This webinar was recorded on Friday, January 27th 2023
Has technology kept pace with asthma? Are there ways we can monitor our asthma with digital tools? Join us as we explore this topic
Speaker
- Dr. Payel Gupta
Sponsored by the American College of Allergy, Asthma and Immunology
Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.
Andrea: Hello everyone. Thank you for joining us today. I am Andrea Jensen. The director for the allergy and asthma education network. All participants will be on mute for the webinar. We will be recording the webinar so it will be posted on our website. You can listen to it again or share the webinar with a colleague. You can go to our website at allergy at — allergyasthma.org. The webinar will be one hour, including time for distance. We will take them at the end but you can put them in the question to have at any time. We have someone monitoring the chat if you need — have questions or need help. We are using a different platform which means we also have a new way of giving you a certificate of attendance. The day after the webinar, you will receive an email with resources about Digital Health, a link to download your certificate, and information about how to obtain CE use. Digital Health and technology have changed drastically since the pandemic began in 2020. Telehealth can improve patient health and reduce costs for patient health and providers. It makes costs more equitable and accessible for patients in medically underserved communities in rural areas. It is important for allergists to understand how Digital Health can be realized in the practice and how it is being utilized in direct consumer models. Today’s webinar helps with needless death and suffering due to allergies, asthma, and related conditions due to outreach, education conditions, and research. It is my pleasure to introduce our speaker, Dr. Payel Gupta. A clinical professor at Mount Sinai Medical Center in New York. She is a triple certified and holds certifications from the American Board of allergy and immunology, the American Board of internal medicine, and the American Board of pediatrics. She is the medical director of allergy, asthma, immunology, and ENT at lifeMD.com. She is cofounder of life.com. She trained both adult and pediatric patients with asthma, environmental allergies, skin conditions, and food allergies. She is also a member of the Telemedicine Task Force for American College of allergy, asthma, and immunology. She is the immediate past president of the –. She is cohost of the itch podcast. Dedicated to helping patients understand their allergic conditions. With all of those, I am surprised you have time to sleep. Thank you for being with us today. We look forward to hearing about how you can use Digital Health to really help your patients.
Dr. Gupta: Thank you so much for having me. I am really looking forward to talking about this topic. My disclosures are that I am a speaker/spokesperson for ALK and an advisory board participant for Sanofi, blueprint and Johnson & Johnson. Everyone should know we are going to record today’s webinar. This information was already kind of discussed. Today, I am really going to be kind of outlining what is the aim of telemedicine and kind of coming to an conclusion of what is the aim and had did we get there? I am going to do it in a storytelling way. I think everyone in 2019 was kind of a skeptic. Then COVID hit and we became non-skeptics and then convert. What are the questions people ask often? There are many pitfalls of telemedicine. How can you connect with patients via virtual care? It will not like it. The technology needs to work for patients and physicians and will be too hard to come up with that technology and make sure it works for everyone. You need a license for multiple states. And you cannot examine a patient through the Internet so how is this going to work? How does telemedicine work? The definitions are confusing. There is Digital Health which means electronic and telecommunications technologies and services used provide care and services at a distance. Whereas digital medicine is what we are really talking about which is the practice of medicine using technology to deliver care at a distance. For the physician is in one place and uses telecommunications. There are various ones and we’ll talk about that. In order to deliver care at a distant site at their home, office, or car. Digital therapeutics are evidence-based, clinically evaluated software and devices that can be used to treat an array of this aces — of diseases. And there is secretiveness which are scheduled, real-time interaction by phone, video or in person. Those are the ones we are most familiar with. But then there are also asynchronous consults which happen on their own time and do not need scheduling. Communication is done by text, email, or hippo validated — a HIPAA-validated Insecure portal. You can simply pictures and other things are stored and evaluated at another time. Dr. Portnoy is one of the people in telemedicine and he put together this info graphic that I love which shows you the different ways you can have a visit with a patient. There are in person visits that we are used too.
Then there is the store and forward where you get data from the patient like spirometry data . It is stored in the cloud and then sent to a provider in a distant location. There is also a remote patient monitoring and remote therapeutics monitoring. That is where you are using wearables like digital inhalers and things like that and putting that information into a set up and transferring that to the provider for remote view. Then there are telephone encounters which we are also used too. Then there is something called direct to consumer health care. This also took an upturn during COVID. I personally was a big part of direct to consumer telemedicine and that is a big part of my life. That is an other way where the consumer is just going to a website and deciding that they want a particular medication or have a particular question. Then they can, directly from their computer into a distant provider, communicate to get a consult. Then there are facilitated and integrated visits were a patient in a remote area might travel to a facilitator location where there is a nurse or other provider that can help do different exams, different diagnostics, and send that information to a physician at another location. Those are the definitions. And the big picture. All of the things that everyone is thinking about in 2019 and before 2020 hit. What does it even mean? It will never even come to fruition. But in March of 2020, when COVID hit, everyone began to think differently. We started to see empty waiting rooms and all, from less than 1% of visits being telemedicine, as high as 80%. I think almost 100%. For me, during the pandemic. That is a 63-fold increase between 2019 and 2020. The college actually did a survey during this time. There was some shifts. April of 2020 to August of 2020, we saw a 30% in person visit to 66% visit. There is a shift going back toward seeing patients in person after the big peak of the pandemic hit. But, you can see that it is still higher than the 1% that we saw before April 2020. In that survey, they also asked, do physicians, allergists, plan to continue to use telemedicine in their practice? 90% liked it. Out of the 250 eight responses, which is a lot of practitioners, they liked it and plan to continue to use it.
I mentioned briefly clinical telemedicine versus direct to consumer telemedicine. What I mean by that is that in a clinic setting, we think about consults and that kind of bottle which we got used to during COVID. But there is also another model. The direct-to-consumer telemedicine which allows patients to get streamlined access where they are filling out a medical intake form. That information is being sent to a physician and then the patient is getting prescribed medication that is being delivered to their home. So they are technically never seeing the provider physically and maybe even not seeing them over a video consult. Mostly, the direct-to-consumer telemedicine is done in the asynchronous fashion. A lot of people have seen Hims and Hers and other companies that started off for conditions that are embarrassing to patients like direct how this function or hair loss. Patients were seeking a different way to get medications so they did not have to see anyone to get them medications they thought they needed. We did see an uptick of companies providing allergy care in the direct to consumer world and I was a part of those. It is an interesting concept. From having lived it, it is much needed. A lot of the patients are those that do not have insurance for various reasons or are between insurance plans and are just looking for alternative, more cost effective ways of getting their. — there health care. Then I became a convert. I think that telemedicine — there was a report put out that telemedicine addresses the shortage of allergy specialists especially in rural and underserved communities and facilitate station access to allergy services. I truly believe that. There is so much data available to us that there are ways that we can provide care to patients that is government to providing patient care. There was a another survey done in conjunction with the ACAAI and the American Medical Association.
These are physicians that filled out the survey. 61% were in suburban locations, 29% in urban, 10% in rural. Mostly physicians in single specialty physicians offices. Some in solo practice in teaching hospitals. It was a nice mix of where our specialists are mostly. 92% of patients said they currently use telehealth. Again, it is continuing to be used. Whether it is — again, most practices are doing a combination and not just doing telemedicine. They are doing a combo of telemedicine and in person visits. The survey that the college did for allergists on how are they using telemedicine in their practices. You can see that most of the visits are for follow-up patients. For follow-up asthma, it is 80% versus new of 28%. Follow-up food allergy is 91% versus 51% new. All of these, the follow-up visits are more than the new patient. Physicians feel more comfortable seeing their follow-up patients through telemedicine then they do seeing patients. What are the benefits of telemedicine? For the physician, there are multiple benefits and for the patient, there are multiple benefits. For the physician, it frees up office’s to see more complicated patient for testing and procedures. Expands office hours without increasing office overhead. Allows reimbursement for follow-ups. There are fewer no-shows. In my small practice I have in Brooklyn, I just use the office space hours that I have for testing. Patients that just you follow-ups like legwork — bloodwork or to see how their asthma has been doing or refills can all be handled through telemedicine. But for a new patient or a patient who needs testing, that needs to be seen in person. The great thing is that through telemedicine, one of the benefits of COVID is we have started to see more reimbursement for this. But now we have a way of actually getting paid for the bloodwork review visits. Whereas before, we were doing the phone calls and having visits without getting paid. There is a lot of physician benefit that I think of telemedicine. For the patient, there is a lot of benefit too. No need to travel, no childcare issues, no need to miss work or school. Quicker access to appointments, lower cost reduction for visits. Meaning you are not taking a day off, not driving, not spending money to get to the appointment through subway or bus or whatever it is. And you are gaining time. Because the average time that you are saving from having a telemedicine visit versus an in person visit can be as high as four hours versus 30 minutes. For the patient, this makes a loss of sense. Obviously it has to be for the right visit and the right conditions, but for any allergic patient, telemedicine can be used in many different ways. We will review that now. One of the pitfalls we discussed early that people were concerned about is how can you connect to a patient via virtual care. They will not like it. The data does not show that. The data shows there is better outcomes, increase compliance, a decrease in no-show rates, and similar outcomes.
Chronic disease patients have better outcomes when a specialist is able to care for them. Having better access means better care and that patients will love it. Then, increase compliance for patients with asthma after telemedicine visits. Meaning that they understand their condition better potentially because they are able to have the in between visits to check in with their doctor and review things they may not have understood. They are able to talk to their doctor about just how they are doing things and get clarification. So we do see increase compliance in patients. Then, decrease in no-show rates. Not having to travel or get childcare or having to do these things allows a patient to be seen more easily. They love that. Then, there are also seeing similar outcomes for virtual visits. We’ll talk more about that too. Again, one study I wanted to highlight was this telemedicine use for pediatric asthma care done at UC Davis between March 2020 and September 2020. There were 502 patients in the study. They looked at electronic health record analysis and a qualitative focus group analysis area their findings showed that alternating telemedicine with in person visits for asthma care may result in improved access to care and reduced burdens on patients and families. Again, just highlighting that patients felt like they had more access to the provider and improved access to care. Now I am just going to put out a patient case that our normal, allergic patient and a patient I think can easily be managed mostly through telemedicine, and partly through in person. A 30-year-old man with a history of PTSD, asthma, chronic lower back pain, allergic conjunctivitis, nasal polyps and has had two surgeries and eczema. Has had frequent sinus infection for which he has had antibiotics. Smokes 1-2 packs of cigarettes per day. Has had asthma since childhood and recently noted increased symptoms with his allergies. He has been going in and out of urgent care for his asthma. This is a patient we are worried about and do not see often enough. Sometimes they are in the cycle and never get in to see us because of multiple reasons. For this occasion, he has a full-time job at a fulfillment center and never has the ability to take time off to come see a physician. He has been prescribed oral steroids early — oral steroids over and over. He recently saw an article about telemedicine and decided to could get more help without missing work. One thing I want to point out is obviously every state has different rules for new patient visit. In some states, you cannot establish a doctor-patient relationship via telemedicine and to see them in person. It depends on the state you are in and we are not going to go into these roles because they vary state to state. That is something you need to understand for wherever you practice.
What can you do with technology? You can embed a medical intake form. I think a us have already done this. Where you have them electronically fill out all of their historical data and have access to that before their appointment. You can also do screening questionnaires with intake forms so you have all of this data. Then the physical exam. What can you do? Physicians like Dr. Tonya Elliott, who have also been doing telemedicine for allergic patients for years and years, there are many videos where she talks about all of the physical exam findings she can find. You can observe how they are breathing and talking and that can give you a lots of information. You can ask them to open their mouth and even look into their throat. There are also devices available that can be used to listen to patients in their home. Wheezing can also be monitored via patient remote devices. So that you cannot examine a patient through the Internet is not true. There are many tools available for how you can examine a patient through the Internet. Then there are out home — are at-home diagnostics and wearables. These are things that if we had the right tech and the right support, you can really utilize a law of information and help our patients in a more effective way. So there are electronic diaries where we can have patients record their systems — symptoms and medication use. Often times I find this for myself to wear patients just do not have time or cannot move their recollection of their symptoms or medication use and it is often flawed. There is research to show that. Everyone is so busy that it is hard to remember what happened yesterday and what happened in the last month or two months or three months is even more overwhelming. Having a way for patients to be able to write down their symptoms, medication use, and get the electronic diary into a system where then it is already there for you to review during your visit and just kind of quickly produced. We are not asking physicians to look through pages and pages of data because that is not feasible. But if it is done in the right way, we can get a lot of information. There is wearable technology to monitor activity and vital signs. And things that can also help us. Dr. MOSIne who I am going to mention later has done a lot of work on how can we find that patient that is not doing well before they are even not doing well? What are the signs in their vitals and their activity that can help us determine what — that something is not going right? Then we have remote patient monitoring. Things like environmental exposures, medication adherence. Those things can also be incorporated into the data that we bring into the visit. Then there are digital therapeutics. Again, the definition is evidence-based, clinically evaluate software and devices that can be used to treat an array of diseases and disorders. For the allergic patient, the main tool and asset we have right now are a number of different digital inhalers.
There are digital inhalers, attachable sensors to inhalers that are already available, which then leak up — link up two different apps and devices that we can use to get that data back and help us understand what this patient is going through while we are not with them physically. Also, that can help us understand how well are they using their inhaler and are they getting the most out of their modification — out of their medications? This is actually from an article that the doctor rode with others that goes into digital devices and digital therapeutics and how they can be used for an application. It is this article “digital inhalers and remote patient monitoring asthma”. If you want to take a deep dive, this article does it. It is very comprehensive and goes through everything you want to know. I kind of put the bullet points of things that I think are important to think about. For things that the article highlighted. Digital inhalers systems like the ones I just showed earlier conserve not only — can serve as a diagnostic tool and therapeutic interventions. There are therapeutic interventions and a medication but then they can also help us diagnose whether or not the patient has poor adherence or report inhaler technique. It can help us understand, is this patient truly uncontrolled or are they just not using their medication? Are they not using their medication well? It can really help change the plan for the patient. What they found is this may specifically benefit newly diagnosed patients to establish good adherence and inhaler technique. For that new patient, before they get into habits that are harder to break, it may be beneficial to start them on a digital therapeutic early on so that you can really help them understand the importance of adherence and the importance of good inhaler technique. Then, also, they found that it may help patients with difficult to control asthma to improve adherence and technique, to avoid treatment with high side effects like oral corticosteroids for costly Biologics. So we can find those patients that we think may be very severe and not to manage under current treatment. When they come in and tell us they are using their medication correctly and all the time, when you have a tool to actually say, it looks like you are not using it all the time or you are not using it as effectively as you thought you were. We get it because you are busy and life is busy but now we have extra data to help you understand that the way you are using the medication is likely part of the reasons were asthma is not controlled. In that, we can avoid patients getting on oral corticosteroids or Biologics. In this article, they also talk about when choosing a digital inhaler system for a patient with asthma, it is important to take into consideration the preferences for either a built in versus an add on sensor. Is the patient just really used to be inhaler they are using into not want to change the inhaler or device or medication because then there is also that psychological component we always have to think about where the patient knows that inhaler works for them and they do not want to switch? Does an add on Senator McMorris once — add on sensor make more sense than getting a new digital inhalers system? I also want to look at whether the system is able to detect inhalation quality.
Health-care providers also need to know about their inhaler and how to teach an inhaler technique and the devices they are giving to patients. So is there an app associated with the device? How do you hair with a mobile asthma app? On the patient’s phone. Do you have someone in your office that takes over that aspect? Who can take over the teaching aspect? I will talk next about this but there is actually billable codes you can use when you do this ongoing boarding for their digital care. Then, if you are implementing these remote patient monitoring or remote therapeutic monitoring devices, in large health-care systems, or in small practices, you want to maybe think about to being a pilot program to test the feasibility of the technology before you print out this very expensive program. In order to see what is the financial impact, what is the patient satisfaction? Are you also — actually going to get patients to buy in in the area that you are in and to the patients you are serving? There is some data to show that patients where English is not their predominantly, a lot of these patients aren’t as likely to use telemedicine or devices. Why is that? They think there is more and more data that will come out to how can we help all our patients feel comfortable using telemedicine and devices? What are the barriers that we need to overcome in order to make sure every patient is served? All of these things need to be thought about. Of course, it is important to have policies in place to manage liability risks. If you are getting a lot of data back from these devices and these therapeutics, it is very important to know how are you managing that data? Who is looking at the data on a regular basis to tell you that this patient is not using their medication? Should you have intervened earlier if you have them? If you know this data. If you did not and there is a bad outcome, you just want to know. Could you be liable for that? The ultimate message was digital inhaler systems, remote patient monitoring, and remote therapeutic monitoring can power — empower patients and remote care providers to improve ICS adherence and inhaler technique. To ultimately improve asthma outcomes and reduce costs for asthma patients. Now, for the hot topic, which I am not an expert, but there are other physicians that have also done a loss of on this topic. One of them is Ridge Walla . Dr. Bridge Walla has a lot of videos online through the college that go into coding and billing. For remote patient monitoring and remote therapeutic monitoring.
There are physicians that are using these technologies in their office and are sharing this information with us. There is actually this article that the college put out, making remote patient monitoring and remote therapeutic monitoring work for your practice. This article really is a great article that goes into a couple clinic scenarios where physicians are using these technologies and how did they implement these technologies? What did they have to think about? What did you have to think about if you want to implement these into your practice? If you’re interested, I would highly suggest the king at this and at data from other providers. Essentially, patient monitoring and CPT codes allows physicians to provide and be paid for physiological data. Those are like heart rate, respiratory rate, blood pressure, weight and storm a tree. — spirometry. That can be translated to the physician office or a third party provider that is managing the data for you. These services can be provided — should be provided under general physician supervision which means a physician’s clinical staff or an outside company that can provide the services without the physician being in the office or on site. You could either train or have a dedicated clinical staff member or you could even hire a remote staff member. Personally, I have had great experience using remote nursing services out of the Philippines where you can have staff there look at data for and you manage those kinds of things in addition to a lot of other things I knew your practice to help make sure you are looking into the data and someone is managing it. All of this can be paid for through these RPM and CPT codes. In the article I was talking about, they have a nice chart that goes into the different codes you can use. I am not an expert on this but there are many people who have written nice articles and then nice videos on this that you can refer to. You can get paid for the setup of the remote patient monitoring. Patient education and use of the equipment. That is billable once. Or supply of the device. Then, treatment management. For the first 20 minutes and every third dust every 30 minutes. For a lot of clinicians, it seems to work for their practice. Once it is in place, you can make profit form it. The remote therapeutic monitoring because I got from Dr. Mosnaim’s article. There are different codes for that with an initial set of codes and supply of the device. All of those things — the RPM and RTM codes, lots of things you can learn and lots of important information that you can gather from all of these articles and people that are — have been doing it themselves. Patient communication and data collection. You can see patients, more frequently, to touch pays — base with them through technology. It is not always just the telemedicine synchronous visit. A phone call, text, or email can also be considered telemedicine because you are asynchronously getting information from the patient and using the patient to help provide care. All of that is important to remember that now we can get paid for it and we can more frequently touch base with our patients and help make sure they are feeling better and doing well with their condition. Going back to our patient, I think now it is hopefully the picture — now, hopefully the picture is set for what can we do? How can we help him manage his condition? It may look like he comes in for a visit at some point when he has time.
But in between, when he is not able to and if you are in a state where you can establish Dr.-patient commissions without seeing him, he can get started on treatment for asthma. You can talk to him and see him physically on the video, see how he is breathing during the visit. See if he has coughing every other sentence during the visit. You can ask him about his entire history and get this entire picture. 90% of how we treat a patient is based on history. I think most physicians I talked to, history is key. You need to know what has been happening and what symptoms a patient is happening. The exam was only a small portion of how we make clinical decisions. Most of it is based on history. For this patient, we can get them on a better controller medication so they are not going into urgent care in the emergency room and seeking care for uncontrolled asthma. We can start their evaluation process for the uncontrolled asthma. If they do start on controller medication but continue to do poorly, we can to bloodwork to see if they high — have a high — count. You can send a patient for bloodwork without seeing them in the office as long as you write a requisition for bloodwork to go to places like Orlando or — quest or llabcore. You can also send them for a full pulmonary function testing or send them a spirometry device to teach them how to do that at home via video. You can also have a nurse go into the induced barometer reading — go to the home of a patient and do spirometry. We can definitely start him on treatment for his asthma and sent him for IGE testing. If you truly cannot, I need to see, what are his allergic triggers? Can we make changes in the home? But I love about telemedicine visits is the patient can go into their medicine cabinet and show you their medications. It is thought an I do not know what I am taking. It is get up and go to your bathroom and show me what you are taking. Show me what your previous doctor prescribed her wet urgent care — prescribed or wet urgent care has given you.
That’s see what the pharmacy has prescribed. With the allergic conjunctivitis we know about, we can say the five nasal sprays you have all have the same ingredient and you can see that when they open their medicine cabinet. That is something I like to be with my patients when they are feeling like they cannot tell me what is going on or what they are doing or I know that they have a million medications in their medicine cabinet. I have them go there and open their cabinet and show what they are using. For smoking cessation, you can also provide counseling and frequent follow-ups. Because for patients interested in that, they really need frequent follow-up. Telemedicine is a great opportunity for that. Ultimately, we can do a lot for patient essay even without physically seeing them in the office. I hope this lecture provided an overview on all the things we can do for this patient. And how much we can help. The key takeaways for me are that telemedicine is here to stay. I think hybrid care is essential in 2023 and beyond. In-home services and monitoring offer benefits to both patients and physicians. Direct to consumer care is also changing the landscape of medicine. From my experience over the last three years, I really, truly believe it is something we need in this country, given the high cost of health care. The adoption of telemedicine is truly driven by patient preference. Because patients just need something different. It is not for every patient. Some patients like the physical connection and do need to be in the office. With our busy lifestyles and everything else, there are a large proportion of patients that really do you love telemedicine and the convenience it provides. That is my son, Phoenix J. He has changed a lot. But he was a big part of my journey. I can say, for me, I chose to leave practice and leave the normal clinic practice because I was pregnant during COVID. I had him in July 2020. I had to think for the first time as a health care provider because a lot us think about others before we think about ourselves. For the first time, I had to think about myself and my baby and how I was going to keep us healthy during the pandemic. I think that, as much as patient benefits, we also benefited from feeling safer telemedicine — safer with telemedicine. I made that huge ships because of him. One day when he is old enough to understand, I will let him know that he is a big reason why in this wonderful change in my life to doing more telemedicine and providing care in that way. I think the fundamental aim of telemedicine is to improve access to care. I think times have changed and things rapidly changed. This is video of my son scooting away. We really have to run to keep up with changing times. I am really excited about all the research that people are doing in the telemedicine space is all the information that we are starting to slowly get about how can we help our patients, what does this mean? How can we do this in the most effective way? Thank you. I see there is a lot of chats. I don’t know if those are questions.
Andrea: Thank you. This was a fantastic conversation. I really like your synopsis about being able to transition to telemedicine because that can really help you and any other physician have a great balance in life between work, life, vacations and other things. This may be a way to help prevent some burnout. I do not know of any physician that knew how to prevent burnout even before COVID. We do have some questions and I will read those to you. Our first one is, our digital devices covered by state and private insurance? If so, what about co-pay options? Some have told me they are experienced — expensive, hence the coupon to lower people into device use?>> This is a complicated topic. I am not an expert in this. I think it will vary based on insurance the patient has. Where you’re located, all of that stuff as to how well, these therapeutic devices are covered. I think that as we have more data on how helpful they can be and how they can reduce or potentially reduce costs and reduce generally cost, that is the ultimate thing that guides things. Not only to mention patient improvement but if we can show that, more and more, the digital therapeutics are going to get covered by insurance and the cost will be lowered eventually. I think that is already happening and going to continue to happen more and more. Of course, cost is a very important part of determining whether or not you want to do something like this for your patient. That is definitely a shared decision-making element to all of this. It does not make sense to do a digital therapeutic if interest — insurance is not covering it. It is not feasible.
Andrea: You make a good point about using digital devices because we all know patients who have had asthma all their life. And we look at their inhaler technique which is incorrect but they have been doing them all their life. To try to make that correction of their inhaler technique could be a digital device for them. Another question we have is, Teva discontinued Pro air but is the digital inhaler still available for Pro air?
Dr. Gupta: I believe it is. Andrea we have a question from a school nurse who asks how can his school nurse get some of this text to help students understand if they are using their stuff correctly?
Dr. Gupta: As a school nurse, I am assuming that you are managing the condition as a secondary provider and the patient is actually being managed by their primary doctor for their asthma. For example, it may be there allergist, pulmonologist or pediatrician. If you think it would be helpful to a patient, bring it up to their physician and see if it may be helpful. I think that obviously in pediatric patients, device use is always a concern. So having proper inhaler technique and those kinds of twins available earlier is always important but this obviously — kinds of tools available earlier is always important but obviously depends on the patient and how they may be able to use digital therapeutics in their game plan. I do think that as a school nurse, if you think this is something you would be interested in, I would talk to some providers that are a part of your patient’s and see if it would be open to looking at that.
Andrea: Good answer. Makes a lot of sense. Another question we have is do you find telemedicine can address psychological needs for patients? It can be different face-to-face versus digital.
Dr. Gupta: Of course. Things are different. But for me, the biggest thing is 2023. The time that we are in right now, even my communication with my best friend for example, my family, everyone, is mostly done asynchronous. Through text messaging. We are catching up with each other through text messages but I still feel cared for. And thought of through a text message. That is just one example. I think Zoom and Facetime calls with family members, coworkers, etc. new obviously, you want to have in person meet ups and things like that with family, etc., but I think that is just a good example of how we are all used two this type of communication. There is actually, I think but I have not looked up studies but I passively got this information from somebody in the psychiatry and psychologist, psychotherapy space. They are finding that there is definitely where access if we do it through telemedicine. For most practitioners, when you want your patient to get in and be seen by a psychologist or psychiatrist, it can be months. If we can reduce that time, because there is not the check in process and this process and that process, and physicians are able to see people through a more streamlined way through telemedicine, then we can provide more effective therapy. I absolutely do not think that we are missing the element with telemedicine. I think it is — obviously, it depends on the person but in this time of our existence, we are communicating with everyone in a different way.
Andrea: That makes sense. That just is another layer. That’s only family and friends and colleagues but our physician as well to use that same platform. In other question we have is I can see how digital NDI detects transitions and transmit split how does it detect? Can you explain how that works?
Dr. Gupta: I am not the expert but some devices can actually monitor the inhalation. I believe. So that can give you information on device — on proper device use. I am sorry. I would have to defer the question a little bit but I do think some of the sensors and things can monitor the inhalation and how well it was done in order to provide that information.
Andrea: Great. Some things I like that you talked about today is just really making it a lot easier for the patients. In a lot of these estates are quite large and have a love rural areas, and it is a three or 4 Hour Drive to get to see a specialist. You talk about them just being able to go to a nearby clinic and you can connect on your end, that is helpful for people who do not realize that is an option. Even if you live in a role area, you can still have access. I think that was one of the most important parts you talked about today. Another point I liked is when you talked about people without insurance. With this also covered — I know some people that have a $7,000 deductible for their family insurance plan. So they are insured by have to pay everything up to their $7,000 level so this can be a good option for that I am assuming.
Dr. Gupta: It can be. There are patients that supplement with this kind of thing. You can use your HSA/FSA account for direct-to-consumer telemedicine options. You can use it for medications but also for using telemedicine for direct-to-consumer.
Andrea: Perfect. Another thing I noticed is when you talked about the number of people that may go in person for their first visit, but we have people who are driving two or three hours to their specialist. But the percentage of people who switch and do telemedicine after that as a follow up is a brilliant idea and will save everyone and lots of time and energy into getting babysitters and those other fun things. Have you found that to be really helpful that initially you can meet them in person? Or some of your colleagues, and then have them switch to more of the follow-up with the telehealth? Has that been a good success?
Dr. Gupta: Yes. I think hybrid care is very successful and I think that is what most physicians are doing. I do not think there are many people doing only telemedicine but I love that. You can have that kind of physical connection with somebody and establish that relationship, test them for their allergens, do whatever diagnostic testing you think they need, and then for follow-up of the blood work and their therapy, refills, and all of that kind of stuff, or questions they have. For physicians, a lot of this stuff was not available — doable but for me and my practice, I do not have a problem telling a patient that is emailing me — by the way, there are codes for email communication now too. Or maybe they have already existed and people are looking into the more. But I do not have a problem telling a patient who is going back and forth on email too much, too let’s change this into a telemedicine visit so I can understand what is going on and we can come to a conclusion and a better therapeutic plan for you by using telemedicine. I think that, again, it is a good option for the patient and a great option for the physician because we are not doing work that we are not getting reimbursed for.
Andrea: That makes sense and that helps you be able to individualize what each patient needs. Some may need more handholding — handholding and help. People were curious about some devices used at home to send to a patient in the home. Is there any information you can provide on that?
Dr. Gupta: Again, I probably should have looked into this more. I do not know too too much about that but there are so many companies that provide these services where you can actually do different things. Where they will send out the device like a stethoscope kind of thing, so the patient can put the device on their chest, and you tell them where to put it, and then that devices picked up on your end. Those devices exist. Also in these rural settings, that same kind of thing exists for the practitioner that is in that rural setting in rural clinic. They can put that stethoscope that is then linked electronically to the other — to the doctor’s system or the specialist so they can literally listen to the patient’s lungs or hearts with you. Those devices exist. I am sorry that I do not have a full or cannot give you complete details. I think that is the overall kind of picture that I have.Andrea: That is very helpful. We are just about done. We have one last question and I will just read the last Ed rated someone is asking how you can help people with no-shows for telehealth? It is probably an issue in person as well as telehealth but that will be our last rested.
Dr. Gupta: I think reminders are very important. Whatever system you are using to let your patient know about their appointment, you just need to have — the system I use since the patient a calendar invite so it is in their calendar. Everything is in their calendar at that link. Having that, maybe even having a system where you are texting them if is something that you can do through your staff, there is online things like Google voice. It is a free service or was when it — when I signed up for it. There are free plans where you can text through a Google voice number two patients and send them reminders. You can have your assistant or staff send messages to all of your patients the day before or even the morning of or even 10 minutes before their appointment to remind them. Again, I’ve found that using the telemedicine company I started, people do respond and see their text more often than they see their email. And even more often than they are willing to answer their phone. Text is a great way of sending reminders to patients.
Andrea: I agree. Previous to coming here to allergy and I coordinated a allergy — to be allergy and asthma network, I coordinated a allergy program. We found that people responded to text. The naked see them in meetings — they could see them in meetings so we did the same thing. Thank you.
Dr. Gupta:. I really appreciate you sharing all your information. If you will just go forward one more slide. This is where you can find this next week. This is what our main page looks like. You will scroll to the bottom and that is what it looks like. It has yellow behind there and you will be able to find webinar. Please join us for our next webinar. One more slide if you could. One more, sorry. And one more. Then, we should be there. Our next webinar . What you should know about COPD, February 9, 4:00 p.m. Eastern time. You can register at allergyasthma.org. You can find all the links there. We had a lot of questions about certificates in the chat so keep an eye out the next couple days. We will have all the information you need about Digital Health and other links to resources for you and how to get your certificate of attendance as well as continuing education credits. Thank you for joining us. This is Andrea Jensen for the staff at Allergy & Asthma Network. Rightness as we work every day to help people breathe better and have a better quality of life. Thank you everyone.
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