So this is an interesting white paper to brought up that concept.

And as we talk about moving forward, there's a new normal, be ready for it. Now my stethoscope is the iPhone or my iPad or my desktop, where I can prescribe, I can do evaluation of the patient virtually, I can get blood work order, I can get other labs, I can do the records, and then I can do their medications, not only from the hospital, from a nursing home, but now from their home. And that's where the new normal will be. The caveat, Rheumatoid, use the term, caveat, MTOR, caveat, Rheumatoid. So let the rheumatologists beware.

CMS came out and Everybody scrambled to come up with something. Can I use Facebook? Can I use FaceTime to kind of get connected because I haven't done anything with telemedicine? The answer is no, you can't. Some of these things are not HIPAA compliant like Facebook Live, Twitch, and TikTok.

You gotta be very careful. They did sort out a list of vendors and these are just not the whole list, but they say these are the ones that HIPAA compliant. Like we say, many people using DoxyMe, they have a free service, they have ones you can pay for. I mentioned others are not here, for example, HealthTap, American Well. And many of these things you wanna make sure, hey, do I need to go into a BAA?

So a business agreement, a business association agreement. So they signed off, they're HIPAA protected, so there would not be any violations by you or by them as you're doing these things. So make sure that the vendor that you are using is one of these that's HIPAA compliant. Again, I'll give you the website where CMS has put out that we can kind of follow those along. Here's my setup that many of you talked about.

So now we use Zoom Healthcare. So Zoom, the patient can sign up and get logged into Zoom. Here I am in my office. I have this screen I just use mock up to show you back behind me. I usually would have that so you can't see my office and my window back behind.

Something kind of web around. You can see that it looks like I'm in a studio. But let me give you an example of what we do for our patients. Also again, for the AMA on that website, again, this is a moving target. This was just updated a few weeks ago to say, hey, if I'm seeing patients who have suspect COVID and non COVID, what kind of interactions I'm gonna have?

So the patient here, I get a telephone call or I connect with them by audio visual like we are now and I do my evaluation. These are the codes and the times that we use if my nurse calls them, if our medical assistant checks in with them. Why is that important? Remember that one step forward slide I showed you for the EMA, it says about chronic care management. And you can get reimbursed for connecting with that patient once a month and say, hey, are you taking a biologic drug?

Or you have any knowledge of on your methotrexate? Methotrexate? You document that and you can get reimbursed for that. We do talk about you have to use the codes and all the things like that we talk about, so the modifiers. Let me go to the next slide that kinda goes you through.

On this AMA website, they go through like 19 different scenarios to tell you what we're looking for. So again, patient connects with you, you do the exam, talk about them, evaluation by telephone or remote by video, and these are things you want to look for. A lot of it is time based. I tell people, first you gotta make sure you have at the top of them I visit, hey, I've got the consent. That in lieu of a physical exam, I'm actually a patient's consented to let me do a virtual evaluation.

That I've identified who that patient is. That they're in one of the states where I have a license, a legal authority to practice. That's my first kind of smart phrase of what are you going to put at the top of my note? And then everything else kind of flows from there. I talk about, hey, I do a mental exam.

If a patient's alert and oriented, they know it's me. I do a look in their mouth, I look at their skin, I do the joints, I'm reviewing labs. And God forbid, I give a Medrol DosePat, it's almost like a level four visit. So you can put your standard codes on, document the time, and down here it tells you the modifiers you want to use. Remember that most insurance companies will go along with the CMS or the Medicare modifiers and codes, but you might wanna check with your individual payers.

They might require other things, but most of them are following suit. Just like I showed you coming from the American College of Physicians that letters have been sent out, they're doing that for all the other carriers. And many people like this year, Aetna, have already taken them both saying, hey, we're covered at full stream. You document a level three or level four exam, we will reimburse just like you were seeing that patient in a little bit of a lifetime. Pay attention to these because I say the target is moving and every week or every other week these things are being updated on the websites.

So let me give you a scenario. This came out by a group called bright.me, thinking about an algorithm. And this is one of the things our patient, I think even heard Jack complaining about it, RWCS, say, Hey, I hate Epic, I spend more time hitting the buttons on the keys and doing the patient. So a patient calls in, example say somebody got some respiratory symptoms or it could be a rheumatoid or a gout flare. They call it for a fifteen or twenty minute appointment.

Most of my time is spent documenting stuff on electronic medical records. I gotta hit the right buttons to be billed for it and do all those different things. And this is where we were before COVID. After COVID and moving forward here, you'll see systems that have come up on this company's chart and say, hey, the patient codes and logs in, they put in their top symptoms, I'm having pain, I'm having stiffness in the morning, I have a fever, whatever. And the computer gives me an algorithm.

Hey, this could be a gout flare. Hey, this could be rheumatoid arthritis. And now it only takes two minutes of my time on electronic records where I can focus on my intervention. So moving forward, you're gonna see more of this kind of artificial intelligence being done to help us kind of tweak out. It might say, come back to say, hey, this is nothing, this is your chronic back pain, you need to call your PMR physician.

So I'll give you some scenarios going back to that saying, which patient needs to get an exam? So I got a patient, he calls me up, Hey, Doctor. Wells, I got these lesions on my skin. I don't do that over the phone. We can say, Hey, let's send me some images.

We can look at that and we can connect live. So in a typical fifteen minute visit, three minutes of my time, through stuff with your issues. Have I a patient already, my MA checks them in, write down the one or two things they want to discuss. Hey, I have some retinas on my eye. I got these sores on my neck, swollen up my jaws, what's going on?

If have rheumatoid arthritis, I'm doing a rapid three. We talk about the health assessment questionnaire. I do a visual inspection like we talked about, talk about the prayer sign, can they move the arms, moving the arm out to the side, suspecting rotator cuff disease. And before the visit even, they have skin stuff, they can send me pictures. So that goes in and my MAs are pulling that up already.

So getting those visits teed up for me already. I do this evaluation, I say, hey, I think this could be your discord lupus. Let me talk about what we want to do, relay that plan. Hey, this could be uveitis flare. I'm gonna call in a Medrol dose pack.

I need you to come in for a sample injection of a biologic and get you started. You recap that and summarize and you do your note and then you move on to the next patient. Do I need to see these people or can I do this stuff remotely? If you can't get them in, they can't wait three or four weeks to take care of these things they can get it under control. Now here's what I really would tease you with.

Do I need to lay hands on this patient before I make the diagnosis? He's got the skin disease, he's got some back to lightest, he's got the nail dystrophic changes. I ordered my x-ray show that he has arthritis mutilans here. This is psoriatic arthritis. I could do this in my sleep.

The same thing, give him my three sessions. I got a lot of skin disease, they had joint disease. This guy was a construction worker. He couldn't even put his boots on. I say talk about what we need to do, hey we're gonna start your own drug for right now, I don't need to wait on the QuantiFERON, I'll get my blood work done, I'll get the results back tomorrow, if I see any issues I'll let you know, relay the plan and then summarize.

This might be somebody you want to see back in a week or two. This might be somebody you want to see in the office the next day. So again, using these virtual visits to make that documentation and kind of follow those patients along. There are some caveats that talking about here. Again, we talk about the benefits and potential harm.

One of the things we're finding, and this is one thing, again, silver lining in the cloud is COVID virus, is that we are seeing that unfortunately not all of our patients, the students in Chicago say, hey, go home, do your e learning, but they found out that 300,000 kids have no internet access and they have no laptops at home. So we find out that, even though I want to do all this stuff and I'm talking about what we are moving forward, many patients are not willing or unable to track themselves, they don't wanna be involved. They might do a telephone call but they don't wanna have any of this other business with the stuff that I'm talking about tonight. So again, you need to know those patients and then you gotta talk about hey, we can stratify which ones need to be seen and how do you do those moving forward. I like telerheumatology because I never run behind.

The patient pays for fifteen minutes, that's what they get. I get a five minute warning, a two minute warning, then the link is cut. They want thirty minutes, they pay for thirty minutes. It allows me for more frequent effective follow-up. I say, hey, this is what we're gonna do.

Connect with me in two weeks. I'm gonna take some repeat images. Let me see those scan lesions. So you can increase consults. I've got some groups, you know, my colleagues says, hey, yeah, I know, I go through all these records, I review them, I say, no, I'm not gonna see them.

You don't get paid for that time. Why not review them virtually? Hey, based on this and this, you got back pain for seven years, oh, you got an ANA of one to 40, that's not lupus. Good news, Mrs. Smith, you don't need to see me.

So don't say no to those things, evaluate those patients, give them due diligence like you talked about, but not everybody needs to be seen. So you can do more oriented problems. I make the analogy, you send a patient to the surgeon, hey, look at the patient's got some right shoulder pain, look at the shoulder, and before the patient leaves the orthopedics office, he say, okay, by the way, Smith, I have some knee pain. They say, woah, woah, woah, my partner's a knee doctor, you need to see the knee doctor. So again, we need to be more surgical.

Somebody comes in with gout, I don't need to be looking at their nose and mouth for gout, it's mostly in their ankle and their toes. Somebody come in with lupus, back pain doesn't cause lupus. You know, we think about that you can do all those different things. The savings on the patient side is time of travel. Many of you are dealing with patients like me coming in for a distance, they come one or two hours away.

But think about if you're in Los Angeles, you're Downtown Chicago, Atlanta, a patient got to leave their office at home, get in six lanes of traffic, God forbid it's a traffic accident, you know, then they're delayed. You get more effective and frequent visits because they get right to the point. It's not going on for thirty minutes and talking about this and crying about all these other things, they really get focused. They don't have to go off from work. Somebody's at work, they go in the office and close the door, they can connect with me.

And one of the things we learned too, hey, Elise, she's got kids at home. She's gotta worry about, got two kids. One kid is sick, what are you gonna do with the other? Like many of you, my patients, they bring the whole family to y'all. They got six kids and the grandparents in my examining room.

But again, this is where telemedicine comes in. All right, so moving forward again, talk to some things from the AMAs things, looking at steps forward, so adopting telemedicine. Some resources out there, I've been talking about all night, the CMS, those that look at that website, cms.gov, if you click on the Medicare button, you drop down telehealth here and it has a list of all the covered telehealth services. You get the codes, you get the diagnoses here, and I just downloaded this and this was updated on March 30. So pay attention to that.

If you have questions about billing and things like that, it is all there, don't recreate the wheel. I can't stress enough, in 2004 when I started doing ultrasound, I came back, I just spent a week in Paris and came back, I said, I'm gonna join the American Institute of Ultrasound in Medicine. And as a result of that, I learned so much about ultrasound that I've seen the different journals, going to the meetings, seeing what's going on in that arena. The same thing about telemedicine, that if you're gonna be serious about this, you need to be. I'm reading this journal every month, The Telemedicine and E Health, a nice article this month in the journal from a group of Iran that talks about how they're doing telemedicine in Iran.

So join the American Telemedicine Association. You get access to all this stuff. All these different tools I learned, your devices to monitor things, I learned about that this year at the meeting. So that's what we recommend doing. So moving forward, and again, this is what I think, being provocative, think what we need to do.

We need to develop a virtual physical examinations. I know we all, was it Bates examination book we had as a second year medical school we looked at, that we need to begin to teach this in the medical schools, okay? And not only for us as physicians, but they need to incorporate into the schools for the APCs, nurse practitioners and physician assistants. So developing a physical exam. We need to develop virtual clinics.

So we talk about my practice, okay, talk about your practice, but it needs to be done in residency. Yeah, they have the hospital visits, they got the outpatient clinic, but they need to be done and now so doing a virtual clinic as well, doing residency and fellowship. So again, you had the tenant, you got the fellow in a room, they all get together, they connect with Mrs. Smith, the tenant's sitting in the corner while the fellow, the resident does exam and then the tenant comes around and get onto the camera just to verify some things and done. That needs to start in doing residency.

And then virtual meetings, I think that's gonna become the rule and not the exception. I think, kudos to what Jack has done. This year at RheumNow Live, only about 25 or 30 people were there physically, but you had a lot of people there virtually from around the world. Our ULOG meeting this year is gonna be a virtual meeting. The American Telemedicine Association meeting is supposed to be the May.

It's actually gone virtual. So virtual meetings will become the rule and not the exception. So moving forward, we talk about the four steps to adapt telemedicine in your office. You need to know the regulations, you need to know your service model, I talk about that. The licensure, know about your malpractice, all those things come in there, determine your technology and support.

So those vendors that you're using, DocsieMe, does it come with some support? If I'm in the middle of an evaluation and I lose a connection and something goes wrong on my end or the patient end, you know, am I still able to bill for that? All those different things need to be specified upfront. And I talk about the HIPAA laws, guys, very cautious out there, making sure you got your BAA in place with your vendors. And understand the appropriate practice guidelines as you go through these things.

So again, we talk about this, think telemedicine, telerheumatology, this is becoming the standard of care. I think the good news after this is that I think this will be able to say, we do need to improve, talk about, hey, we improve patient care. It's just not out there for me to make more money or see more patients. I gotta show that I'm doing something. We will become of other ways to virtual monitor our patients.

So all these devices, we haven't found the ideal thing for rheumatology yet. It's been used in ophthalmology and other areas as well. We need to know now the reimbursement and malpractice coverage, all those things are being worked out by AC, AMA, ACP and all those others. I tell you it's here to stay and don't go backwards. Here's one scenario I tell you, say, if you're in a group of three or four doctors, it might not be the 80 year old guy who's working a half day a week seeing five patients, it's gonna be the younger doctor that you put in charge, hey, I want you to become a member of the HEA, I want you to go to the meeting every year and bring back the resources to help me do my job.

So designate a key staff. Have the one inmate who's gonna set up your virtual calls and get people set in, when they log in to see you, the images are there, their refills are already set up, you click off and you got that fifteen minutes, you're off and running. Because I tell you, if you don't have a digital strategy in 2020, you don't have a healthcare strategy. So those are things I want to share with you. Again, this is why I say, hey, take a screenshot of this slide because it gives you all the resources and everything out there.

I try to be evidence based when I do my presentations. I have resources and references at the bottom of each slide, and just give you where I pull most of these data from, and of course some of my own experience. So with that, Jack, I'll end on this. I like the TNR here, Rheumatology. Why don't I end there and turn that back over to you for some time to questions and answers.

Alvin, thank you a bunch for a great review again on a very important subject. I just wanna flash this up so everyone can think about next week as well. Artie Cavanaugh is gonna give us Journal Club, a great article in the last few months from Annals Rheumatic Disease on the withdrawal of low dose prednisone in SLE patients and what does that do to outcomes in SLE. It's a very interesting article and I think that it will generate a lot of discussion going forward. So what we're gonna do is we're gonna do some Q and A.

Alvin, thank you for that. You know, there's so many places to begin. I'm gonna begin with a recent statement from the president of the ACP, American College of Physicians, said telehealth delivered remotely is essential to patient care during this public health crisis. That's really where we are. You know, I think that many of us have gotten better at this in the last few weeks.

What kind of maturation have you seen in your colleagues in the last month?

I tell you that the learning curve has been steep, but people have kind of hurled it. I go back, Jack, remember we're all dreading the use of ICD-ten and now we can know these codes in our heads, right? And that's what many people, they were actually forced to kind of get there because they had no other option. Physicians say the group practice was closed, they're having any revenue, patients are calling in, they need to have refills, they got all these different things. So we've seen that as well.

There have been some glitches and there will be, even I still have some too as well, okay. How do I connect that patient who doesn't have the internet access? We're talking about maybe getting them to go to the libraries to get it into the cubicle, the libraries are closed. So we're talking about what do we need to do? So there's gonna be a learning curve and that's why I say connecting with these meetings, now that ATA meeting, like I said, is gonna be virtual.

You can go in and learn all these different things about updates, about new devices and new tools and that's gonna be really key.

So I wanna be, before we get into a bunch of questions which are starting to pile up, if you have any questions go to the Q and A section and enter your question there. We'll try to get to all of them in the next half hour. I wanna do a sort of checklist, sort of a workflow if you will, for the telehealth visit. So patients are contacted ahead of time by my staff. I'm sure you do the same to schedule it.

And whether you're gonna do a telephone call, whether you're gonna do a tele video call within an EMR or within an application like you're using. So it's scheduled and then you have a time. And I like what you said that, you know, you're on time and everybody pays for the time that they get and that's how you should do your billing. Do you begin your visit with obtaining consent and permission?

No, my MAs do that. So when they call, the MAs do this, say, hey, first they document that they are, just review, give them, tell me your birthday. They don't go ask for social security numbers and things like that, but they do the consent for me and I confirm that I've done the consent as well. They do their refills refills and ask other questions. What are the two things you wanna talk about today?

So my MAs do some work already. And while I'm on the phone with one patient, my 01:00 to 01:15, she's already teeing up the 01:15 to 01:30 patient. So they got these people in the queue and kind of going through that. It makes it very, very nice to do.

So a lot of our docs are doing telephone calls. I don't know if they know they can use the DoxyMe to use the dialer there so they don't have to let their cell phones out there or their home phones out there. You can also, if you are using your cell phone, you can do a star 67 and dial the patient's number and it comes up as a private number so your information is kept private. You're not doing telephone visits pretty much. Are you doing almost all of them, video visits how do you mix them?

So now, I would say about 75% of mine are all done with the video. Again, of my older patients who don't have internet access at home or don't have a laptop, it's gonna be a telephone call. And Jack, I'll also tell you too, so on Doximity you have an app here, you can do a video, I don't know if that's HIPAA protected. So you can do a virtual, a video call or block your number from your cell phone using Doximity.

So one of the problems I encounter using, doing video inside of Epic is a screen issue and sharing the screen. So I have my documentation screen up and then when I want to look at the patient video, it's behind it. So when I'm at home and I have a two screen setup, it's beautiful. When I have a one screen setup, it may help to have a separate screen, Windows can figure that out for you, or to use your cell phone and on a tripod, and if you're doing calls by using your cell phone, whether it's in Zoom or in WhatsApp or FaceTime or whatever, you can use this as your second screen. How do you handle a second screen issue?

And Jack, I'm the exact opposite. So at work, I have a very nice setup, a large monitor, and I have a second one that I use for looking at my x rays, but now that's what I have. I can see the patient here and I got my other nice big screen to look at my Epic chart. At home, even I've got like a 17 inches laptop, I'm a little shortchanged. So I've actually submitted the question to the Epic team and to the people at Zoom, is there a way I can anchor that picture?

I just need a little box in there to kind of see them as I'm typing there. So at home until this crisis is over when I'm back in the clinic, have my little laptop where I can see it but at work, just like you, I have the two different screens where we can look at things as well. I like the idea about having my phone to do that as my Zoom and I can then look at stuff on Epic. So that might be something I try. I got the tripod thanks to your recommendation.

Having a separate tripod makes it, just makes it work really well. It seems like from your presentation, time is the essential issue here and time drives coding. Is that what you would you, can you restate that?

100%. So the two things that you have to get for CMS, you gotta do the consent and you have to document your time because it's all based on that. If you spend twenty or thirty minutes on the time, write that down, document, hey, I've on for thirty minutes and this is what we did. So time is money and that's what we're finding out now. And this is why the push here say, if you spend twenty minutes on the phone with somebody, you should be able to bill for that at the same level that you're doing.

And that's why the push for the ACP is not to go back.

Right, so the coding that I'm using is for phone calls, it's 99442 and 443. 443 for that twenty to thirty minute telephone call. And then everything else that I do by televideo is the same codes that I would use otherwise. 99214, 99215, 99204 for the new patient visits. So I think that that's really helpful.

Trying to get into too many codes gets a little too confusing for us that are just starting out. You know, when I looked at a lot of the questions, it seems like one of the most important, one of the most common questions to begin with is how comfortable are you at doing a tele video visit on a new patient? Are you comfortable doing that or do you only do face to face? Again, new patients, what do you do?

So like I said, I've been doing telemedicine for almost six years and before this crisis I would only see my follow-up patient by way of video. But now I've been seeing like the day I had two, I got two more patients tomorrow. And last week I had one, I said, why they even consulted me? A lady had a positive ANA and she didn't know why she, the test was done and they're calling me saying she had lupus and she didn't have lupus. So I am feel comfortable doing things.

So I think about those different things. Think about ankylosing spondylitis, think about psoriatic arthritis. There are a lot of different things where you don't need a physical exam because hey, I connect with you for fifteen minutes, based on this I suspect this could be whatever my disease, I get my blood work and x rays, I connect with them next week virtually and say, hey, you need to come in. So that's the thing that we do. So right now, we're trying to avoid patients actually into the clinic, I'm seeing new people that way.

Doing my workup, I still wanna do a hands on, listen to the heart and lungs, do a lymph node exam, all those different things, but I don't need to do that to get started on things.

So I got a question here from about what time do you use based on the AMA slide you showed? Do you use CMS time or CPT time?

So I'm using the CPT time just like you said. So I'm spending fifteen minutes with, like you said, I'm doing a 99,213 for most of my calls and follow ups. I put down for fifteen minutes with that and that's what I'm doing. So if I'm doing a telephone call, most of those are lasting ten to fifteen minutes. Those patients really wanna go on.

And unfortunately with the telephone call, I can't pull the plug or cut the link like I can with the video. With the telephone calls, they can go on and on. I have a timer going, I'm looking at that. Okay, now let me summarize, this is what we're gonna do, and we're gonna go from there. So the telephone calls, be careful because you can't go longer than you want.

You're talking about everything. The biggest question I get from my patient on the telephone, they say, hey, Doctor. Wells, how are you with the virus? You know, you ask about my health, but I really wanna focus on them. But no, I'm using a CPT code for most of my other visits.

So one of our listeners makes the statement that Medicare has proposed paying the same for audio and audio visual visits. Is that true?

Yes, and that's, yes it is. I'm sorry, it's a little lag. Yes there is, Jack, and that's a letter from the ACP that for telephone and all these other ones, they want to be able pay the same visit cost that it is for that we see them in person. And the reason that is they don't want all the patient to get sick and have to go to the hospital because that's gonna cause Medicare even more. So kind of evaluate them, assess them and treat them over the phone as opposed to having them come into the clinic.

And I don't think we're gonna see that change. Like I said, we won't be getting billed as much. It's gonna be somewhere in between. And that's one thing that's gonna come out of this. You're gonna have some patients say, hey, I saw them three months ago.

I'm doing a follow-up with someone with PMR just to make sure she's doing okay on the prednisone and go from there. I don't really need to have her to come into the clinic if she's doing okay.

So Doctor. Shikamitu from Toronto says, great talk, Alvin. What applications exist where you can independent of an EMR have patients upload images or things for you to use and still be secure. Is there something that you would recommend?

A very good question. Like I said, talk with your vendor and make sure they HIPAA protected. So with Zoom it is. Zoom healthcare, some issues came up that people are doing a regular Zoom conference and hey, was some security issues and people were tapping in, they didn't even know it in the background, but the Zoom healthcare platform is actually secure. So they said take pictures and then show them there.

We actually tell them how to do that. We even on a link, there's like a little instruction about how to do those as well. American Well, Docs. Me, they all have ways that your patient can images and those all protected. I don't want patients that's taking the pictures and emailing those to me.

They don't even have access to my email. I don't look at those. But that's one thing to look at. I think what to think, what you think about your vendors, many people got a vendor now to get things started to get over this hump, but moving forward, you need to go more to the Cadillac vendor. You need to get something that's gonna be all the utility of things that we talked about.

So one of our nurse practitioners here in North Texas asked the question, how do you set limits with patients when doing these kinds of visits? She's having visits and the patient's driving and then their phone dies and then they wanna go on and on and whatnot. So do you have any tips on how to set limits and set rules?

I tell you, setting the limits is always a challenge still because I got some patients like you, I've had them for years, Jack, and they just want to talk, they want to ask about me and do everything. I say, Hey, yeah, doing fine now. We're trying to really get to them. You got to keep bringing them back in. So knowing those individuals, But one of the ways I get to help that I have my medical assistants say, hey, what are the two things you wanna talk with me about?

They don't have much more time for anything else. I need a refill on my methotrexate, I'm having trouble sleeping. That's what we talk about. If they have a headache, they got the stomach upset, they got constipation, that's gonna be the primary care or it's gonna be another phone call or another visit. So you really gotta upfront, I see you wanna talk about this, I see you're still having pain despite your treatment and you're gonna focus things right there.

So know upfront when you open up the door, open up the line, what they want to talk about and that way you can kind of hone them in that way.

So of all those many tools that we could possibly use remotely, do you think thermography could be one of them?

So we might see that coming back Jack. There's some friends, there's a group out of Germany looking on something called a hand scan, all these different things. I think they'll look at a portable device that you can get to look at things. Mean there's this glove you can get on Amazon and say, hey, can I have my mobility there to look at all the different stuff there? So I can tell you companies are out there.

When I showed you, patient can log on and one hour get the device at home and another hour have the drugs, it's gonna be through the Amazon delivery systems. Amazon might even have like a little medical kiosk in their parking lot where you can go there and get see everything. It's just, the world is changing very, very rapidly. And that's why I tell groups to be involved and be ready and identify that individual who's gonna take this by the reins and run with it.

So Joanna Davies says out in California, she seems be surprised that her insurance biller is saying that you can get the same reimbursement for a phone call as you can for a Doximity video visit. Is that really your experience?

Oh, 100%. And that's why I said that the rules will loosen up at March 17. They say, hey, basically because we don't want people going to the clinic getting sick, instead of that visit, the telephone call will be reimbursed. Now that letter I showed you with all the signatures on there, they say, hey, we're reimbursed in that way, we don't wanna go back. We wanna continue to have that in place, but that's 100 percent.

And I verified that with my billing group as well for the last few weeks doing that stuff and for the two weeks your money for Medicare is into your bank account and that's what we see. So yes, but we don't want to go back for that. What we will find that with the insurance companies, Blue Cross, Humana, United, will they go along with what CMS has done? So yes, I mean, that's gonna be really huge for us.

So Alvin, I think Mark Fisher was thinking what I was thinking when you showed us that time breakdown, how many minutes you spent on everything. We're wondering while you're doing three minutes here, four minutes there, five minutes there, three minutes wrap up, who's doing the documentation? How do you handle that?

Oh, I am, and Jack, I'm doing, so I'm doing documentation as I go along. Well, I have my microphone. That one slide I show you, I'm dictating, I'm talking about stuff. She says, yeah, I have a pain, pain score of five. Yes, that my right wrist, right wrist pain.

I'm dictating as as I I go go back and forth using my Dragon speaking, going through things like that. If you don't do that, I can tell you since I've been seeing so many people back to back, I am kind of a little stressed to kind of get everything done. So every hour I may have to go back and wrap up a couple of notes, but the goal is to do a couple problems and be really, really focused. It's not gonna be the detail, you know, two page list and I'm looking at everything for a new consult, it's gonna be very, very fine. Arthrologist, I suspect rheumatoid arthritis, this is my workup.

You can just go bullet points and go from there. I'm not going on and like a prefaceorial dictation about what we're seeing.

So is there a cost to these services that we're talking about here? You mentioned that some of them are for fees. What kind of fees would a practice, let's just say a solo practitioner incur in doing some of these things?

You get what you pay for when you, that was right. You get what you pay for for some of these. I use American Well, for example. American Well, they charge you a fee for what you get out of your collection. Doximie, .c.

Me, they have a free service. You can actually go up to the next level which I recommend you get more utility doing those things as well. HealthTap, the same type of thing. They charge the patient, it's all cash based. The patient has to pay before coming in.

That model is slowly going away. That's why I didn't put it down because these things are being covered by the insurance companies now. So they're all different based on what kind of utility and tools you want to have with them. So Docs to Me is good but you need to look at some others. I really like American Well.

We use that and move with that because it couldn't cross talk the Epic. I had to have American Well print that thing out and get it scanned into my chart. So now with Zoom it goes directly in there so it decreased that step. So play around with that. And another reason to join the ATA, you can go there, all the vendors are there and thinking about that so that's something to look at.

We've even talked about proposing to the ACR say hey these are three vendors that we buy, let the ACR buy the license and as a rheumatologist board certified and a member of the ACR I can sub license those in. So all those things are being talked about. We gotta be creative in this new environment.

So one of our speakers says that, you know, we're we're going into another phase now where the shelter in place may get relaxed, you know, and there may be a return to clinic in, I don't know, probably not May, but certainly by June and whatnot. How do you see telehealth going forward even as we start to transition back to the new normal, whatever that is?

Yeah, we will have a new normal. I mean, you're gonna have some people who are like the scary cats. I got people when they stopped taking their meds, don't care what I told them. I got some people, hey, no, I don't wanna come in into the clinic because I want them to be exposed. I can tell you as I go around, I went out on Sunday to get gas Jack and I'm seeing people with no mask on, no gloves.

I mean people are already beginning to come out and doing things already. So no, I think that even as we see stuff, like I say many of us like I on average day I'll see 25 patients before COVID. I might still say, Hey, let me see half of those or a third of those virtually. And if I can get paid with the telephone calls, we'll do that. And then see the other half, really my new patient, acute patients, all those different ones.

So to come up whatever's gonna work best for your flow and for your office, whether it's gonna be new or acute, some of your follow ups you can do. Like I said, for OA, fibromyalgia and back pain, don't I really need, they wanna come in, they wanna talk about pain and stuff like that, but they, you know, what else am I gonna do? It really gonna make a big difference.

So John Goldman in Atlanta asks, how do you get patients to fill out information ahead of time? Do you have a form that you send to them? Do you have an online service? I can tell you that I'm working on developing this on RheumNow as a service that your patients can use. And then when they fill it out, automatically will go to you the provider and you can have it in front of you when you see them and it can all be done ahead of time.

But I'm a few weeks away from having that. What are you doing in lieu of something like that?

And that's what we really need. And like I said, some patients, that one slide I said, the caveat is not everybody wants to be involved. They don't want to do the self tracking. They don't have the access. It's my medical assistant.

So we don't do the full hack, but they ask their pain scores, they ask about their overall function and then how they are fatigued. So those are three scores I have up front. In reality, they fill that form out every visit. Some patients push back, they don't wanna do it at every visit, but my medical assistants. So again, because they're not having the time to take the weight and do the blood pressure and do all those things now, they're taking those times they would do that to ask those three questions, have the patients say what are the two things they want to discuss?

So have your medical assistant to kinda do those things before you set that up. So when they say, hey, I get alert on Epic, it turns it from green to yellow means it's time for me to go in, I see that it turns yellow, I can contact the patient on the phone or I can connect with them on the video. That means they've done their work and they already had the refills there. I go in, I click off, yes, they're methotrexate, they're folic acid and boom, it goes to the pharmacy. So they've done all that stuff just like they were, they were rooming the patient.

So no, my medical assistants do that. I don't send out a form to people because I tell you the big challenge we need to do is talk about how we have internet access and is it, like Obama and others say it should be free. And that's what medicine is gonna be delivered now so it should be free as we talk about how we can provide care to everybody.

So we have a question about centers that have fellows and how are fellows using telehealth and telemedicine. I can tell you at my center where we get a bunch of fellows, the fellows are way ahead of the faculty using the technology and are actually teaching the technology in many instances to the faculty. So it's really, it's a partnership. But what's your experience been with the training centers who and fellows who are using telehealth?

And that's where I think that we really need to begin to grow. So using now our physicians and learning. So residents and fellows as well. Like I said, the analogy would be here, their attendance over there reading a journal article while the fellow is talking to a patient on the phone a video and then the attendee gets up and verify what they want to do and go back. So you're gonna see that kind of scenario.

I think they have to be together the real time. I gotta see on my thing, can we do like a three way that we got here? Can I see them with the patient, the fellow and myself? Can I do that virtually? Do I need to be physically there for billing purposes and things like that?

So all those things need to be worked out. I can tell you that medical schools are to begin to do that now. They are doing just like they're teaching second year students ultrasound. Are already going into telemedicine. How can you use these devices?

Hey, here's a tracing, you look at the heart, here's what you're looking at from there. But this is something that we need to develop and move along and definitely for rheumatology.

So Doctor. Von Felt asked the question about less educated patients, you know, is telehealth, telemedicine sort of a best fit for people who are computer adept and have technology and not afraid of these kinds of things? And our patients who may not have those skills or that fascism with technology, are they gonna be handicapped or is this going to be a time and education thing?

So, and that's another thing as a society we got to address. I'll put another little spin on that as well. So what about the patient whose English is not their first language? So now with Zoom and Epic I can connect with a virtual translator or interpreter who can go through things with me as well. So now we've seen that.

So with some of my older patients, say if they don't even have a smartphone, like my mother in South Carolina, she doesn't have the internet access, she doesn't have a laptop. She see all that, the old cables, no voice over internet. So we said, hey, have a grandson or somebody take you to the library where you can connect and get on. Have somebody to show you how to develop that app or get it up on your phone. Now the old iPhones, iPhone three or four, dollars 99.

I would love to see like we do in Germany, when I write for that script, should be covered by the insurance. So virtual kit, that might be that smartphone going home and they can have somebody walk them through that. Just like we have patients come in, they have their wife come in with it because unfortunately they don't read, they don't understand, hey, I'm taking that purple pill, we don't know what that is. And they ashamed are to tell you that. So you need to say, if they don't feel comfortable, that's what a telephone call comes in.

And that's why the push is for us to get paid when we do a telephone call because not everybody has internet access and not everybody is not gonna be instrument savvy. They're not gonna know how to use these tools.

So I guess I wanna end with someone who's not quite so happy. And this anonymous person says what happened to the patient physician relationship? This screwed up relationship is on the basis, this sacred relationship is the basis of our vocation as physicians. Are we technicians only? What about the importance of touch in medicine?

Are we disintegrating into automatons? Will physicians become extinct? I think he goes on and on and on. He's really unhappy with the current situation. It's a crisis, buddy.

Get over it. I mean, you gotta adapt. Telemedicine may not be for everybody in the future, but I think that telemedicine is going to be one of the things that will happen during this crisis that might change the way we practice. And maybe not for everybody, maybe not for this person who's kind of unhappy with their current situation, but for a lot of us, this could change the way we practice and without, as you pointed out, without detriment to the patient or even the relationship. What do you think about, is there gonna be a lost relationship with this?

No, I do not think so. Again, I've heard that sentiment as well. I think the opposite. I can't tell you how grateful my patients have been. Oh, Doctor.

Wells, thank you for the phone call. I know you're thinking about me. All those different things. A couple of minutes on the phone, I'm reminding them to wash their face in their hands, I'm doing all those different things. I'm telling her, hey Mrs.

Smith, we got this crisis going on but I still wanna see you in the clinic. Can you come in in four months? You know, if you have anything in between that you can let me know. So it doesn't mean, hey, I'm just doing this virtual visit. I'm never gonna touch a patient again.

That's not the impression I want to leave. That you still need to see patients, that you will still need to do the physical exam. I'm still gonna interact with them. How often do I need to do that? I use fibromyalgia as a good example, not to pick on that disease, but I'm seeing that they wanna come in every other week, but what intervention am I gonna do?

On the other hand, I got somebody who's got uveitis, I need to see them making sure they are under control. I need to make sure to gout and all those different things. No, there's not gonna be say, Hey, I'm just gonna do computer stuff like I, we still need to see these patients. And I agree with you, Jack, we need to adapt and we need to use this stuff. Won't be every patient, but some patient where it's gonna be appropriate, I think that's gonna be the future.

I wanna end with a question from Melanie Barron about, you're seeing a patient by televideo and the connection drops and you have to complete the call by phone. A, how often does that happen to you? And B, which do you bill it as?

Yeah, but the default in the past, when I was doing charging people, said, Hey, I won't even give you a bill for that. But now the default is, Hey, if I lose a video connection like we do here, my internet has been slow, my wife's a teacher, she's downstairs teaching her class. I'm doing this presentation. If I lose this, would default it's gonna be a telephone call. Because the caveat is you still get paid at that same level.

There's gonna be some pushback, they're say, hey, got billions of dollars we're spending, so it's be gonna somewhere in between that. It's not gonna be zero, it's not gonna be the same amount, it's gonna be somewhere in between. So you're still gonna be reimbursed for that. So if I lose the internet connection, even if it's on for ten minutes, I lose it for the last five minutes, charge it as telephone call.

Alwyn, a number of our attendees would like to get some of your resources. Could you make a few of these available slides that we can put up on the website people Absolutely, can

that's why I put that there. Know many of you too can come, yeah Jack, I'll have you to reach out to let me know how to do that. I'm happy you can make all those available for you.

Okay, I wanna thank my good friend, Professor Alvin Wells for really another informative hour. You can find all of Alvin's content either wherever you listen to our podcast or on our YouTube channel or on our website. We got a bunch of Alvin content and this is gonna add to it. Next week, Artie Cavanaugh on doing a journal club on withdrawing steroids and lupus. We wanna thank everyone for their participation.

We'll see you next week on Tuesday night rheumatology.

Great, thank you all very much. Thank you.