Dr. Ken Nischal discusses benefits and potential future advances of telemedicine

The use of telemedicine has become an important tool for both health care providers and patients during the COVID-19 pandemic.

Telemedicine visits skyrocketed across UPMC facilities because of the pandemic. UPMC Children’s Hospital of Pittsburgh went from about 500 video visits in January to more than 90,000 between April and August.

Ken Nischal, MD, chief, Division of Pediatric Ophthalmology, Strabismus, and Adult Motility and director of telemedicine at UPMC Children’s Hospital of Pittsburgh, discusses his view of telemedicine, its benefits, and potential for advances in the future.

Q: Before COVID-19, what was your view of telemedicine? How has COVID-19 changed that view?

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A: My view of telemedicine has always been that it was underutilized before COVID-19, mainly because people felt that they couldn’t provide the same quality of care when they were speaking to someone over a screen or evaluating them over a screen, which is reasonable.

I think the really important thing is that you have to understand that there are two types of doctors. There are those who are risk tolerant and those who are risk averse. For the doctors who are risk tolerant, their toleration of risk can be improved by giving them more data. For example, say you’re a dermatologist and you’re used to looking at skin to see where a rash is. If somebody takes a picture and sends it to you, you’re not taking much of a risk in making a diagnosis because that’s what you would normally do. But if, for example, you’re a cardiologist and you’re used to listening to somebody’s heart and you can’t do that, of course you’re taking a massive risk now.

Imagine if I am a risk-averse ophthalmologist, and I can’t work out the exact vision my patient has in each eye. That’s going to make me very uncomfortable. But if I am risk tolerant, I’m going to say to the patient, “Cover up one eye, cover up the other eye — does anything look different? Do you think your vision has changed?” And you can then cajole, if you like, the fact that everything probably is stable. But you’re not 100% sure. You’re taking that risk.

During COVID-19, the urgency of knowing that you might not be seeing your patient for months — and the fact that, to some extent, there was this question of economic survival — that crushed the risk aversion in many doctors. The fear of not seeing your patient for a long time allowed doctors to be much more risk-tolerant.

As we come out of COVID-19 and people can come back to see doctors in person, the risk aversion is likely to come back. Now we create remote testing sites so patients can go in the evening and get their tests done. Then I can do a remote visit and counsel the patient with all the data in front of me. You have to change the paradigm of how you work.

Q: How do your colleagues view telemedicine? Do you think there’s a universal view?

A: The universal view of telemedicine has changed. Doctors realize that it wasn’t actually as awful as they thought; they also see that their Press Ganey (patient satisfaction) scores have shot up through the roof. People love being able to spend five, 10, 15 minutes facing their doctor and talking to them from their home. They love the convenience. So I think that doctors need to balance how the get the data they need to do a thorough evaluation of the patient against fully understanding the convenience and satisfaction that the patient feels.

Q: How do you think patients felt about telemedicine at the start of COVID-19, and how has that changed?

A: One of the things that made it really easy for patients was the lifting of the security, the HIPAA issues. People love using FaceTime. They love these other platforms. They’re easy to use. As we’ve recognized that they like the ease and convenience of use, the platforms that we use have become easier to use as well.

I think parents like it. I don’t think they always understand that it’s not a full exam. I often have parents saying, “This is great. It’s so much easier than coming in,” and I go, “Well, actually, you do need to come in because there’s one thing I need to see that we don’t have, and we need to see you for that.” But they understand that.

Q: How has telemedicine changed during COVID-19?

A: I think people are more willing to use digital apps to evaluate themselves. They’re much more open to doing that. People are willing to pay $5 for an app, which they probably weren’t willing to do previously.

Telemedicine has also changed because there are so many platforms now that provide a video/audio link. Before, there was a handful; now there’s a myriad that you can use. I think the access has improved, and people’s willingness to use “digiceuticals,” as we like to call them now, has improved.

Q: What is the biggest benefit to telemedicine from a patient’s standpoint?

A: I think there is a general improvement in the awareness that patients and parents of patients can evaluate themselves or their child to see how things are going. They can do it more regularly. Parents and patients are more aware of their ability to help themselves.

Q: Are there any drawbacks or gaps in telemedicine?

A: The quality of the video that you have is not always good in a parent’s home, and it’s often because they think they can do the telemedicine on cellular. Or they don’t realize that the bandwidth of the wi-fi is affected because so many other people in the house are using it. That is an issue. But that’s an education issue, right? We have to educate our parents better.

Q: Are there things you just can’t cover in a telemedicine visit?

A: There are. For example, if you have glaucoma, which is when the pressure in your eye is raised, I cannot measure that over a screen. Now, you could go and have your pressure measured by a local optometrist local and then let me know what that is. That would maybe stop you from driving a long distance to see me. But I can’t do that over the screen.

Q: What changes or improvements would you like to see in telemedicine?

A: There are two paths to telemedicine. There’s the provider, and there’s the patient. First, we have got to make the provider’s job plan take into account that regular telemedicine slots are a much better way of working than interspersing telemedicine with in-person visits. So we need a a shift in the job paradigm for providers. Second, we need to get patients to accept more digital apps that assess what they’re doing to help the doctor. Ideally, I’d like to have that information stream directly into their EMR (electronic medical record) so when I open it, I get a graphic about what their blood pressure is doing or what their nutrition is like. That’s the kind of thing I’d like. I’d like more of an artificial intelligence (AI )application of the digital apps that we have.

I’d also like more doctors, more providers, more physician assistants (PAs), more nurses to think about what app could help them provide better care. And I’m not just talking about outside the hospital. I’d like a nurse in ICU to have the ability to send me information and say, “Can you have a look at the EMR? This is in real-time, so what should I do?” rather than me running across the hospital. It’s so much faster, so much more convenient.

Q: What do you think the future of telemedicine looks like?

A: I think the future of telemedicine will be literally — I know this sounds very George Orwellian — something we put underneath the skin that will tell us the oxygenation level of a patient’s blood, as well as their pulse rate and temperature. We will be able to detect when people are at risk for heart attack just from their biodata. Now, I don’t know if people want to go down that route, but that’s what we can do. Maybe we’ll have contact lenses for people with glaucoma that will tell us what their eye pressure is. And through that contact lens, when we see that the pressure is high, I’ll be able to program a drug that brings the pressure down.

That’s not possible now; it’s in the realm of reality. The question is how much of our information do we want to give up to a third party.

Q: Do you see the use of telemedicine continuing to increase?

A: Yes. I think the use of it will continue to rise. I think it’s a good thing for schoolchildren and adolescents with mental health and reproductive health issues who don’t want their parents to know. They can do a one-to-one with a provider. We may be able to save a lot of lives. Mental health is a really serious issue in terms of depression and suicide in teens across the country. Telemedicine is instant access for someone who’s too shy to be able to talk or walk into a clinic.

Q: How do you think UPMC Children’s has adapted to telemedicine over the years, especially during COVID-19?

A: We did 500 total telemedicine visits in January; between April and the end of August, we did 92,000. We’ve adapted. We’re changing the way we do things to make digital health a top priority for 2025. I’ve been tasked to make UPMC Children’s Hospital of Pittsburgh No. 1 in the digital health space for pediatrics by 2025.

There’s telemedicine, there’s tele-education for both the parent, the patient, and the doctors.

We’re developing a wayfinding app so that two days before your appointment, you’ll be reminded you have an appointment. Depending on where you live (the app will know how far you live from the hospital), that app will say, “The traffic conditions are bad — you need to leave now to be on time.” When you get here, and the app will tell you where the parking spaces are. As you walk along, it’ll tell you where you can get refreshments. If your appointment is running late, it’ll tell you your appointment is running late. We have the capability to do this. That’s what we’re investing our money in — to make the patient experience seamless. We’re a virtual hospital.

About Pediatrics

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