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Melanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole. And joining me today is Dr. Jeff Curtis. He's a rheumatologist with UAB Medicine, and he's here to highlight how digital technology has really changed the landscape of medicine.

Dr. Curtis, it's a pleasure to have you join us today. I absolutely love this topic. I'd like you to start by speaking a little bit about how digital tools, digital health tools are changing the practice of medicine. I mean, I think even during the pandemic, it encouraged healthcare systems to be creative and innovative in their ability to deliver patient care. What role has technology played in the management of patients as it is now?

Dr Jeff Curtis: That's a great question and thanks for asking. It's a delight to be with you. This is a topic that I love to speak on because I think this really is going to be transformative for the practice of medicine in so many ways. We're only going to have time to touch on a couple, but I'm thrilled to be able to share with you. Some of them are recent advances or the applications, recognizing we're just going to scratch the surface of some of those digital health tools and their impact on medicine.

Let me start with the first one that maybe is the most glitzy, but really is maybe more useful than physicians might expect, and that is the use of virtual reality or VR. There's variance of course, mixed reality, augmented reality. Technically, it's whether you're in a fully immersive virtual environment or whether you are overlaying some virtual element of something that isn't there in real space onto your real life, but where you're going to bring new digital elements into the care or management of patients or one's own education. So, this might be quickly dismissed by physicians as something that video gamers are excited about. And there's obviously companies that have built brand strategies around gamification, et cetera. But in fact, medicine has done very well by this technology.

It was first evaluated in helping patients manage chronic pain as well as acute pain. But acute pain has honestly been the first focus that this, I think, has proven itself. So, acute pain is a problem for many of us. But in certain settings, it's incredibly vexing. For example, a burn victim that is on a burn or a trauma unit or cancer patients or somebody in a sickle cell crisis, those are incredibly painful conditions. Those are often consults to palliative care medicine for hospitalized patients. And virtual reality has been demonstrated to be able to greatly alleviate the pain and suffering of people in acute care settings. And in fact, in some of the places in which this is deployed, it's actually a tool that a palliative care team uses to help manage pain.

In some research studies, it's been shown to be able to reduce the need for opioids, either to reduce the dose or to more effectively taper, because you can bring people into an immersive world. You could bring them into sort of a cool glacier cave while they're having their burn dressing changed, or if they're in the middle of a sickle cell crisis where you can enrapture them and grab their attention to put them in another environment that frankly will be opioid-sparing with all the complications that we're aware of. It's a form of distraction, admittedly, but there is absolutely a physiologic response. You can measure that on a functional MRI. That's the place that's first proven itself. There have been numerous studies demonstrating effectiveness there, but the applications beyond that are myriad and I think there's great things that we're going to expect from this technology in the future.

Melanie Cole (Host): That's so cool. And I think I even just saw that on one of those hospital shows recently where they did use virtual reality for just that purpose. How cool is that? So, there are so many digital technology innovations right now, Dr. Curtis. As we're looking at some of the other forms besides VR, we've got heart condition monitors, we've got all kinds of things really on the market today, how much do you rely on some of that data and patient-provided data when you're managing patients' health? And how is that self-monitoring digital technology really transforming the health of individuals?

Dr Jeff Curtis: This is a work in progress and, honestly, most physicians are not using this. And frankly, for most, it may not be on their radar screen. Fundamental, as in all of medicine, is to ask the question, "What problem do I need to solve? What's not getting it done using the tried and true methods?" So for example, in my world as a rheumatologist, there are many people that are on biologic drugs or targeted or immunomodulatory therapies for rheumatoid arthritis or lupus, or other kinds of inflammatory conditions where I just don't have access to a pain management specialist or a pain psychologist because they're in short supply or a mental health provider.

So, that's the problem that I and, frankly, many in medicine might need to solve. We're using virtual reality and a digitized program to teach patients skills. In this case, cognitive behavioral therapy skills, what some might consider some of the wellness behavioral interventions, you know, mindfulness or meditation techniques. So, we're using VR to help manage chronic pain and anxiety for patients that I don't have somebody to refer them to because those specialists are in such short supply.

So, to be able to teach someone skills or to help them think through what are the future decisions that you might need or want to make about your own healthcare, let me help put you in a scenario where you have to think about you in the future. VR has done that with smoking cessation. "Here's what you might look like if you quit smoking your two packs a day of cigarettes at age 60, versus if you continue smoking two packs a day for the next 20 years, here's what you may look like at age 60." So, this idea of age progression, but envisioning your future self to help make treatment decisions today. So again, teaching people skills, thinking about making decisions today, but predicting or envisioning the future in a visual, immersive way, virtual reality is great for that. But as you just alluded to, the pandemic has brought us different problems, and that is people don't want to come back to get care because of a global pandemic.

So, remote physiologic monitoring or RPM and remote therapeutic monitoring or RTM, these are new digital health technologies where patients could use physiologic biosensor devices or mobile apps or both to help inform their doctor as to how they're doing. And to answer your question, in some specialties, not as much mine in musculoskeletal medicine and rheumatology, this has taken off. Because for primary care and some specialists, you've got a physiologic biosensor that is absolutely critical for some of the disease states you mentioned. For diabetes, continuous glucose monitoring tells you most of what you need to know to manage a patient's blood sugar. There's a sensor for that. For a heart failure patient, the idea that your patient could step on a Wi-Fi equipped scale, that's all he or she has to do every morning, and that lets you or your heart failure clinic nurse titrate the dose of diuretic to the goal weight that makes perfect sense. Or for dysrhythmia detection in primary care cardiology settings, or a simple a hundred-dollar home ambulatory blood pressure cuff that connects to your patient's phone, you can get a blood pressure reading every day. All of that is called remote physiologic monitoring or RPM.

During the pandemic and even right before it, that is now a reimbursable technology. So, this is not something that's kind of an, oh, gee-whiz, a few researchers in their ivory tower are doing that, but this is now something that is slowly percolating out to primary care and specialist settings. This has now been reimbursable by Medicare, the Center for Medicare and Medicaid Services since 2019. And this approximately would reimburse a physician for a patient who has Medicare or some commercial insurances about a hundred dollars per patient per month. And the reason that I mention that is how to sustain that sort of an intervention or program is always important for physicians to think through. And frankly, this probably provides some practices a source of ancillary revenue, as well as helps them improve care. So if there is a disease state like those I mentioned where a biosensor device might be helpful, I think this is a tremendous blessing and augmentation to the care that we provide in the office.

Melanie Cole (Host): What an exciting time in medicine. And I can hear that in your voice, Dr. Curtis, too, because it rises as you're talking about all of this digital technology. I can hear that you're passionate about this. In my mind, it's not only innovation in terms of all the new technology that we're talking about. And as you mentioned, continuous glucose monitoring, diabetes, that really is amazing stuff. But there's also been an innovative shift as a physiological and philosophical shift from providers working in silos to working together, providers taking advantage of artificial intelligence and clinical research to disseminate their data and research quickly, especially for public health emergencies like we saw with COVID and digital research and information sharing, basically what we're doing here on this podcast, but in other forms. How have you seen that manifest itself as well?

Dr Jeff Curtis: That's a great question. And I think all of us have started to realize even those in academia, you know, one even large academic medical center or health system is not going to be able to nimbly answer all the questions that need to be answered using the tried and true brute force methods. So, I've seen a tremendous enthusiasm for data normalization and, as you said, data sharing. So, the idea that we're going to create a data infrastructure, some of those might be a health information exchange where multiple health systems, hospitals, or even networks that span states could share information in a very rapid fashion. And then, you can apply big data or AI or machine learning approaches to sift through that data. And there's a number of highly visible studies, particularly looking at long-haul COVID and some of the treatment options that have been tried, some successful, some not so successful to help manage acute COVID, where if you didn't have a digital infrastructure to aggregate data and to be able to analyze it in a very fast fashion using state-of-the-art analytic and data visualization tools, there's no way that you could get the rapid cycle answers that we need to take care of patients.

Melanie Cole (Host): Yeah, it is amazing to me how that's working. Now, how have you been using telemedicine and how has that evolved during COVID? We've been talking about all the digital monitoring and the remote monitoring. Also, telemedicine kind of came into its own during COVID, and I don't see it going anywhere because, as you mentioned, people are a little bit fearful still with an ongoing pandemic, but also, and I hate to say it, there's the convenience factor for both the physician and for the patient. Certainly in rural areas, telemedicine has proved itself.

Dr Jeff Curtis: Well, I think you're absolutely right, although I think it's rather specialty-dependent. Based on some large national surveys and data sources, psychiatry seems to have been the bastion that really, really wants to, and of course, values telemedicine. That feels pretty intuitive to me just because the physical exam aspect of seeing somebody face to face is presumably lessened for most psychiatric conditions than a number of other medical specialties. So, you're absolutely right. I don't think that the need for it or the benefit is going anywhere, anytime soon. That said, I have seen a rather attenuation in many providers' use of telemedicine. I think some of it is comfort with technology. This was sort of thrust upon us and we had to get to be digital health experts, at least in this one small way, almost overnight in March of 2020 with the pandemic. And many said, you know, I don't really need that, and it's a convenience for me to have the patient right in front of me, et cetera.

On the other hand, what I think sometimes providers lose sight of is, is it convenient for the patient? And as you said, if you live in a rural area, and certainly for my university practice with my colleagues, people may drive two or three hours each way to see me. So sure, it might be slightly more convenient for me to manage conditions in-person because they're in front of me, but not every single patient in every visit needs that. And so, I think sometimes providers fail to recognize your patient would really value this. Because if it's something routine where you don't need an exam to really help figure out what to do, history and visually looking and visual inspection over a video feed might be sufficient, figuring out who are the patients that are best suited for telemedicine, what are the diagnoses that are most amenable to telemedicine, and that's where some of the other technologies like that remote therapeutic or patient monitoring come into play.

Remote therapeutic monitoring actually allows now for reimbursement with patients just using an app. So, patients can tell you how they're doing once a week, couple times a month, for example. and to give you patient-reported outcome or PRO data several times a month, so that you, the provider, can know exactly what's going on with your patient. Not every three, four, six months over telemedicine in isolation, but, you know, if you had a near continuous data stream where you're having your patient spend five minutes on their smartphone, answering a couple questions that you've pushed out to him or her, so you know when there's a deviation or a perturbation of how she's doing. And now that telemedicine visit is much more comfortable for you because you get a sense that, "Oh, all of her PRO data is tracking just the same as it was as when I saw her six months ago, now I'm comfortable with a telemedicine visit and I don't necessarily have to lay eyes on her." So, my point is really that telemedicine coupled with some of these remote patient monitoring strategies, whether they're app-based or biosensor-based, I think offer tremendous potential to make care more efficient for us.

Melanie Cole (Host): I agree with you completely, and I think we're learning more about which service lines in which areas of medicine it's proving itself, as you said, psychiatry. Whereas in ophthalmology, really, you need those hands-on physical examination and rheumatology, orthopedics, I mean, it's all kind of-- we're learning, right? We are learning. And as we wrap up, Dr. Curtis, I'd like you to kind of summarize how remote patient monitoring fits into clinical care and research, practical applications, where you see this going in the future. And if you were to speak about the areas that are unique to UAB that set you apart and why it's important to refer to the specialists at UAB Medicine, that would be great.

Dr Jeff Curtis: Absolutely. So, the idea that we could provide continuous care and that that continuous care is appropriately reimbursed, not for research where a research grant ends and the whole infrastructure comes to a crashing halt, but simply as part of providing continuous care or what I think of as 360-degree care. I want to know how my patient is doing, not just the three or four or five times a year that she's coming to clinic. I want to know how she's doing all of the time to best help her and to manage chronic illnesses. And most physician specialties have that same ask and opportunity. So to be able to use a mobile app for patients to tell us how she's doing, to me, that offers tremendous potential to improve care and to get us out of this episodic mindset where I don't think much about how you're doing except the several times a year that I might see you in person.

I think also it allows itself to blend co-management of care between primary care physicians or people who are referring to UAB and UAB providers. And there's a number of diseases for which co-management or co-production of care is essential. For example, gout. Gout is often undertreated or poorly treated. There's a variety of reasons for that, but that's been shown over and over again. And that or many other examples like it is where integration of how the patient is doing with both what the primary care or referring physician might know and be managing in terms of comorbidities as well as what a specialist like a rheumatologist might be managing, having a digital data stream interspersed with the serum uric acid that might be drawn at the primary care doc's office might be drawn at UAB or a specialist's office. To me, those kinds of diseases where information-sharing is intrinsic to the infrastructure that we have built for care production. To me, those are just natural winds and the patient comes out much enriched by having their physicians effectively communicate via this digital data stream where both sets of providers know what's going on.

Melanie Cole (Host): Wow. Very beautifully said, and such an exciting time as I've already said. I hope that you'll come back, Dr. Curtis, as things update and as we learn more about this digital age and this digital technology and how the medical innovations are really making these advancements happen at such a fast rate, sometimes it's hard to keep track. And thank you so much for joining us today and filling us in on some of what's going on.

A physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. For updates on the latest medical advancements, breakthroughs in research, follow us on your social channels. I'm Melanie Cole.