Doctor on the other side. The concept has been around for a while in the late 60s is when it got going and puttered along for the next several decades until a couple of months ago and of course we told everyone in the u. S. That they had to stay in their home and we as clinicians had to take care of them and things blossomed overnight. Host how can it be used today . Guest in a number of ways. I think the best use is of all his Mental Health is number one probably used and god knows it is a growing need so that is wonderful. A lot of urgent care type of things such as earaches, sore throats and actually screening for the krait virus is done using this type of technology so virtual urgent care and then chronic illness management followup visit for patients with diseases like hypertension, diabetes, Heart Failure and the like are very handily done. During the pandemic we did everything this way and im a dermatologist and we did a lot of dermatology this way and i think where we are headed now with some kind of what i would call hybrid, most people are pretty confident that we will continue to have telehealth as part of our care Going Forward and there are a lot of reasons for that and perhaps we can get into some of them later but most of those things and then even more what i would say finish off i say not everything and that is important. Really the conversation that we need to have is with your doctor and for us as clinicians to be able to think through the information we need to make either a diagnosis or a change of care plan and if we can do that without touching the patient then we can do it with telehealth. Host lets bring Kimberly Leonard of Business Insider into this conversation to explore some of those issues. Guest, doctor kay, i thank you for being available for this interview. My understanding is that the Trump Administration had to make a lot of changes to rules to allow telehealth to be used in more doctor offices. Could you tell us what some of those changes were for those who might not be as familiar . Guest i was told the other day that i testified in front of the senate panel and i was informed that there are 31 to be exact. I can only flush the highlights. The biggest one is that the federal government and most private payers came on board with this our pain physicians and other clinicians the same amount of reimbursement for telehealth patients as they would for the Office Amount was a critical one. Second one was allowing us as clinicians to see our patients wherever they were, medicaid used to limit two people in rural or Health Profession shortage areas that went away so i can beat ym right now which is my home and you could be where you are how we could have a visit and that would count and we could bill for that. The second tier regulatory relaxation was in the area of technology and hepa, hepa is our privacy standard rule that many people know about and it went away overnight. People could use facetime and zoom and Google Hangouts and skype to do these calls and the telephone and we could talk about whether that is a good idea or not the third area was licensure and 49 out of 50 states now have loosened their life license requirement so that you can practice across state lines great i in the boston area in eastern massachusetts if you happen to come visit me lets say you move to New Hampshire which is about half hour drive north and you came to visit me in the office and we wanted to do a followup while you are in your home we couldnt do that before because that wasnt licensed in the state of New Hampshire but now we can do that because so its really those three areas i think as a highlight. This week President Trump said he thought a lot of the telemedicine changes that the administration had made might become permanent and weve heard administrator from the centers for medicare and Medicaid Services say the same so if you were to look at the landscape which do you think are the most important factors that remain in a post pandemic america . Guest thank you for asking. There really is when i mentioned i testified in front of the Senate Health committee and there was really strong bipartisan support for this so we are very hopeful but to be specific and to be specific and to answer your question, number one, what we call the originating site concept. I should be able to care for you wherever you are, not just in a Health Profession shortage area or rural area. That is number one on our list at the apa. Second one being federally qualified Health Centers and rural Health Centers should be able to get reimbursed for providing the services and that was not the case before. Importantly, the Health Secretary of health and Human Services should be able to decide which services are reimbursable or not as part of their mandate for those are three areas that are important. There are many others but we are trying to be synced. It sounds as though some of the changes might be able to happen to rulemaking but other probably require legislator for congress, is that right . Guest i believe so. The originating site was a statutory rule and that would have to be, as i understand it, that would have to be a new statute to change that. Host doctor kvedar, congress usually doesnt move this quickly and these things are happening pretty fast, arent they . Guest this is a bit of a new world for me and im not been direct the involved in government before but i was so impressed the other day when i was on the hill virtually and i was in the same room testifying that how committed the senators were in to move as fast as possible. We have a term that we call the telemedicine clip and what that means is that this isnt a abstract notion and i am back now seeing patients in the office at 40 of our previous volume and when we get a little bit more cranked up we will be at 75 and we wont go higher than that. In order for us to meet the demand for patient care we have to have telehealth embedded in our workflows now and if we cant do that then all of a sudden the Public Health emergency goes away and there is no way to fix some of these regulatory restrictions and we will be in trouble in our patients will be in even more trouble. Host as a dermatologist how do you diagnose [inaudible] . Guest interesting question for the way we do it is it turns out in this is research that i did almost 30 years ago now but your smart phone camera is quite adequate if you get Quality Images so when we do this and we have our patients submit those images over the patient which is the first to secure and they wind up in my in basket in my electronic records and then we can do a video call or phone call of them to go over and review the images. For dermatology a single lesion that is bothering you or a rash this is a great thing and a lot of my patients need their patients with head skin cancer and need a sixmonth or full body skin check and that has to be done in the office but that is why again the hybrid environment is where we are going with this and its critical that we are able to do both. Host Kimberly Leonard. Yes, my understanding is that this is from talking hospital ceos and doctors is that the amount of care with telemedicine has increased so drastically in the past few months and for a lot of hospitals it was something they wanted to do for a really long time and plan to roll out of the next two years and instead they did it within two weeks or two months even. What percentage now would you say of doctor businesses are happening over telehealth and what are some of the biggest lessons that have come out of it, anything unexpected with the volume that we have seen telemedicine visits . Yes, thank you for that. One thing i will say is that im not always proud to be proud of my profession and we mishandle things as a profession but this is one where im incredibly proud because doctors who were previously skeptical or thought of this as a curiosity or im too busy and i cant get involved that everyone jumped in with both feet and we really havent had a bad patient outcome. Of course, patients have always loved it patients and when you can give patients what i call magical triad of access quality inconvenience everyone is happy and everyone knows that the patient knows it and the doctor knows it so i would say thats the biggest surprise. It went so well. Where i worked in boston and the Delivery System was called mass general we did 1600 virtual encounters in february and we are now up to 60000 a week and it has gone pretty smoothly. Everywhere i talked to in other Delivery Systems and providers are experiencing a similar growth. You asked about what sort of how we will settle out because we went from, we went from only seen people in the Office Overnight to overnight seen people virtually and except for emergencies so we know thats not right either. And most people its too early to tell but most people are thingy between 30 and 50 of their activities will be virtual Going Forward and we will see how that turns out pit some people have said 70 and i think thats probably a little bit aggressive but i think between 30 and 50 and it does depend on your specialty and my wife is an ophthalmologist and they do very little so you have to go to the office when its all the gadgets you need to make the diagnosis. One thing im curious about is for people who might be uncomfortable using that Technology May be because they arent used to it or they might live in a part of the country where there isnt really very good highspeed internet so how do get around some of those obstacles to make sure that this becomes things patients can use or try or have as an option for them . Guest thank you for that. Again, a pleasant surprise from their view but health plans on the government started for telephone interaction with the part patients and up until the epidemic there was never done and it was felt like they would say if you call your patients after a visit then its bundled in for the visit and now that is not the case per the reason i bring that up is because for our patients that are in areas where they dont have broadband or for those patients that cant afford a tablet or smartphone the telephone works and theres been a lot of research to show that a lot can be done, not everything but there are things we miss if you dont have video, especially to early Mental Health but theres a lot that can be done and in my case if you send me a few images im perfectly comfortable calling you to talk about the results of that and we can formulate a care plan quite well on the telephone. Telephone is an anchor point to solving that problem. Of course, we would love it and this is not me speaking as an ata official but we would love it if there were more broadband and we would love it if the government put Stimulus Fund integrating more broadband creation and that would be great for everyone, not just for healthcare but for all kinds of things so more broadband would be great, telephone visits are good and then finally making one of the things we all own is making the interactions more patient friendly. God knows some of the software is hard and some people have trouble downloading an app et cetera and we had to find ways to make it so that its very easy. There is one telemedicine platform that has a workflow that you send the patients a text message when youre ready for the visit and they just click on the text and open up into the video and chat with you so we have to find ways to make it easier like that. Host doctor kvedar, at the beginning of this discussion you mentioned that hipaa has gone out the window. Could you expand on that a little bit . Guest well, yeah, i didnt mean it that way but yeah, for the pandemic the federal government relaxed the requirements that your video platform had to be different so we could again use any number of things doctors do not have two or before to get something and you had to hire an it consultant and we made it very difficult for people and hipaa is a great thing because we care so much about patient privacy and we take that very seriously but if you are up practice with two or three doctors and you had to go through all of that that was before just an excuse not to even get involved so the federal government and their wisdom was trying to let people overcome that in a time when, as i said before the only way we can provide care to you was to either by telehealth and as we see the pandemic start to wane and we get back to some level of in person care i think we will probably see that they will reinstate hipaa and i think thats a good thing because for vendors to supply us with Video Conferencing and other types of Patient Engagement technologies they should be willing to hold your information as a patients care and that should be part of their bargaining and they should be able to do that and if they cant do that we shouldnt be using their technology. How can patients be confident that their Health Information when done over Video Conference or over the phone could be confidential . I think of instances where we have a physician might take a call from a patient when theyre in a public place and at the Grocery Store or if the information or to get hacked somehow as a patient is having a conversation so how to make sure that patients are can feel comfortable and note their Health Information is secure and wont be leaked for everyone to see . Guest sure, sure. Thats a good im glad you brought that up because we are concerned about that at aca. Number one, it turns out that even though we allowed these various non hipaa compliant platforms and most of them are secure so for instance, skype is secure. Whats app is secure and there are many, many of them are secure and so i think the likelihood and this is important for patients and people that are watching, the likelihood that you would get your information compromised during a video call is infinitesimally low. It is very small. Could it happen . Yes. It is very unlikely. That is one thing and again as we move forward we will get back to a state of normalcy where we are demanding those technologies are secure before we use them and so we are headed in that direction again i am sure. With regards to your question about the clinician and making sure clinician is in a private place were treating people as fast as we can breed one of the other activities im involved with is the association of american medical colleges created training competencies for residents and medical students so we can teach them home whole number of things about being a good Telehealth Provider and one of them is keeping your video chat private from the where you have it. We are getting that word out as fast as we can and there arent too many people who are foolish enough to take it in the car or public place so we are already i think pretty well on the way to that. Host are you getting resistance from physicians at all to this . Guest surprisingly may be a little but i dont know if its surprising or not because one thing that you get into a Public Health emergency like this for people true stripes come out and as i said earlier everyone seems and came to the party and jumped in with both feet and use whatever analogy you like and participated. Very little resistance and i think honestly if youd asked me this in january and i said here was a scenario i wouldve said here there should be more but there wasnt anything its because fundamentally people want to take care of the patients and thats our calling as clinicians. Thats a good thing and again very little. There are some specialties where they need to do a procedure we need to use a piece of equipment and they just cant do this. For them thats not resistance but just quality of care. Doctor kvedar, post pandemic should telehealth visits be paid the same amount as the brickandmortar in person visit, is that something youre advocating for specifically . Guest thats a complicated answer and very highly nuanced actually. I will try to break it down without sounding too nerdy but clinician compensation comes in three buckets, complexity of thinking, time spent with the patient and practice and then we would argue that the complexity of making your time spent is what it is no matter what vehicle and it should always be compensated by the same way. It is possible and this is not been proven yet at all but it is possible that when we scaled telehealth we will find the practice expense may be less and that may be a way to differentiate between and what the specific or official ata policy is is that for the federal government yes, hes alluded the sink should become sated for at parity we also recognize in private markets health plans will inevitably want to negotiate with pears as they always do and we dont feel like its our place to get in the way of that. We heard from a lot of Different Health insurers when telehealth became much more prominent toward the beginning of the pandemic a lot said they would provide telehealth at no copay to patients and as a reporter at Business Insider i have heard from patients who have gotten the Surprise Medical Bills from telehealth visits and they understood them to be included in their benefits but then ended up with that surprised bill. How do you prevent Something Like that from happening and make sure patients know what exactly their benefits are supposed to cover . Guest we would all probably benefit from more transparency and simplicity in our industry but face it, it is convoluted and difficult sometimes to communicate the nuances of the various plans and coverages and determination to plan members. I would say that during this time im not making excuses for anyone but i would say weve thrown a lot at our health plan colleagues and payer colleagues and weve said please pay for all of this and they are weeding through it as best as they can. And so its a longwinded way of saying i would cut them a break and, you know, any member has the opportunity to go back and question any of that. We all do but its been a tough time for everyone and i think there weeding through it in a very careful way so some of those things may slip through the cracks. It sounds like you feel its more speed bumps in a particul particular. Guest i do, again, this is another thing i would not have predicted but i talked to a lot of health plans, not universally but a lot of the ones i talked to are on board in continuing their and there is a belief and its only a belief or i should not say that because it some data to support it but there is a belief that if we could keep people healthy in their home we could lower cost by keeping people out of the emergency room so if we do it right we will save premium dollars. Host doctor Joseph Kvedar is president of the American Telemedicine Association and Harvard Medical School professor as well and a practicing dermatologist. Kimberly leonard covers healthcare for Business Insider. Doctor kvedar, is there a chance that these sessions could start to be recorded thus increasing the Privacy Concern . Guest now as we are currently doing this and as we alluded to earlier people are using every kind of platform and some of those allow you to press the record button for sure. We strongly advise clinicians to never to do that and it doesnt make any sense whatsoever. Unless perhaps they are recording part of a neurology exam for the record or Something Like that. Patients will have the options again of doing that as well. I dont think that should be part of our future but right now it could happen. But what about the patients, what if a patient wants that recording to listen back and say okay, particularly during a visit with psychologists and they want to listen back and embedded in their brains and rehear the advice that they received, is that permitted if the patient wants that information wants to record it . Guest i believe it is. I would have to double check but i believe it is. Im not so sure this practice Going Forward but i think it is okay. Host have there been liability concerns with this . Guest thank you for asking. There always has been but there has been very little, almost none, [inaudible] and all of our malpractice carriers even before the pandemic were covering physicians from a malpractice perspective and like any other malpractice conversations or any other negligence conversation common sense is really important and i said in another interview that doctors need to decide what they need to make a decision and if they can get that information but if they cant get that information they shouldnt make the decision. You know, if you have to come into a brickandmortar to get something done that is the best way to get your care. We have to be thoughtful and we can to be sloppy and we are getting to a point now very quickly where as i alluded to earlier, we no longer have to say the only way we can get care is by this and it will even out and people will start to say no, id rather you come in four acts but i think it is okay that we do wide by telemedicine as we do more and more those liability concerns will naturally ease. Host how is 5g advance or change telemedicine . Guest 5g should be an amazing thing for us and i should say i was underwhelmed by 4g some little bit of a skeptic naturally but if it works as advertised it should be an amazing thing so how many of us and im guessing people watching, both of you have probably been on failed zoom calls during this crisis and there are bandwidth is restricted and we found out just how restricted it is. One of the promises of 5g is that it will be much more elastic if i could use that term and thats the main thing, not only faster but more available and so if we will start doing more and more of this video base communication, not just in healthcare but business with people saying we will not go back to the office but be virtual then we need that bandwidth to get it all done for sure. How we prevent cases of fraud and abuse of the technology . I would think it might be fairly easy for some physicians to bill for many visits that they did not actually conduct, just to give an example. Does that need to be new legislation or guardrails passed by the Trump Administration to prevent those types of scenarios . Guest fraud is a terrible thing and at 88 we are very, very committed to a world where there is minimal broad and we would advocate for that. With that background i guess i would say two things print one is another principle that ive lived by for almost 30 years of doing this is that we shouldnt hold telemedicine to a higher standard than in person care and we know that up fortunately there is plenty of fraud in the office visit rome and a fraud means people randomly sending bills for things they did not do there is no difference here except we may be able to be better off because as you know software can time and date stamp when youre having a conversation with the patient. For instance, and my Delivery System we have zoom embedded into our so we can track whether people are having those calls were not as part of that system so we can be pretty sure that we wont be committing any fraud in that regard. I think more and more systems that allow us, again, not to record the content but to record that the visit happened and you could envision the future where just care shows us or at least results in less fraud than in person care because you cant always document that someone came to the office. Host unfortunately, we are out of time. Joseph kvedar, president of the American Telemedicine Association, Harvard Medical School professor as well. Kimberly leonard covers healthcare for Business Insider. Thank you both for being on the committee caters. Guest real pleasure. Thank you. Weeknights this month we feature booktv programs to preview what is available every weekend on cspan2. Tonight is part of our 2020 year end review we focus on biographies. To merit pain her National Book Award Winning biography the dead are arising and pulitzer prizewinning Washington Post reporter mary jordan and her book the art of her deal. Later, edward fall in the life of a klansman that starts at 8 30 p. M. Eastern. Enjoy book tv this week and every weekend on cspan2. You are watching book tv on cspan2. Every weekend with the latest nonfiction books and authors. Booktv on cspan2 created by americas Cable Television company. Today we are brought to you by these companies provide book tv to viewers as a public service. Hello, im randall and welcome to the Miami Book Fair with tomorrowai