Whats been the growth or use of it in the past couple of months . Guest its been around some people think the early 1920s. There was a lovely picture in one of the magazines, not popular science. They had different name for it then but it shows a family huddled around the radio having a visit with a doctor on the other side. The concept is been around for a while, the late 60s when it got going and it has puttered along for the next several decades until a couple of months ago when of course we told everyone in the u. S. They had to stay in their home, and we as clinicians had to take care of them. So blossomed overnight. Host how can it be used today . Guest they can be used in number of ways. The best uses worst of all Mental Health is the number one probably used and the diagnosis is growing need so thats wonderful. A lot of urgent care type things such as sore throats, earaches and actually screening for the coronavirus is quite handily done using this type of technology, so virtual urgent care. Then chronic illness management followup visits for patients with diseases like hypertension, diabetes, Heart Failure and the like are very handily done. During the pandemic we did everything this way. Im a dermatologist. We did a whole lot of dermatology this way. Where we are headed now is some kind of what i will call hybrid. Most people are pretty confident that we will continue to have telehealth as part of our care Going Forward and are a lot of reasons for that. Perhaps we will get into some of them later. Most of those things and then even more. What i would finish off by saying that everything, and thats important, and really the conversation 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 change of care plan. And if we can do that without touching the patient then we can do it via telehealth. Host lets bring Kimberly Leonard of Business Insider into this conversation to explore some of those issues. Dr. Kvedar, thank you so much for being available for this interview. Those were not that familiar my understanding is the Trump Administration had to make changes to rules to allow telehealth to be used in more doctors offices. Can you tell us what some of those changes were for those who might not be as familiar . Guest i was told the other day i testified in front of a senate panel and i was informed there are 31 to be exact, but i can only brush the highlights. The biggest one is that the federal government and most private payers came on board with this, are paying physicians and other clinicians the same amount of reimbursement for seeing telehealth patient as if some would come in the office. That was a critical one. A second one was allowing us as clinicians to see our patients wherever they were. Medicare used to limit it to people in rural or Health Professional shortage areas. That went away so i can be where i am right now, which is my home, and you can be where you are and we could have visit and that would count and we would deal for that. The second tier of regulatory relaxation was in the area of technology and hipaas, our privacy standard rule that many people know about. It went away overnight. People could use facetime, zoom, google hangout, they could use skype to do these calls. They could use a telephone. So we could talk about whether thats a good agenda but third party was licensure. 49th out of 5050 states now have loosened the licensure requirements so that you can practice across state lines. I am in the boston area, in eastern massachusetts. If you happen to come visit me, lets say you live in New Hampshire which is about half hour drive north, and you came to visit me in office and wanted to do a followup while you are in your home, we couldnt do that before because i was a license in New Hampshire but now we can do that because of these relaxations. Its really those three ares i think are the highlight. This week President Trump said he thought a lot of the telemedicine changes that the administration have made might become permanent. We heard administrator verma from the centers for medicare and Medicaid Services say the same. If you were to look at the landscape which to think of the most important factors that need to remain in a postpandemic america . Guest thank you for asking, and there really is, when image and and i testifiedn front of the senate h. E. L. P. Committee and was really strong bipartisan support for this, so we are very hopeful. But to be specific to answer your question, number one, what we call the originating site concept. That i should be able to care for you wherever you are, not just an Health Profession shortage areas or a rural area. Thats number one on our list at the ada. The segmenting federally qualified Health Center is and rural Health Centers should be able to get reimbursed for providing the services. That was not the case before. And partly that the secretary of health and Human Services should be able to decide which services are reimbursable or not as part of their mandate. Those are three areas that are very important. There are many others but we are trying to be succinct year. It sounds as though some of these changes might happen to rulemaking but others will probably require legislation from congress, is that right . Guest i believe so. For instance, the originating site will imagine was a statutory rule and that would have to be, as i understand that would have to be a new statute to change that. Host dr. Kvedar, congress usually doesnt move this quickly. These things are happening pretty fast, visual changes . Guest well, this is a bit of a new world for me. I have not been directly involved in government before but i was so impressed the other day when i was on hill virtually. I was in this very same room testifying in front of them. But how committed the senators were that hearing to move this fast as possible. We have a term that we have coined called the telemedicine cliff, and what that means is that this isnt an abstract notion. I am back nursing patient 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. If we cant do that and all of a sudden the public of emergency goes white and there are no ways to fix some of these regulatory restrictions, then well be in trouble and our patients will be in even more trouble. Host as a dermatologist how do you diagnose via camera . Guest its an interesting question. The way we do it is it turns out that, if this is research i did maybe almost 30 years ago now, but your smart phone cam is quite adequate for taking good, quality images. So when we do this we have our patients submit those images over the Patient Portal which is of course secure, and the windup in my in basket in my electronic records, intimate interview call or phone call with them to go over and review the images. For dermatology, a single lesion that is bothering you or a rash is a great thing. A lot of my patients need there are patients of skin cancer, they need a sixmonth aura one your full body check so thats why said this i give a hybrid of five is way were going with this and is critical we are able do both. My understanding is that many this is some talking the hospital ceos and to doctors, is that the amount of care that offer to telemedicine has increased so drastically in the past few months. For a lot of hospitals it was something he wanted to do for a really long time and had played a role in the next two years, and instead ended up doing it within two weeks for two months even. What percentage now would you say doctors visits are happening over telehealth, and what are some of the biggest lessons that of come out of this, anything unexpected with the volume weve seen of telemedicine visits . Guest thank you for that. When think i will say, im not always proud to be in my profession. I think sometimes we miss handle things as a profession but this is one where im incredibly proud because doctors who were skeptical or thought at of this a curiosity or i am too busy, cant get involved, everyone jumped in with both feet and we havent had a bad patient outcome. Just been extraordinary. Of course patients have always loved it. Patients are really just, when you can think about it when you can get patients what i call magical triad of access, quality and convenience, everyone is happy. Anyone knows it, the patient, the doctor knows it. I would say thats the Biggest Surprise is it went so well. Where i work in boston, we did 1600 virtual encounters in february and were not up to 50,000 a week. Its going pretty smoothly. I do i talk to other Delivery Systems, other Healthcare Providers are expensing similar growth now, you asked about what sort of how we will settle out. We went from only thing people in the Office Overnight to only thing people virtually essentially. And except for emergencies. We know thats not right either. Most people, its too early to tell but most people are thinking between 3050 3050 r activities will be virtual Going Forward. We will see if that turns up. Some people have said 70 . I think thats a little bit aggressive, but between 3050 and it does spend on your specialty. I wife is an ophthalmologist and they can do very little this way. You have to go to the office with all the gadgets they need to make the diagnosis of your eye condition. One thing im curious about is for people who might be a little uncomfortable using the technology, maybe just because they are not used to it or they might live in in a part of the graduate isnt very good highspeed internet. How do you get around those obstacles to make sure this can be something that patients can use or try to have as an option for them . Guest thank you for that. One really again pleasant surprise from this, and there have been a few, but when was that health plans and the government started paying us for telephone interactions with patients. Up until the pandemic that was just never done. It was always felt like by the payers they would say if you call your patient after a visit, then its bundled in the fee for the visit, and now thats not the case. The reason i bring it up is because for our patients that are in areas with it on a broadband or for those patients who cant afford a tablet or smart phone, the telephone works and theres been a lot of research to show a lot can be done. Not everything. There are things we missed that we dont have video especially for Mental Health but theres a lot that can be done. In my case as i said if you send me a few images i am perfectly comfortable calling you to talk about the result of that and we can formulate a care plan quite well on the telephone. Telephone is an anchor point to solving the problem. Of course we would love it, this is only speaking as an ata official, we would love it if there were more broadband. We would love it if the government put some stimulus funds integrating more broadband penetration. I think it would be great for everyone not just for healthcare but for all kinds of things. So more broadband would be great. Great. Telephone visits are good. And finally one of the things we all own is making these interactions more patient friendly. God knows some of the software is hard. Some people have trouble downloading an app, et cetera. We have to find ways to make it so it is very easy. Theres one telemedicine platform that has the workflow you send the patient, a text message, when youre ready for the visit. They click on the text and open up into video and are chatting with you. We have to find ways to make it easier like that. Host dr. Kvedar, at the beginning of this discussion you mention that federal Aviation Administration has gone out the window. Hipaas has gone out the window. Could you expand on that a little bit . Guest i didnt actually mean it that way but yes. For the pandemic the federal government relaxed requirements your video platform had to be complaints we could again use any number of things and doctors didnt have to before to get something in you had to hire an i. T. Consultant and what made it very difficult for people. Hipaa is a great thing because we care so much about patient privacy and we take that very seriously but if youre practicing to a three doctors and get to go through all that that was just before an excuse not to even get involved. The federal government in the wisdom was trying to let people overcome that in a time when as i said the only way we could provide care to you was to do this by telehealth. As we see the pandemic starts to wane and we get back to some level of in person care, i think we will probably see they will reinstate hipaa, and i think thats a good thing because for vendors to supply us with the videoconferencing at other types of Patient Engagement technologies, they should be willing to hold your information as a patient secure. That should be part of their reorganization, they should be able to do that and if you cant republish shouldnt be using their technology. How can patients be confident Health Information when done over videoconference or over the phone can be confidential . I think of instances where a physician might take the call from a patient when theyre in a public place such as a Grocery Store or if the information were to get hacked somehow as a patient is having a conversation. How can we make sure patients can feel comfortable and know their Health Information is secure and will not be leaked for everyone to see . Guest sure, sure. Im glad you brought it up because everyone is concerned about that and we are concerned about that at ata. Number one, it turned out even though we allowed these various nonhipaa compliant platforms come most of them are secure. So for instance, skype is there secure. Whatsapp is very secure. Many, many of them are secure. So i think the likelihood, and this is important for patients, people that are watching this, the likelihood that you would get your information compromised during a video call is infinitesimally low. Its very small. Could it happen . Yes. Its very unlikely. So thats one thing. And again as we move forward we will get back to a state of normalcy where we are demanding that those technologies are secure before we use them. We are headed in that direction, again, im sure. With regards to question about what of the clinician and making sure that the clinician is in a private place. We are training people as fast as we can. One of the other activities i am involved with is the association of american medical colleges creating training competencies for residents and medical students so that we can teach them home, a whole number of things about being a good telehealth provider. One of them is being, keeping your video chat private from the point of view of where you have it. We are getting that were not assessed as we can, and that are not too many people who are foolish enough to take it in the car or a public place so we are already pretty well on the way to that. Host are you getting resistance from physicians at all to this . Guest surprisingly may be little. I dont know if it is surprising for not because the one thing, you get into sort of a Public Health emergency like this and peoples true stripes come out. As a set of you one really came to the party, jumped in with both feet, use whatever analogy you like, and participated. So very little resistance. I think honestly if you were to ask me this in heres the scenario, i wouldve said that wouldve been more, but the wasnt and its because people unfamiliar with what to take care of her patients and thats really our calling as clinicians. Thats a good thing. Again very little. There are some specialties where they need to do a procedure or the need to use a piece of equipment and they just cant do this, and so for them thats not resistance, thats just quality of care. Dr. Kvedar, post pandemic, should telehealth visits be paid the same amount as brickandmortar in person visit . Isnt something youre advocating for specifically . Guest its a complicated answer and its a very highly nuanced actually. Im going to 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 expense. We would argue that the complexity us time spent is no matter what it is, 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 scale telehealth will find the practice expense may be less and that may be a way to differentiate payment. Its possible. What the specific or official ata policy is is that for the federal government yes, we believe the thing should be compensated at parity. We also recognize in private markets health plans will inevitably want to negotiate with payers as it always do, and we dont feel like its our place to get in the way of that. We heard from Different Health insurers when telehealth became much more prominent towards the beginning of the pandemic. A lot of them said they would provide telehealth at no copay to patients. As the reporter i have heard from patients have gotten these Surprise Medical Bills from telehealth visits. They understood them to be included in the benefits but then ended up with that surprise bill. How do you prevent Something Like that from happening and how do you 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, lets face it. It is convoluted and it is difficult sometimes to communicate the nuances of various plants and various coverage determination to plan members. And i would say that during this time, im not really making excuse for anyone but i would say we have thrown a lot at our health plan colleagues and our pay our colleagues. We have th