Brad Puffer: Welcome, everyone, to this episode of Field Notes, I’m Brad Puffer on the Medical Office communications team at Fresenius Medical Care North America and your host for this discussion today. Here we interview the experts, researchers, physicians, and caregivers who bring experience, compassion, and insight into the work we do every day. In December, the Department of Health and Human Services reported that more than 52.7 million telehealth visits were performed during the COVID-19 pandemic nationally, and for Fresenius Medical Care North America, more than 1.2 million telehealth visits were delivered. While the pandemic might be finally slowing down, telehealth technology has clearly changed the game when it comes to delivering health care to patients. Of course, patients will always require in-person visits and examinations, but will telehealth maintain the same pace after the pandemic? And what have we learned through the use of telehealth? What are the improvements we can make to the existing technology? We're happy to welcome Dr. Shelly Nash, Senior Vice President and Chief Medical Information Officer for Fresenius Medical Care, to answer these important questions and explore telehealth further. Dr. Nash, welcome to Field Notes.

Dr. Shelly Nash: Thanks Brad, I'm really happy to be here. 

Brad Puffer: Well, as I noted in the introduction, we've conducted more than a million telehealth visits at Fresenius Medical Care since the beginning of the pandemic here in North America. And from a technology standpoint, how exactly did we do these virtual visits and how were we able to pivot so quickly and adapt? 

Dr. Shelly Nash: Fresenius was really not performing telehealth or video visits at any regular cadence or in a centralized fashion, but once the public health emergency was declared in March of 2020, the teams really went to work to put this together. We used a tool that we already had in place, Microsoft Teams, which is a web-based application and is very secure, to try and create a workflow or groups or teams that we could then use to interact with our patients as well as our providers when they were not in our center. So, the provider, the patient, anyone who wasn't in the same place could access Microsoft Teams. They could see the other participants, they could also access our medical record system via the Internet, so they had that available and they could create their visit note, write orders, or prescriptions. It's a safe and secure system, it was a way that the IT teams were really able to pivot quickly, and I think the dedication of our IT teams, our staffs, our clinicians, the nurses, the doctors, the technicians, and also all of our patients to make this happen so quickly is really something and really shows how you can adapt in an emergency in the way we did.

Brad Puffer: Well, I mean a lot happened in a very short amount of time to make all that possible with quite a lot of success. There must have been some challenges too, Dr. Nash. What did we learn during this extended kind of two-year experience? What were some of those challenges that we faced? 

Dr. Shelly Nash: Yeah, we have learned a lot in this two-year experience, just like everyone. First, let's talk about our patients. We've learned that our patients are able to adapt better than anyone thought to new ways of receiving care. While we always thought patients would not be comfortable seeing or talking to their doctor or their care team via a screen or over the Internet, if you look at most of the satisfaction surveys that CMS and healthcare systems, and we did ourselves, we found that patients were really quite satisfied with the care they received via telehealth. Most patients appreciated the ability to interact one to one with their care team to see them eye to eye or screen to screen if you think of it that way, and continue to get the care they need, even if it wasn't done in-person. Secondly, we can talk about our care teams or our providers. They've also adapted and learned new ways to interact with patients while not being able to be in the same physical location with them. This brings challenges, but you can also see the patient via telehealth, and you can assess many things about their general state of health. You can ask some questions; you can even ask them to perform parts of a physical exam. For example, show you on camera or on screen a lesion or point out where the pain might be, and even without touching the patient or being in the same room, you can get a good idea of what's going on with them and what your plan of treatment might be. I think many clinicians were really surprised by how much information they could get without touching the patient, but perhaps spending more time by listening and talking to the patient. Now when we talk about challenges, there are challenges, of course. The biggest one might have been and still is connectivity or technical issues. If the Internet goes down or doesn't work, then a visit needed to be performed via telephone, which has been done in some cases and it worked fine. But this doesn't obviously get as much information as a video visit does. Also, while many patients are good with computers and technology, and we tried our best to make the Microsoft Teams experience very easy, and we did have a team and we still do of IT experts, or helpers to address issues. I think patients like all of us have really become more Internet savvy during the pandemic, and we've seen some really good improvement in their ability to access the applications. 

Brad Puffer: Yeah, I would agree and a lot of what we've been talking about here is really the virtual visits component of telehealth, which is an important part. But there's so much more to telehealth because it's really not just about a visit over a computer or with a physician or a care team member. Connected health, for example, is really part of the broader telehealth umbrella. Can you talk more about some of the other telehealth offerings and why that's so important to work with virtual visits? For example, the Hub, which is our suite of connected health applications and how important that's been even during the pandemic to support patients at home, for example. 

Dr. Shelly Nash: Yes, connected health is really about creating a digital ecosystem or a digital world. We’re enabling connections among patients, healthcare professionals, medical devices, technical operations, and even customer service. We want our patients and our care teams to connect with access to the recent treatment information, appointment information, their plans of care, and things they need to know to take better care of themselves and their families. So, here at Fresenius, we have created what we call our hubs. We have a Patient Hub, a Care Team Hub, and a Provider Hub. These are three separate but connected digital systems that allow our teams and patients not only to see information, but also to send information. For example, from a home nurse or a care manager to a home therapies patient, or for a patient who's doing home dialysis to send information to his care team and even send information from his dialysis device directly into the team. This can then all be incorporated into the medical record, so all of the care team—the doctors, the nurses, the dieticians, the social workers—everyone can see the information and help to create the best plan of care for the patient. Now these hubs continue to evolve, and we've really been working hard to create even more features and connections for them. For example, patients can see lab results on the Hub. They can order supplies that they might need for their home treatments via the Hub. And on the physician side, our Provider Hub can be accessed on any mobile phone or iPad. And it allows providers to quickly and easily see information about their patient even if they're not in one of our centers. They're not in their office if they're out in the world, out at dinner, anywhere they can access it on their mobile device. These hubs really allow all of the teams to be connected to the information they need whenever and wherever they are. 

Brad Puffer: Yeah, I think it's really clear that telehealth is much more than those virtual visits. It's all of this data. It's all of this infrastructure that's supporting patients. And my understanding is we even have some really powerful studies showing how important that connectivity is for our patients, especially our home dialysis patients who are using connected health. What are some of those improvements that we're working on right now? Whether it be for the Hub or other connected health technologies to help our patients live their best lives? 

Dr. Shelly Nash: Yeah, we really are trying to improve all of our hubs, but for example with the Patient Hub, our home patients can directly communicate with their home therapies nurse and the care team. So, they can upload information from the session, they can order their supplies which they need to perform treatments, they can request new prescriptions or new medications, and we've been doing a lot of work around ensuring they can access educational materials about kidney disease and diet. So additionally, and importantly, they can access an online community of other kidney patients for peer-to-peer support. We really want to make patient hub the place for patients to learn and to have access to all the tools they need to be successful in their home treatments. Now, we're working with patients who are our users to solicit feedback. We want someone to be able to log in the first time and to know what to do and how to do it. We want to make it very easy and convenient for them to use these applications, and it's a continuous process. 

Brad Puffer: And I'm sure it's a learning process to hear directly from patients and our providers about how they're using these technologies so we can improve them. Any real-world stories that might help people better understand the impact that telehealth can have on a patient?

Dr. Shelly Nash: We did survey some of our patients who are using our telehealth services over the last two years. One of our patients said the following: “Home dialysis is great and it has allowed me to continue to work. I was really worried about this if I had to come into the dialysis center three times a week. Being able to do telehealth and work with my care team in this way has made things much better. I hope the telehealth option continues even after COVID.” What we're hearing from our patients is that telehealth is convenient and safe. Also, not only do they feel more safe, but they find it more efficient in convenience. We had a patient who told us he lived 60 miles from the dialysis center and his wife had to take off work each time she had to drive him to the center. Telehealth and the ability to do telehealth visits have really improved the quality of life, not just for that patient, but for his whole family. 

Brad Puffer: I know there's a lot of questions about how telehealth will continue in the future. Clearly, it's shown its value, but there are very specific rules and regulations that providers, that we have to follow. Can you talk about the new legislation that was just signed by President Biden that might make some of these provisions more permanent? 

Dr. Shelly Nash: So, on March 15th of just this year, President Biden signed the Consolidated Appropriations Act of 2022. This bill will extend federal telehealth flexibilities for 151 days, post-Public Health Emergency or PHE. So, included in that are the following things: telehealth, flexibility, location. So, what that means is that patients do not have to be in an area considered rural, or where there is not in-person access to care of a specific type. So, the waiver allows any geographic location or any site including the home of the patient to be appropriate to conduct into bill for telehealth visits. Additionally, there's the telehealth flexibility provider type expansion, which will continue. So, what this does is it adds specific types of providers like occupational therapists, physical therapists, speech language pathologists, audiologists and also allows Federally Qualified Health Centers, what are known as FQHCs, as well as Rural Health Clinics, or RHCs, to be eligible as a provider. Also, audio only telehealth visits, these will be allowed to continue, and in-person requirement for a tele-mental health or a tele-behavioral health visit. Meaning, prior to COVID, to bill for a telehealth behavioral health services visit, a patient needed to have seen that provider in-person. With COVID in the Public Health Emergency, this barrier was removed, and the requirement will be delayed as well until after the 151-day extension. You can also still continue to use telehealth for recertification of eligibility of hospice care for the 151-day extension period. And I think all of this really shows that the Biden administration wants to put more time into evaluating how telehealth continues to be used. If it affects patient outcomes, and it's likely after the 151-day post-PHE, they will be open to making many if not all of these changes permanent. 

Brad Puffer: What do you think is needed to keep up the momentum of telehealth that we've seen through the pandemic and to really accelerate its growth and adoption? 

Dr. Shelly Nash: Yeah, I mean there is some really good momentum to keep these telehealth services available and reimbursable for our patients and for our clinicians. I think the policymakers want to ensure two things. First, that patients are getting the care they need and it’s high-quality care. Meaning their outcomes or course of disease or diagnosis is being treated just as well if not better through the use of telemedicine. To find out if this is true, there needs to be an examination of data and perhaps even long-term comparative studies on how patients do when treated with telemedicine or telehealth versus traditional or in-person visits. And there have been some studies or research on this. One was published in the annals of Internal Medicine in February this year. Researchers found that in most cases, care provided by telemedicine had the same or even better quality than in-person visits. Now, some of the conditions that patients were treated for via telehealth were diabetes, respiratory illnesses, and chronic pain. So, while this is reassuring, I do think there needs to be more work to look at this. Secondly, policymakers want to be sure, as do all of us, that the cost of care doesn't go up because of telehealth or because of the ease of use of telemedicine. They want to be sure patients are using these services appropriately and that they're benefiting from them. Interestingly, the concerns about overuse have not been supported if you look at the data, especially during the pandemic. So as a provider of medical care, I believe we really need to advocate for our patients in regard to ensuring they have access to the care they need, whether that's in-person or via telehealth visits. 

Brad Puffer: From your perspective as a doctor and for our nurses and other providers, what are those biggest benefits when they take advantage of this full suite of telehealth services now available? 

Dr. Shelly Nash: I think the biggest benefit of the full suite of telehealth services or technology is the ability to interact, and I mean really interact with patients in real time. So, without delays that can lead to progression or problems or worsening of conditions. With some of the telehealth tools available, like remote patient monitoring, the ability to take and receive EKGs, or to review an image live with the patient immediately from them when they're not in the same location as you, can really significantly alter a patient's course of treatment and outcome. You can feel more secure as a clinician in your decision to tell the patient, no, you don't need to go to the emergency department, you know, I'll see you in the office tomorrow. Or instead, you need to go to the emergency room, or I'm calling an ambulance for you now, this needs to be evaluated. So, I think these tools that we now have available are really game changing in how we care for our patients. 

Brad Puffer: And I'm sure it's some of the same reasons why our patients should be excited about telehealth, but some may be hesitant. They probably enjoy meeting one to one in-person with their doctor, they may be skeptical of some of these digital tools. What would you say to patients to relieve their concerns? 

Dr. Shelly Nash: Right, I don't think that we'll ever be at the place where patients will be completely remote from their doctors. But I think they can be excited about the fact that they can get access to care immediately from their own home when they need it. I mean, it is convenient. You don't have to fight traffic, bad weather, worry about transportation. You know, it is safe, meaning you don't have to worry about sitting in a waiting room. The idea of waiting rooms is somewhat antiquated for most doctor’s offices these days. You don't want to be sitting with other sick patients where you might be exposed to infectious agents or viruses, and I think this has really been true during COVID. And what we've been hearing from patients via surveys is exactly these things. They really appreciate the safety, the privacy, and the convenience it offers. It will never completely replace the in-person interaction, but it's another alternative.

Brad Puffer: Yeah, and I'm sure for patients who live far away from access to care or rural patients and others, these types of technologies really can be game changing. What is your prediction for 10 years from now, for example. How much will care delivery change and what will it look like? 

Dr. Shelly Nash: I think how we deliver care is really changing. The pandemic has forced us to start doing things like video visits and remote patient monitoring. There's been an expansion of what's called the hospital at home and things like remote physical therapy, remote group behavioral therapy sessions have become acceptable. I think in the same way that we moved from working in brick-and-mortar offices to home offices during the pandemic, medical care is now shifting as well. Now, I don't believe that means everyone and everything is going to be done via telehealth, but it might be in 10 years that it's very normal or expected that a patient sees their physician or goes to the physician's office much less than they did in the past. So, for our patients it might be they interact with their dietician, their social worker, their care manager, their physical therapists, all via telehealth and come into our centers less often or their doctor's offices less often if they don't want to come in as often. Some people might say oh no, that won't happen or that can't happen, but I think if you look at how we've already moved from having patients stay long term in hospitals for things like cardiac procedures or surgical procedures, even complex orthopedic surgical procedures are now being moved to outpatient surgical centers, and we're sending patients home almost immediately. I don't think this is really such a different idea. Medical schools have even started incorporating courses on telemedicine into their curriculum for medical students. In the future, I don't think we'll really be talking about telemedicine as its own discrete area of practice or its own topic. I think instead, we'll just be thinking of telemedicine as medical care enabled or delivered through or with the use of technology. 

Brad Puffer: It's exciting to think about what the future will look like, and as we shift more and more to home care, home dialysis, it just seems natural that telehealth would be a huge component of that evolution. So, Dr. Nash, thank you so much for joining us today, it's been a really interesting conversation.

Dr. Shelly Nash: Thank you. 

Brad Puffer: And to our audience, thank you for joining us. Don't forget you can find Field Notes on the Apple Store or Google Play or right here at FMCNA.com where you can also find our Annual Medical Report and other featured articles. Until next time, I'm Brad Puffer and you've been listening to Field Notes by Fresenius Medical Care. Take care everyone.