Episode 34: How Telehealth is Reaching Underserved Communities in Crisis

The rise of telehealth has been one of the lone bright spots in the midst of the COVID-19 pandemic, particularly for traditionally underserved patient populations. This week, we speak with Dr. Daren Anderson, director at ConferMED, a telehealth platform for eConsults, and an expert in safety net practices. Dr. Anderson describes the plight of front-line workers during the outbreak, the different types of telehealth platforms, and their roles in serving patients.

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Full Transcript

Announcer: It’s time to think differently about healthcare, but how do we keep up? The days of yesterday’s medicine are long gone, and we’re left trying to figure out where to go from here. With all the talk about politics and technology, it can be easy to forget that healthcare is still all about humans, and many of those humans have unbelievable stories to tell. Here, we leave the policy debates to the other guys and focus instead on the people and ideas that are changing the way we address our health. It’s time to navigate the new landscape of healthcare together, and here’s some amazing stories along the way. Ready for a breath of fresh air? It’s time for your paradigm shift.

Michael: Welcome to the “Paradigm Shift of Healthcare,” and thank you for listening. I’m Michael Roberts here today with co-host Jared Johnson and Scott Zeitzer. On today’s episode, we’re talking to Dr. Daren Anderson, an expert in safety net practices and the director of ConferMED, a telehealth platform for eConsults. Dr. Anderson, thank you so much for coming on the show today.

Dr. Anderson: Thank you very much. It’s my pleasure.

Michael: Absolutely. So, just a couple of weeks ago, our team started talking, and we were talking about a potential pandemic, and now here we are two weeks later, and we’re very much in the midst of the COVID-19 pandemic. It’s obviously happening, it’s affecting every aspect of everybody’s lives. And I’m sure that with your business, with everything that you’ve got going on, it’s impacting you quite a bit. So, can you describe the communities you serve as a safety net commission and what are those typical patient interactions like?

Dr. Anderson: Sure. So, I’m a general internist and practiced primary care in a safety net, practiced a federally-qualified health center for many years before moving more into the telehealth space and the work that I do now. And, you know, the safety net is a term that describes a loose network of different types of healthcare facilities around the country, federally-qualified health centers, other category called free clinics, as well as often immediate health service, migrant farm workers clinics, and healthcare for the homeless sites.

And I think, collectively, these are the places where the lower-income, most vulnerable populations of patients in both rural and urban communities around the country come to get care. And, traditionally, these types of facilities have focused on the uninsured and on the Medicaid population. And in states that have gone through Medicaid expansion, we’ve seen a shift away from uninsured as those numbers have declined to largely a Medicaid-insured population. But, in all cases, they tend to be a racially and ethnically diverse group of patients, they tend to be on the lower end of the economic scale, and they tend to face, you know, higher rates of what we call barriers related to social determinants of health, making it more difficult for them to stay healthy or to get well when they have illnesses and obtain access to care outside of the clinics.

Michael: Absolutely. Is telehealth making a big difference in responding to this group, and especially during this pandemic?

Dr. Anderson: Well, I think it has the potential to. You know, it’s interesting. In, you know, previous potential pandemics, I don’t think telehealth was even on the radar, but we’re in the early stages of adopting telehealth strategies and solutions around the country in safety net practices. And, you know, one of the biggest limitations to rapid deployment and scaling of telehealth has been a variety of state and federal legislation, or rather licensing regulations and that sort of thing, that may make it not always a reimbursable service.

Most Medicaid plans don’t reimburse for most types of telehealth at this point. Although, that is changing rapidly before the pandemic, and now with the pandemic, many states like ours here in Connecticut where I’m talking to you from, have rapidly made adjustments and changes in providing at least temporary reimbursement to support telehealth. And I think that’s critical because the infrastructure and the tools are there, and they’ve been available for a while, and with the funding mechanism in place, it’s allowing us to do a really rapid scale-up and deployment of telehealth solutions to help address the pandemic.

Scott: Yeah. The fact that telehealth is even an option during a public health crisis is quite a paradigm shift. And you’re right, the infrastructure’s there. You know, the internet…I get that there’s some very rural communities where they don’t have the speed that they may need, but, overall, we’ve got the infrastructure, and I did just see where states…I think it was actually in the tri-state area where you’re from, they’re making it easier for doctors to practice across state lines just physically, and I think that’s occurring via telehealth as well. Is that correct?

Dr. Anderson: Yeah. That’s another really critical element that limits the scalability, at least when you’re trying to rapidly deploy telehealth. State licensure laws have, up until now, in most cases, prevented doctors, and other care providers, and other states from treating across state lines. And that’s not so much of a problem if you’re in a really populous state like California, but we’ve been working to provide services in really rural locations as well, and, you know, that can be difficult, to recruit an in-state network of providers in a less populous state like, say, Montana.

Scott: Yeah. No, it makes a lot of sense. Let’s dive in a little bit. How does it work? How hard is it for patients to “be seen by a doctor” compared to in-person or consults?

Dr. Anderson: Well, so, I’m gonna try to draw a distinction between two different types of telehealth that we’re using, you know, and trying to take the scale in the safety net. I think the more traditional type of telehealth, the one that most people think of when they hear the term telehealth is, you know, essentially the FaceTime communication, Skype-type communication where there are two people on either end of a video conference device, a smartphone, communicating and talking and providing healthcare. And, you know, that certainly is one form of telehealth, and that’s an important one. And I think now, as we’re trying to keep patients in their homes and provide care, it may well be the most important one.

And so, I’ll talk about that one first. And then, I wanna touch also on what we call asynchronous telehealth, which is a slight variation on that theme, but infinitely more scalable and able to meet a lot of the needs of our patients and providers as well. But I think the direct-to-patient telehealth is limited only by the limitations for providers needing to lay hands on a patient to touch, feel, look at things closely, I think. Although, there have been telehealth carts with a variety of sophisticated gadgets and gizmos that can help you actually examine or listen to a patient’s heart and things like that. Those generally can’t really be deployed directly in a patient’s home.

So, what we’re focusing on now as people are rapidly being forced or required to stay in their homes, really the types of communications that you can have just similar to a direct video conference. And I think a substantial amount of the care that we need to provide in these challenging times can be done in that way, particularly with behavioral health, and stress and anxiety are a major factor always, and, obviously, even more critical in COVID-19 times.

Scott: No doubt about it. You said there were two categories. What was that second category you just mentioned?

Dr. Anderson: Yeah. So, the two categories that I’m referring to in the primary care field, the direct-to-patient that I talked about, and the second is what we call asynchronous telehealth. The problem with the former type of telehealth, in particular when you’re looking to provide telehealth care for certain specialty needs, if you need endocrinology, or neurology, or surgery, there is an access issue that we had before there was any COVID-19 pandemic. Unfortunately, there are a limited number of specialists and subspecialists that are available and willing or able to see patients with Medicaid or without insurance.

And so, even a telehealth solution doesn’t solve that problem if there’s a limited number of specialists able to see a patient face-to-face. And from a safety net practice, there’s even fewer able to see them with telehealth. And so, asynchronous telehealth, often called eConsults, is a platform that we’ve actually developed and taken to scale in our safety net practice in Connecticut and around the country that allows primary care providers to submit consult questions, content from their electronic health record, and send them to be reviewed by a specialist. And that specialist can review the information, they can view it online. If it’s a rash or dermatology case, they can look at the images that we send over, if it’s a cardiology case, they can review the chart and the EKG that we send, and, in an all cases, respond back to the primary care provider.

And one of the things that we’re finding as we deploy these solutions is a substantial percentage, in many cases, a majority of the specialty care needs that we, primary care providers, have and send requests in for visits can actually be managed in this way. I like to think of them as what we call cognitive consults. When I need a specialist to give me advice, information, make suggestions about a particular medicine, or advise me on a lab test, but I don’t need them to see or lay hands on the patient. And in those scenarios, an asynchronous telehealth consult, an eConsult, can really effectively manage a significant number of consults and reduce our need further for sending patients around. And, in particular, today, with the pandemic when we wanna avoid sending people into hospitals or into specialty settings, this is a really important strategy that often gets overlooked.

Scott: Yeah. That’s fantastic. And you’re right. I can only imagine how you’re going to triage out orthopedic care or other types of secondary care. That’s obviously a much more effective modality. Has that been working out well for you as you’re rolling it out?

Dr. Anderson: Yeah. So, you know, we’ve been implementing this strategy now really for the last two or three years around the country and found that it is extremely scalable. And the access issues that we were facing in rural locations, you know, inner-city clinics taking care of Medicaid patients or the uninsured, this has proven to be a highly effective strategy. The technology is very straightforward. There are many simple ways to communicate between electronic health record systems and others and to transmit that data.

And we’ve seen reductions, in some cases of over 50%, in the volume of face-to-face referrals that we need to send out from the health center into the specialty center. And that has lots of consequences that are positive. It keeps patients in primary care, keeps them in their community, it devoids unnecessary tests, and procedures, and additional expense, and allows us to focus our resources on getting the patients in for face-to-face care who really need it.

And, you know, we weren’t expecting this, but as the pandemic has swept across the country, that type of a solution has proven to be even more important because what we’re, I think, kinda forgetting with, very appropriately, the focus on COVID-19, is that there are a lot of people out there that still need orthopedic care or an endocrinologist. They have diabetes, they’ve had a stroke, they need cardiology guidance around hypertension. And so, we’re trying to really, you know, rapidly take this to scale even further to make sure that those patients can still get access to that expert care guidance and information that they need to manage all the other illnesses that aren’t related to the pandemic.

Scott: Yeah, absolutely. I mean, have you seen any barriers that there is, any barriers to adoption by the clinicians, or is it more of a mindset kind of a thing?

Dr. Anderson: You know, mindset is probably one of the major barriers that we had been seeing prior to the current situation and that most of us as primary care providers have developed a certain way of doing things, and a certain communication style and protocol, and we send people out for face-to-face when we think they need it. And this really represents the adoption of a new paradigm, a new way of thinking about the way you practice, really, as the leader of a team with various sources of information coming to you, you know, from your nurse, from your specialists, but really being implemented by you, the primary care provider. And I think this is a critical change that needs to happen to strengthen primary care and really make the healthcare system more efficient.

And I think just the barriers that you would expect when you’re making a significant change were the main ones that we were facing. And the other one we’ve already touched on is the variation in laws and regulations related to state licensure.

Scott: True.

Dr. Anderson: It’s interesting, with this type of asynchronous communication where the specialist is not communicating directly to a patient, some states view that as not requiring an in-state license, whereas other states consider that it does. And so, we’ve had to go and do a state-by-state analysis and we’re updating it constantly to determine which states we can use out-of-state providers to do this type of eConsult and which states require us to recruit in-state only. And it’s changing rapidly, and it’s changing even more rapidly now in the face of the pandemic.

Scott: Yeah. And I hope it actually starts to make things a little bit more… There is no reason why an orthopod — we deal with a lot of orthopedic surgeons and [inaudible 00:13:10] surgeons — shouldn’t be able to have a cognitive consult with a primary care provider. It just doesn’t make sense to me. It doesn’t matter what state he or she is in, you know? So, how are those specialists overall responding?

Dr. Anderson: We’ve had no difficulty recruiting specialists that are interested in doing this type of work, I think for a variety of reasons. It can be just something that you can do in your off-hours, you can do in the evenings, that obviously can be batched. They don’t need to be responded to, you know, within minutes. We usually turn around a response in the same day. But they allow the specialist to kinda fit them into their day.

And I think, you know, the second reason that we’ve had no trouble recruiting specialists is I think many of them really appreciate the mission behind this. You know, we are trying to get specialty access to rural and underserved populations, and these people, traditionally underserved, have really kind of gotten the short end of the stick in healthcare. I think, you know, a lot of our specialists who join on are, you know, certainly committed to that mission and happy to be able to help out in some of these really rural and remote locations.

And I think, you know, the third is there’s obviously compensation associated with it. So, it’s a way of augmenting your income a little bit and doing something that doesn’t require overhead, going into the office and all of that. So, I think, you know, the combination of making the system more efficient, making a difference for people that need it has actually made recruiting one of the things we don’t worry too much about, although there are some exceptions to that. There’s a couple of specialties that can be challenging, but we’ve been doing pretty well in bringing on board. We have about 200 specialists now that work with us and are on call to answer eConsults as they come in.

Scott: Awesome, awesome.

Jared: So, Dr. Anderson, tell us what it’s like as a provider during this pandemic, like, just in general. What’s it like to be consulting with patients? I mean, what’s the general feeling right now?

Dr. Anderson: So, I work really closely with a large federally-qualified health center. I work for the federally-qualified health center in Connecticut, and although I’m 100% involved in administration, quality improvement, and eConsults, and telehealth, I speak to them all the time. And I think the things are changing so rapidly. I think all of us have this kind of dizzying sense of uncertainty. There’s obviously a lot of fear. I think the recently reported stories of emergency room physicians and others that are really on the front lines of the epidemic getting ill themselves and being hospitalized, obviously, makes it scary for a front-line provider. And that is, I think, combined with the balancing of your home life, your family, and keeping them safe.

Our kids have all come home from college and from school, we’re juggling those issues. At the same time, we’re trying to, you know, be there professionally to treat patients. And then, I guess, the third part of it, I guess, contributes to that dizzying sense, is just the rapidly changing and evolving access to information. You know, initially, very little was known about this virus. We just learned yesterday that ibuprofen actually probably shouldn’t be prescribed or utilized in patients with suspected coronavirus because it may augment the virus and make the illness worse. You know, things like that.

The evidence and the information is coming to us so rapidly and it’s changing so quickly. What we thought was true one week ago may not be true next week. And then, you know, combine that with the lack of access to basic things like tests, N95 masks, those sorts of things, makes it really, really kind of a warzone feel, I think. And physicians have faced risk and put themselves at personal risk throughout history, that’s part of what it is to be in the profession, but this one is presenting some really, I think, unique challenges and a lot of stress.

Jared: Well, we definitely wanna commend you and all clinicians, everyone on the front lines in the healthcare profession who are doing all you can. We know you’re doing all you can to help get us through all this. And we wanna commend you for that first and foremost. So, what’s your message to other front-line clinicians who are engaged in the pandemic, who are helping respond to patients? What’s your message to them?

Dr. Anderson: Well, I think what’s unique about this pandemic, I think, in all human history, is that unlike any previous pandemic, we are now connected in ways that we never were before. And I think, you know, we’re connected through technology, we’re connected through Facebook, we’re connected through tools that allow information to spread much more rapidly than ever before. And so, I think it’s critically important to use those tools and those technologies to keep in touch with your colleagues, keep in touch with colleagues in other countries, and learn as rapidly as possible what we know, what we’re learning, and what we think is the best approach.

Through the health center where I work in the Weitzman Institute, we’ve developed a weekly video conference where we have four or five specialists and experts in the topics of infection control and infectious disease. And we open that up and allow health center providers and other front-line providers to join from around the country. And it provides really an open forum to ask questions, to listen from experts. And one of the things we’ve seen now, just over the last couple of weeks as we’ve been doing this, is it’s very helpful to have clinicians from some of the earlier sites where the coronavirus hit because they’re telling us things and give us a sense for what we’re gonna be seeing several weeks later.

So, in this week’s session, we had a team from San Francisco, which is several weeks into the pandemic. We’re hoping next week to have somebody from New York City on sharing sort of what they’re seeing. And I think you can be pretty sure that what you’re seeing in those locations and what they’re telling you is helpful for preparing for other sites where it has been a little bit slower to roll out by connecting people. And this is just simple video conference technology. eConsults allow you to exchange information back and forth. There’s a lot of new ways to keep in touch and communicate with colleagues in different ways to stay current and make sure that you’re providing the most up to date evidence-based treatments, not only to patients with potential COVID-19 but also to your other patients as they continue to need care.

Jared: So, on a personal level, any words of encouragement just to the community out there in terms of, like, how do we get through these times, you know, how do you personally keep the panic from getting to you?

Dr. Anderson: The most important thing for me is to recognize the difference between personal risk and community risk. We know, individually, you know, the risk of dying from coronavirus is not that high. We know that certain susceptible populations have the highest risk. But we also know that we have the ability in our own hands to flatten that curve and reduce the risk. And, you know, it doesn’t require going to war, it doesn’t require taking complicated medicines, it requires staying home on your couch.

And so, I think, you know, the hopeful words that I have are that staying on your couch isn’t the worst thing in the world. It’s a very effective tool and approach that all of us, regardless of who you are, can take to have an impact, you know, in your own immediate neighborhood and community, and it makes a big, big difference. The experience that we’re now seeing from countries, particularly in Asia, indicate that the quicker you implement these types of procedures to keep people out of harm’s way, keep infection rates down, and keep people out of contact with people who are exposed, the more effective you can flatten that curve and reduce the morbidity and mortality from the illness.

And so, you know, I was telling my kids the other day, great-grandparents lived through the Depression and World War II. You know, my parents lived through the Cold War, and duck-and-cover drills, and the Civil Rights Movement. I’ve been pretty charmed and blessed. So, our challenge today is to stay on the couch and stay home in the face of a viral epidemic. And I don’t think that’s asking too much, and it’s really the one thing that I think everyone can do that makes a difference.

Scott: Yeah, I couldn’t agree more. And then, after you say that, “And give me my iPad back.”

Michael: Guys, thank you so much for this discussion. You know, all of us have, I’m sure, family members that are susceptible to this, we know people that are in some way dealing with it on the front line. Just this week, watching #MedTwitter, watching the different hashtags that are out there, and seeing the stories of the heroes that are showing up and just doing this day after day, and so, it’s very inspiring to see that happen.

I couldn’t agree more with, “And just stay home.” We can help out with this part of it. You know, I’ve got some family members that are prone to things. And so, we’re definitely practicing that distancing as much as we can. So, definitely a great message there. Dr. Anderson, thank you so much for your time today, especially in the midst of everything that’s going on. We greatly appreciate it, and we look forward to being able to reconnect when things are getting better.

Dr. Anderson: Thank you so much.

Scott: Stay safe, stay at home.

Dr. Anderson: Yeah, do the same. And thanks for the chance to talk on your show, I really appreciate it.

Announcer: Thanks again for tuning in to the “Paradigm Shift of Healthcare.” This program is brought to you by P3 Inbound, marketing for ortho, spine, and neuro practices. Subscribe on iTunes, Google Play, or anywhere you listen to podcasts.