Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we're highlighting using telehealth to improve access to trauma care among injured rural patients in the U.S. And joining me is Dr. Zain Hashmi. He's a trauma surgeon and an Assistant Professor at UAB Medicine.

Dr. Hashmi, thank you so much for being with us. I love this topic. I love the aspect and the benefits of telehealth. I think it has transformed and changed the landscape of medicine and certainly since COVID. Can you tell us as we begin how you've been using telemedicine for patients and any examples you'd like to share of how it's being used for your team, such as remote patient monitoring, ambulatory inpatient on demand, critical care? Anything you'd like to mention how you are using it.

Zain Hashmi, MD: Well, thank you for having me. And I'm excited to talk a little bit more about some of our experiences and the efforts that we're putting in into establishing telehealth specifically for trauma care. We've been starting to use telehealth in certain aspects. But as I'll go through and explain, you know, I don't think we are utilizing the entire spectrum of telehealth services that are available to benefit our patients. And I think that's the challenge that we're trying to overcome here.

So in trauma care, you know, one of the biggest challenges for our rural state like Alabama is access to timely trauma care. So, when a patient gets injured in rural Alabama, they have two options. The local EMS crew can transport them to the nearest available hospital, or they can transfer them to a trauma center, which has the entire gamut of patient care resources available to take care of that patient. And in most of the cases, the patient gets transported to a local hospital where they undergo initial evaluation and subsequent transfer, and that is where we get involved and have an opportunity to affect care.

Currently, what happens is the patients at those hospitals, the physicians who are caring for them, they give us a call using telephone and we discuss their care and decide whether the patient needs to get transferred over to UAB or can get care locally. But, you know, as you can imagine, this form of telehealth is quite rudimentary. It lacks, that two way audio-visual communication. We don't have access to patient's chart and imaging. And I think that's where we're looking forward to using the more modern system of telehealth in an established fashion to take care of patients in rural communities.

Melanie Cole, MS: Then, let's talk about putting that into action. And as we're applying this to trauma care and we think of whether it's accidents or even stroke care, do you envision that EMS will be using both audio and video to show you what's going on at the time?

Zain Hashmi, MD: Yeah, I think that's the way of the future. I think what will happen is you will see that telehealth in some way, shape, or fashion will get incorporated through every phase of trauma care from right at the point of injury with talking with the EMS crew at the scene to taking them to an outside hospital where they get initial treatment to make sure that their injuries are stabilized and they get initial evaluation and then assessment if they need transfer to a higher level hospital or a trauma center. And not only that, even after they get discharged from the trauma center, we have an opportunity to engage and provide long term care through, you know, there are programs for telehealth and rehabilitation and there are programs for telehealth and psychiatry. And I think that's very important for our patients to know that we are actively working through to make sure that patients get benefit from the entire spectrum of telehealth services available to them through their entire continuum of injury care.

Melanie Cole, MS: Dr. Hashmi, we've seen since COVID this shift into telehealth for even regular appointments or quick visits and certainly mental health appointments, as you've mentioned. And I don't think it's going anywhere any time too soon. But when we talk about trauma and we think of some of the challenges or barriers, is HIPAA considered one of those barriers if it's on site and on scene of a trauma or stroke or something along those lines and information is being transported in real time to doctors that can help EMS or the on-scene responders? How do you envision all of that going together?

Zain Hashmi, MD: Yeah, that's a great question. I think that comes up often in terms of making sure that we have total health information security. And also, the perception of health information security, both for the providers involved as well as from a patient perspectives as well. And I think the way to do that is to make sure that the platforms that we are using both for telehealth are HIPAA compliant, as well as the entire programmatic infrastructure that we set in motion takes care of that. This is the technical aspect of it.

The other aspect of it is the messaging that we put out associated with that to dispel some of these concerns regarding, you know, health information security. Majority of the health information is now stored in some sort of a server somewhere, even for regular in-person hospital care. And that is not much different in terms of when we talk about telehealth. All that information is stored in similar servers with similar data security infrastructure. So when we talk about that, I think, yes, managing that telehealth technical aspects of health information security is important, but I think even more important is that messaging to make sure that everybody understands that we're taking this absolutely seriously.

Melanie Cole, MS: Messaging is so important. And as you say, the perception of whether or not this would be secure. So, how do you intend, if you're planning to address some of these challenges, and to implement some of this into your practice, how do you address these challenges?

Zain Hashmi, MD: Yeah, I think the way you address these challenges is to talk to people. I think that's the key. And by that, I mean, I think we engage stakeholders 360 degrees from patients, from EMS providers, from providers out in the community, ED physicians, to general surgeons out in the community, to trauma surgeons at level 1 and 2 trauma centers. Engage the entire village, so to speak, to achieve consensus about how we are going to do this. And it'll take dedicated programmatic research efforts to accomplish that. But I think that's exactly what we are setting out to do now, is to engage with this broad community and achieve consensus about what's the best way to do this.

Melanie Cole, MS: And as you're looking at some of those barriers, Dr. Hashmi, what about insurance implications? Is this cost effective? I would imagine it's very cost effective because you're reaching rural areas without actually having to go there and the satisfaction for patients and for the responders because they are getting immediate in real-time information and help from doctors such as yourself. But what about insurance implications?

Zain Hashmi, MD: I'll give you some numbers for that. So when we look at across the nation, reports suggest that up to 40% of patients get transferred between hospitals to seek care, trauma patients. Once they're transferred to another hospital, a lot of those patients get discharged. And so, we think that we can reduce this transfer rate and potentially avoid these interfacility transfers, and that could be huge cost savings for the system. And I think there are insurance companies which will be interested in and getting on board with this when they realize the care efficiencies that will go up when utilizing telehealth.

Melanie Cole, MS: I agree with you. I think the cost savings alone, not to mention the actual life saving that will be so helpful to first responders in the case of trauma. As we think about the ways that telemedicine is changing the landscape of medical practice all over the country, I'd like to think about provider collaboration and opportunities for growth, new research being shared. When it used to be researchers working in a silo, now they can reach out to their colleagues all over the country in this fashion. Where do you see telehealth being used as far as research and collaboration for trauma, specifically.

Zain Hashmi, MD: You know, from a programmatic research effort, when you look at it, I think there are tremendous research opportunities. I think the one thing that it will enable us to do is really develop what we call an inclusive network of trauma care facilities where we get this data synthesis from multiple facilities, all in one place, so that we can do quality improvement efforts. This is not unlike what has been done for level 1 and level 2 trauma centers across the country that is already being done by the American College of Surgeons through their Trauma Quality Improvement Program. So, it will enable this data collection, which will further enable quality improvement initiatives. But it will also enable this crosstalk of understanding what the challenges are, which is the key step, asking the right questions. That will lead to problem-solving initiatives downstream.

And I think the first step really is to understand these knowledge gaps. When we start talking to each other out in the community, we will really understand what the challenges are in the community when taking care of these trauma patients that we may not understand sitting in big cities and level 1 trauma centers. And once we understand those knowledge gaps, we can address them by setting research priorities and then work collaboratively to overcome some of these challenges.

Melanie Cole, MS: This is such an interesting topic, Dr. Hashmi. And as we're thinking about how telemedicine can transform your decision-making scenario, I'd like you to speak to other providers and summarize for us some ways that you really feel the key learnings from this episode today that other providers should know about if they may be setting up their practice for telehealth and specifically for trauma situations.

Zain Hashmi, MD: Yeah, I think I would say is approach this opportunity with enthusiasm, but also approach it with a lens of learning, because there's so much to learn from actually doing this, but also learning from what other fields have experienced so far. So, for example, stroke is a very good example. Tele-ICU is a great example. You know, and we have so much to learn from how other telehealth programs have been implemented, that I think, you know, once we understand how other people have done it, once we start engaging with community partners, I think it will lead us to this conclusion that telehealth is here to stay. And if we use it well, I think we will help improve the care of our patients.

Melanie Cole, MS: Great information, Dr. Hashmi. Thank you so much for joining us and giving us a little look into the future of telehealth and trauma and what you're doing at UAB. Thank you again. And for more information, you can visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. Please always remember to subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. Thanks so much for joining us today.