Be open-minded to innovation: The world of digital health equipment and remote monitoring tools is evolving rapidly. While not all patients have access to smartwatches and wearable devices, for those that do, this can be a game-changer. Currently available devices can monitor blood sugar, heart rhythm, activity, and sleep, and data gleaned from these digital tools can be incorporated into virtual medical visits.
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. Rashmi Mullur.
Dr. Rashmi Mullur is an Associate Professor at the David Geffen School of Medicine, and is the Chief of Telehealth for the VA Greater Los Angeles, as well as the Education lead for the UCLA Integrative Medicine Collaborative. She has also partnered with the Academy of Integrative Health and Medicine (AIHM) where she has lectured and created educational curricula on endocrinology, telemedicine and integrative medicine; she now serves on the AIHM BIPOC committee to promote health equity in integrative medicine. Her clinical practice is focused on the use of mind-body techniques, integrative approaches, and remote monitoring tools in the management of chronic disease. She led her health system in the implementation of virtual care during the pandemic and is inspired by the opportunity to leverage digital health technology to advance healthcare.
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 have always been fascinated by the field of endocrinology, which is the study of hormonal disease. During my medical training, I worked in a research lab studying the biochemical and molecular mechanisms of diabetes and metabolic disorders. Over time, I also became quite interested in the role of mind-body approaches in the management of chronic diseases like diabetes and heart disease. As I completed my fellowship training, the VA was implementing WholeHealth approaches and I became involved in that effort. I started by piloting a yoga program for patients in my diabetes clinic, and eventually, created the telehealth programs in diabetes, yoga and tai-chi for Veterans at the VA Greater Los Angeles.
My favorite quote is “Do not let what you cannot do get in the way of what you can do” by legendary UCLA coach, John Wooden.
My eldest son was born with significant medical disability, and this quote captures my son’s essence. Despite his profound challenges, he thrived in school, had many friends, and beamed with pride at his accomplishments. He passed away in December 2019 and I’m still heartbroken, but I cherish the time I had with him and remain inspired by his resilience and strength.
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 am grateful for so many people in my life that helped me achieve my goals. My family has been incredibly supportive in helping me navigate the juggling act of mothering and establishing my career. I’ve also been incredibly lucky to have mentors that have allowed me to pursue my academic interests on my own terms. One story that comes to mind is when I was a junior faculty, and still trying to garner support to incorporate mind-body techniques into medicine, my mentor invited me to teach an experiential yoga and meditation session to a handful of faculty and students at our hospital. The session was a success, and people started to reach out to me to learn more for themselves and their patients. After that initial session, I was invited to create more educational curricula and mind-body medicine programs that have been the backbone of my career.
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?
Seeing a patient in a clinical setting is the mainstay of traditional medical practice. We are trained to take a history and perform a physical exam on a patient in a clinical exam room, and have access to tools and equipment to assist us such as stethoscopes, otoscopes, blood pressure cuffs, and an examination table. Most healthcare professionals are comfortable in this environment, and we are equipped to handle any urgent or emergent situations that arise.
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?
There are several challenges for both patients and physicians when conducting a virtual medical visit. Firstly, if this is an initial visit, it can be somewhat challenging to establish connection and rapport in a virtual exam room, and this is especially true if the patient and physician have any language barriers or any visual and hearing impairment.
Also, digital health literacy and internet access can be a challenge for many patients. Gaps in these areas contribute to a “digital divide” which has been shown to disproportionately affect elderly patients, patients of color, and patients who live in rural and socioeconomically depressed areas.
Clinically, performing a physical exam and addressing any clinical emergencies is much more difficult in the virtual space. As clinicians, it is a best practice to confirm your patients physical location in case of emergency. Also, a virtual physical exam can be performed, but it does take more time, and patients need to be guided on how they can assist.
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.)
Digital education is the main step we can all take to improve a virtual exam experience. There are educational modules for physicians on creating a “webside manner” and medical schools and training programs are now incorporating digital health education in curricula. For patients, it is important to have a member of the medical team assist with digital access and education one-on-one for our most vulnerable patients. As a society, we should be advocating for improvements to our broadband service and petitioning our local governments to create programs to increase access to digital devices to mitigate the digital divide.
Five things that physicians should know to provide virtual care:
- Set expectations: Not every medical problem can be addressed in the virtual setting. It is important for you and your patient to understand the limitations of virtual care. Patients should be prepared to speak with their physician in a location that maintains privacy and should not be driving, shopping, or multi-tasking during the visit. Patients should also be advised that often times, a virtual visit can take longer to complete.
- Don’t skip the exam: A virtual physical exam can still provide useful clinical information. There are published guides on patient and/or caregiver-assisted physical exam maneuvers that can be performed virtually.
- Use available tools: Home scales, thermometers, and blood pressure cuffs can provide standard vital sign information. Additionally, the use of handheld mirrors can be used by the patient to help you visualize rashes or lesions on hard to reach areas of the body. Finally, use of digital cameras can be helpful in evaluating a lesion or rash, especially if it can be sent securely and interpreted asynchronously by a specialist.
- Be open-minded to innovation: The world of digital health equipment and remote monitoring tools is evolving rapidly. While not all patients have access to smartwatches and wearable devices, for those that do, this can be a game-changer. Currently available devices can monitor blood sugar, heart rhythm, activity, and sleep, and data gleaned from these digital tools can be incorporated into virtual medical visits.
- Meet the patient where they are: Clearly, virtual visits offer the patient the convenience of being seen in their own home. Providers can utilize this opportunity to evaluate the patient’s home environment for safety as well as more easily communicate with caregivers and family members who would otherwise not be present in the office.
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?
In addition to the benefit of seeing a patient in their own home environment, televisits offer the added benefit of providing in-home patient education. Some virtual platforms also permit screen sharing so that educational handouts or videos can be displayed during the visit. This is especially helpful when counseling a patient on healthy lifestyle behaviors such as diet and mind-body approaches. I’m able to teach my patient how to read a nutrition label using items from their own pantry as well as teach them safe, seated yoga poses that they can learn and practice in their own home. When caregivers and family members are also able to participate virtually, the patient often feels more comfortable and supported when making these lifestyle changes.
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?
As I mentioned, the world of digital health tools and remote monitoring is growing exponentially. I can’t say that there has been one singular device or tool which has been more useful than others. I think the most important aspect is to match the device to the patient’s needs.
Many of these digital health innovations, such as digital stethoscopes or heart rhythm monitoring wearable devices, are best implemented in patients with severe and chronic disease. They are more expensive and often require training on use, but offer the benefit of keeping high risk patients healthy at home instead of in the hospital. Other wearable devices, such as continuous glucose monitors have been much more widely accepted and accessible since the pandemic as an optimal way to monitor blood sugar in patients with diabetes. Finally, activity trackers and sleep monitors offer the patient opportunities to log their health behaviors, and are starting to become more incorporated into standard medical practice.
If you could design the perfect Telehealth feature or system to help your patients, what would it be?
The ability to immediately transcribe key aspects of the video visit to be emailed for patient education would be a huge benefit for my patient. When patients leave a clinical visit, they often leave with educational materials and an after-visit summary; if this same option was available for video visits, that would be great for my patients. Many colleagues would also appreciate key aspects of the video visit could be transcribed into the medical record.
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?
As I mentioned, it’s important for patients to understand the expectations of a virtual visit. It would be ideal for patients to connect to the platform for a “test call” prior to the visit to make sure there are no unforeseen technical challenges. Additionally, patients should measure any health data (blood pressure, weight, etc) prior to the visit and have it readily accessible during the visit. They also need to expect that virtual visits can often take a bit longer due to limitations of the virtual physical exam.
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?
The use of VR and AR in medicine is still developing, but there are certainly several companies developing training tools for surgical simulation and other procedure-based approaches. From a patient standpoint, there are new mobile-health apps that use VR-based approaches for patients with chronic pain and mental health disorders that are exciting, but they are still in pre-clinical phases. At this point, the cost of these tools also limit the application of these novel approaches, but as the health outcomes data emerges and the technology evolves, I do see these tools becoming more broadly used in combination with virtual care.
Is there a part of this future vision that concerns you? Can you explain?
My main concern is that the technology will evolve faster than the medical evidence. For many of the medical grade wearable devices and remote monitoring tools, they are now being utilized after years of rigorous study and FDA approval. For some of the newer, patient-facing wearable devices, such as fitness and activity trackers, the medical evidence to support their use is still being investigated.
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 the most important thing we can all do for each other is to let each other know that we care. The time since the pandemic has been lonely and isolating for so many. Knowing that someone cares about you can be life-changing, especially if you are struggling or going through a hard time. Whether it’s quick text or phone call or to simply offering kindness to a stanger, letting people know that they matter and are not alone can help us all remember that we are all experiencing life on earth together.
How can our readers further follow your work online?
You can find me on Twitter @rashmi2008. I often tweet links to my talks and recent publications.
Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.