Serafina: Hi, I’m Serafina and we’re at Angel MD’s Alpha Conference over in Napa, California. I’m joined by Drs. Whittington and Hockschuler. Thank you so much for being here today. We really appreciate you taking the time to join us.

Stephen: It’s a pleasure. This is so much fun.

Serafina: This is a lot of fun, isn’t it?  So, earlier in the other room you guys were sharing your insights on telemedicine, so I just want to go right into it. When were you both first introduced to telemedicine as a concept, and then maybe, when did you first adopt it into your own practices?

Wendy: You know, it depends on what you call telemedicine. So, years ago, when I was picking up the phone and calling patients, that was telemedicine. But where I really got involved in it professionally was in my current career as a health care consultant working with health care delivery organizations who are trying to be more efficient. About three and a half years ago I had a client say, hey, we need help with our telehealth strategy. So, for me it was a wonderful sweet spot between information technology, the business process of how medicine is carried out, and the clinical world. So, for me it’s relatively recent. It’s been fun.

Serafina: And you say efficiency, but I don’t want to glaze over it, so what exactly are the metrics that health care organizations look at when they’re looking at efficiency?

Wendy:  It’s not much different than anything else, right? It’s better, faster, cheaper. In healthcare we talk a lot about the Triple Aim in health care, so we’re always looking to increase that patient experience at a lesser cost for better outcomes. That’s what it’s all about.

Serafina: And fewer resources. And what about you, Dr. Hochschuler?

Stephen: Well, I’ve always been kind of looking at what’s downstream.  So, as an example, when I was in the military I helped train the first physician assistant class, which now is a big deal. The same in telemedicine; I spent seven years training at Harvard, I help set up a company called WorldCare. We are in like 48 countries. We never figured out a revenue model, so it’s been a great thing. We did teledermatology, telepathology, and teleradiology.  Now it’s used for much more.  I’ve always looked at what’s next, I was only 45 years too soon on this one.

Serafina: So, what exactly are the specialty areas where these kinds of models are easily more adoptable? And then, where is it, I suppose, a little bit more difficult to adopt? What kinds of specialty areas?

Wendy: Sure, so areas where adoption is already pretty high are in fields like neurology; telestroke, specifically. So, there are a lots of emergency rooms out there that have a stroke patient come in and they don’t necessarily have that physician on staff right there in the ED who is equipped to make the decisions about care for that patient. So, it’s very common now to have a stroke neurologist beam in via telehealth to assist that emergency room physician through that episode of care. So, that’s just one of the more common fields. We’re seeing a real increase in telebehavioral health, telepsychiatry. There’s such a need, there’s an increase in mental health problems, not enough psychiatrists, and hospitals in particular are often figuring out how are we going to move these mental health patients through our emergency room? We want to give them the right care, we don’t have a psychiatrist here on staff, so that’s a real increasing area.  I think when a lot of people think of telehealth today they think of more ambulatory. You know, you wake up with a sore throat in the morning and you want to see your doctor (Serafina: Critical care.) virtually.  And that’s certainly on the rise. So, it’s all across the board. That was just a teeny little sampling of what the possibilities are.

Serafina: Got it. Anything you’d like to share on the topic?

Stephen: I think it’s going to be applied to everything. So, as a surgeon, preoperatively seeing a patient, being sure they were educated; postoperatively, for wound checks. And in Texas, they’re big distances. So, to have to drive 500 miles is not unusual. And now if you can see the patient for a wound check from a distance, or they have a question and they want to see you eyeball to eyeball, that also can be handled. Now, with the whole problem of opiate addiction and alcoholics, people are starting to apply the technology for follow-up. So, every day you can check in telemedically.  It’s on the cutting edge right now, it hasn’t been done, but they’re doing it, they’re starting to do it. That should help because Alcoholics Anonymous works, but it only works for as long as you attend meetings, in most cases.  This is a different way of attending where you might not have the money, or a car, or the ability to leave work, but you can check in every day.

Serafina: Right. So, we’ve been alluding to this throughout the conversation, even in your panel discussion, that it’s immensely cost saving. What does the data say? I know this is best practice, but you tell me.

Wendy: The data is not necessarily lining up. So, I would maybe qualify that. It is potentially cost savings, with a real underline under that (Serafina: Asterisks) potential, yeah, because we’re not really doing it the way we could and should be doing it yet.

Serafina: Why is that?

Wendy: As I mention in the talk earlier, the incentives just aren’t aligned, right? If I’m still getting paid every time you walk through my clinic door, yet I’m not, or maybe getting paid for an episode virtually, it’s just not all matching up. So, I think there’s huge potential for cost saving. It’s the absolute right thing to do, we just need to get it all sorted out.

Serafina: So, who yields the power in this situation? Is it the insurances, hospital, the providers?

Stephen: All of the above.  And that’s why I agree with Dr. Whittington that you have to align incentives. So, now everybody is going to episodes of care, global fees. Well, if you can limit the expense, cost savings, while maintaining quality, which is key, you’ve got to go to the public, like pharmaceuticals. They talk about all sorts of drugs for asthma, for erectile dysfunction, and they get people to go into the doctor and say that’s what I want. Well, it’s not the most reputable way of selling a drug, but it’s worked. Well, guess what? You need to do a similar thing on a national basis of how telehealth could serve you better, cost you less, cost insurance companies less, and everybody wins. And it’s one of those situations where everybody wins.

Wendy: It is no coincidence that countries that have a single payer system have gotten this rolling-

Serafina: Music to public health kids’ ears.

Wendy: Right.  There’s no mystery behind that, it’s clear. So, until we really sort things out and align our incentives, whether it’s via a single payer system or at least an understanding that we need to work toward keeping populations healthy rather than-

Serafina: It’s a population health strategy.

Wendy: It is.

Stephen: Exactly. And that’s the big buzzword right now; population health.  So, somebody mentioned diabetes and having an external pump, and all of this. Well, you look at the cost of diabetes, it’s incredible (Serafia: And its’ growing.). Through telehealth, through measuring your weight, by your insulin utilization, your sickness, your obesity, all these things could all be handled in a different aspect of telehealth where you’re recording daily. If you’re being recorded and you’re exercising, and they’re seeing how often you show up, all of the sudden you show up more frequently. Same thing with diet, the same thing with taking your insulin. Years ago, I worked at the Joslin Clinic, which they believed in the accurate measuring of blood glucose, not once a day, not twice a day, but every few hours. And guess what? It was the best way to treat diabetes. Well, you could do this now with telehealth.

Serafina: And while we’re on the topic of chronic health management, and we have this booming market of direct to consumer health products, where do you see the future of telemedicine going?

Wendy: Where I see it going, at the risk of using those buzzwords, right? We’ve got all this data now, so we’ve got big data around this. What needs to happen is the boiling down of that big data into usable information that a clinician can then take and act upon together with the AI and all of the other tools that–

Serafina: All the other buzzwords.

Wendy: Right, that we need to pull in, but it’s real.  It’s going to happen, we just have to align it.

Stephen: Apropos of what was just said, when you look at IT, and you look at the financial world, the information you can glean in seconds about what you’re invested in, how it’s done today, not two years ago, is there. Medicine is twenty years behind in the IT world.  So, now we’ve had companies that, you know, big companies made a lot of money on electronic medical records, and now on big data. The problem with big data, you’ve got to know the right questions to ask big data. Big data, in and of itself, is worthless.  If you ask the wrong questions, garbage in, garbage out.  It all has to be integrated. That’s why I think, you know, leaders need to get involved in this. It’s a big nut to crack, but whoever cracks it is going to be the Amazon of healthcare.

Serafina: Well, I think I found my new calling in life.

Wendy: And who’s going to benefit by all the integrative?

Stephen: Everybody.

Wendy: The patient, first, right?

Serafina: The physician.

Wendy: And our total spend. Look at that GDP, right?

Serafina: We spend the most out of any country in the world, yet we suffer–

Wendy: With not the best results.

Stephen: If you ask any citizen how much is spent, they’d never guess 20% of GDP.

Wendy: If this is going to continue it’s going to break us in this country. We can’t, and we’ve been saying this for a long time now, so this is a known problem, we’ve got to tackle it, but there are still too many folks profiting from the status quo.  So, until we fix all of that, it’s going to be an uphill battle.

Serafina: Well, thank you, Drs., for joining us today. We really appreciate your insight and education on the topic of telemedicine.  And again, we’re here at the Alpha Conference over in Napa, California.

Wendy: Thank you.

Stephen: Thank you.