Telemedicine Champion Dr. Peter Yellowlees Discusses Impact of Telehealth on Access to Care

Peter Yellowlees – President - Elect of the American Telemedicine Association

Mark Masselli: This is Conversation on Healthcare, I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well, Margaret, after several months of hand wringing and
political posturing, the efforts to repeal and replace the Aff ordable Care Act came
up short in Congress. The Republican American Healthcare Act never made it to
the House floor. Some analysts are calling this a stunning defeat for the GOP
and the President, all of whom promised to repeal and replace ObamaCare with
something better.

Margaret Flinter: Well, there was groundswell of opposition to the replacement
legislation, particularly when the Congressional Budget Office predicted the GOP
law would not only cost many consumers more money, but would lead to 24
mil lion Americans losing their health coverage. The bill’s author House speaker
Paul Ryan admitted defeat saying apparently ObamaCare would be the law of
the land for the foreseeable future.

Mark Masselli: There will still be healthcare legislation requiri ng budgetary
approval and that’s an area, where a simple majority is needed at the Senate, so
I think this isn’t the last we’ve heard on health reform.

Margaret Flinter: But, you know there are areas of healthcare that are
transforming outside the scope of policy makers and legislation. Areas that we
think are poised to have improved access to care and outcomes of care across
many sectors of healthcare and one of those very promising areas is certainly
telehealth or telemedicine.

Mark Masselli: Our gue st today, Peter Yellowlees, President elect of the
American Telemedicine Association, really looking forward to that conversation
Margaret.

Margaret Flinter : And Lori Robertson will be checking in , the Ma naging Editor of
FactCheck.org. She is always on the look out for misstatements made about
health policy in the public domain and no matter what the topic, you can hear all
of our shows by going to www.chcradio.com .

Mark Masselli : And as always if you have commen ts, please email us at
[email protected] or find us on Facebook or Twitter , we love hearing
from you.

Margaret Flinter: We’ll get you our interview with Dr. Peter Yellowlees in just a
moment.

Mark Massell i: But first, here is our producer Marianne O’Hare with this week’s
Headline News.

Peter Yellowlees – President - Elect of the American Telemedicine Association

Marianne O’Hare: I am Marianne O’Hare with these Healthcare Headlines. The
swift death of the American Healthcare Act still leaves many questions in its
wake; chief amon g them, what comes next? House speaker Paul Ryan said it is
the law of the land for the foreseeable future, but some calls for bipartisanship
are starting to rise to the surface. Republican Senator Susan Collins of Maine
says the collapse of the GOP Heal th Bill actually paves the way now for some
t rue bipartisan solution making. S he was among the vocal minority of Senate
Republicans, who were opposed to the intent of the American Healthcare Act,
which would have removed many consumer protections and wou ld have led to
the loss of insurance coverage for an estimated 24 million Americans. She said
more Democrats may feel free to come to the table. The Human papillomavirus
is responsible for 6 million cancer in adults and the HPV vaccine is the only
known hedge against catching the virus, but still a relatively low percentage of
teenage girls and boys are getting the recommended dose of three vaccinations
spread out from age 9 to age 14. Now, a study shows the most current format of
vaccine, Gardasil 9, on ly required two doses in the same age group. The
vaccine protects against 9 types of HPV, ones that are responsible for over 90%
of cervical cancer or variety of cancers and other parts of the body connected to
sexual contact. In 2015 only, about 30% of teen girls have been properly
vaccinated and 25% of the boys. There are almost 40 thousand HPV related
cancers diagnosed per year and that number will be significantly reduced with
proper vaccination. I am Marianne O’Hare with these Healthcare Headlines.

Mark Masselli: We are speaking today with Dr. Peter Yellowlees , Professor of
Clinical Psychiatry at the Department of Psychiatry and Behavioral Health
Sciences and Vice Chair of Faculty Development at the University of California
Davis. Dr. Yellowlees serves the National Academy of Sciences Review
Committee, evaluating mental health services at the Veterans Administration. He
is President elect of the American Telemedicine Association, the leading
international organization promoting the use of remote medicine technologies in
healthcare. He has written over 200 peer review articles. He earned his medical
degree in Behavioral Science at the Royal Free Hospital School of Medicine.
Dr. Yellowlees, welcome to Conversations on Healthcare.

Peter Yellowlee s : Thank you very much. It is real pleasure to be here.

Mark Masselli: You know, over the past few years there has been significant in
the interest and uptake of telehealth and telemedicine in the United States and
before coming to the United States, y ou spent your early year career practicing
psychiatric medicine in Australia. Wonder if you could tell our listeners your early
experience utilizing telemedicine and help us understand the scope and potential
of telehealth in the United States.

Peter Yel lowlees : Sure, I mean I was living in Australia for a number of years
and at once stage lived in the Outback . I am a psychiatrist by training and the

Peter Yellowlees – President - Elect of the American Telemedicine Association

area that I was responsible for was the actually the same land mass as
California. So imagine this one psychiatrist for the whole of California; that
meant that I spent a lot of time on airplanes to do clinics. I got very used to using
the telephone to speak to sort of suicidal people and so I got interested in
telemedicine and remote technology is really from a clinical point of view, I just
had a problem. I couldn’t manage the whole area all by myself. You might be
interested to know, how much you had to pay for the first video conferencing
machines that I brought back in about 1990. You know they were actually 170
dollars.

Mark Masselli: Oh my gosh.

Margaret Flinter: We remember those 300 dollar calls.

Peter Yellowlees : Right, exactly. It was just incredible, so it was never going to
be economically viable in those days, but it was very interest ing from a research
point of view and I guess that what’s driven over the years to try and demonstrate
how effectively you can use these technologies. I mean the difference is n o w, it
is just you know dramatic and really technology is no longer a problem. You
know, you could more on your phone, when you could on those early systems
that I spent enormous amount of money on. There’s been also a huge change in
attitudes, particularly with the younger generation. People under 30, you know,
we typically thin k of as being digital natives. You have never lived without the
Internet and to have different expectations of being able to get information
immediately whereas, you know, people in my generation in reality, what we call
digital immigrants, so now that ju st leaves us with a different set of attitudes
unfortunately and then people would use to think of telemedicine or using these
technologies as being an eye of a choice situation and the reality of life is that
increasing numbers of patients are being seen in a hybrid manner. You know
they sometimes see their doctor in person, they sometimes see them online, and
essentially with doctor - patient relationship nowadays, you know with the help of
technology has become a much more fluid and quintessentially bette r
relationship.

Margaret Flinter: Well, Dr. Yellowlees, UC Davis has been a leader in the use of
telemedicine, I think having utilized some form of telehealth since 1992 and your
department at UC Davis has just released a longitudinal analysis of outcome
data, that’s called from almost 20 years and looks at everything from improved
patient access to care, what did the study reveal in terms of improved access
and also cost savings?

Peter Yellowlees : The two biggest disciplines that we have using it are a ctually
psychiatry and dermatology. We also do quite a lot of emergency medicine,
particularly in the child area, pediatrics and professor Jim Matson, who is the
leader author on this study and he is a pediatrician, so what essentially Dr.
Matson did was to just review 20 years worth of consultations and he looked at

Peter Yellowlees – President - Elect of the American Telemedicine Association

the disciplines involved and you know what we found is that clearly access has
improved. The clinical outcomes for the individual patients that we have seen
generally are at least as good as if they were seen in person, but they tend to
have less hospitalizations and that’s actually where the savings are in
telemedicine and if you look at our results and also the results from a number of
studies from the VA, what you find is that because you c an access patients often
earlier in their illness, you get savings through less emergency visits and less
hospitalizations and then the other formal thing that Dr. Matson did was to look at
carbon emissions that has been reduced through the use telemedicin e and this is
a very important issue and it is something that at national level, the American
Telemedicine Association is going to taking up. It was clearly, if we could in fact
have less travel in medicine by using more telemedicine, more remote
monitori ng, then we will absolutely reduce the amount of carbon that goes into
the environment and thereby slow climate change.

Mark Masselli: So your experience is a little different, may be you can tell us are
there other randomized clinical trials going on to sort of look at the cost benefit
analysis that clearly everybody would want to see in what look like a better way
to deliver redesigned part of the delivery system.

Peter Yellowlees : Yes, I think if in fact you look more broadly at savings and you
look at the savings made by both patients and providers, then in fact you find
telemedicine incredibly efficient, because I mean, you know yourself, it’s common
to have to take a half day off work to go and see your doctor. If you could in fact
just log in fro m your work and see your doctor in a sort of half - hour slot, you
would save an enormous amount of time and potential money and time at work,
so I think we have to look broadly at the savings you make through these
technologies and if you include patients i n the actual equation, then the savings
become really, really impressive.

Margaret Flinter: Well, Dr. Yellowlees, you’ve also spent some considerable
time, I think focusing on the efficacy of asynchronous telepsychiatry, utilizing, I
understand, taped in terviews with patients and then sharing them with the
psychiatrist and I understand that’s a took that you’ve used for sometime in your
own practice. What’s different about this approach from other approaches in
telemedicine?

Peter Yellowlees : For many years in psychiatry, we have done what we call
curbside consultation , so that a primary care doctor will ring a psychiatrist, you
know have may be a 2 - to - 4 minute conversation with that person, the psychiatrist
will give him an opinion, all we are doing wi th the asynchronous telepsychiatry is
saying that’s a great model to use, but the one that we actually record the
patient, and instead of me just ringing you about the patient, I can actually send
you a recording of the patient. You can get to see what th ey look like, you can
get to see how they answer questions, and then you can give me an opinion. It’s
really very simple. We’ve seen many hundreds of patients like this now. We’ve

Peter Yellowlees – President - Elect of the American Telemedicine Association

done a number of studies showing that you could be just as accurate
diagn ostically. We are not obviously providing therapy like this. We are able to
however to monitor people and we’ve been doing a study recently looking at
several hundred patients, who have chronic medical and psychiatric illnesses
and we are doing these asy nchronous consultations every six months to
basically help the primary care doc with overall management of that patient.

Mark Masselli: We are s peaking today with Dr. Peter Yellowlees, President elect
of the American Telemedicine Association, Professor o f Clinical Psychiatry at the
Department of Psychiatry and Behavioral Health Sciences at the University of
California Davis. Dr. Yellowlees serves on the National Academy of Science
Review Committee evaluating mental health services at the Veterans
Adminis tration. I would really like to talk a little bit about the VA, obviously it’s
been struggling to improve timely access and health outcome for American Vets
and given that you are serving in an advisory capacity, what are you sharing from
your own persona l and clinical experience that you believe will help improve
access, as well as outcomes?

Peter Yellowlees : Sure, the VA is actually the world leader in telemedicine as an
organization. They have been amazing. They’ve done a lot of work in this area
in multiple different specialties and my own discipline, for instance of mental
health, they did something like half a million consultations in the last year and
they’ve done some very nice research showing that these consultations are
highly cost effective as I mentioned earlier on, mainly because patients tend to
get admitted to hospital less frequently and what I think the VA needs to do in
reality is to expand that use of telemedicine even more. If you look at
posttraumatic stress disorder, for instance, as an illness, the nature of the illness
is that people tend to be avoidant. They tend to prefer not to have to go out and
deal with perhaps the local hospital or the local bureaucracy and there is a lot of
evidence, in fact, that if you can video confer ence or connect with Veterans in
their homes, that you can actually provide better care using technologies than
you can in person and you get better results. There has been several very good
studies of PTSD showing actually more engagement of Veterans in treatment,
and particularly in psychotherapy, so this has been some really interesting
studies that the VA has done that really, I guess, paves the way for what I hope
will be a substantial increase in that use of these types of treatment modalities.

Marg aret Flinter: Well, Dr. Yellowlees, I understand you have a very keen
interest in online learning and it is game changing potential in medical training.
How do you see it potentially shifting paradigm of health profession training in the
coming years?

P eter Yellowlees : Sure, I think, one of the things that we have really learnt is that
in particular the younger generations really do see the world and interact with the
world very differently from people of my generation, who are typically the
teachers an d so you know, we need to connect with them. We need to work in a

Peter Yellowlees – President - Elect of the American Telemedicine Association

way that they prefer to work and they are used to working. We need to, you
know, essentially move away from the tradition of sort of hour - long lectures and
you know the sort of non - interac tive approach, so almost a passive dependent
approach of traditional education and become much more experiential, much
more interactive and provide information in shorter amounts, but in a very
concentrated and focused way, so we are developing all sorts o f, you know,
literally bytes of information. For instance, I’ve been working with Med s cape for
the last eight years now to produce the Med s cape Psychiatry Minute, which is,
you know, available for training. There are something like 160 of those
Medscape Psychiatry Minutes available on the web now, none of which are more
than 2 minutes long, but all of which focus on a very specific paper and then
some comments and editorial fills that I have about that particular paper and they
are clearly able to reach a n enormous audience very much more than you can
possibly reach in the traditional approach, teaching in a lecture theater. So I
think, we’ve got to really think very carefully about essentially our consumers of
information in healthcare and the consumers basically want online information,
they want it just in time when they need it now and they want it, you know, in a
visual way.

Mark Masselli: Dr. Yellowlees, obviously there are lots of changes going on in
the American healthcare system. The American T elemedicine Association
probably found some wind in it’s sails under the Affordable Care Act in terms of
advancing your cause, I am wondering what your agenda is for your organization
as it seeks to advance in this new political environment, more access an d better
reimbursement for telemedicine, what’s the agenda look like?

Peter Yellowlees: Sure, I think this is a really important issue and telemedicine, I
think in reality is actually supported by both sides of the political spectrum. The
beauty of it q uite honestly is that it increases the efficiency of the healthcare
system and it is particularly likely to be successful in an environment where there
are sort of capitative payments, so where you pay for services over time and
that’s very much a duration that the essences of Medicare have been going in.
You know, we don’t know if that’s going to change, but you know the general
approach from certainly both Federal and the State regulators is to start trying to
pay full care over periods of time and it is in that environment that telemedicine is
really valuable and so the ATA is very positive about the political climate overall
and akin to progress these discussions.

Margaret Flinter: Well, Dr. Yellowlees, you have said that things like Google
Glass and Mobile Health are you know potentially poised to really transform the
patient - provider experience by adding real time data and health monitoring to a
patient’s profile and then may be just talk with us a minute about some of the
more promising technologica l advances that are supporting the growth of
telehealth and are there are any clear technological hurdles that you think we
have yet to overcome.

Peter Yellowlees – President - Elect of the American Telemedicine Association

Peter Yellowlees: Well, I think the best way to answering this is to think about
two examples of slightly mo re futuristic projects that I’ve been involved in, in the
last few years and the first is one that is being run out of my own lab and that’s
when we are looking at automating the process of translation, language
translation and I think that’s really import ant. We know that people who don’t
have English as a natural first language do worse in the healthcare system
despite you know all of the attempts of the many interpreters that we use, they
spend longer in the hospital, they get less good care and so we a re working on
essentially developing automated translation systems that will allow you to
interview and record patients and have that immediately spun back, you know, in
real time, essentially in any other language you choose, so that you can you
know take a patient who speaks Hmong, have that interview immediately
reviewed by may be an English speaking physician, so I think that’s one area that
is potentially enormous and that can be done both in person with patients,
perhaps, our, you know, iPads or phone s or you know Google Glass type
devices or it can be done, you know, on video at a distance, so and I think you’ll
find that within a few years, we’ll be using those systems pretty routinely. The
second one is, you know, is more way out than that and that is the potential to
use to say virtual reality. There’s been a lot of studies looking at that and
medicine generally and essentially creating avatars for both patients and
providers and then getting them to meet in the Cloud, but there is some
fascinatin g studies that are being done at USC at the moment in Los Angeles,
where they had actually developed a whole series of avatar providers, so if for
instance, you know, you have depressional PTSD, you can literally log on and
you can speak to a you know a th erapist, who is, and the therapist is an avatar
that is basically trained to respond to your questions and your movements in
certain ways that are hopefully helpful. Now, we are certainly not there yet with
automated providers, but I think that’s down the track.

Mark Masselli: We’ve been speaking today with Dr. Peter Yellowlees, President
elect of the American Telemedicine Association, Professor of Clinical Psychiatry
and Vice Chair of Faculty Development at the University of California Davis. You
can l earn more about his work by going to ucdavis.edu/medical
center/peteryellowlees - psychiatry or you can follow him on
twitter@peteryellowlees and you can also follow the American Telemedicine
Association at Americantelemed. Dr. Yellowlees, thank you so much for joining
us on Conversations on Healthcare Today.

Peter Yellowlees: Thank you very much indeed, both Mark and Margaret, it has
been most interesting and I appreciate your time.

Mark Masselli: At Conversations on Healthcare we want our audience to b e truly
in the know when it comes to the facts about healthcare reform and policy, Lori
Robertson is an award - winning journalist and Managing Editor of FactCheck.org,
a non - partisan, nonprofit consumer advocate for voters that aim to reduce the
level of de ception in U.S. politics. Lori, what have you got for us this week?

Peter Yellowlees – President - Elect of the American Telemedicine Association

Lori Robertson: Both democrats and Republicans have been spinning the
Congressional Budget Office’s analysis of the Republican Healthcare Bill. The
White House Budget Director oversold what the CBO said about the bill’s impact
no premiums. Mick Mulvaney, the Director of the White House Office of
Management Budget said the CBO report confirmed the GOP philosophy that a
free market would reduce premiums. Mulvaney said “CBO says that pre miums
will go down by at least 10% with this plan. Premiums on the nongroup market
where individuals buy their own insurance will not go down from what they are
right now. They will just be lower than what they would be under the Affordable
Care Act on a verage by 2026.” Also, Mulvaney ignores two important points.
Average premiums would increase in the first two years and older Americans
would see substantial increases in the short and long run. The CBO report says
that in 2018 and 2019, average premiu ms on the nongroup market would be 15%
to 20% higher than under current law for a single person’s policy . For older
Americans, the GOP Plan would allow insurers to charge them up to five times
as much as younger people. Under the ACA, the ratio was 3:1. CBO said that
would lead to premium for a 64 - year - old that would be 20% to 25% higher by
2026. The GOP plan changes the current income based tax credit for those
buying their own insurance to age - based tax credit, but CBO said those wouldn’t
be large eno ugh to offset the premium increases for older Americans and that’s
my FactCheck for this week. I am Lori Robertson, Managing Editor of
FactCheck.org.

Margaret Flinter: FactCheck .org is committed to factual accuracy from the
country’s major political pla yers and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you would like
checked, email us at www.chcradio.com , we will have FactCheck.org, Lori
Robertson , check it out for you, here on Conversations on Healthcare.

Mark Masselli : Ea ch week conversations highlights a bright idea about how to
make wellness a part of our communities into everyday lives. Pregnancy is
normally an exciting time for most women, but according to the research, an
estimated 10% of prenatal women experience some kind of depression during
their pregnancy and many are reluctant to treat their depression with medication
for fear of harming the fetus.

Dr. Cynthia Battle: In fact a hig her percentage are experiencing lower grade
depressive symptoms, so they might not meet full criteria for major depressive
episode and left untreated those mild - to - moderate symptoms can progress, in
some cases lead to a more serious postpartum depression.

Mark Masselli: Dr. Cynthia Battle is a psychologist at Brown University with a
practice at Women’s and Infant’s Hospital in Providence. She and her
colleagues decided to test a cohort of pregnant women to see if a targeted

Peter Yellowlees – President - Elect of the American Telemedicine Association

prenatal yoga class, which com bines exercise with mindfulness techniques might
have a positive impact on women dealing with prenatal depression.

Dr. Cynthia Battle : It was a typical kind of Hatha yoga that would include
physical postures, meditation, exercises, and we enrolled 34 wom en, who were
pregnant, who had clinical levels of depression and we measured their change in
depressive symptoms over that period of time.

Mark Masselli : Not only were women able to manage their depressive incidence,
they also bonded with other pregnant women during the program and found
additional support from their group.

Dr. Cynthia Battle: Women who are depressed during pregnancy unfortunately
do often have less ideal birth outcomes, so one thing we are interested in seeing
is when we provide prenat al yoga program, can it improve mood and then can
we even see some positive effects in terms of the birth outcome.

Mark Masselli : A guided, non - medical yoga exercise program designed to assist
pregnant women through depression symptoms without medication ensuring a
safer pregnancy and a healthier outcome for mother and baby . Now, that’s a
bright idea.

Margaret Flinter: This is Conversations on Healthcare, I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli, peace and health.

Conversations o n Healthcare broadcast from the campus of WESU at Wesleyan
University , streaming live at wesufm.org and brought to you by the community
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