Dr. Julita Mir of Community Care Cooperative: “Spend time doing a complete data-gathering”

Make sure someone on the care team calls the patient ahead of the session and helps her/him understand know how to connect to the visit. This is also the opportunity to hear any concerns and administer screening tools, and for the patient to prepare and ask any questions. This is also a good time to […]

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Make sure someone on the care team calls the patient ahead of the session and helps her/him understand know how to connect to the visit. This is also the opportunity to hear any concerns and administer screening tools, and for the patient to prepare and ask any questions. This is also a good time to assess the need for interpreters.

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 interviewing Dr. Julita Mir, Practicing Infectious Disease Physician and Chief Medical Officer of Community Care Cooperative.

Dr. Julita Mir is a practicing internist and infectious diseases physician with more than 20 years of experience in community health and serving the most vulnerable populations. She is also the Chief Medical Officer of Community Care Cooperative (C3), a 501(c)(3) not-for-profit, Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs) in Massachusetts, where she oversees medical operations and its network of 19 community health centers throughout the state. Dr. Mir specializes in HIV and Hepatitis treatment, paired with a strong interest in addressing behavioral health problems within minority communities.

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?

I grew up in Venezuela, a country — like many in Latin America — with tremendous socio-economic disparities. Experiencing and recognizing the need for improved public health in my own community so early in life, I realized my passion and my calling to help those with less opportunities. I went on to receive my medical degree at the Universidad Central de Venezuela and came to Boston in the 1990s to complete my residency at the Boston Medical Center with the intention of training as an internist and then returning home to practice in Venezuela. However, during the time of my residency, it was the early years of HIV research and treatment discoveries, and my training became almost like a specialized education in caring for HIV patients. I was completely immersed into the world of HIV treatment; I developed a new interest and personal passion to find the best care and solutions for these patients. This experience led me to enroll in an Infectious Disease fellowship to ensure I had all the formal training needed to care for this new population of patients who had a disease that was spreading rapidly throughout the world.

I look back and there are so many similarities to the early days of HIV to what we saw in 2020 and continue to see now with the COVID-19 pandemic. What stands out is the disproportionate effect these public health crises have had on minority populations. This unfortunate reality compels me to address issues emerging now so we can avoid the same inequitable impact in hard-to-reach or minority communities that was evident during the HIV epidemic. I developed a passion for telemedicine implementation because it is a powerful way to address the gaps within diverse communities and avoid even deeper ramifications of disparities on their physical health. I hope that lessons from the past will inform research and policy decisions in the future.

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

It would not be possible for me to pick one story; every patient is a great story. Whether it is a story of success or of challenge, or an amazing diagnosis or a missed opportunity — each patient I served offers a great, teachable moment. One major, overarching “story” in my career is when I started my residency at the Boston City Hospital. I was overwhelmed by patients with HIV, most of them severely ill and at end stages of the disease. I learned a lot about the disease, but more importantly, I learned a lot about dealing with death and the sensitivity around accompanying patients and families in that journey. Getting immersed into this unique situation at the start of my career shaped who I am as a physician and a person. I learned how to prioritize life and how much passion I have for my work and the people I serve. Through these tough times, I was able to find the meaning of trust in the patient-clinician relationship, something that I have never forgotten and built on throughout my career and even in my personal life. Working with HIV patients, you have to be empathetic for their situation, understand their fears and concerns in order to establish a collaborative relationship to find the best treatment for them. But through my patients, I also witnessed, over and over, the trust that my patients only gave to a spouse or a parent, deep and honest trust. I admired their resiliency and their deep love for one another through such dark times. My patients have been my best teachers.

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

I love to quote Albert Einstein when I think about life lessons. One of my favorite quotes of his is: “I have no special talent. I am only passionately curious.”

I was blessed with a deep sense of curiosity, so I get energized by constant learning. Every person I meet, every experience — as trivial as it may seem at the time — adds something to my life. It’s in the experience that one learns the most and I’ll never forget the emotions I feel in certain moments, and that has been tremendously helpful for me.

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?

I have many people to thank in my life, starting with my parents who allowed my curiosity to take flight, but when I came to the United States to further my medical education, there was one person to whom I may owe my career. Dr. Bart Celli, a gifted pulmonologist and head of the department at the Jamaica Plain VA Hospital in Boston at the time, was well known for helping medical students and foreign medical graduates. Five minutes after meeting me, Dr. Celli gave me his white ironed coat and said: “if you want a job in this country, go and show who you are and what you know.” He continued, “I can’t help you if you don’t show how good you are,” and then he sent me down to the medical wards for four weeks. The veterans in those medical wards corrected my English, took the time to chat with me, and even helped me understand how things worked — breaking down many of the cultural barriers I faced in coming from Venezuela. The help from these veterans really allowed me to immerse myself in American culture. This was critical in my journey and eventually led me to a position as an Internal Medicine resident at Boston University.

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 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?

A few of the main benefits of having in-person sessions with patients is that it’s easier to communicate and get a ‘read’ on people in-person. You can more easily detect body language and non-verbal cues particularly when caring for individuals who don’t speak English. Working in health centers in the Boston metro area, its common to treat non-English speaking patients and trying to communicate over telephone or video poses a challenge. It’s also more personal and easier to physically examine injuries or review symptoms with the patient at hand. Throughout the course of the pandemic, we have learned that many of our health center patients prefer being in the office because of the personal attention and the ability to address multiple health concerns, not only primary care, but also dental and behavioral health. But we recognize that it isn’t always easy to have people constantly come into the office, and sometimes, it’s impossible given patients’ job demands, child-care challenges, and travel constraints.

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?

Given the immediacy of telehealth for working people, the convenience of it outweighs the challenges for many. It allows them to access care in the middle of their working day — a big concern for the working poor who do not get time off for doctors’ appointments or have easy access to childcare or personal transportation. Still, there are a few challenges.

One of the biggest is the language barrier. For many health center patients, English is not their first language, so with telemedicine appointments, we need to either speak their language or provide translation services. We also have to make sure our translation efforts are up to the task at hand. Nationally, this challenge been neglected since most telehealth users are White or English-speaking. To continue using telehealth with intention to act as a comparable replacement to in-person care, all providers and services should find a way to address the more than 43 million Spanish-speaking, the 2.9 million Chinese-speaking and other non-English speaking Americans in order to truly care for all populations.

Another challenge is digital literacy. Sometimes, patients lack technical skills or comfort around connected devices, this is especially the case with older patients or those who lack experience with a tablet or smartphone. In these cases, digital literacy training is needed. At the health centers I work at, we provide this training and education to our patients.

Along these lines — and part of what’s now known as the “digital divide” — patients who live in rural areas and even underserved urban areas lack access to reliable broadband. Whether it is not available where they live or they can’t afford it, the lack of internet access is a direct reason why some patients do not find benefit or satisfaction to telehealth services. In this case, we become advocates for phone and utility companies to more quickly wire neighborhoods and regions that lack this important necessity for living in the current digital reality. Part of closing the digital divide is helping those patients who are resource poor and lack smartphones, laptops and tablets. Through my role as CMO at Community Care Cooperative (C3), a not-for-profit Accountable Care Organization of Federally Qualified Health Centers, we are engaging with our partners to provide tablets and smartphones to health center patients, specifically for telemedicine appointments. These devices are needed to help ensure health equity and provide access to the quality care that our most vulnerable patients lack, especially those in underserved communities and communities of color.

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.)

Make sure someone on the care team calls the patient ahead of the session and helps her/him understand know how to connect to the visit. This is also the opportunity to hear any concerns and administer screening tools, and for the patient to prepare and ask any questions. This is also a good time to assess the need for interpreters.

When the visit starts, it is important to allow some time to build a relationship and trust, particularly if it is a new patient. This provides a great opportunity to learn about their life. For example, you can gain personal insights like whether your patient needs to take care of his/her child(ren) and understand whether their financial situation prohibits the hiring of child-care services. This can guide decisions on how best to set up future appointments. Building that initial relationship also lets you learn about their culture/ethnic background, which may alter the way you communicate or address certain issues during your telehealth sessions.

During the visit, speak clearly, slowly and allow the patient to respond. If you are using video conferencing, use nonverbal reassurance such as nodding and eye contact at all times. Being cognizant of your own verbal and nonverbal communication skills will improve the patient experience during the telemedicine session. Patients deserve HCPs who can make the most out of these visits.

Spend time doing a complete data-gathering, including asking about the medications the patient has at home and reviewing their recent labs, X-rays, or reports from consultants. Preparation for the appointment is essential in order to make the most of the time available and not review their medical history. This pre-learned knowledge also builds a sense of comfortability for your patient.

As you get to the end of the visit, ask the patient if all their concerns were addressed and discuss when and how the next visit should take place. At the end of the day, the patient needs to feel they got the most of their session and know what their next steps are. This is also a good time to ask them about their experience with the session to gain constructive criticism and adjust care based on their individual preference.

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?

Telehealth can ease the financial strain and time constraints that patients in underserved communities can experience when arranging for an in-person visit. In my experience, patients aren’t skipping the telehealth visit as much when compared to making it to in-person office visits prior to the pandemic. They can “come” to their appointment wherever they are — there’s no need for transportation, or to take time-off from work. This is especially valuable for salaried workers or those who would need to get childcare. This increase in attendance rate is also translating to an increase in continuity of care among the health center population.

Last year, I saw a 62-year-old female patient from Cape Verde, a small island country in Africa, who discovered she was HIV positive in May 2020. She was not a U.S. legal resident, did not speak English and was without stable housing. While in-person visits were still restricted, with the use of telehealth, my HIV team and I were able to get her engaged in care within 48 hours of her diagnosis. She was able to receive all her needed lab data, engaged behavioral health and social services and started medication. That initial use of the telehealth visit allowed my team and I to take immediate action and get the patient on the right track in navigating her diagnosis — a true collaborative effort that may have been even quicker than what would have resulted from a regular in-person visit. In just a matter of months, she is now receiving fresh food, coverage for her medications and enrolled in remote English classes. The availability of telemedicine truly helped this woman find her right path and I am so proud of how my team was able to implement telemedicine into her successful treatment journey.

And lastly, as we know, the COVID-19 pandemic restrictions limited in-person visits to ensure safety. Telemedicine still allows patients to stay safe and keep others safe by meeting from the confines of their home. Even without a global pandemic, let’s say a patient is experiencing flu symptoms, with telemedicine they can stay rested in their homes and not risk spreading the virus to others they may come in contact with when trying to get into the office. This is something that we need to take into account when the pandemic is over.

Let’s zoom in a bit. 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?

Smartphones and even regular phones have been critical during the pandemic. We would not have been able to manage patients, whether they had COVID-19 or not — during this period without phones. This allowed us to connect with our patients, wherever we and they happen to be. We also realized early on that we should have been prepared for staff to work remotely, and providing the right equipment, broadband at home, proper digital training, would have made for a more efficient start to telemedicine implementation.

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

Ideally, we would have a very user-friendly technology platform that patients could access in several languages from their smartphone or computer, one which also allows other care team members to join — something like a “hub” for multiple HCPs from different specialties to collaborate and build out a comprehensive and individualized patient profile. It would also allow patients to be put in waiting rooms, have the capability for instant, care-team messages and interfaces with the portal. But with the success of telemedicine, there is a real possibility that an improved platform like this will exist in the near future.

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?

It would be helpful to patients to understand while they have a choice, telehealth is a great alternative to in-person visits. Especially with our health center patients, I hope they know the importance and benefit of getting educated on technology and ensuring they have broadband access in order to make telemedicine sessions more productive — and to access other parts of the digital world that can improve life.

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?

In 2020, we learned that technology was not there to provide comprehensive primary care, but instead had been developed to provide episodic care. New technology has many applications in addressing public health issues, but experience shows that tools like VR, AR and Mixed Reality won’t be immediately beneficial to the patients we serve who can benefit most from telemedicine care. The digital divide will get worse, and the gap will get wider if these technologies get adopted by large health systems and our patient population has no access to them.

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

Similar to my previous answers, my main concern is once again neglecting the underserved communities who need these advancements the most. If expensive technologies are adapted, we must ensure that they are not only available to the upper classes, but also to those on Medicaid and others in the lower-income population — and we must find policies and funding that will ensure equitable health benefits. Or else, we will keep creating a bigger gap in the digital divide, thus compromising public health in underserved communities.

(See answers 10 and 12 for more context)

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 believe that change happens when you focus your work in the most upstream interventions. That means those that reach individuals, families and communities at critical stages of life, such as early education, pregnancy, or parenting. If we could put more resources to work and enlist top strategic minds to think about elevating the voice and possibilities for underrepresented individuals — rather than just handing them short term “solutions” — we would have a different, more prosperous, and healthier generation. And just as importantly, if we could live in a less individualistic way and more as a collective, as many other countries do, we would quickly see healthier children and larger, better quality social connections, with people who are embraced and protected by their relatives and their larger communities…. I would call it “upstream and together”… that would be the title of my proposal to build healthier communities.

How can our readers further follow your work online?

Community Care Cooperative

Twitter: @C3aco

LinkedIn: Community Care Cooperative (C3)

Thank you so much, this was very inspiring!

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