Episode 2: Telemedicine: Getting to the Heart of Patient-Centered Care

10 June 2019 Health Care Law Today Blog

We are pleased to provide you with Episode 2 of The Health Care Law Today Podcast - your connection to timely health care legal updates. Each episode, a Foley attorney will connect with a thought leader to discuss legal trends currently affecting the health care industry. It is important to note that this podcast does will not cover any specific client legal matters, but covers topics that all health care organizations may be navigating.

For this episode, Emily Wein, Foley Telemedicine and Digital Health Attorney, visits with Rebecca Canino, Administrative Director at Johns Hopkins Health Systems Office of Telemedicine, to discuss telemedicine innovations. Johns Hopkins Medicine has six academic and community hospitals, multiple suburban health care and surgery centers, over 40 primary and specialty care practices, home care services and more. The conversation specifically addresses how telemedicine has helped clinicians at Johns Hopkins get to the “heart” of clinical care, where they are able to see patients in their own settings to enhance patient-centered care.

We encourage you to listen to the podcast in its entirety.

Following is a transcript of this podcast. Please feel free to download a PDF version here

Please note that the interview transcription below is not verbatim. We do our best to provide you with a summary of what is covered by our presenters. Thank you for your consideration, and enjoy the show!

Podcast Transcript

Emily Wein

For today's podcast, we're going to focus on innovation within telemedicine and how it is the future of healthcare. With me today is Rebecca Canino, administrative director at Johns Hopkins Health Systems Office of Telemedicine. In addition to being a friend who I have gotten to know through a multitude of conferences across the country, Rebecca is a pioneer in this [Telemedicine] industry. She has been with Hopkins since 2007. Her background includes a long history of international non-profit startups [where she lived abroad], and when she returned stateside, her collaboration, creativity and compassion for patients continued on here at Hopkins. The role that she is in now fits her personal mission perfectly, because she's passionate about reaching as many people as possible, with clinical excellence and the game-changing approaches. She believes that telehealth/telemedicine is the optimal platform, and we'll talk a lot about that today.

I'm sitting here in this pretty awesome suite, it just emanates telemedicine and innovation as soon as you walk in. Hopkins is one of the oldest, and of course most highly-regarded hospitals in the country, if not the world. Rebecca, tell us what is Hopkins up to in this very important area, and how is Hopkins utilizing telehealth to continue to spread the good works that it's been doing for decades?

Rebecca Canino

Well, it's really a privilege to be here at Hopkins, to be doing this great [telemedicine] work. When you look at Hopkins and its long history, like you said, here in Baltimore and the world, as Emily and I were walking over to the suite here, we actually were privileged to help a gentleman find his way across the hospital. He was sharing with us that he was actually born in this hospital, and he was pointing out the buildings. And then he said, “Oh, and I worked here at Johns Hopkins,” and he very proudly shared about his department. And then here he is, receiving patient care in the latter part of his life. And this responsibility to not only care for our community - these are people that we see every day -but to impact the care around the world, is something that we take quite seriously. And telemedicine is really just a vehicle to foster greater connections to our community, to our patients, and to the world.

We look at [telemedicine] as a way to reach out. We want to increase our patients' access to care, we want to lower the cost of care, and we want to reach more patients. Telemedicine is just the cart that we drive to get there. When we look at who we want to reach first, because there's this awesome responsibility and this wide array of people we really want to reach, including our most vulnerable. So we're looking at our pediatric patients, our geriatric patients, our behavioral health patients, where the need is the greatest. When you have this need, and you have a vehicle of telemedicine that can lower the cost and actually get more care to more people, it's just an amazing privilege, and honor, to be in the space and in the field.

Emily Wein

That certainly resonates with the themes and the story people are telling about telemedicine. It's not just the newest, coolest, version 2.0, to treat your patients. It really is an efficient and effective way. With Hopkins, you and I were talking about how you view telemedicine not just bringing the latest and greatest in efficiency, but really trying to emphasize the focus on the patient, and patient-centric care.

And I mentioned to you as a side note, being a Baltimore native, I've obviously have been very well aware of its [Hopkins] capabilities. And when my son, 3 years old at the time, needed surgery, we came here. With the magnitude of Hopkins, I was just purely focused on the technical aspect of it. But I have to tell you, when I left there, it was a successful procedure, I was overwhelmed by the personnel - he could have been the only person in the unit. I was overwhelmed by the care, the attention to him, and then when you talk about wanting to bring that type of [personal care] into telehealth, it's interesting to me. Because [with telehealth] they won't be in the unit, in-person [with the patient]…or maybe in some ways they will be.

Can you talk a little bit about how you're using telemedicine to continue Hopkins' very successful ability to provide good, patient-satisfactory, in-person care, even though we are in a virtual setting? Some people think that is not an easy task to take on.

Rebecca Canino

We love to hear that when patients leave, they felt cared for and loved. It's not only about the clinical care, but it's the focus on the person and their family. So this is a way that we can take that in-person care and bring that level into the home, so now we're coming to you. You came to us, we take care of you, but now we can come to you and take care of you in the home, and you're going to have that same nurse who looks at you and asks how you're doing, and is focused on your child's care. You're going to have that same person focused on your care, that physician is there for you. There is an intimacy in screens, and there is a comfort.

We're finding that people are so comfortable connecting with one another through screens. We're out there, we're dating through screens, we're doing our job interviews through screens -- this barrier isn't there. We can have that level of personal care, and indeed even more personal. We're coming back to the bedside, and not to the hospital bedside, but to your home bedside. This is a doctor's visit at home, where we can do the same as we do in the ambulatory setting, for your doctor's visits, for your follow-ups, we can do it for sick visits. The child that wakes up with the earache, now you no longer have to take off work and come in, but you can actually get that care right there and decide: should we go to school? Should we go to work? Do we need to come in? Or should we just go to the pharmacy and pick up that medication that my physician has prescribed me?

It's almost become more personal, which is so interesting in this age of technology. We're just removing the barriers of time and travel, and it's more immediate. And it's actually more personal in some ways. I really want to be very clear that there is a place for in-person. That is never going away. We need that touch, we need that assessment that touch brings. We are not looking to eliminate that, we're looking to add to that, so that you can have access to that, because we've given you access to the technology as well. So it goes hand-in-hand. We're looking to maintain that one-on-one, personal care, be it can be via technology or in-person.

Emily Wein

I don't know if you were at this particular conference, but this is a really interesting anecdote, which illustrates exactly what you're speaking about. It was a pediatric mental health consultation, and the feedback from the pediatric patient was, it was either from the primary care physician or the parents speaking and asking the patient how did that go? Are you comfortable sharing your information, and your story with the counselor? And he said, it's too close. I felt like she was right in the room, in a good way. The range of care and the treatment plan went off as planned, but he felt that the proximity and the screen interaction was actually even more intimate than the in-person setting. Which I thought was extremely interesting.

Rebecca Canino

J.P. Morgan predicts that 78% of behavioral health can move into the virtual space. And when you look at that, and you look at the shortage of behavioral health specialists, and the rising need in our communities and around the nation for behavioral health services, this is just a perfect vehicle. We're hearing from adolescents that the screen is actually comforting. They're much more comfortable sharing to the person across the screen, versus in the room. So you still have that level of intimacy, but you have that safety, where teenagers are really opening up. The more we can get this out there and make it available, the more we can equip our physicians with this technology, then the better for our whole population. [Using this technology with adolescents] is a game-changer. It's huge.

While the millennial population is rising, they want care in a different way. They don't have PCPs [primary care practitioners]. They want care on demand, they want to reach out to other people who've received care this way and have influencers tell them how to do this. But these same millennials, who want care in this manner, are in medical school. They're the doctors of tomorrow. So it feels very natural to our physicians coming up through the university to integrate this technology, just as natural to the patient as this is how I want my care.

Emily Wein

I've heard various thoughts that telemedicine education should be part of medical school. But interesting that you bring that up, as far as that's what they're living, to the extent they're actually living it, and the use of technology, it's almost a real-life education while they're going through medical school as well.

Rebecca Canino

It's fascinating. We sponsor a health informatics technology group at the university, and it's run by first- and second-year medical students. And they're just on fire, they come to us with ideas and fully-formed business plans, [e.g.] we want to use robots for our pediatric patients. I think part of the challenge of starting a telemedicine program is the legislation isn't there, the payers aren’t there. How do we move culture at the national setting, so the legislation fits the need that the patients have, and the desire of the clinicians to meet the patients in their setting.

One of our challenges that we work through every day is keeping the innovation alive on the provider side, while we're working with our government affairs folks to change legislation at the state level and at the national level. And working with our legal teams, thank God for you, really to look at what can we do safely here, because the need is there. You have this huge, gaping need, we need services. And you have providers saying, “We want to provide services.” How do we get them across that bridge while following regulations, compliance? It's a challenge that we're up for, but it's something that you have to divide your time, and keep both sides healthy and both sides moving forward to really get to the patient.

Emily Wein:

Wow, you summed that up very, very well, and I think that some folks like you, in a department like this, are uniquely positioned to lead that charge, and to illustrate the steps to forming a very successful telemedicine program.

Back to the patient-centered care, because I want to make sure that we highlight a little bit about that. I know there's not enough time to highlight all of the success stories, but if you had to pick, two or so of your favorite stories, could you share them with us? Because I feel like that really is what resonates with the entire industry or just individuals interested in how to grow a successful program like this, and why we would even want to start.

Rebecca Canino

It really ties in everything we're talking about, because [telemedicine] is all about the patient. One of my favorite stories is about Dr. Nicholas Maragakis and Mr. Parker. We have a video out there on the Internet if you're interested, you can look us up. But, Dr. Maragakis was looking for ways to reach his patients, and ALS is such a fast-moving disease. And symptoms that you have today, you woke up with. You didn't have them yesterday. And having access to your physician, to come up with some real-time answers, how to deal with these new symptoms is paramount. Typically, the ALS patient has to pack up, you’ve got to get your wheelchair, your ventilator, and travel in a specialized van. Family members are taking the day off work, they're coming in, and they’re getting set up, all to meet with the doctor to describe something that's happening at home.

Dr. Maragakis wanted to use this technology and see the patient where they are. Mr. Parker can actually show, “I'm having difficulty getting from here to here.” Dr. Maragakis says “show me,” and Mr. Parker walks from here to here, and when we can see the issue, we can treat the issue, and say let's change this, or let's up this level of oxygen, or let's use this tool to help us solve this particular problem. There's more layers to this, because it's amazing. The caregiver can be on that same video call. The daughter, who's at college across the state, can be on that call. The spouse, who is at work, can be on that video call, and be part of that care, and describe the challenges and be part of the solution.

When you look at that work and those visits that Dr. Maragakis did, and then sharing that information that resulted in a grant, so that we could reach more patients because those services are only covered for patients with commercial insurance. Here in Baltimore, half of our patients are Medicare and Medicaid, and those services aren't covered at home. So, to have a grant where we could reach those patients, and increase those services, and meet the need where those patients are ... it's just a win-win.

You just want to share the good work that you're doing so all the telemedicine programs out there, because a lot of what you're doing, you're doing for free. You’re providing these programs because you want to reach your patients. We need to show our lawmakers, our payer decision makers, that these services are needed, and we need to show the patient impact. So that's one of my favorite patient stories.

Dr. Deirdre Johnston’s specialty is behavioral health with patients with dementia. Here are patients where it is hard for them to leave the home. It's hard for them to leave their familiar settings. By the time they've gotten here, with the confusion and the stress, when the physician sees them they're not at their baseline. They're not seeing them at the best of their capabilities. If we can reach them at home, we can see them in a comfortable setting. We can see the challenges they're having there, and address those specific challenges. Dr. Johnston has set up a service where a coordinator actually goes to the home with an iPad, and is assessing the home and the caregiver. What kind of support does that caregiver need? Because if the caregiver goes down, now you have two patients. Being able to support not only the patient, but the caregiver is paramount to their quality of life.

Emily Wein

It's almost as if you're actually able to help implement those discharge instructions, you're given instructions, and you're expected to implement them on your own, whereas in the home...

Rebecca Canino

[You can answer questions such as] I didn't have that exact thing [that was recommended], can I use this? Or I know you said this, but does this mean once a day or once every meal? And these are things that we can all relate to. You leave the doctor's office and you're ok. Then the next day you don’t remember. So, to be able to have that touchpoint, and to get that clarification outside of the doctor's office is amazing. This is what a coordinator does. They not only answer those questions, but also fire up a visit with the psychiatrist on the iPad for the patient, and the patient in the comfort of their own home now has that visit with that psychiatrist. There is such a lack of resources for these patients, and such a rising patient population, that if you can enable that 15-minute, that 20-minute, that 30-minute, however long the patient needs visit with that provider, you've saved time on both sides, and that provider can now reach more patients. It's because we've gotten right to the heart of the matter. What's the issue? How can I help? Here's what we're going to do. It's just amazing, not only efficient, but so caring way to really wrap that patient in services.

Emily Wein

Heart of the matter, I think you have your new coin phrase.

It's seeing them in their own home, it takes all those variables out, you can focus right on the problem, in and of itself, and your strife and your goal and your focus on patient-centered care.

Clearly you have the ability and the knowledge on how to create a successful program. You also just have the background and the perception as to what the other challenges, the other moving parts that need to have attention, and to be coddled a bit. You talked about compliance, you talked about legal issues, legal shortcomings, or legal barriers, if we could say that. If you were Rebecca several, years ago when you started this, what little tidbits would you have liked to been told, or knowledge to have had? I say people look to Hopkins as the leader in all respects, with respect to healthcare, and are very interested in how, if your department had challenges, then of course any other institution, whether shape or size, location, is going to have similar [challenges]. What are the two or three top pieces of information or suggestions you would like to convey to your younger self, or as someone in your position, trying to get something started?

Rebecca Canino

I would say be brave. Be brave. The task is monumental, so you want to think big, for big solutions. But while you're thinking big, you want to start small. Think what could revolutionize it, what is the real need here, how do we get to it? And then start small, with engaged clinical champions. Once you're pinpointed where you want to be, in the huge picture of it all, really having those champions by your side ... because the clinicians, they're the soul of this. They're the hands, they're the brain, and they’re the ones actually providing the care. The technology's such a small piece of this, maybe 10% at best. The other 90% is getting the clinical care to the patient, and that's just operations of workflow and trying things and failing, and trying again and failing. Making that iterative process. Don't spend too much time on things that have failed. Move forward, try again.

That's where your clinical champions are going to be carrying that, and carrying the ball. Because you want to get there. We see the patient need, we have the expertise to meet it, and we just want the best way to get there. The smoothest way, the easiest way, the most effective way. So I think that's number one. Think big, start small.

Number two, partner with your government affairs team, partner with your lawyers. Because no use-case [a scenario addressed by telemedicine] is the same. When you look at the population and the needs, your programs are going to have to be crafted very specifically to those populations. You're talking about practicing medicine across state lines. You're talking about all different payer models, and so when you really look at those programs and have to focus, like on ALS or behavioral health or pediatrics or rare and expensive medical conditions, your programs have to be tailored pretty specifically.

You're going to need those partners. You're going to need those partners up on [Capitol] Hill. What are the exceptions to licensure? What is the best vehicle to reach as many people as possible, and then what does that population, what are the limitations of that population? Do they have the bandwidth they need, do they have the device they need? Do they have the technical knowledge? What do we need to eliminate to get care to them? Do we need to design something that's just voice, do we need to get the device out of there and go with an electronic assistant? Do we need to have a wearable, do we just need to do it through your phone?

All those questions are very specific to the population, but if you don't have your team of experts, with your government affairs folks, with your legal team, with your compliance folks, with your payer, you can't do it on your own. It can't just be you and the clinician and your IT team. You need this whole team of people backing you up. So I'd say that's number two, that's really, really important. So while you're being brave, have your team, have your focus, and you can change the world.

Emily Wein

It's nice to be a lawyer that helps... instead of being perceived as a barrier. That is a nice aspect to working in this area. I personally feel that we are able to help facilitate instead of saying no.

Rebecca Canino

It's such a comfort, especially because things are changing so quickly. Florida just put out their new ruling that we can take care of patients, if we register with them. We don't need licensure in Florida. How huge is that for our geriatric population?

Emily Wein


Rebecca Canino

It is a leap forward. We really urge other states to move in this direction, because folks are flying across the country and across the world for care here at Hopkins. If we can't follow up with that care at home, we’ve lost that benefit. Being able to reach our patients hinges so much on legislation, and without the help of our lawyers, I think we'd reach much fewer patients. We want to expand that reach.

Emily Wein

I was thinking, we were talking about patient-centered care. Have you ever thought of having a patient be one of your champions? I bet you have a good pool of potentials to choose from, having them come in and share their stories. I bet you'd have a really easy, easy time convincing somebody, and it would be a great way to illustrate.

Rebecca Canino

All around Hopkins, we have patient-family advisory boards, and they are very active in looking at how we provide care, and making sure that it's patient-friendly. Our programs pass through these various boards, depending on the entity sponsoring it. Also, the wonderful thing is our employees are our patients. Actually, we are our own patients. The Office of Telemedicine, we all receive care here at Hopkins. And so, it's fascinating to be the provider of care and the recipient of care. And having the privilege to be able to overcome that barrier. Because we get to craft our programs. It's really exciting. Telemedicine is not only patient-centered, but it's patient-driven. And so, patients are telling us how they want to receive our care, and it's our honor and privilege to build systems and get the care to them in the way that they want it.

Emily Wein

So to close out, I thought I'd ask you, being a trailblazer of course in this wonderful institution and your programs, three to five years from now, where do you see telehealth? Where do you see it, and/or where do you hope to see it?

Rebecca Canino

We definitely see it expanding. We see it exploding. It's just so exciting. When you look at telemedicine, it's not only utilizing the technologies we have at our fingertips now. It's a lot of future casting, and looking forward and saying, what are we going to use, or what are people going to need in this future, right, in this uncertain future? Especially moving from fee-for-service to value-based care. You've got this massive shift at the national level, and then you've got this shift in technology, things are becoming cheaper. They're becoming more accessible, where we're [using technology to] tell our lights to turn on, we're not flicking a switch. We say it and it is so. Star Trek come to life. Really that dream is coming through in medicine, as well. As we move forward into the future, at three to five years, I don't know that we'll be talking about telemedicine. We'll be talking about medicine. These will just be the new tools to provide care, and so we're just committed to enabling our physicians, both clinical and research, to reach as many people as possible in the most meaningful way possible.

Emily Wein

I love that. And I think that's a great place for us to end, and I really do hope that in the future, I continue to see what Hopkins is doing and what you personally are doing. This has been a true pleasure, and super fun.

Rebecca Canino

Thank you, Emily. It's been a privilege.


Foley would like to thank Rebecca Canino for her time on our podcast.

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