On Friday, WIRED’s editor in chief Nicholas Thompson hosted a Facebook Live with ER doctor-turned-cofounder Caesar Djavaherian, who now serves as the Chief Medical Officer of his telehealth companionship, Carbon Health. This was the first in a series of four conferences in which WIRED will explore what the coronavirus pandemic will mean for the future of business, education, engineering, and health. Hundreds of books tuned in, and we took questions from observers in real epoch. The discussion has been lightly edited for clarity.
Nicholas Thompson: Hello, I’m Nicholas Thompson. I’m the editor in chief of WIRED. Thank you ever so much for connecting us on this Facebook Live. We’re going to be talking about the future of telemedicine. Thank you to Caesar Djavaherian for participating us.
Caesar is an emergency room physician, “ve been here for” numerous, many years. He’s also one of the founders of Carbon Health, which is building one of the first at-home coronavirus exams. He’s been at the front lines of combating the coronavirus since the very beginning in the Bay Area. He’s on the front lines of helping to build the technology to fight it. He’s on the front lines of figuring out the future of telemedicine.
So, Caesar, good morning.
Caesar Djavaherian: Good morning. Thanks for having me.
NT: Let’s start with a little bit about you.
You started as an emergency room physician. And at some object a marry years ago, you made the decision that the most important thing you could do is try to stimulate prescription guys more efficient, particularly through telemedicine. Tell me about that alternative and a little about that transition.
CD: I started off as an ER doctor. I actually trained in New York City, where the pandemic is hitting hardest. And just like numerous physicians who practice medicine, I became a little bit disenchanted with all of the administrative loadings that physicians must be addressed in their daily lives. And I wasn’t satisfied with the answers to my questions about why we do things this behavior. And I was told, “Well, we always get it on this lane, ” or “This is the way we’ve traditionally approached X type of healthcare.” And I imagined, you know, in 2013, 2014, 2015, with incredible technology developing in every other industry, why couldn’t we take a step back on how healthcare was being delivered? And genuinely expect ourselves, if we were to create a brand new healthcare system today, what would that definitely sounds like?
And part of it is that you can do so much in person. But there’s a lot you can do actually online, outside of the clinics. And given the opportunity to take a step back from it, and asking that question, and genuinely trying to strip down healthcare to its bare bones, almost like, you know, how Elon Musk talks about first principles. So what are the first principles in healthcare? It’s really a provider and a patient and some work that has to happen around that interaction. And formerly you can break it down to those bare bones you can then start to build technology that can enable that experience to be much better from the patient perspective, and, frankly, much better from the doctor perspective.
NT: So, you’re trying to beat Elon Musk without the tweet blizzards, right?
CD: Well I’m not very good at tweeting.
NT: We have a quick first question, which is’ What is telemedicine? ’
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CD: Ah. So, you know, the definition of telemedicine is fairly broad. So it’s anything from, you know, taking care of a patient’s needs through the telephone–so exactly the old fashioned way–to having video interactions with your patients, to actually having video interactions with your patients assisted with maneuvers. So whether it’s loading intelligence from your Apple Watch, or exercising a remote stethoscope like ECHO Health has built or some of the at-home products like blood pressure cuffs, connected proportions, that sort of thing. And there are lots of companies that have gone into this field under the umbrella of telemedicine. But frankly, it entails different things to different people.Advertisement
NT: Ever since the internet was invented, I’ve been hearing fibs about how the internet will allow physicians in rural communities to treat numerous parties. But it hasn’t taken off, certainly, perhaps up to now. And significant differences are, as I understand it, we have much better bandwidth, we have better computers, we’ve got better cameras, we have Zoom, we have wearable machines, which give us more data. What else do we have? What else do we need?
CD: Oh, it’s a good question. So first and foremost, large-scale shout out to Zoom because the video quality has gotten much better under the Zoom platform for telemedicine providers. I review without trying it, most cases didn’t think they’d be able to get their questions refuted. So they’ve maybe tried telemedicine as an early adopter, tried to onboard, connect with their providers. And what I’ve heard from cases actually is that that was an unbelievably disheartening suffer for them. And they’d much very just go to a sit where they know they can get care. And unfortunately for a lot of them, that required the emergency department, and that’s where I would verify them. And so patients were showing up with proposals that actually could be taken care of at home through telemedicine or frankly, wait til the next day to see their primary care doctors. And so, one thing that’s in place, to your question, is that patients need to try it. And I think this pandemic should certainly magnetism a lot of us to try telemedicine for the first time.
And then what is necessary more of is to have a broader directory of actual ailments that we can take care of virtually. So, today if you’re a young woman with urinary tract infection character indications, that’s a excellent lawsuit for telemedicine. Now, if you have back anguish and excitement and upchuck, that’s probably not the right bag for telemedicine. It might be in the future, vary the connected manoeuvres that the patient has in their homes.
NT: And so then with Covid-1 9 there are a whole bunch of interesting stairs where telemedicine can play a role and a bunch of steps where it can’t. So the initial was a matter of: Should I proceed see a doctor? Should I get a test? That not only can be done via telemedicine, it should be done on telemedicine. Plenties of people who weren’t positive have gotten polluted by going into a infirmary to see whether they should get researched. So consultations, emphatically. Testing you can’t make love via telemedicine, but you are working on an at-home test, which I want to talk about for a second. And then there are other theatres like treatments–you can’t have a ventilator run in your dwelling. So is it the right framework, that with every kind of illness, there are steps where telemedicine can be appropriate and steps where it’s not?
CD: Yeah, well, I think to that place, we shouldn’t try to, again, fit a clinical scenario into the telemedicine box and simply try to use telemedicine because it’s there or because we want to. The healthcare method is unbelievably complex, the number of different patient productions is incredibly diverse. And we should use telemedicine in areas where telemedicine operates, and is effective, and can resolve a patient’s problems with the same clinical standards as an in-person visit.
But then there are instances where having a patient come into the clinic is more appropriate or into the hospital is more appropriate. And frankly, that’s really the tilt that Carbon Health has taken, which is that, yes, we do have telemedicine video trips. We can do a lot through that, but we can then connect them into our own clinics, or into a partner hospital, so that from the patient perspective, they’re getting the best care possible for every instance. You’re absolutely right, there are telemedicine companies that do the surveillance of patients in the intensive care unit so that one doctor can actually experience several cases at the same time through their monitors. They can look at the vital signs, make recommendations to the nannies, but they can’t perform procedures, they can’t positioned a patient on a ventilator when they need it. So there are still limits out there. And I recollect, again, going back to some first principles, we know that this is a tool in the toolbox, but we can’t have it siloed off from the rest of the healthcare ecosystem because we know that there are too many things that need to happen for a patient to be well cared for. And this pandemic has highlighted all of those.
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So in this pandemic, you have a disease that is deadly in certain populations. If you’re male, 70 to 80 years old, with diabetes and nerve necessity, this is a extremely deadly disease. If you’re a younger lady, you might just have very mild indications, like not being able to taste or smell.Advertisement
And the reason that telemedicine kind of rose to prominence within this pandemic is that we needed to very efficiently risk-stratify a huge percentage of entire populations , not only in the US but around the world. And so you can see that for some people, having information about coronavirus was sufficient. And more for other parties being on a ventilator was the care that they needed. So how do you unionize all that? Well, we think through technology you can inform those who need the information and keep them away from the healthcare organisation. For a subset of those people, you can provide some maintenance, whether it’s symptom ascertain, or steer them to the right testing facility or the title clinics. And then for a subset of those people, they’ll need more advanced care and you want them to go to the emergency department or research hospitals, but you want them to get there having informed the staff before they arrive so that they can be protected when the patient affects the door.
Now, I know in New York the supposition is that nearly everyone has coronavirus and that’s clearly an regrettable phenomenon. In the rest of the country, the frontline providers mainly be supposed that patients don’t have coronavirus. And so when individual patients punches the door, if they’re given the heads up that this patient is at risk for it, they can better protect themselves, they can be more on guard and avoid transmission further , not just to the healthcare workers but then to their families and the rest of the community.
NT: An amazing question came in that is so dark and contemptuous that I choose I had was just thinking about it myself. The question is about the business model of telemedicine. Clearly, one business framework is: I announce Caesar and health insurance bribes Caesar. Or I compensate Caesar directly, if you give me a consultation or some treatment. Somebody invited: Is there a business model where pharmaceutical companies can insert ads during a telemedicine consultation, is that something that has come up or that has already been seen?
CD: You know, Practice Fusion was a health tech startup that generated an electronic state be reported that doctors could use for free. But in exchange for that free application, they would show advertisements for pharmaceutical products. And that busines, unfortunately, I believe blurred the lines of ethics, and clear has get in trouble with what they’re done. There’s a recent penalty that the company intent up having to pay. I haven’t seen that same prototype in telemedicine and I hope I never do. The idea that you can monetize and profit from a doctor-patient relationship is frankly, flustering. And clearly it’s not at all within our business sit , nor in any of the current telemedicine companies’ business models that I’ve seen. I think that the industry hopefully has learned a big lesson from the rise and fall of Practice Fusion.
NT: So let’s talk about a concoction that has already been, which is the at-home coronavirus measure. You devised it, “youve had” some interesting technical course of doing it that wasn’t being to be undertaken by others. The FDA said, “Wait, you can’t do this right now.” You’re in the process of negotiating with the FDA. I won’t ask you to talk about that. But tell me how your measure made, what was different, and why it was optimized for personal at-home testing.
CD: So we had our first coronavirus case come into our clinics, or a highly suspicious coronavirus case, on January 23, so before all of this started to happen. And from day one, we mustered our busines to try to address the needs. We also realized that effective testing wasn’t available even to public health officials. So in retrospect , now that I’m reading more reports about it, we were regrettably not prepared for this pandemic, even though we had seen non-eu countries go through it. So the relevant recommendations was: Okay, we have a disease that’s highly transmissible that’s putting not only our healthcare workers at risk, but too using up all of our resources when it is necessary to personal protective gear( PPE) and also has put a lot of strain on the furnish series for really the basic testing components.Advertisement
We too realized that the test itself is frankly age-old. You know, when I was in college, I utilized the RT-PCR technique in my experiment exertions, and that was 25 years ago. So, again, going back to the first principles, what is it that we need to get accomplished? And what are the different ways that we can accomplish it?
The at-home test doesn’t rely on the usual supplying chain. So it squanders a different type of swab. And the idea of being able to administer the test within the patient’s house, where they’re not at risk of polluting others, was incredibly compelling to us. So we worked with our laboratory marriage to identify a workflow where patients who are at risk for coronavirus illnes would be evaluated by one of our doctors at scale. We can look at hundreds, if not thousands, if not tens of thousands of patients’ manifestations at the same time. And just like you’re analyzing something in a dashboard, you can identify who would benefit from an at-home test. And the doctor can go through those patient responses, require the tests appropriately, have the test delivered to the house, the patient then self-swabs–and the swab that we’re utilizing is actually a buccal mucosa, it is therefore makes saliva from within of the cheeks and the gums and patient would place it back into this tube and ship it back through the US Postal Service to our laboratory marriage for analysis. We would get those results in 24 to 72 hours, and then communicate to them again, and then initiate further video inspects with the patients who are positive. We can focus on societies that are being hit hardest, without having to introduced our healthcare workers at risk.
So we were working within FDA guidelines where reference is launched the test. We immediately stopped when the FDA modernized its guidelines around the testing, and are continuing to work with the FDA to obtain approval, because the officials have said publicly that they support the idea of dwelling testing. They want more data around it. And frankly, we’re hoping that between the FDA and the local governments in each state, that we can get this experiment approved because we know that it acts incredibly well compared to the standard that’s out there.
NT: How do you know that? I intend, you know that the test is effective because you’ve measured it. But you haven’t experimented the process where people actually have to placed it in the tube and put it in the Postal services, and they forgotten to articulated molds in it, or their kid positions a peanut butter and jelly sandwich on it, right? Like all the things that happen at home.
CD: That’s such a great point. And frankly, that clinical study hasn’t been done with the at-home test. But it hasn’t been done with any of the existing experiments in this pandemic. So when you ask your doctor, you’re going to run a nasopharyngeal–so you’re going to positioned a swab through my nose into the back of my throat–and you’re going to send it off to Labcorp or Quest, what’s the predisposition? How do I know how accurate this is? You won’t get a straight answer. And the reason is that clinical data don’t exist for any of these experiments. So the real world data doesn’t exist, whether it’s for the at-home test or for the commercially available testing.
We do know that, to your point, that the process of obtaining the DNA and coming an appropriate sample for the RT-PCR machine is highly effective and replicable. But how good are people at swabbing their own openings and noses and putting it in mail? We do have data that we’ve associate myself with the FDA. And so we’re optimistic that it is an effective way of doing it.Advertisement
NT: We have a good question here. What do you view as the biggest bottleneck in telemedicine that needs to be urgently resolved?
CD: So my concern , not only with telemedicine, but with healthcare in general, is that the regulatory network is an old one. So if you’re a doctor and you moved away from medical academy in the US, and you’ve gone to residency in the United Commonwealth, and New York State gives you a license to practice medicine, and then you need to practice medicine in Pennsylvania or Connecticut or New Jersey, you actually have to go through the same sometimes six, eight, or nine-month process to get approval to practice medicine that other state. It determines zero gumption. When you get on Metro North in Manhattan and you come out in Greenwich, your DNA doesn’t change, your body doesn’t deepen at all. You’re still a human being but the doctor that could treat you in New York can’t treat you in Connecticut. And that’s a number of problems. And telemedicine faces the exact same trouble, where a provider who is licensed in California can’t provide services in Idaho.
And I know there’s a concern about, for example, discussing patients in underserved communities or rural communities where healthcare providers don’t definitely live because there isn’t a population density that’s large enough. Well we need to take a step back and request ourselves, “What are these regulations good for? ” Is New York state that much better at figuring out whether I’m a good doctor than California is? Let’s identify the state in the country that’s the hardest to get acceptance in, and let’s say that if you get accepted in North Carolina, then you can be a doctor anywhere in the country. That’s what we’re looking for.
And having parity with the telemedicine trip, symbolizing if you’re find via telemedicine or in-clinic, insurance companies should pay roughly the same amount. I would say that is also an important impediment because currently, if you look at incentives for providers, it’s to ask the patient to come into the office because they won’t get paid otherwise.
NT: They get paid zero for a telemedicine consultation? Or they get paid half, they get paid a quarter?
CD: Yeah, it’s mood by district, and it’s insurance company by insurance company. So you have to read your plan to find out what your benefits are.
NT: But what’s the straddle? On average, it’s 10 percent, or on average it’s 92 percentage?
CD: I would say that, on average, it’s zero. Unless you have a specific kind of telemedicine clause in your benefits. And well, this is why what Trump said, you know, earlier today, which was, there’s now parity. You can be found in a Medicare patient who you’ve never seen before, so you haven’t established with that patient, “youre seeing” them and you can get paid for it. That was novel. But what does it do? Again, what are we trying to achieve here? What we’re trying to achieve is that a patient comes maintenance. If it’s appropriate for telemedicine, it’s appropriate for telemedicine. If it’s inappropriate for telemedicine, the doctor shouldn’t be providing that care through telemedicine. The payment ought to be secondary. And hitherto, we’ve gated it with the rules of procedure and with these guarantee contracts, and moods was beginning to, in 2018, say, “Well, we want parity between telemedicine and in-clinic visits.” However, there’s no stick to that. So the caveats were if you had an substantiated case, you are able to, next time, ensure them via telemedicine. You is necessary to do a video trip versus only an asynchronous see where individual patients crowds out their intelligence, the provider looks at it later on. There were all these subtleties to it, where in the practical world-wide, it didn’t fix telemedicine a viable option for numerous. And it incentivized physicians to say, “Oh, you want that prescription refill for the blood pressure medicine that you’ve been on for years? You have to come into the clinic for me to see you.” If you’ve been on the receiving point of that statement, you now know why. It’s because your provider is not incentivized to take care of you remotely and say, “I understand that it’s hard for you to come in to get that prescription refill. I know you need it. I’d like you to send me your recent blood pressure from the residence blood pressure monitor that you took the other day. And as long as it’s in compas, I’m going to refill your medicine.”Advertisement
NT: Ok, so I’m just going to restate for everyone in the audience that this is absolutely insane. If there are any congressmen, governors, legislative aides: If doctors do telemedicine consultations, the doctors should be paid. And I agree with Caesar, if I go to see you and you give me good suggestion about something that can be dried to telemedicine, you should be paid. If you try to instruct me on my own surgery with a assure, that’s unwarranted, you should not be paid. So I think that’s where we should be going.
We have a whole slew of really great questions. So one of them is: What about telemedicine in prisons? I’d like to broaden that out a little, but that’s an excellent question. Where are the populations, or catching fields, where telemedicine is particularly appropriate?
CD: So I repute the prison population is one that’s ripe for telemedicine. I work in an emergency department that’s very close to a district prison, as well as the province jail. I foresee too rural communities that may not have access to a dermatologist or a specialist–telemedicine is perfect for those arenas, specially when it is necessary to things like stroke attention. So most of the decisions made around stroke care can be done remotely. And it’s a service that can really change someone’s life.
So the prison population is a great example. The regional incarcerates will contract with medical groups that simply do confinement caution. And that’s a very limited amount of payment for mostly chronic editions, and they’ll send out to the regional emergency bureaux for the more acute issues.
If you know of local utilizes for telemedicine, and you’re wondering, why haven’t they been adopted, I would say look at the pay scheme, and look at the incentives for that structure and how money is allocated. And I guarantee you that there’s waste there. And it’s one of the frustrating parts of being in the field; you encounter a ton of waste, you receive an incredible amount of press around the cost of health care, and hitherto very few people are doing anything inventive around it, to be modified. There’s just too much money on the other side of that equation.
NT: I’m going to read something from a viewer. This is something I think you’re going to agree with because it delineates closely to something you just said. This is what Rich says, “I have been using telemedicine for 10 years. Regulations and lack of parity from payers are what’s been harbouring it back , not information and communication technologies. Can’t be used for everything , no. But patients adoration it and are not going to tolerate it will cease to exist after Covid-1 9. Payers need to pay for it ongoing, and regulations across position ways need to go away. My cases live in two states and travel all over. I should be able to help all of them via telemedicine , not just the commonwealth where I’m licensed.” Godspeed, Rich. Thank you for that excellent comment.
Now I want to go back to something “youve said”. You were talking about telemedicine in rural areas, which wreaks me to issues and questions from three spectators on a similar topic. And that is basically: In rural areas, there’s a need for telemedicine, but sometimes there isn’t broadband. What can you do?
CD: Well, I’m hoping 5G and the additional capabilities “il be there” eventually. So I know that the T-Mobile/ Sprint uniting happened partially on the basis of providing broadband to these rural communities. I’ve been able to time telemedicine consultations through my cell phone on a soccer orbit when there’s been an urgent condition that a patient needed to be seen for. So I think we’re less reliant on broadband issues than we were a few years ago.Advertisement
I would say also that there’s a subset of telemedicine called asynchronous telemedicine, where a patient can input some information about what they’re going through. So, for example: My age is 25, I’m female , no other medical problems, and I’m having burning when I urinate. What should I do? So you input that report as the patient, and medical doctors at some nonsynchronous day later on, speaks that information and says, “Sounds like you have a urinary tract infection, you should have an antibiotic sent to your pharmacy.” And does so. And that helps to not have the best broadband service but some sort of access to the internet. It allows your provider to see countless cases at the same time. And it’s exhibit located. It is about to change that in the clinical scenario I just “ve given you”, having a urine test and a urine culture doesn’t affect your management of the patient, as we once thought it did. And so it’s better for the patient because it gets them treatment before the illnes gets to their kidneys, and it’s better for the provider because now they can see more cases at the same time and do so efficiently. And then waste their epoch following up and apprise individual patients on their problem, rather than the administration of the healthcare.
NT: Okay, we have a question from Facebook: With Carbon Health telemedicine and Covid-1 9 testing, how much would it cost to get at-home tested once it’s approved by the FDA?
CD: That’s an stunning question. So I study I was pointed out that on January 23, we had our first patient in our clinics with what was suspected to be coronavirus. We had two patients, from Wuhan city, tachycardic and with fever. From that instant on, we rallied the entire firm, and part of rallying the company was: What can we contribute to this pandemic? And part of what we’re contributing is our doctor services for free, for the at-home test. So the only cost to cases will be the cost of the test itself and the shipping. And we’ve gotten the payments down to be around $ 167 for the at-home test. The sentiment is that if our politicians are being straightforward with us, and that these evaluations, which should be covered by insurance, the test will be free to patients, the doctor visit which Carbon Health stipulates, we won’t charge for.
And so we’re trying to do everything we can to do widespread testing to patients to follow the same trajectory as, you know, South Korea and Germany have done. We understand that payment is a problem. So we’ve prepare our contribution to the cause.
NT: Let’s look at your crystal ball about the future of telemedicine. As with many other things in the world, coronavirus has accelerated directions that existed before, like operating from dwelling and communicating via video discussion. Look into the future 5 year from now, I would imagine it’ll be much more telemedicine for certain kinds of treatment. I would imagine you would then need differently designed hospitals because you need less seat for consultations and maybe a higher percentage of infinite for invasive treatments. So you need to redesign infirmaries. I would imagine that there will be different kinds of physicians who will succeed and you know, a person who’s very good at telemedicine, is very good at communicating through Zoom and has good lighting, as you do Caesar, will have an advantage versus some of the soft skills you have for in-person consultations. I would imagine that the number of goes beings go to the hospital for no upshot will go down.What else is going to happen because of telemedicine?