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Michael Carrese: One of the most dramatic changes in healthcare caused by the COVID crisis is the exponential growth in the use of tele-medicine. People are now routinely doing doctor's appointments over zoom and similar platforms. And that's something that was unthinkable just a few months ago, but the use of technology to help patients get and manage their care goes beyond just a video session with your primary care doctor. There's also a growing number of technologies to support care in the home and more web-based and mobile tools for patients as well. We have three experts with us today to sort through all of this, talk about what it means for patients, and also take a look at the future of what's known as e-health. Dr. Dragos Banu is Physician Leader and Medical Director of Primary Care at the University of Vermont Health Network, Alice Hyde Medical Center. Todd Patterson is an Occupational Therapist and currently Director of Home Health Services and the Interim Compliance Officer at UVM Health Network, Home Health and Hospice. And Todd Young is Director of Tele-health Services for the UVM Health Network. Thanks to all of you for being with us today. So there's obviously a lot to talk about here, and perhaps it makes sense to start with assessing the current state, how it's working out for patients and providers. So Dr. Banu first, how has the increased use of tele-medicine been working out for patients and providers at Alice Hyde?

Dr. Banu: All of us had to transform ourselves along with having compassion and understanding for our patients, because it is also new. To answer your question in a rural area where Alice Hyde is located, which is Malone, New York things have been working really well. Patients were, and some of them still are scared. And although we're all doing our best to make it as safe as possible, there's a degree of comfort for some of my patients and my colleagues, patients just to log on the internet on different platforms. Zoom seems to be working really the best for us and get on with their providers and take care of their issues. That is something chronic that is something acute. We have had the tremendous experience with this program, and we have seen less and less patients, agglomerating our emergency rooms, which is important at this time.

Host: So, tell me a little bit more about that. You think that they are comfortable enough with tele-medicine, that they're connecting with their doctors that way and not holding off and waiting until the problem gets bad enough to go to the ED?

Dr. Banu: I wish to tell you that everybody's comfortable, but there's different degrees of comfort that different patients have. I think we have a good pool of patients that are very comfortable. And as a matter of fact, prefer that type of appointment, they are not feeling well. They're in their homes, at their discretion in their bed as some of them. And they could FaceTime me or get on zoom with me or their provider. And they, they feel safe and they feel very comfortable. We have patients who is not necessarily a question of comfort, serving a rural area. I think one of the key points that we're challenged is connectivity issues, internet issues. Some of our folks live very remotely off the grid sort of speak, and it's difficult to access this type of technology. And there are some things that we've been trying to innovate to the best of our ability. An example was for that type of population, we have a sort of a drive-through service. They can come in, get in from their cars. Somebody gives them an iPad, they connect to zoom and we sort of try to help them. And then you have the folks that really feel more comfortable to come in person. And we serve all of the above to the best of our ability.

Host: Yeah. There's got to be flexibility on both sides. I guess Todd Young, a director of tele-health for the UVM Health Network. I know that issue of access to technology has been something you've been paying attention to. What would you add to what Dr. Banu said about that?

Todd Young: We are trying a lot of different creative things and Dr. Banu's example of drive-through is great, but we're also working with different agencies in both States to find places where folks can get tele-medicine if they can't get it at their home, because they don't have a device at home or they don't have bandwidth. So we're working with libraries, we're working with congregate homes, we're working with municipalities to find places where folks can come in and both get technical assistance and networking devices to make these types of visits happen. If folks can't come into the office.

Host: What would you say about access to technology in terms of the home health space?

Todd Patterson: Yeah. We've had similar challenges. Some of it's generational comfort using the device. We expected to see a lot more tele-health than phone, but we found that there were certain individuals that prefer the phone. Even though we really encourage the use of zoom. We've also reached out to local sub-acute nursing facilities and assisted livings that we partnered with and put tablets within those buildings for the duration of the pandemic, so that we have an opportunity to access them.

Host: So, staying with you, Todd Patterson on home health, in addition to the zoom interactions that we've touched on already, you also with home health, have a lot of remote monitoring capability. What would you say has changed in the last couple of months during COVID, as far as the use of technology in home health?

Todd Patterson: I think that we've seen a change in trending initially. It was interesting. People were declining the use of remote patient monitoring because they didn't want a visitor in their home now that they understand that we have enough PPE, and it's become more normalized in the world, people are accepting those services again. So we've seen a large uptick again in the ability to get in and provide this remote patient monitoring support to families and people in the home.

Host: Dr. Banu, I want to circle back on the experience over the last couple of months, what do you say has happened on the provider side? What's your assessment of that?

Dr. Banu: That's very good question. We've had as anything in life. We have various personalities and various degrees of comfort. And as we have different types of patients, we also have different types of providers from different ages. And I've seen sort of a dichotomy, some of the folks that are very comfortable and extremely efficient and have actually increased access in their practice. In addition to that satisfaction and happiness at work has increased because of tele-health. Most of them also have the opportunity to work from home, which is very nice to be able to do, especially when you have young kids. On the other side, we've had providers that really had a hard time with this. Somebody more traditional that really is used to putting hands on their patients and examining them and listening to their lungs and abdomen and their heart, then have a more hands-on type of training, have had a more difficult time adjusting. And that's also a reality and I think everybody's doing their best. And as my colleague mentioned, some of our providers prefer the video. Some of them like more in person, some of them like the phone, but again, I think we have a combination, and we're flexible and that's how we've been dealing with it so far.

Host: Yeah. And it certainly was a quick adjustment for everybody to make back in March and April. So Todd Young, I'm turning to you to get a bigger picture view on what's happening with tele-health in our region, still with the COVID situation in mind. At this point, what are the lessons learned do you think about having to make this shift and how it's all playing out?

Todd Young: Couple lessons learned are around patient satisfaction. We've done a lot of surveying of our patients to understand the difference between in-person telephone and video. And we're finding that our patients are quite satisfied with these new modalities for care. And so part of that big picture is knowing that patients want this to stay. So what we need to do as an organization, that UVM as well as any of the partners in both States is really focused on making our programs sustainable. And a lot of us have had to grow our programs really rapidly. We went from 150 users to over 3000 and in a month’s timeframe. Not everything was done completely well during that period. So now we're coming back and we're refining workflow and operations and improving infrastructure to make it sustainable. So that's the focus. The other focus is working with our payers. A lot of regulation, a lot of payer decisions were made during this period as well to accommodate tele-medicine. And we continued to work with both the government and the private payers to make this a sustainable part of healthcare going forward.

Host: Right. They sort of suspended a lot of those limitations to make care possible during COVID, but it's still an open question as to whether there'll be reinstated or not. Are you sensing that this is the new normal? We just cannot turn back the clock?

Todd Young: Yeah. Our state governments were in good shape prior to COVID and their modifications were minor. Our private pairs have been very supportive, but we certainly need them to be supportive going forward as well, where we're really concerned. And we continue to work is with CMS and the Federal government. And that's where we were most restricted prior to COVID. So lots of work being done with the delegations to make sure we have a good path going forward.

Host: Todd Patterson at home health and hospice. So I'm wondering if you want to address a little bit, the patient end of this talked about getting over kind of a comfort level hump, but do you think this is increasing the ability to serve more people at home?

Todd Patterson: We serve a number of different populations because we have our family and children's program as well as our adult programs. And what we're seeing is that the family and children and programs are really benefiting from this. The families seem to really be embracing the technology. They've been doing therapies over the tablet as well. And so I can see that continuing on that's of course, mostly state funded. And so the reimbursement was there to support it. Whereas with our adult programs, we also lean heavily on Medicare. They allow us to do the work, but they won't recognize the work as a visit for reimbursement purposes. So I think the other part about the adult home health is that we didn't leave the field. We continued to treat people in their home unless they refuse to see us. If they refuse to see us, then we would try and use some of the tele-health platforms. And that allowed us to have some connection with them, which was really good to see them through the pandemic.

Host: Dr. Banu, I'm wondering if you can address the folks listening to this who haven't yet had a tele-medicine experience and who are apprehensive about it, what advice do you have as far as doing this for the first time and what the experience is like?

Dr. Banu: As a patient, and I remember myself experiencing it being on the other side, at the beginning it's totally fine and normal to be apprehensive and does something different and it's something so personal, but the best way is really to try it and see fits for you. Most of us who have tried a tele-health service with our providers, experience a different type of feeling. You can feel safe and comfortable that your home, in your car, at work, and you have somebody on the other side who is just ready to take care of you. I would say, try it and see if it's for you and make a decision after if that's something that you and your provider are willing to continue. And we sort of all going through this change, all of us together, new for everybody. So I would urge you to try it and talk about it with your provider.

Host: Todd Young, I wanted to also touch on what's happening on the patient portal side, if you will. Some of the access to providers using technology was happening and getting solidified, if you will, on the primary care, and particularly before COVID hit, I'm thinking of the e-visits that were being offered some places. So talk a little bit about the role of that and going forward, do you see that maintaining and increasing as well?

Todd Young: Yeah, we're actually spending a lot of effort right now making our, My Chart presence within our network, the digital front door for our patients. So My Chart is our patient portal and it's been in place for quite some time, but it was mostly just for patients to get information from their records and to do light messaging with their offices, but going forward, we're migrating our video visit to be launched from there. We have expanded our use of e-visits, crossed all our patients our primary cares that use our primary, you know, EMR, Epic. And then we're also exploring and doing some pilots around on-demand video visits as well. So think about it as urgent care within the portal itself, when you need to see a provider without an appointment. So all those things coming together will provide a digital way for patients to connect with their provider and allow them to make choices on the venue of care, depending on the urgency of the matter and what they're comfortable with as far as the type of care that they want. And it will give our patients a lot more options in the realm of virtual care going forward.

Host: Well, that's a pretty good peak into the future there, and I'm afraid we're going to have to wrap it up at that point, but I want to thank all three of you very much for your time and advice today, it's been fascinating. You've been listening to Dr. Dragos Banu from the University of Vermont health network, Alice Hyde Medical Center, Todd Patterson from UVM Health Network Home Health and Hospice, and Todd Young director of tele-health services for the UVM Health Network. For more information, please visit UVMhealth.org/coronavirus. If you've enjoyed this podcast, please share it on your social channels and check out our full podcast library for topics of interest to you. Thanks for listening.