Pandemics and the Need for Telehealth: Dr. Joseph Kvedar of the American Telemedicine Association

Dr. Joseph Kvedar

[ M us ic ]

Female : Welcome to Conversations on Health Care with Mark Masselli
and Margaret Flinter, a show where we speak to the top
thought leaders in health innovation, health policy, care
delivery, and the great minds who are shaping the hea lthca re
of the future.

This week Mark and Margaret speak with Dr. Joseph Kvedar ,
President Elect of the American Telemedicine Association,
seeking to advance the adoption of telehealth services to
improve access to care for all patients and yield better
outcomes for ever yone , talks about Coronavirus and how this
outbreak will likely lead to more clinicians seeking to adopt
teleheal th services moving forward. Lori Robertson also checks
in , managing editor of factcheck.org , looks at misstatements
spoken about health policy in the public domain, separating
the fake from the facts , and we end with a bright idea t hat's
improving health and well being in everyday lives. If you have
comments, please email us at [email protected] or find us
on Facebook, Twitter or wherever you list en to p odcasts , a nd
you can also hear us b y asking Alexa to play the program
conversations on healthcare. Now stay tuned fo r an interview
with Dr. Joseph Kvedar of the American Telemedicine
Association here on C onversations on Health Care.

Mark Masselli: W e're speaking today with Dr. Joseph Kvedar , President Elect
of the American Telemedicine Association, the larg est
organization in the world p romoting t he adoption of
telehealth . Dr. Kvedar is Senior Advisor for virtual care at
Partners HealthCare in Boston and board certified
dermatologist and Professor of Med icine at Harvard Medical
School.

Margaret Flinter: And Dr. K vedar is internationally renowned for his leadership
in advancing connected health to better manage chronic
conditions compliance and we llne s s through digital and
tele health monitoring. He ha s written numerous papers and
books on the topic, including the new mobile age, how
technology will extend the health span and optimize the
lifespan Dr. Kvedar we welcome you back to conversations on
health care.

Dr. Joseph Kvedar: I'm delighted to chat with you today.

Mark Masselli: We're In the midst of a pandemic with COVID - 19, disrupting
travel, leading to quarantines impacting healthcare delivery
across the globe, and you've been a champion of telehealth as
an important untapped resource in our healthcare system.

Dr. Joseph Kvedar

And I wonder if you could talk to our listener s about
telehealth, especially a gainst this backdrop of the epidemic
we're experiencing now.

Dr. Joseph Kvedar: Well, it's extraordinary how fast thi ngs are happening. My
daughter i s a law student at USC here . C lasses are now going
to be all virtual after spring break. Same thing, I just noticed
that in my neck of the woods at Harvard, I l ive with that
because the technology we're using to talk today , video chat is
mature enough now that most people have used FaceTime to
talk to a loved one or Skype. And so the concept of if I can use
the phrase Skyping with your doctor doesn't sound so odd to
people. We have enough experie nce now in the healthcare
wor ld t o be able to, to be able to do a lot of what we do in the
office using a tool like we're using to do this interview against
the backdrop of telling everyone stay home, don't go
anywhere, quarantine, etc. A couple of just very quick
examples of how our systems are already implementing this .
M any hospitals n ow , when you arrive, if you have symptoms,
you're escorted to a private isolation room and you're done
your intake by video. That's a simple application. And of
course, more and more follow up visits in the home following
people who are quarantine d, so enormous opportunity for
that technology.

Margaret Flinter: Dr. Kvedar , it was somewhat surprising to us how relatively
slow the pace of adoption has gone. And I think the last sort of
figure we saw quot ed was maybe 15% of the nation's clinicians
and health systems had adopted telehealth. But there's so
many clinical needs that would benefit from expanded
telehealth support and one of them that we've been very
focused on is Behavioral Health just in and o f itself, but also
with all the anxiety that's being caused by maybe an increased
need. And one of those areas that is just ripe for a major
uptake in telehealth. Talk to us about that or other areas that
you see where adoption is most likely to have a sub stantial
impact?

Dr. Joseph Kvedar: Sure, well, first thing is to , it's a little more rosy than 1 5%. That
data comes from 2016 f rom the AMA. They just released their
2019 data , it’s now up to about 28% . Hospitals about 76% said
they have a program of some sort, virtually every health plan
offer s some sort of virtual Urgent Care solution to their
insured. On the mental health side, almost half of mental
health professionals have used this tool in some way for
shaping their practice. So the reason mental heal th is such a
natural fit is because the physical exam is talking to the
patient, you can do that very, very capably with a tool set like

Dr. Joseph Kvedar

this. I grew up in this field in an era where people were
constantly grading me with I'm not sure it's as good as face to
face. Maybe if you're stuck in some rural part of the world like
Antarctica, this might be okay. And in mental health, we think
that probably it's better. And what's probably better for a
couple of reasons. One is that you as a clinician get to see the
individual in their setting. And there's so much about that
setting that could influence their mental illness that you might
not know. And the flip side is they don't have to endure the
trauma in some cases of traveling and so forth. So it seems to
be almo st better for mental health. And that's why I thi nk the
rapid growth that we see.

Mark Masselli: That's interesting. We had a newspaper story today that
featured one of our psychiatrists, and we made the reporter of
the patient from home and he wrote a bea utiful piece on how
easy it was and how connected he felt to the clinician. So I
couldn't agree with you more. But to get there, we need the
federal government and state governments to really align in
terms of their policies. Now, we had the federal govern ment
that passed an $8 billion Coronavirus relief bil l or whatever
they're calling it, about 500 million I believe went over to
Medicare for some enhanced telehealth services, b ut they
certainly haven't got down on the Medicaid level to the state
level. So walk us through what the American Telemedicine
Association is asking for in its legislative agenda.

Dr. Joseph Kvedar: Well, it's a long and winding road that the new funding that
you mentioned was something that we advocated for and
we're very pleased th at for Coronavirus related visits that
some of those Medica re restrictions will be relaxed , two
things. One is that health plans continue to be worried about
over utilization so we would constantly have to fight that
Brumby you might say Gee, I have a sore throat you might
connect With a tool like this, and I would say, you have a sore
throat, you need to throat cultures. So you've got to come in
the office and then I built twice. There's lots of data to show
that doesn't happen. But health plans, one of th eir goals in life
is not to pay people. So the second is this idea of state
licensure crossing state boundaries. We're getting some
traction slowly but surely, but on the Medicaid side, it's, as you
know, set up so it's a state by state decision. So we go state by
state, foxhole by foxhole to try to get more and more
Medicaid reimbursement more and more Medicaid
engagement. Medicaid is the most cash strapped health plan
in any state. So it's a challenge, but we're continuing to work
on it and I think we're making progress at the national level, I
would just put in a plug for the AMA's work on reimbursement

Dr. Joseph Kvedar

codes, which has been quite prolific over the last three years.
And part of the reason we were a ble to do that is because they
t he current administrator o f CMS is the most telehealth
friendly administrator we've seen. So I realized there's still a
long ways to go. But that's how I continue to get up in the
morning and fight for the costs.

Margaret Flinter: Well, I think it's good to note for our listeners a nd viewers that
Since launching connected health at partners in Boston, you've
served about 1.5 million people with some form of remote
monitoring or telehealth service. But as you know, we are
particularly concerned about the most vulnerable patients and
certainly those on Medicaid, also those who don't have any
health insurance at all. What are your thoughts about the
scaling of telehealth access for patients and populatio ns who
are already struggling t o access health care? We have issues
certainly around training providers about the system's
infrastructure. We'd love to hear your thoughts , but if you
could wave your wand around really making this available to
people? What are some of those strategies for scaling?

Dr. Joseph Kvedar: Well, one thing I'm inv olved with is Association of American
Medical Colleges has a telehealth effort a nd the idea behind
that efforts is to promote standardized training modules for
medical students and residents. It's interesting that today's
trainees are all digital natives. They all grew up with mobile
phones in their hands, but we kind of teach it out of them,
unfortunately, in medical school, so they still are cautious
about using these tools, and it's moving forward. We've been
working on that for over a year now , it'll s tart to see the light
of day in the next few months and then as medical schools and
residences pick it up, we'll see more and more comfort
amongst our trainees with how to integrate this into their
practice. Patients are usually not hard to convince. We ha ve a
program at partners where I work a virtual Urgent Care
program through our health plan for all of its members, which
includes our employees and their dependents. It is a small set
of complaints that you can get a virtual console for but on
average wit hin five minutes you get a provider, and 80% of the
time your problem gets fixed. Who wouldn't want more of
that, right compared to what we go through when we visit the
office [inaudible 00:10:11] waiting in the waiting room, and all
of that nonsense that we go through. So I think patients are
generally on board, health plans, and particularly, you've
mentioned Medicaid a few times, they're the biggest
challenge. I would say Medicare Advantage on the other end
is, is doing some wonderful things generally. S o the only thing I
would say about that, about the commercial plans that I

Dr. Joseph Kvedar

mentioned earlier to stay in business application for , but it's
very silent and that bothers me because we have this scenario
where you have a sore throat, we, we interact, I prescr ibe
something. It's good for you. But that never really makes it to
your own doctor because your own doctor i s n’t involved with
a care. It's a shadow network. So we want to fix that as soon
as we can. That's bot h an interoperability challenge.

Margaret Fli nter: Yeah.

Dr. Joseph Kvedar: But It's also a physician training physician comfort challenge.
We're speaking today with Dr. Joseph K vedar, P resident E lect
of the American Telemedicine Association, the largest
organization promoting th e adoption of telehea lth. Dr. Kvedar
is Senior Advisor, virtual care at Partners HealthCare in Boston.
He's editor in chief of NPJ Digital medicine, and Dr. Kvedar for
the past three years, your enterprise. I think it's called the
connected health symposium merge d with the per sonal
connected health con ference, an event hosted by HMIS . And
of course, HMIS was about to have its annual conference , and I
think rightfully made the decision with this gathering of so
many people from hundred plus countries that it was probably
more pr udent to cancel that . I know our National Association
of Community Health Centers just canceled its annual Policy
Forum in Washington DC. And, I was reading today in the
Atlantic a n interesting ar ticle about social isolation. AD A is sort
of hearing the adm inistration really hasn't come clear on it. So
I'm just wondering what important opportunities are being
missed by these cancellations and how can we address them?
Perhaps through the use of telehealth? I'm not sure we've
gotten people to understand outsid e of smaller gatherings
how to do a national conference, through telehealth, what are
your thoughts about this?

Dr. Joseph Kvedar: It’s an enormous challenge . A s much as I'm an advocate for
using this kind of a tool set for the right set of activities,
whe ther it be educational or clinical, there's nothing like being
together for certain things and one of them is forming
relationships around moving the industry forward. Whether
those be relationships with people who deliver care or
whether relationships bet ween people who deliver care to try
to move the rising tide that floats, all boats, those things are
harder when you're doing something that looks like a
Hollywood Squ ares thing on a video call, just it’s har der . W e're
trying to figure it out because we ha ve to continue to move
our agenda forward, not just at ATA b ut in general and
whether whatever it be I was to speak at an event three, three
events that I was to speak at, and the next three, sorry, six

Dr. Joseph Kvedar

weeks are now either cancelled or I can't go because I'm not
allowed to go to conferences by my employer. So it's getting
pretty bleak. S o we're working very hard at AT A, our
conference i s currently scheduled for May three through five.
Right now we're on. We're hoping that by then that we'll have
some clari ty on either transmission or what have you that we
can actually ho ld meeting, because we are the A TA . We're
working very thoughtfully to come up with alternate plans that
will allow us to continue to educate one another two uses of
technology. So if anyone can do it, we can and.

Mark Masselli: There's an a pp for that.

Dr. Joseph Kvedar: Yeah exactly. So we are working on , it is it's an enormous
challenge, though.

Mark Masselli: Yeah. Because just gathering people together, that's the
reason conferences are so prolific. There is something about it
that is very powerful for everyone involved. There's a lot of
mutual benefits. So we're working on it.

Mark Masselli: Yeah.

Margaret Flinter: Well, that's great. And it reminds me that last week, we
decided to put together a Project ECHO, I'm sure you're
familiar with the ECHO model of case based distance learning.
Communities of providers and experts and a 1000 people
joined down to that ECHO from all over the country with a
tremendous feeling of community based on the chat room
going simultaneously. A few minutes ago, you noted that
today's health professional trainees are digital natives. And I
wonder if you could speak because I know one of your many
hats is that you're also a professor of Harvard Medical School,
about the faculty, the curriculum, if you will, all of whom need
to get on board with these changes in order to both have the
ability to train our students and our trainees, you run up
against a lot of barriers in doing this. And I wonder if you have
any thoughts on that for our listeners who are en gaged in
education and training.

Dr. Joseph Kvedar: You've outlined an enormous challenge. People ask why
haven't we got farther, faster. And there's a number of
reasons, the classic ones reimbursement, liabilit y, etc. They're
all still relevant. But there's also something in the background,
which is our current service delivery platform. That means you
come see me in some physical location, and we call that
healthcare. That platform is quite alive and quite busy and
cluttered now with physician burnout, and so forth. The idea
that not only do I come to work and work all day in this

Dr. Joseph Kvedar

environment where I'm busy seeing patients that are in front
of me, and I've got to go home at night and do my notes and
so forth, an d then you say, hey, I've got an idea. We're going
to change the whole thing up into telehealth, what do you
think?

Margaret Flinter: Wow.

Dr. Joseph Kvedar: You want to take a a p p right? So Don't forget most training
centers are by the very nature those p atients really do need a
lot of face t o face here.

Margaret Flinter: Right, right.

Dr. Joseph Kvedar: Their people are complicated illness. So factory we're looking
at, I got to go see my clinic full of weird diabetics now I can't
really think about this. So it's an enormous challenge. And it's
a little bit like when I st arted working in this area, we i t was
about 1993. And we had a new technology come in, it was
called email. Everyone was really worried because we already
had fax machines and voicemail the y were like another
channel I don't know . Of course now you don't get many f axes.
So it's a bit like that l ike we're introducing a new channel of
care into an already busy e nvironment. It's hard. So it's a
challenge for sure.

Mark Masselli: Well, speaking of challenges, one of the things that we have
stood up here at our health center, through an organ ization
we call confirm ed is e - consult platform and particularly
focused in on sp ecial populations. And when we s o this we
cover about 1.3 million lives, we have about 40 different
specialty areas covered. And our worry is the population that
simply through anxiety or also because of lack of insurance
coverage, you simply can't get to a specialist, love to hear your
thoughts about the council movement that's g oing on around
the country.

Dr. Joseph Kvedar: At Partners HealthCare, we do this, we've done it for several
years, our being in a risk contract with every pair at some
level, we're at risk with every local payer, with Medicare and
with Medicaid now. And s o one of the areas that we know we
can control costs on is specialty access, if it's done
thoughtfully, and so we do this as well. We do it right through
epic, but we do it like you across all of our specialties. And in a
couple of years, we've done about 35,000 of them. As we look
at the data, we've avoided about 25,000 specialty offices with
wh at's interesting about that is a ll of the specialists are still
really busy. So they're seeing a more enriched sample of
people that will need to see them. It's a b eautiful thing and it

Dr. Joseph Kvedar

works really well. And by the way, there's a code now to pay
for it. So if people that are listening or watching say, Oh, I can't
do that because we can't get paid. We're not at risk. W ell,
guess what? They are supposed to pay for it now.

Mark Masselli: Absolutely.

Margaret Flinter: We've been spea king today with Dr. Joseph Kvedar the
President Elect of the American Telemedicine Association. You
can learn more about their work by going to American
tele med. org. Dr. K vedar , we want to th ank you for your long,
steady and persistent dedication to the quest to expand
telemedicine and modern healthcare to improve healthcare
delivery and outcomes for patients and providers alike. And
thank you for joining us again, on Conversations on
Healthca re .

Dr. Joseph Kvedar: It's a pleasure, we're just hitting our stride. So thanks to
venues like this where we can get the word ou t and thanks for
inviting me.

Mark Masselli: Great, at Conversations on Health Care, we want our audience
to be truly in the kn ow when it comes to the facts about
healthcare reform and policy. Lori Robertson is an award
winning journalist and Managing Editor of FactCheck.org, a
nonpartisan, nonprofit consumer advocate for voters that aim
to reduce the level of deception in US p oli tics. Lori, what have
you got for us this week?

Lori Robertson: We looked at s everal statements by President Donald Trump
and members of his administration during the last week of
February that gave inaccurate or misleading informat ion about
the new Corona virus. And in February 26. Press Conference,
Trump said the current number of COVID 19 cases in the US is
“ going very substantially down not up ” . But the Centers for
Disease Control and Prevention has said to expect more cases
and has warned that is highly unlikely that the virus will not
spread to some degree within the United States. Economic
adviser Larry Kudlow also misled on the potential for the virus
to spread within the US saying n a television interview on
February 25. We have contained this and “ i t's pretty close to
airtight ” . The President said that the US is rapidly developing a
vaccine for COVID - 19 and “ will essentially have a flu shot for
this in a fairly quick manner ” . That's misleading. The director
of the National Institute of Allergy and In fectious Diseases,
said a vaccine at best won't be ready for a year to a year and a
half and won't be available for the current epidemic. So far,
the fatality rate for COVID - 19 has been about two to 3% higher
than the influenza fatality rate in the United States of about

Dr. Joseph Kvedar

0.1%. But in talking about those rates, the President made
confusing remarks that left a false impression that “ the flu is
much higher ” than the coronavirus rate. Since 2010. influenza
in the US has caused between 9 million and 45 million i llnesses
annually. The CDC says with 12,000 to 61,000 of those
resulti ng in death, that puts influenza fatality rate at about
0.1% t he fatality rate for COVID - 19, i n late January, the
worldwide fatality rate was 2%. But as of February 27, the
figure would be 3.4%. And that's my fact check for t his week.
I'm Lori Robertson, M anaging E ditor of factcheck.org.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the
country's major political players and is a project of the
Annenberg Public Poli cy Center at the University of
Pennsylvania. If you have a fact that you'd like checked, e - mail
us at chcradio.com , we'll have FactCheck.org's Lori Robertson
check it out for you here on Conversations on Health Care .

[Music]

Margaret Flinter: Each week Conversations highlights a bright idea about how to
make wellness a part of our communities and everyday lives.
Healthcare providers are forever on the lookout for that magic
elixir that can cure a host of chronic ills in one step, and in the
case of obesity, depression, anxiety and stress that elixir could
be turns out a number of steps as in taking a hike. A large
study conducted by several institutions, including the
University of Michigan and Edgehill University in the UK,
looked at the medicinal benefits derived from regular group
hikes conducted in nature.

Dr. Sara Warber : This study had enough people in it and following them over
time, that we could see that these two different types of help
for a mental well being they're operating independently, that
means that if we go out in nature for a walk, or getting an
addi tional boost to our mental well being .

Margaret Flinter: Researchers evaluated some 2000 participants in a program
called walking for health in England wh ich sponsor ed some
3000 walks per week across the country.

Dr. Sara Warber : This is a national study in the UK, there was investment In
these walking groups , in training leaders to take people on
walks, finding trails that were good for people to do, ev en if
they had health problems.

Margaret Flinter: Dr. Sara Warber , professor of Family Medicine at the
University of Michigan School of Medicine, said this study
showed a dramatic improvement in the mental wellbeing of

Dr. Joseph Kvedar

participants, especially those who have recently e xperienced
something stres sful.

Dr. Sara Warber : Depression was reduced, perceived stress was reduced, and
people had experienced more positive feelings or positive
emotions. And there's been really lovely research that's shown
that when we have positive emotions, we actually have better
health in the long run.

Margaret Flinter: The participants almost universally reported reduce stress and
depression after participating in group date your hikes, and
the effect was cumulative over time. Other stud ies have
shown a link between mood and exercise, but Dr. Warber says
this is the first study that revealed the added benefits of group
hikes in nature and significant mitigation of depression .

Dr. Sara Warber : Because we were real ly interested in w hether i f you are more
stressed, would you get some better benefits from being in
nature. And in fact that did pan out .

Margaret Flinter: Walk for Health , a simple guided group nature hike program,
which incentivizes folks suffering from depression and anxiety
to step into the fresh air with others to talk about their
thoughts while taking a hike, improving their mood, reducing
their depression, increasing their overall health at the same
time. Now that's a bright idea.

[Music]

Mark Masselli: You've been listening to Conversations on Health Care. I'm
Mark Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Peace and Health.

Female : Conversations on Health Care is recorded at WESU at
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