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Dr. Colin Banas of DrFirst: “I’ll go back to setting patient expectations and understanding”

Know that you can still accomplish quite a lot in terms of a physical exam even from afar — especially given the fidelity of HD video connections, which allow a doctor to examine a simple rash or assess how well an incision is healing. Telehealth has also been very effective for patients who already have a diagnosis […]

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Know that you can still accomplish quite a lot in terms of a physical exam even from afar — especially given the fidelity of HD video connections, which allow a doctor to examine a simple rash or assess how well an incision is healing. Telehealth has also been very effective for patients who already have a diagnosis to plan ongoing care and review data with their doctor, especially data that patients can collect on their own, such as blood pressure, blood sugar levels, weight, and symptoms they are experiencing. It works so well because even within the “in-person paradigm,” we often told patients to record this data on paper and bring it in to discuss at the next in-office visit because data trends are so much more valuable than a one-time measurement taken in the office.


One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?

In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewingDr. Colin Banas, MD.

Colin Banas, M.D., joined DrFirst in 2019 after 15 years at VCU Health System in Richmond, VA, where he served as Chief Medical Information Officer and practiced as an internal medicine hospitalist. He also was an Associate Professor at VCU School of Medicine. Dr. Banas is proud to have testified before the U.S. Senate and the Office of the National Coordinator (ONC) on the topic of Health IT and the Meaningful Use Program, and he is a former Health IT Fellow for the ONC. His interests center on the role of big data and analytics in patient outcomes and on novel forms of clinical decision support, including those outside the realm of traditional rules and alerts, such as real-time dashboarding and intuitive usability designs. He also helped spearhead the VCU effort to participate in the OpenNotes initiative, where patients have access to their clinical documentation in real time. Dr. Banas received the 2018 HIMSS-AMDIS award for Physician Executive of the Year.


Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?

Sure. When I finished my Internal Medicine residency training at VCU, I stayed on as an Attending Hospitalist and simultaneously pursued my MHA (Master of Health Administration). I was quickly involved in many quality assurance and administrative leadership roles (e.g., Medical Director of Care Coordination and Utilization Management). From there, I fell into Clinical Informatics. My mentor, Dr. Alistair Erskine, and I started the first Clinical Informatics initiative at Virginia Commonwealth University — The Office of Clinical Transformation. We were on a mission to better apply technology at the point of patient care and demonstrate and publish positive outcomes. By 2010, I became the Chief Medical Information Officer, a role I was honored to serve in for close to a decade.

Can you share the most interesting story that happened to you since you began your career?

Being invited to testify in front of the U.S. Senate on the topic of Health IT and the Meaningful Use Program is one of the most interesting experiences I’ve had. Talk about butterflies in your stomach! It was an absolute honor to sit in front of senators and speak to the pure potential of the Health IT and the Meaningful Use Program, which was brand new at the time. The invitation came out of the blue, and I jumped on it immediately. From there, I found myself in a variety of national roles that enabled me to lend insight and opinions on the topic. I later testified in front of the Office of National Coordinator (ONC) and then joined the ONC as a national Health IT Fellow. It’s funny how organic and viral these opportunities are when you look back at them. Just being open and willing to contribute can lead to so many opportunities.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

“It doesn’t cost to be kind.” It’s really a nod towards a multitude of things in healthcare. Healthcare is truly a team sport. The days of the lone physician calling all the shots and taking all the credit are long gone and were never appropriate, quite honestly. So in your interactions with others, any workplace included, only good things can come from being kind. For one, everything we do is for the benefit of the patient. There’s no room for ego. The patient is often in front of us at their absolute worst, and it is well documented that a team-based and transparent approach to patient care improves patient outcomes and satisfaction. Secondly, progress thrives in a kind and team-based environment where everyone is helpful and can perform to the top of license. And finally, you never know where you will interact with these teammates later. It could be years later. Perhaps a student who was on your teaching service is now the subspecialist you’re asking for a late-night consult. You don’t have to think too hard about how that request will be received if you embarrassed that student on rounds years ago! That sentiment works for the entire care team. Another cheeky way to think of this would be the quote, “Be nice to people on your way up; you’ll meet them on your way down!”

None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?

My mentor in Informatics, Dr. Alistair Erskine. He’s currently at Mass General and Brigham and Women’s Health System. He had a remarkable vision for clinical transformation at our health system way back in 2005, and I was honored and humbled when he brought me in to co-found our “Office of Clinical Transformation” at VCU Health System. Alistair is a true visionary in the field of Clinical Informatics. I like to think that we made an incredible one-two punch for our health system and for the industry. He would dream big, I would bring him back down to earth, and the magic and success, of course, occurred somewhere in the middle. We were able to do incredible things together during our tenure at VCU. One of our proudest moments was having a manuscript accepted in the Journal of the American Medical Informatics Association (JAMIA) for publication. I still consider him a dear friend and mentor to this day. I will always be able to pick up the phone to get sound guidance and advice at any time, and for that, I am eternally grateful.

Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them, of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can, of course, be very different than working with a patient that is in front of you. This provides a great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?

You can build trust more easily and form a connection more quickly with the patient sitting right in front of you. We all pick up subtle cues from interacting face to face — that’s especially important when assessing someone’s health and psychological state. Also, things like listening to the heart and lungs or examining a complex rash require an in-person physical exam to truly discern what may be going on with the patient.

On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?

It’s possible to miss subtle physical or emotional cues that may impact your assessment and diagnosis when you aren’t in the same room as the patient.

Another challenge is patient distraction. In fact, we’ve conducted our own survey showing startling admissions of distraction for patients during a telehealth visit. Unlike an in-person office visit, patients have openly admitted to a variety of multitasking events during a telehealth visit. Things like surfing the web, watching TV, checking social media, and even playing video games made the list!

Video calls have just become such a regular part of our lives these days that people are getting used to multitasking, and that’s being carried through into telehealth visits. It’s tempting for patients to check social media or answer a text, but it’s just so important to put distractions aside and fully engage with their healthcare provider.

Setting patient expectations for what is appropriate for a telehealth visit is key and ensuring they know what symptoms still require an in-person visit. Making sure patients follow through with that in-person visit can be a challenge as well.

Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You? (Please share a story or example for each.) (5 examples needed here)

First, properly prepare patients in terms of expectations and needs. Make sure your patients know what they need to do ahead of time to come organized and ready to discuss their questions and desired outcomes for the visit. This includes making sure both provider and patient can be in a quiet space, have the broadband they need, have tested the network connections ahead of time, and have the links they need to click or have downloaded any special apps they need. Also crucial to success is having access to the data you need, such as pulse rate and pulse oximetry from home devices or a smartwatch, blood pressure, or blood sugar values.

Know that you can still accomplish quite a lot in terms of a physical exam even from afar — especially given the fidelity of HD video connections, which allow a doctor to examine a simple rash or assess how well an incision is healing. Telehealth has also been very effective for patients who already have a diagnosis to plan ongoing care and review data with their doctor, especially data that patients can collect on their own, such as blood pressure, blood sugar levels, weight, and symptoms they are experiencing. It works so well because even within the “in-person paradigm,” we often told patients to record this data on paper and bring it in to discuss at the next in-office visit because data trends are so much more valuable than a one-time measurement taken in the office.

Understand the documentation and billing requirements of a telehealth visit for your specialty. Make sure those processes are smooth and do not distract from patient care.

Practice your “Webside Manner.” Similar to patient preparation, make sure your camera is at the appropriate level. Typically, higher is better to approximate eye contact. Also, make sure your background is professional and non-distracting.

Take advantage of the benefits of remote care. You can use this technology to observe the home setting in a way you could never do before. You can bring multiple individuals into the visit from literally anywhere in the world — translators, family members, additional team members, and specialists.

Can you share a few ways that telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?

I think the benefits in the space of mental health and therapies are showing tremendous progress. Close to half of the current telehealth visits that are occurring today (even after we experienced the “pull back” where telehealth visits started to slow down in favor of returning to in-person visits) are in the field of mental and behavioral health. Literature is showing some patients prefer to conduct these kinds of visits via remote technology. It saves them from needing to commute, taking extended time off of work, arranging care for children, etc. It also contributes to a reduction in “no-show” rates, which of course, allows for better continuity of care and ultimately better outcomes. I am reminded of a story from a colleague where a complex psychiatric patient was slated to come in for an office visit soon after the pandemic began. He was going to cancel. My colleague was able to convert the entire visit into a telehealth visit and, because of family availability and video capabilities, he was able to keep the visit and gain much better insight into the state of the household. Literally, by having the family member walk through the house with video, my colleague was better able to understand challenges for the patient and family and line up additional resources for a social worker and durable medical equipment. That extra insight into the patient’s home life would never have happened before the advent of telehealth after house calls largely disappeared decades ago. It also speaks to the ongoing and increasing recognition that the social determinants of health play a massive role in patient health and outcomes.

Let’s take a closer look. zoom in a bit. (Pun intended LOL? Added by me) Many tools have been developed to help facilitate telehealth. In your personal experiences, which tools have been most effective in helping to replicate the benefits of being together in the same space?

Tools that take the experience well beyond simply “making the connection.” At DrFirst, when we discuss our own care collaboration platform, we often say making the video connection is the easy part. In fact, I affectionately call that Telehealth 1.0 because a simple video call is the most basic level of what you can do. That’s why, early in the pandemic, we saw temporary success for some solutions that are meant for business and consumer use, not healthcare — even though they didn’t necessarily comply with government regulations to keep patients’ health information secure.

The next level of telehealth, or Telehealth 2.0, goes beyond just a video call to allowing real collaboration among clinicians for patient care, just like we would do if we were all in the same room. The visit is only one piece of the patient’s healthcare needs and is often the beginning or continuation of a symphony of care, including medications, lab tests, PT, and more. The most successful tools for this next level of telehealth offer multiple features that can all work together, including comprehensive medication management that can reduce financial barriers for patients in real time, address clinical concerns, and minimize procrastination in picking up prescriptions. Features that instantly facilitate care transitions, secure communications across specialties that protect patients’ private information, and e-signatures are also key.

If you could design the perfect telehealth feature or system to help your patients, what would it be?

I’d like to see frictionless service and care with an abundance of choices. The term “friction” can apply to so many different areas within the telehealth construct. First, from the provider perspective, there’s the friction of using the application, the “when” and the “how.” For example, if I am in my office setting using my EHR, I want to be able to launch the virtual visit entirely within that context and workflow. If I am away from my EHR, I probably want a different but equally facile experience on the device of my choosing. From the patient perspective, you can apply a similar framework: how can the experience be as robust as needed without being overly demanding in terms of additional applications, hardware, or connections? Let me choose, as the patient, how to interact with my healthcare team. The perfect telehealth system also must have frictionless, secure data flow for all stakeholders. Envision being able to access all necessary information from within the visit and to be able to take action right then. This would require things like photo and file exchange, interactive forms and e-signature, and obtaining any needed external data for the visit. Reducing friction is all about providing choice and possibilities within the visit framework to maintain a seamless and easy experience.

Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?

Yes! Patients have different levels of comfort and skill with technology, and sometimes that can be a challenge for a successful telehealth visit. There are some things I wish every patient knew:

Your full attention during a telehealth visit is so important. We all are bombarded with distractions these days, so taking extra steps so you can really focus during the session can make a huge difference in your ability to have a meaningful conversation with your doctor.

Using unfamiliar tech can be stressful for anyone, so setting up early for a telehealth appointment gives you time to make sure all systems are “go.” And if needed, get a family member to help you get set up.

Having a list of what you want to discuss and taking notes is just as important for a telehealth appointment as it is for an in-person appointment.

Now, this last thing is important for every type of healthcare visit, whether in person or via telehealth. Everyone forgets things discussed during doctors’ appointments — usually about half of what was said! Taking notes can help. But on top of that, I wish more patients understood they have a right to get their medical records, as mandated by the 21st Century Cures Act. You can ask for your data in a form that the app of your choice can use, so you can have ready access to see your physician’s notes and the plan of care outlined at your visit. DrFirst’s app, Huddle Health, does exactly this. It’s so important because studies show that patients have better outcomes when they have access to this sort of information.

The technology is rapidly evolving, and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?

Artificial Intelligence…Machine Learning…and Big Data. I believe we are finally at the tipping point for the ability of technology to help the clinician and the patient reduce the cognitive burden. I think there is a lot of angst around the idea that AI will somehow replace the clinician in some way. What we’ve seen time and time again is that these types of tools are actually augmenting the clinician’s work. Take pattern-recognition AI, for example. These tools are getting very good at taking the first pass at reading an X-ray or CT scan or even a photo of a skin lesion. They are excellent at spotting what is normal and what could be potentially life-threatening. If, for example, you were a radiologist and allowed this first-pass data to help prioritize your work, then you could review the most critical studies first and potentially intervene more quickly to help your patients. What’s incredible is that this technology is constantly evolving and improving. We’ve seen tremendous strides in this field within the last five years, and it is clearly accelerating.

DrFirst is proud to hold patents in this kind of technology as it relates to prescription instructions, which is a true game-changer for medicine — and it’s relevant for telehealth and in-person visits. You know how before you see a doctor, you are usually asked to confirm what medications you take or have stopped taking? That’s called “medication reconciliation,” and it plays a very big role in helping prevent medication errors. However, most people aren’t aware that the medication history list your clinician is looking at on the computer is often filled with errors or omissions because it’s far more complex than you would think to transfer this information accurately between different systems. DrFirst made a huge breakthrough by developing a machine learning and AI approach to solve this problem.

Of course, all AI technologies, as well as telehealth, will benefit from how data creation and collection are accelerating from new home monitoring devices.

Is there a part of this future vision that concerns you? Can you explain?

I’ll go back to setting patient expectations and understanding — where the sweet spot of telehealth visits really lies. We will need to see the data on this. It’s still early to know where the telehealth numbers will eventually land. We often hear things like, “well, the genie is out of the bottle” or “the toothpaste is out of the tube,” meaning that when it comes to telehealth, we’re never going back. For the most part, I do agree that some semblance of telehealth will persist once the end of the Covid public health emergency is declared. However, there are still significant legislative hurdles and payer agreements needed to make things more permanent. Without a doubt, the two things that drove the thousand-fold increase in telehealth visits during the pandemic were: 1) necessity — things were locked down, and there was literally no other way to see our patients safely, and 2) regulations and reimbursement rates were expanded, so virtual visits matched the in-person rates. I do believe that when we see things getting back to the new normal, there will be an adjustment in reimbursement. Depending on how the scales are tipped, you could see the tremendous adoption we’ve realized start to retreat even further.

I am also concerned that patients and clinicians may “settle” for a telehealth visit even in cases where it truly isn’t the correct forum. Patients may pressure the doctors to conduct a visit remotely or make a diagnosis from afar simply because they’ve become accustomed to the convenience of telehealth. It can become a slippery slope for sure, and that’s where we need to make sure we are setting appropriate boundaries and expectations.

Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 🙂

I think a movement that brings quality care right now to all people worldwide is the one every doctor and healthcare provider, including me, wants most. There’s no time to waste in alleviating human suffering, ending disparities in care, and providing immediate access to effective medications and treatment, healthy food, clean water, and safe, hygienic conditions. Mobile device technology has spread across every continent and into remote areas. Despite social, economic, logistical, and political barriers, I’d like to see innovators push hard on systems that are already in place to make change now — such as connecting a pediatric specialist in Boston to a child thousands of miles away in need of that expertise and compassion.

How can our readers further follow your work online?

@colin_banas on Twitter

LinkedIn

DrFirst.com

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