Telehealth has become part of our new normal as we practice physical distancing during the COVID-19 pandemic. Several of the barriers that prevented us from being able to see our doctors for an appointment via a telephone call or a video call have now been managed. However, it’s still a new way to receive healthcare, and both patients and clinicians are adjusting. Learn from Neilanjan Nandi, MD, gastroenterologist and Associate Professor of Clinical Medicine at Penn Presbyterian Medical Center and the University of Pennsylvania about what patients can do to be ready for their telehealth appointments and what it’s like from the doctor’s side of the video conference call.

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Concepts discussed on this episode:

• What Is Dyspnea?
• An Overview of Anal or Rectal Abscess
• Anemia and Its Relationship With IBD
• How to Use Telehealth Services During the COVID-19 Outbreak and Beyond

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For more information on telehealth appointments, see Tips for Telehealth and Managing Your IBD Care During the COVID-19 Pandemic from Tina Aswani Omprakash of Own Your Crohn’s and Telehealth: Where Have You Been All My Life? from Natalie Hayden of Lights, Camera, Crohn’s.

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Find Neilanjan Nandi, MD on Facebook, Instagram, Twitter, and Linkedin.

Find Amber J Tresca at AboutIBD.com, Verywell, Facebook, Twitter, Pinterest, Linkedin, and Instagram.

Credits: Sound engineering courtesy Mac Cooney. “IBD Dance Party” ©Cooney Studio.

Transcript [ROUGH]

[Music: About IBD Transition]

AMBER:
I’m Amber Tresca and this is About IBD. It’s my mission to educate people living with Crohn’s disease or ulcerative colitis about their disease and to bring awareness to the patient journey.

We’ve seen an explosion in the use of telehealth while we are working to keep up physical distancing. Many practices are seeing patients in the office only when truly needed. That means we are all having telehealth appointments using a variety of different types of technology. Telehealth isn’t new: after all, we have all used the phone to talk to our physicians or other members of our healthcare team. What is new is that we can now use video calls or other technology to connect with our doctors and that our doctors can get reimbursed for these appointments. The pandemic has compelled government, providers, and payers to figure out how to make telehealth work for everyone involved. And it’s about time.

My guest is Dr Neilanjan Nandi, who is Associate Professor of Clinical medicine at Penn Presbyterian Medical Center and the University of Pennsylvania. Dr Nandi is a gastroenterologist, social media guru, one of the most energetic people I know, and a friend of the pod. I asked him to share his thoughts and ideas around telehealth. He makes some great points about how patients can prepare for telehealth appointments and he also lets us know what it’s like on his side of that video conference call.

AMBER:
Dr Nandi, I want to talk to you about how telehealth has been going for you what kind of appointments that you are able to do and then how patients can better prepare. What kind of telehealth appointments are you doing at this time?

DR NANDI:
So really, we’re doing pretty much all visits via telehealth. So, you know, I’ve been looking forward to telehealth for quite some time. Even when I started my new position here at Penn. I never expected a pandemic to bring it my way. But I’m happy that it has. We are seeing pretty much all patients can benefit From a telehealth visit, The only disadvantage and this is important for our patients that telehealth cannot fulfill as a physical exam, right? And a second one, which is telescopes, right?

[LAUGHTER]

I had to make the joke, okay, we don’t use telescopes anymore. And I don’t know if you want me scoping you through a robot in another room. But I’m in probably only one laughing now. 

Okay, so, telehealth has been really helpful. But you know, we can at least get much of the history much of the medicines, how you’re doing your clinical response or clinical remission. But a physical exam is necessary in many cases. For instance, when people have apparently abscess or a fistula that’s active. And so, you know, one thing I don’t want patients to think that oh, you know, they can examine me at least we can see that the telehealth visit, or even just a phone call, right just, you know, good old fashioned telephone, and then bring you back to the office because we are doing clinic visits for select patients when the situation mandates.

AMBER:
That leads me to my next question: what kind of things might be going on that would prompt someone to say okay, telehealth is not going to cut it right now I need to go in. Are there any like sort of specific to IBD? But also maybe outside of IBD?

DR NANDI:
Yeah, absolutely. So I mean, patients, obviously, you know yourself best. The signs and symptoms like fever, chills, sweats in there, you’re shaking, you’re sure sweating through your shirt, or unintentional weight loss, weight loss you didn’t intend on losing, you might look better for a few days. But then you’re like, Oh, this is too much. These are called constitutional symptoms or B symptoms. That’s the medical jargon for it. And pretty much any discipline, not just GI, we ask those questions.

So if you’re experiencing those, call your doctor don’t even just wait for a telehealth, visit or not call your doc review it but you’re certainly going to want to come in if there are unexplained two signs or symptoms of anemia. So anemia, low blood count is very subtle, insidious symptoms. usually occurs very slowly from intestinal blood loss. So signs and symptoms of anemia can be fatigue and low energy from low blood counts. You can also have a feeling a feeling of being cold, short of breath because you don’t have enough blood volume you’re going to have enough oxygen pumping to your lungs and your heart and your brain so you get naked short of breath might be dyspneic, meaning short of breath when you exert yourself. You also might be dizzy, lightheaded, pass out, okay, so those are signs or symptoms that you’re either dehydrated or have a low blood count. And then the physical things right?

If you have a perianal fistula, meaning it’s hard to sit on your tuchus so if you’ve already been through this, you know what I’m talking about. But if you, this is your first go around, and you find that there’s pain or pressure, like there’s like almost a pimple, okay, which is what an abscess is. It’s a bigger pimple underneath your bottom and you can’t sit then you should you should come to the to the hospital for a clinic visit or go to the emergency room.

AMBER: 
Is there anything that patients can do to prepare before their telehealth appointment to make it go a little smoother, both for them and for the healthcare professional?

DR NANDI: 
Yeah, absolutely. So there’s a couple of things. There’s the office things that you can do. And then there’s the technology, things that you can do. And then there’s a standard clinic preparation visit, things that you can do. 

So what do I mean by office in the telehealth space, it’s not so simple that we just call you up on the phone. There’s pre registration. Imagine when you go to the doctor’s office for a regular clinic visit you got to check in you got to share your insurance card, your thumbprint, your DNA, your you know, blood of your last child, you got to give them all that stuff that’s registration. So you want to make sure that any phone calls from the doctor’s office in advance you return because they’re probably looking for really important information they need in order to plug into the computer. If you’re not plugged in, then the doctor may not be able to ask access your file and call you to there’s also questionnaires. So in our office, we use questionnaires that we send out in the mail, or electronically through our electronic medical record smartphone app. We use electronic medical record, it’s very popular called epic. And our app is called my chart. And we sometimes send surveys there about your illness and that help the doctor kind of razor focus on your primary symptoms. That’s really useful that saves you time. Okay. So that’s the pre registration pre visit stuff. 

Then there’s the technology stuff. So we all know that technology is great except for when it doesn’t work. And when it doesn’t work, it’s when you need it the most right like that doctor’s is that you’ve been waiting for. So I recommend that when you get ready for a telehealth, visit. One you want to make sure that you have good signal that you have a good Wi Fi connection. If you’re using video conferencing, or at least good cellular signal if it’s just a telephone phone call. You want to be comfy okay wear bottoms. Okay, just in case it’s video definitely wear a professional top. Alright. definitely seen some patients get up when they weren’t supposed to do that on a video conference, but it’s okay. You know. So you want to be comfortable. You want to have a good Wi Fi connection, a good a good location, we’re also not going to be disturbed. Right now we’re doing telehealth in quarantine. You know, if you have kids or spouses or other people living with you, you want to make sure not interrupting your visit just for your own privacy, and just for the smoothness of the visit. But then once people get back to a new normal, that’s going to be another challenge, right? So you want to make sure that again, that you’re in a comfortable spot, not going to get interrupted with people going to and fro. 

Then there’s the standard stuff you do for a clinic visit. You bring all your questions, you review your medications at home, make sure that you don’t need any new refills. I always recommend especially for the vital immunosuppressants that you check when your authorization expires, the insurance company will send you a letter that tells you when it expires. If you don’t know that’s okay. Call your pharmacist. They’re the unsung heroes that we don’t think enough or call your doctor’s office and find out. That way. When you see the doctor in your telehealth visit, you can say, Hey, Doc, my medicine, my biologic or specialty authorization expires in about eight weeks. I just wanted to give you advance that is can you and your team help me make sure that it gets authorized again, that’s probably the biggest thing. 

So registration, technology stuff, and then all the standard clinic stuff that we always ask you to do.

AMBER:  
As far as all that paperwork goes. I know every doctor that I have does things differently. Sometimes you walk in and they hand you an iPad and you fill things out and sometimes they still give you pen and paper which is always fun. What kind of challenges are patients having and our healthcare professionals having and getting this kind of paperwork all lined up and finished before you can actually hop on calls with your patients?

DR NANDI:  
So most of it is the technology aspect. So if you’re an individual who knows how to use your smartphone, you’re probably going to be able to do this. Because the companies that design our interfaces design it for I’m not, I’m not making this up, by the way, I’m not insulting you, but for like an 11 year old to us, it’s like, we design educational literature at a fifth to sixth grade level, fifth grade level, actually. And we make sure that the applications are user friendly. At the same time, that is not always the case. So if you have technological issues, then there are it helplines on that should be in the app or online or on the printed paper. And then of course, you can always call the doctor’s office and ask for help through their administrative systems.

AMBER: 
I’m laughing because I have a 10 year old and a 12 year old and they’re way smarter than I am. So if the apps are built for them…

DR NANDI:  
Hey, no, kids, kids start playing video games. I mean, they have stereoscopic skills. And like talented, they can type. They know how to use iPhones, you know, at the age of two. It’s crazy.

AMBER: 
It’s very amazing the first time that you hand them something like that, to see how they intuitively understand it. And I’m laughing too, because we’re distance learning. And I’m having to figure all of this out. I don’t consider myself a slouch in terms of technology. But, but wow, it has been a serious learning curve. So I really feel for anybody that doesn’t use technology on a regular basis, because this has to be just such a, you have to feel so unmoored. If you’re suddenly having to do this.

DR NANDI: 
Totally. There’s one other thing I thought of that might be institution specific. Depending on what software the doc is video conferencing with you. So depending on the software, you may not need to download a software program to your phone. Okay, Doximity has an app where the doctor can call you on a video call, but you don’t need to download anything, you get a text message, you click on the link and it opens up. That’s very convenient. There’s pros and cons to everything. 

There are other software packages, such as Zoom, GoToMeeting, WebEx BlueJeans, we use that, require that also require a smartphone or tablet or laptop download. They’re very secure. And they require a meeting ID code meaning if you can imagine in cyberspace, there’s a virtual clinic room and you can unlock it with a code you get to go in and the doctor goes in nobody else that secures your digital privacy. So you may have to download a software before to your computer. And you may need a meeting ID code. And so if you get any phone calls from the doctor’s office, they’re probably giving you one and mailing you a meeting ID code. So again, if you know you’re having a telehealth visit, and you haven’t received instructions, don’t wait till the last minute, you know, call as far in advance as possible to prepare for any software stuff.

AMBER: 
All of those interfaces that you mentioned, I’ve used with different clients. They all require a download. And I can’t tell you how many times I show up for a meeting, a couple minutes before the meeting, and then oh, shoot, I have to download the software, and then I’m five minutes late for my meeting. So I think you definitely have to give yourself at least 10 or 15 minutes to sort of go through all of that and sort that out.

[MUSIC: About IBD Piano Transition]

AMBER: 
So we’re in a situation now where certain places are talking about opening back up certain aspects of our world. What do you think that might look like? As far as telehealth goes? Do you think you’ll continue doing telehealth appointments or will institutions want to just go back to the way that it was before? What are your thoughts on that?

DR NANDI: 
Well, I think society has been completely changed by this in especially in terms of telehealth, I think the whole crisis shows that we need a major overhaul. I’ll tell you when things don’t make sense in the world, I have this thing. If things don’t make sense, it’s usually because of money. Okay. And you, you and I both know that there is a huge convenience factor to telehealth. And there always has been telehealth isn’t new, right. It’s been around for a while. It’s just been about money reimbursement. And now, insurance companies and corporations, they are forced, right. And the government and the state government, right, they are they’re forced to change laws which are obstacles, right,to telehealth, so now we’re overcoming those barriers. 

So I think telehealth is here to stay. I don’t think we’re going to do 100% telehealth anywhere because like we mentioned telehealth is not a full replacement of real clinic visit, right the art of medicine is to see Put your hands listen and take care of a patient. So we’re always going to need a clinic space. But I think the fact that telehealth saves a patient a whole lot of acts of travel time, sometimes hours to see right? parking, some patients come stay overnight in a hotel for certain illnesses, right? If they have to go to a rare disease specialist, I’m also you know, having a ride to take you home having to call in family or friends if you’re not able to drive right, having to find bathrooms on your way. Great. All these things affect our our community so much right and telehealth can save them all that, you know, we haven’t gotten there yet. 

But one of the things I found is that patients are more comfortable when they’re at home, they have less anxiety instead of coming to my office and you know, and you know, they’ve been there a million times but you know, it’s it’s you feel more comfortable with your own surroundings. So, to answer the question, yes, I think telehealth is going to stay. I hope that I get to do more telehealth, but I it won’t be a substitute for all my patients and I don’t want it to be but I think a lot of policies will change and we’ve already seen some insurance companies make amends to provide reimbursement equivalently for video conferencing and telehealth, so I think it’s going to stay and it’s going to be all for the better.

AMBER: 
Even so you said you were looking forward to it and you gave some really compelling reasons to why it is good for patients and it’s good for you and your colleagues. But this is all still new. So how are you coping with it? How are your colleagues coping with it? You are very technologically savvy, but there might be people that are struggling with it a little bit more.

DR NANDI: 
Yeah, you know, it’s a variable experience for everybody. It has to do with the individual clinician, doctor, nurse, pharmacist nutrition, but it also has to do with the resources provided to you. So in a resource rich system, meaning institutions got the money to make good software to have it all accessible, make it work, it becomes easier. But if you’re, you know, as a clinician if you’re in a place where they don’t have that capability, It’s much more frustrating in terms of the actual technological leap. It’s not too bad, you know, doctors.

One joy of medicine is that every few years you change your electronic medical record and have to learn how to do your notes again, which is crazy. But it does happen often. And so we’re no stranger to it. The good thing, though, is that telehealth it’s not that a huge leap, because we’re documenting in the same EMR. We’re just using a video camera usually, ideally, in my opinion, and we’re typing. So there is some learning curve, but once you get it down, it’s not so bad and you can actually be very efficient. Now has telehealth perfect. No, it can be frustrating. And you do in a good and bad way you keep on schedule, but when you know that you need more time with the patient, you know I’ve had some stress where I know when you get to sit next to the patient or waiting for me in cyberspace. But I think that’s just growing pains for me and growing pains for my patients. 

I’m very lucky my patients know that if I’m late late for a good reason. Otherwise, I think I’ve been doing much better actually, if my patients are listening, of staying on time, okay, and not and still not rushing any part of the visit. So there’s a lot of learning, there’s a learning curve, but it’s not so bad technologically, it’s more about efficient time management. And I actually think it’s maybe made me more time efficient, and helped me actually listen to my patients more.

AMBER:  
That’s really interesting. And I think something that will compel patients to ask for more telehealth appointments as we go forward and start to ease the physical distancing restrictions that we have right now. Especially if you don’t have to sit in a waiting room and wait for an hour to see somebody — that’s very attractive to me. This is new for all of us. Although you are welcoming it with open arms. It sounds like but have you learned anything about the way that you practice medicine in person via the way that you do it via telehealth that has surprised you?

DR NANDI: 
Yes. But they’re different things. There may be odd things, to some people and they’re kind of weird to say out loud.

AMBER:  
Oh, I love it. Let’s hear it. 

DR NANDI: 
Well, I’m a hugger. And I told you, right, so I don’t hug everybody, but I’m a hugger. And it’s a good relationship with most of my patients in you know, I miss that, you know, I, I think the other aspect is I have a health care team behind me that that makes healthcare work. I couldn’t do it without them. So I don’t get to see my team. You know, and you can this, you know, my team is a family in and of itself, you know, beyond my immediate family, right. So, that dynamic has been, you know, hard to get used to, but I know that we’ll we’ll find a new normal, so I’m not too torn up about that. But as far as the visit itself, um, yeah, you know, just being able to be in the same person. There is something about sharing physical space, that there’s really no substitute for. 

Didn’t notice that before we got the video conferencing aspect up and running, when I was forced to only do a telephone call, I’m a very good typer. So I’m going to look at a keyboard. But I found myself and I think I’m a good listener to begin with, but I found myself listening even more, I would just close my eyes and just listen for the question and the answer from the patient. And, and, you know, it actually paid off, you know, it helped me take a better history. And I think that can still happen with video. But I think those are the differences. I still miss seeing the patient and sharing the physical space with them, because it makes it a more humanistic interaction. I still think it’s possible to create on video, but it’ll never be perfect. 

AMBER:  
Yeah, it’s an adjustment. Are you spending much time at clinic anymore or How are you dividing your time between your telehealth and then your in person?

DR NANDI: 
Yeah, you know, I’m, I’m very fortunate. I really don’t consider myself a frontline worker at all. You know, I’m a colleagues who are in the ER, who are on the COVID floors in the ICU all the time. And then and everyone who supports a member of the healthcare team, those are the real front liners, I would love to be there. That’s my my personality is I want to be there. But my responsibilities to my patients and keeping them out of the hospital. So I’ve mostly been telemedicine, telehealth, but I have had to go in for a couple of days, not many at all. For doing urgent cases, we’re talking like dilations, and things that really can’t wait for our patients. 

And, you know, we’ve really kept patients safe by multiple levels of screening to keep them before they get to the hospital for them and the staff. And so you know, we’ve been very good about protecting patients, I have to be on service in a in a two to three weeks or so. So then I’ll be on the floor where there might be some more exposure to COVID. But again, we know that response PPE counting can keep us all safe. So no, I’ve been very fortunate. And I fight my good fight if I can’t be on the front line, this is how I look at it again by by fighting for my patients to keep them out and doing talks like this. Thank you for the opportunity to arm people with better information.

AMBER:  
I know how hard you fight for us all so I really appreciate that.

[MUSIC: About IBD Transition]

AMBER:  
Anyway, is there anything else that you want to add or that you thought of?

DR NANDI: 
I think that um, you know, just a message that our community already embraces and has shared with the world. So I’ve been very happy that IBD patients have done this which is you know, there is this the message of stay at home and stay home and stay safe. And I also in turn, by helping you stay safe and stay home you I don’t want you to think that your doctors and your Care Team aren’t there for you, I want you to know, and this is why we’re doing talking about telehealth here. We want to be there for you. We care about you. We don’t want you to feel abandoned. And we will do whatever it takes to continue taking good care of you. 

So if you’re listening to this, if you’re a patient or a caregiver or your family member, remember, we’re doing whatever we can to take good care of patients, whether there’s a will, there’s a way and we’re doing it in large part through telehealth. And when we have to, we will, we will come to see you in person and take care of you. So I think that’s an important message. We’re not giving up on anybody.

AMBER:  
Thank you for that. I think, though, where there’s a will there’s a way that has been proven out over and over again over these last several weeks. Yeah. Thank you so much for talking with me. I really appreciate your time. And thank you for everything that you’re doing now. And in the future and in the past for the IBD community because you are a force and we appreciate you and make sure that you tell me all of your social media information, Instagram Twitter, are you the same on every platform.

DR NANDI: 
I’m the same I’m FITWITMD on Instagram, Twitter, Facebook — that comes out of Fitness Witness MD. Don’t be a nitwit be a FITWIT! So that’s my little slogan but thank you for having me Amber I just want to say you’ve always been a passionate advocate and the content that you put out it’s practical it’s real people need to hear it they don’t know where to go but when once they learn about you it’s trusted information it’s very much needed. And so if your listeners out there, she didn’t tell me to say this. I’m just putting her on the spot here. Please, please shout shout out put a message out. Tell around what you love Amber, because we all do. Thank you, Amber. 

AMBER:    
Oh, thank you, Dr Nandi, you made like the rest of my week, and probably next month too.

[LAUGHTER]

[MUSIC: About IBD Piano Transition]

Let’s wrap this episode up by going over 5 Tips to having a Great Telehealth Appointment

1. Get your registration paperwork done prior to your visit. Dr Nandi joked that they can ask for a lot of information at times but it does need to get done before you can get on a telehealth appointment with your doctor. You don’t want to wind up rescheduling because of red tape.
2. Prepare for the visit by knowing how to use the technology. That might mean downloading software or reviewing a how-to document or watching a video so that you know how to log in and make the most of the tools you’re using. If you have any questions or something isn’t working right, get in touch with your doctor’s office right away.
3. Make sure your physical space is ready for the visit. We all have challenges right now and it’s not easy to get alone time, but as much as you can, you’ll want to try for a quiet room where you can talk to your doctor without distractions.
4. Wear some pants! How often are IBD patients told to put their pants on? Usually we’re asked to take them off! But do remember that if you’re using video during your telehealth appointment, that you’ll want to arrange yourself and your environment so that you’re comfortable but also so that you’re aware of what the camera is showing.
5. Last but not least: get ready for the actual visit. You’ll want to do all the things you normally do such as write down your questions and review your medications beforehand. One thing to keep in mind is that when using a new medium you may feel a little off kilter so take an extra minute or two and ensure that you’re able to get  all your needs addressed. 

And one bonus tip I’ll throw in: remember to have patience with everyone involved, including your doctor, the office staff, and yourself.

[Music: About IBD Transition]

AMBER:
Hey, super listener. Thank you to Dr Neilanjan Nandi for taking time to answer my questions about telehealth. You can find Dr Nandi on Facebook, Instagram, and Twitter as FITWITMD. I will put all of his information in the show notes and on the episode 69 page on my site, aboutibd.com. 

You will also find links to more information about telehealth in the show notes. For more updates, follow me as aboutIBD on all social media or on my site at aboutIBD.com. And as always, don’t take my word for it, check with your healthcare team about anything in regards to your IBD.

Maybe you don’t open up your podcasting app as much as you used to. Or maybe you find you have less time to listen because of how the pandemic has changed your day-to-day life. I want to tell you two things: the first is that my show is for all ages so anyone can listen with you, and I actually encourage that. The second is that if you head to aboutibd.com, you can sign up for my newsletter and I’ll email you whenever I have new episodes or other content for you. Thanks for listening and remember until next time, I want you to know more about IBD.