Episode 2: Telehealth in the COVID-19 Era with Dr. Ahmad Sharif
Dr. Ahmad Sharif, Senior Vice President and Chief Medical Information Officer at Fresenius Medical Care North America, discusses the important use of telehealth to safely treat patients during the COVID-19 era and what the future holds for virtual patient care when the pandemic ends.

Brad Puffer: Welcome, everyone, to the second ever episode of Field Notes. I'm Brad Puffer on the Medical Office Communications Team at Fresenius Medical Care in North America and your host for this discussion today. In this series we interview the experts, researchers, physicians, and caregivers who bring experience, compassion, and insight into the work we do every day. We hope to learn together as we discuss a wide range of topics, including those related to kidney disease.

It goes without saying that our primary focus during the COVID-19 pandemic is to keep our entire community safe while we provide life-sustaining care to our patients. And that's why today's discussion is so relevant.

The implementation and adoption of telehealth had been slow across health care, that is until now. A recent survey showed that before the pandemic only one in four people had even tried telehealth, a slight uptick from a few years ago. But now many providers and health insurers are reporting hundreds of times more telehealth visits than usual. It's certainly true at Fresenius Medical Care, and telehealth technologies have become critical tools in our effort to keep our patients safe.

To talk more about telehealth, the impact of COVID-19, and what it means for the future of care, we're joined by Dr. Ahmad Sharif, Chief Medical Information Officer and Senior Vice President of Fresenius Medical Care North America. Doctor Sharif, welcome to Field Notes.

Dr. Ahmad Sharif: Thank you for having me, Brad. Greetings, everybody.

Brad Puffer: Well it's great to have you, and I thought we'd just start with level setting, an understanding of what we're talking about when we say telehealth. It can mean different things to different people, but how would you define it?

Dr. Ahmad Sharif: Right, I consider telehealth to be a remote or a long distance audio-video interaction between patients and their care teams. That could include, but not limited to, delivery of direct patient care, training, education, and public health administration.

And I also want to draw the distinction between telehealth and telemedicine. Telemedicine is relatively limited to just a direct patient care, whereas, telehealth is more broad and includes services like provider training, administrative meetings, continuing medical education, and other things.

Brad Puffer: Got it, and how would you say connected health and that terminology fits into this? Because we've also been doing a lot with connected health.

Dr. Ahmad Sharif: Yeah, in my view, telehealth is a subset of the connected health activities. Connected health is a broader, social, and technical term. In addition to the audio-visual care delivery or educational content, connected health offers an ecosystem of many technology tools and services, like remote patient monitoring, secure messaging, and other patient engagement features.

Brad Puffer: So if you were to step back and say, ultimately, what is the goal of telehealth, what are we trying to accomplish by doing these visits virtually? For example, what is the answer?

Dr. Ahmad Sharif: Great question, Brad. I think that the telehealth's main goal is to advance that quadruple aim. And what I mean by that is that it should improve the quality of care and patient outcomes. It should improve the access to care, particularly in the rural areas. It should address the staffing shortages. We have heard about the clinician burnout. And I think that telehealth's goal should be to address that as well. It should increase the patient engagement and the convenience factor for the patients, so that they can have care delivered to them at their terms, and wherever they prefer. It should also reduce time to care. And last but not least, it should also help with reducing the cost of care.

Brad Puffer: And I'm thinking, especially for our home dialysis patients and home patients in general, there's a push more and more to providing care in your own home whenever possible. And obviously with dialysis, we have that ability to do it. The government's pushing it hard. We are embracing that challenge and have seen rapid growth of home. How important is telehealth to really ensuring that our patients can succeed on home therapies?

Dr. Ahmad Sharif: Exactly, so besides many other factors, one of the things I and the rest of the industry has observed is that you need to give that confidence to the patients and their care-providing teams that you can connect them in a almost similar fashion like you connect them when they're in person.

If a patient has the confidence that their care team members are a push of a button away or there are tools which are actively monitoring different parameters in their care or health, and they can be receiving callback based upon their blood pressure readings being off, or for example, specifically for our home dialysis patients, that their ultrafiltration rate is not right, or there is something wrong with their care delivery, and somebody can intervene proactively, I think that provides a sense of comfort and a sense of confidence that you have direct connection with your care team members.

Brad Puffer: Well our company has certainly embraced telehealth over the last several months. How important do you think the technology has been to help mitigate the risk for patients during the pandemic, especially those individuals living with chronic kidney disease?

Dr. Ahmad Sharif: Brad, I think the role of telehealth has been critical in reducing the exposure risk for patients and health care workers. Telehealth helps avoid unnecessary visits to the health care facilities for patients dialyzing at home for example, and also affords the option to reduce traffic on the treatment floors off the dialysis centers. Our provider partners deliver care at multiple care locations, including hospitals, and telehealth helps with reduction of that transmission risk for our patients and providers wherever clinically appropriate.

Brad Puffer: And how did we get everybody onboard so fast? I mean this really ramped up over the last couple of months, because we had to. But it was quite an effort to get it done?

Dr. Ahmad Sharif: Indeed this was an amazing, incredible, cross-functional effort by multiple members of the Fresenius team. And again it what-- the real thing which prompted it was to keep our patients safe and provide a safe mechanism for continuity of care. That was sort of the driving force which led to an unprecedented, quick delivery of this tool.

The one of the things we did very early on was just the selection of the tool. While federal government had allowed for consumer grade technologies, like Skype and Zoom and WhatsApp and FaceTime and other things, they had still asked us to take every reasonable precaution to safeguard the information of our patients and providers. So we went and selected a tool which was HIPAA compliant and end-to-end encrypted and less vulnerable to the cyber attacks.

We also created a lot of training assets based on refined policy and procedures to address this COVID-19 pandemic. We created a centralized repository of all of our frequently asked questions and how to do these things, how to conduct these sessions. We created a support structure which included live agent support for all roads, patients, providers, and staff. We continued to do ongoing education. And we were there with a solutions mindset to remove any potential barriers. Our field teams vetted and pre-assessed all of our network capacity and capability to ensure optimal performance of these sessions within our clinics.

Brad Puffer: Now it was quite impressive just to see everybody come together like that and really make this work. Now that we've made it work, do you expect it's here to stay?

Dr. Ahmad Sharif: Brad, it's very hard to think that we'll go back to the pre-COVID era, because I believe that the necessity of today will become a habit and preference of tomorrow. All stakeholders, patients, providers, staff, physicians, they've become accustomed now to using this tool. And we are seeing a lot of positive benefits come out of it.

And some of this was also propelled by the federal government its waivers and the change in regulatory landscape. And I think that all the stakeholders on that level are also figuring out what are the best practices and lessons learned from this era, which we want to take to the post-COVID-19 world.

So I think that there would be a lot of things which will remain from all of this set up or ecosystem, if you will. But there is a lot of careful balancing which has to happen for what are the most suitable and clinically appropriate cases for a telehealth visit versus an in-person visit.

Brad Puffer: And you touched upon regulatory changes, and also just, I would imagine the awareness of telehealth has just skyrocketed over the last couple months. What have been some of those barriers that held up adoption today and what has changed?

Dr. Ahmad Sharif: Sure. So one of the things which many surveys have indicated that people weren't even familiar that is telehealth an option? Is telehealth a service their provider provides? Is telehealth reimbursable? Does their insurance cover it? What are the co-pays? So there were a lot of these things which were confusing people. And beyond that, there were some regulatory imperatives well intentioned.

We were on a path of refinement and evolution, but this COVID-19 crisis really fueled all of that. And within a matter of weeks, we accomplished what would have taken years otherwise. And some of that regulatory changes that you don't now have to worry about, the distance sites and originating sites, meaning where the patients are versus where the providers are. You don't really have to worry about an existing, established relationship between a patient and a provider.

Typically traditionally telehealth was only reimbursable in the rural areas of the country. Now that has been lifted too. Some of the cross-state barriers have been lifted. Although that is still under a lot of debate, because that's the state's purview as well. But there's a lot of opening up of the regulatory framework, which has allowed us to really see this very broad adoption of the telehealth tools.

Brad Puffer: And now that we've seen that broad adoption, what has been the reaction from both our patients and our physicians to these tools, now that they've experienced them?

Dr. Ahmad Sharif: So I think our patients and providers, both are generally very positive in their reaction, because this was a tool which allowed them to safely continue providing care or receiving care. And our patients initially were a little bit skeptical of what tool, what are we-- How are we going to do this? How's it going to work if I don't see my patient-- sorry, provider, am I going to get the same type of care delivered?

And I think they have become comfortable over the period of time. And some of the things which the rest of the organizations like us have also done is that keeping that tool, the technology, very, very simple. I call it click ready. So that there is the least amount of technological barrier in developing this relationship with their providers.

On the provider side as well, as I mentioned before, some of the clarifications from a regulatory standpoint have really helped. And one of the things is that the providers feel that they can structure their day better. They can provide better care. They can have more engagement with their patients. And at the same time, also the reimbursement for these interactions have sort of been brought up to the par of an in-person visit.

So overall, positive impact. We are seeing good responses. We are hearing good feedback and input from both our patient and provider partners. And I think that over the period of time these technologies will also evolve, which will change the care delivery paradigm, at least with new options available.

Brad Puffer: Is there any concern about this being adopted too quickly, meaning are there downsides to telehealth, and can it even really replace that one-on-one connection?

Dr. Ahmad Sharif: So I think there is no exact replacement of those in-person warm interactions. But at the same time, there are many other areas where telehealth can really augment that care delivery paradigm. And when we move very, very quickly, obviously you have to very carefully monitor your programs to make sure that you have not introduced unintentional bias.

And we have seen some reports in the press as well that there have been some inadvertent consequences of moving very fast, meaning in some areas where we really wanted the impact of telehealth, the rural areas, there might be a lack of general broadband availability or general lack of devices in patients' home.

We deal and sort of have the good fortune of serving all kinds of different demographics around the country. And most of us who just have a laptop or a device as an integral part of our daily lives, we don't tend to quite think about that there are still cohorts of population around the country who do not have access to either the devices, hardware, or the broadband services in the same way the rest of us have-- do have.

So I think all of this is being carefully monitored. The federal government, the FTC, the Federal Trade Commission, and many others are creating programs to help alleviate some of those concerns for telehealth and make it ubiquitously available for everybody.

Brad Puffer: Yeah, those are good reminders. At the same time, it seems like, as you say, this is here to stay in some capacity. Do you think that this rapid adoption of telehealth over the last few months is going to change health care and how we deliver care in the future?

Dr. Ahmad Sharif: Yes, Brad. I think that we will see a lot of new paradigms emerge out of this experience we had within COVID. There will be better triaging of patients. There will be better delivery mechanisms using telehealth with patients getting care at their home at the point of their convenience and choice and schedules.

We will also see a lot of effort being put into advancing these platforms themselves. I think we'll see these technologies evolve pretty rapidly to make it as close to in-person visits as possible as well, which would include the provisions for a physical exam, a remote physical exam. [INAUDIBLE]. There are Bluetooth-enabled stethoscopes available, for example.

I think using machine learning and advanced analytics and artificial intelligence, we will see a lot of improvements and refinements within these telehealth tools. And all of which will combined help us be more effective and efficient in the care delivery. So yes, it will be a paradigm changing shift.

Brad Puffer: Well that is an excellent point to end on. So I really enjoyed speaking with you Dr. Sharif today, and thank you so much for taking the time.

Dr. Ahmad Sharif: My pleasure. Thank you for having me, Brad

And to our audience, we hope you will come back and join us as we discuss more important issues in the weeks ahead. A reminder that you can access our annual medical report and other feature articles on our website at fmcna.com. And you'll find our Field Note series on our website, at the Apple store, and Google Play. Until next time, I'm Brad Puffer, and you have been listening to Field Notes by Fresenius Medical Care. Take care, everyone, and stay safe.