We are looking forward to our way on location from the Ohio State University,

Wexner Medical Center, outpatient care at Lewis Center, Ohio.

This is Brett and with me, Carol. All right.

You know, this is a good time to ask, how are you since we're at a medical center?

Exactly.

Particularly with the person who's going to be with us today.

I need to let her know that I'm good, that

things are going well.

Brett and I am so excited.

You know, you have to maintain good health.

And today's guest is a very special person.

Stacey Kelly is a nurse practitioner at

the Ohio State University, Wexner Medical Center, Lewis Center, Outpatient Care.

She is also my nurse practitioner and she has a huge following of people.

I heard about her from other folks and that's how I got connected.

She's wonderful.

I told her I was going to embarrass her by telling everybody she has a four point

nine plus, plus, plus a lot of 5.0 rating scale.

But it's testament to the incredible care she provides many people.

Stacey, thank you for doing this and joining us today.

Thank you for that nice introduction.

Carolyn Bratten, thanks for having me today.

Sure.

You know, we've been talking about this telehealth and trying to figure out who do

we go to to talk to about it, because, you know, health has been difficult at the

most well, I should say at the least here during the pandemic.

But we often talk about the goals of this podcast program to it

to address issues and bring in experts and provide resources.

And we finally figured it out who we got to talk to.

So today we're going to address our

healthy living category as living with a pandemic all around us.

It's it's a top concern.

Stacy, we asked you to join us today as

the critical need of health care during this crazy time didn't stop for the

pandemic, probably got worse, quite frankly.

Let's first talk about your background and

experience as a nurse practitioner at one of the largest hospitals in the country.

Sure. So I come from a family of nurses, and

growing up, I helped to take care of my grandmother.

So I knew from a young age that I wanted to take care of other people.

During high school, I worked as a nurse's

aide at our local nursing home, and after I graduated high school, I went on to

attend my undergraduate program at the Ohio State University.

And during my studies there, I worked as a

patient care assistant on the bone marrow transplant unit at the James.

After graduating with my BSN, I accepted an arm position on the

bone marrow transplant unit and jumped into the Family Medicine Nurse

Practitioner Track at the Ohio State University.

I worked for three years as a nurse on the

transplant unit and after graduating with my master's in nursing, I then accepted a

nurse practitioner position on the bone marrow transplant unit.

So I worked there as a nurse practitioner

for two and a half years before making the major change.

I was ambulatory outpatient care in 2013

and my desire for that change really stemmed from wanting to help others in my

local community be the best versions of themselves.

I've been a practicing MP for the past ten years and I really feel blessed to work in

such a large organization where resources are readily available at my fingertips.

You really started that nurse practitioner early on in those then that program.

She did, yeah.

So I knew what I wanted to do.

I'm glad to have had the experience as a

floor nurse for those three years while I did my master's program.

I think it prepared me really well to do the advanced level of nursing.

Right, right. That's that's amazing.

So we before we started recording, we were

saying, you know, who ever even heard of telehealth? You know, before the pandemic,

it was sort of one of those out there kinds of programs

and now everybody's doing it. So let's talk about, you know, who is your typical

patient? Is it mostly older folks, moms and babies? Are there particular kinds of

illnesses that you're seeing more often? And do you usually suggest patients use

telehealth or do they make that choice on their own?

Sure.

So really, everybody is utilizing telehealth, young and old patients.

I would say generally patients in their teens through age fifty probably feel the

most comfortable with telehealth visits are conditions that we normally see over.

Telehealth services are mean.

A lot of mental health problems right now.

I think in the midst of the pandemic,

really, though, I've been utilizing telehealth for anxiety, depression, blood

pressure, check ins, diabetic medication management and acute illnesses,

particularly those with respiratory symptoms at this time.

So patients can choose on their own if

they would like a telehealth visit or an in-person visit.

However, we are not allowing patients with

any respiratory symptoms to be seen in person at this time.

But we do have a special location that those patients.

Can be assessed at if they've connected

with us via telehealth and we feel that they need an in-person evaluation,

some patients are more comfortable with telehealth given the pandemic, maybe their

high risk are they don't want to risk exposure.

A lot of college students are utilizing

telehealth since they're not living locally.

And on the other hand, some patients don't

prefer telehealth and want to be evaluated in person.

So we can always arrange that for them if they would like.

When you mentioned that issue about

college students hadn't even dawned on me about them.

I remember eons ago when I was in school and you didn't dare go to the student

health center, you weren't sure you were going to get out of there alive.

But, you know, and that meant, you know, Mom and dad had to make an appointment

around your school schedule, go and pick you up or you home.

What a great way to make. Take it.

Take care of that.

Yeah, I usually ah, I feel like prior to us utilizing telehealth, we would see

college kids only on holiday breaks like Christmas spring break and summer time.

But now it really has increased the access

to care for them because they can just connect with us on a video.

So I'm going to ask you a question kind of off on on a little bit of a tangent.

When you're having those successful telehealth, then do you feel like folks

are more and more comfortable so that they if they can do it, want if you can

convince them to do it once, they're going to come back?

Yeah, I have this sort of patient to get

connected with me on the video and they're like, oh my gosh, I did it.

I figured out a way to get on here with you.

And I was like, you don't worry.

You don't have to be nervous.

We can we can do this.

It's pretty easy.

So, yeah, I think once people dove in and

do it, they realize it's really not that hard to get connected and very cool.

Yeah.

You had referenced earlier about respiratory problems and making

accommodations for them. Has the medical center had to make changes in the

processes and procedures of telehealth in order to accommodate specific groups of

patients or something a little bit different than respiratory sulla?

So the medical center, of course, has had

to make a lot of accommodations and there's definitely been a

learning curve for all of us, which I think in the past year.

We've all gotten better at providing and utilizing telehealth services.

But initially our biggest barrier was with

our patients, where English was not their primary language.

So typically in the office we have a

device that's called Mardie that if somebody needs an interpreter, we dial

an interpreter who speaks their language and they are.

The machine is in the room with us with a

live interpreter on the machine that can kind of communicate between us.

But obviously we don't have this machine

when we're working from home, are doing telehealth visits.

So since then, those kinks have been pretty well worked out.

And we have figured out how to basically

do a three way call with an interpreter on the line with us.

There's an internal platform that OHSU

uses where patients connect via video with us to their minecart account.

But not everybody has my chart.

So we also had to figure out what do we do

for those patients who who don't have my chart account?

So we mainly utilize to private parties called up docs and Doximity

and nurse maintains confidentiality through a secure video chat.

But initially, as you can imagine, there were overload on all of these platforms.

Oh, I see my chart up docs Doximity

where it was creating all of these

connectivity problems with providers and patients because the servers were so

overloaded with how many how many people were actually on the server.

So since then, it's been improved greatly,

though, and it still remains difficult to perform telehealth visits for those with

hearing impairment unless a family member is there to help with that.

You know, we did some podcasting on

creativity of the arts during the pandemic.

I just think medicine and science have

gone gangbusters on being creative to make it work because you can't not continue to

take care of yourself whether you've got covid or not.

I mean, there are other things that have to be done right is really, really help.

That's wonderful.

You mentioned a little bit ago about somebody having a blood pressure check up.

You know what? What do people do?

How do you take care of those kinds of issues? And it's I mean, we all have a

thermometer, but we don't necessarily have a blood pressure gauge.

So there's it's definitely helpful to have

vital signs when you're doing a telehealth visit.

But if they don't have the equipment, we just can't determine.

You know, you can't determine what

somebody's blood pressure is without having a blood pressure cuff.

So

with telehealth, since we don't.

Always have their vital signs and there's no way to complete a full physical exam.

Sometimes it just might not be an

appropriate type of visit if the patient doesn't have the correct equipment like a

blood pressure monitor or something to check their blood glucose or a pulse

oximeter if they're feeling short of breath.

So those types of visits we would consider

a failed telehealth visit and then arrange in-person evaluation for them

for chronic disease management.

We allow telehealth for those who have

access to their own equipment, which most people who take blood pressure

medication or have a blood pressure monitor and diabetics have a glucometer.

So

can you use things like your smart, not smartwatch?

What are these things? The Apple Watch?

Yeah, the you know, the little sports thing that checks your steps.

Yeah.

So the apple watches and a lot of fitness trackers will give us a heart rate.

Some of them have EKG monitoring on there,

but it doesn't necessarily give you a blood pressure.

It doesn't give you a temperature.

It'll give you a pulse reading.

It won't give you a pulse.

Oxygen level, though, you're right.

It's useful for some things, but not everything.

So

I think in part, getting a good history is essential.

So we realize the limitations of telehealth.

But I'll give you this example.

I met with a patient last week who

connected with me for a shortness of breath and she thought

she was just having a bronchitis flare, which is pretty common for her.

But an unusual symptom she was

experiencing was leg pain are like swelling.

Sorry.

So I was immediately concerned about her symptoms and I ordered some blood tests

because I didn't have any vital signs available to me.

Like she didn't have a blood pressure cuff or a pulse oxygen,

a pulse oximeter.

So I ordered some labs and figured out she was in heart failure, actually.

So sent her to the emergency room and she got taken care of.

But I think even more so on telehealth when you're not able to physically examine

your patients in a way that you would be able to examine them in your clinic.

It's really important to get all of the details about about what's going on,

because you wouldn't want to treat that patient for bronchitis when she's

actually, you know, having a medical emergency and being able to see them is a

step up from only being able to talk to them on the phone, too.

Exactly.

So being able there are some things you can assess while seeing a patient.

Of course, you can't listen to the heart and lungs, but you can see if they're in

distress or have labored breathing or something like that.

So. All right.

So how do you prepare for each appointment?

You know, normally we see or you come in and you're checking a chart, looking at a

patient, especially looking at the patient, get the whole body view versus

the face and then able to talk to them to actually hear them a little bit better

than through a zoom in your your speaker on your computer.

What are the steps followed so that you

are providing complete health information in a very different setting.

So much of it is actually the same.

My medical assistant calls each patient before they are connecting with me on a

telehealth visit for one to make sure they know how to connect to the video chat, but

to to get their basic information like what's your reason for the visit if you

have any vital signs available, what are those vital signs?

And then they ask some general signs and symptoms that the patient might be having.

So after that, so I review what my medical assistant has documented.

I review the patient's history, their medications.

I start my note and then connect with the

patient either on their my chart or by sending them that secure video chat link.

Once connected, I get their history and examine what I can via the video visit,

and then I provide a diagnosis and treatment.

So like I said, much of it is the same.

A big differences in the way I give my patients instructions for a follow up or

for other testing maybe that I have ordered.

So my typical flow in the office as I order all these things and my medical

assistant kind of wraps it up nicely for me and tells my patients what to do next.

But I'm kind of responsible for that now

because I'm they're not talking to anybody else after they talk to me and they're not

stopping at my front desk to schedule their referrals.

So that's been changed a little bit

where I've had to get some phone numbers for specialists.

We create a lot of something called smart phrases where I can just pull in the phone

number to schedule with these specialists without having to memorize all of those

phone numbers, because there's just no way I could memorize all of that stuff.

So.

That's been the biggest change is really

the follow up instructions that we've been needing to give to give patients after

their visit, so when a patient is a little bit off of it, but it came to mind when

you were talking about this, when a patient normally has a relative or a

neighbor that comes in with them, is the technology have the ability to

bring a third party in if they're not there in the home with the patient.

So currently through the OHSU, my platform, there is not an option to add a

second color you can on our private party option.

So Doximity and uptakes, you can add other lines.

So if there were somebody like that who I knew had a need, who needed to have

somebody else on the line with them, I would just send them and their preferred

Shanly member both a link to the video chat in a private secure chat link.

Because a lot of older adults do that just because they want a second pair of ears

right here and could have a multitude of prescriptions.

And they don't remember write something down.

And, you know, and I think not have ever seen you as a patient, but I you're slow

enough and you, you know, make sure that they understand.

But a lot of docs aren't.

They're just kind of on schedule and they

got to keep moving and they don't pay attention that the patient didn't get it.

One thing recently, too, that's been gone

into effect, that kind of helps with some of that now is by law, we are required to

allow patients to see their medical record online.

So if I saw you for a visit and then I

complete I signed my note, when you are on your portable, you can read my note.

Actually, if we hide it from a patient for whatever reason, say we feel like the

information in the note is harmful for them to see for any reason.

Or maybe it's a minor who we are trying to maintain confidentiality from.

A parent say we would hide it, but you

have to document a reason why you are hiding the note.

So I think that in part helps with some of the instruction that we're giving, though,

too, because at the bottom of our note, we're writing our assessment or writing

our plan out so they can you can actually get on your

portal and see all of the notes moving forward, which is good.

You know, I have to give OHSU a big shout out, though.

My chart is phenomenal.

I mean, our our system and I haven't been on the systems on any of the other

hospitals in central Ohio, but there isn't much I can't find on my chart as it is.

Yeah, we really try to get patients

engaged in their and their own health care.

And I think part of that is being able to

see, you know, what's in your medical record and and asking us questions.

If you don't understand something or you don't understand the written instructions,

you have that opportunity to ask us questions.

Well, it's even it's if I want to know, when did I go to see Stacy last?

I need to make another appointment.

I can do it right there on my chart.

So it was hitting me this morning.

I have to get my eyes checked.

When was the last time?

You know, and there's no way to figure

that out unless I pull out last year's calendar or I call their office.

And this is just so much easier.

So this is a good Segway into my next question.

Most of us are used to just calling the office, make an appointment and show up

and do nothing to prepare ourselves to meet with you.

So in looking at the telehealth issues, I started looking at, you know, what

information does Ohio State give to to patients on telehealth, looked at some of

the other hospital systems and what they're doing.

What's your expectation?

What would you like to see a patient do

when they're getting ready to see you on telehealth?

Sure.

So it's always helpful if the patients are connected on their video visit on time.

So like we were talking before starting this podcast, it can be difficult to

to maintain such a strict schedule on the on the telehealth visits because all of

your patients are kind of waiting virtually for you and wondering where you

are because you don't see anybody, actually.

So that's always nice when patients are

connected at their time because it really helps the flow of your day

go much more smoothly and prevent some other upset patients later in the day.

Really, I guess my other expectations would be, you know, if if you are

connecting with me for a rash, I need to be able to see your rash.

It would be helpful if you're seeing me for for blood pressure on telehealth.

I should be able to check your blood pressure.

You should have equipment.

So I know what your blood pressure readings are.

Same with diabetes management.

I think if you're connecting with me for a mental health concern, you it might feel

uncomfortable, but you have to be willing to talk with me about that.

Sometimes patients kind of get shy or embarrassed and they just don't want to

talk about stuff, but you've got to got to talk about it.

So I'm going to go back to that medical emergency reference you made earlier.

And, you know, I you know, the patients have to be complete early.

We put in quotes truthful in answering their questions.

You're going to have to need the

individual to give you complete information.

I mean, if that your patient had not told

you about her leg pains, but only about her breathlessness,

she would have been in much worse scenario. So I is it a common concern?

I mean, I'm a guy I usually don't talk

about what's probably it'll go away, you know.

Exactly.

Do you see the complete or the truthful answer is not forthcoming? More so in this

scenario or maybe just as much as face to face?

I think overall we can understand maybe why patients would choose to be dishonest

or maybe not disclose certain information to us.

So you think,

you know, people get scared if they tell

us something is going on that maybe, you know, we might recommend something that

sounds scary to them or something that they don't want to do.

For example, people don't like to disclose the amount of alcohol that they drink or

that they use drugs or the amount of food that they eat or that they don't exercise

or take their medications like we prescribed or or maybe in a pandemic.

It's they're afraid to tell us about some

covid symptoms that they're having because they fear that we might be upset that

they're not social distancing or wearing masks or or something like that.

So I'm sure there have been plenty of

patients who have not told me the truth, and I've had no idea.

But I also feel like a fair amount of the time that we can kind of sense when

a patient is maybe not being so truthful with us.

So there's a few checks and balances.

One is there's a statewide database that

we are able to pull up and see all controlled substances that

patients are being described if we're concerned about

about any controlled substance abuse.

And the second is medication filling patterns.

So if I gave you six months of blood

pressure medication and it lasted you a whole year, I already kind of know that

there's a problem there with your medications.

Is this something that you're able to go into that database and know?

It's called the orders report.

And so this is a it's actually a national thing, which has been helpful with the

opioid crisis that is even going on here in central Ohio.

So it's a way for health care providers just to be knowledgeable

about what medications people are getting or using from pharmacies that are

controlled, meaning they have they're a high risk medication to be

addictive or habit forming.

So it's just a way to keep us all kind of

connected in uniform, in the prescribing patterns that we have.

So it's not a new database, but sometimes

people don't know that we can can see that information.

And it also includes medical marijuana on that report.

So so sometimes, you know, that information is helpful, but

we expect patients to disclose that information to us as well.

So really, if if I know that somebody is

being dishonest with me or I have a feeling that somebody's not answering my

questions thoroughly are completely I, I just try to have a heart to heart

conversation with them, let them know I'm not here to judge you.

I'm just here to help you, you know, be the best version of yourself.

I'm here to coach you, encourage you, keep you healthy or get you healthy.

And you deserve to have a health care

provider that you feel you can be open and honest with.

And if that's me, great.

Let's start working on that so I can help you.

And sometimes I'm surprised maybe somebody

isn't taking their medication because they can't afford it.

But they were embarrassed to tell me that some more.

And it really opens up the door for a conversation.

And usually there's a solution if I know that there is a problem.

So I might be able to prescribe a

different medication or refer them to my social worker, or they might be able to

qualify for our financial assistance program.

Or maybe I could fill out an application

so they could get their medication for free.

So I do feel like a healthy therapeutic relationship between the provider and

patient is essential for the overall care of the patient.

Wonderful.

You had mentioned that mental health is really an issue that that has come up.

Have there been other issues or syndromes that you've noticed?

I've noticed some of my friends

there, it's almost like they're a bit of hypochondria, but even more fear of

dealing with trying to come and see a health care professional.

Right. So like you mentioned, we've seen a major

spike in mental health problems since the beginning of the pandemic.

And it being an election year really didn't help us out any there.

So election years are always bad for

people suffering from anxiety and depression, but throw a pandemic and on

top of that, and people are barely getting by sometimes.

So telehealth isn't a great and valuable tool for managing anxiety and depression,

and it increases access to care substantially.

So people aren't needing to take four hours out of their day to come see me for

an appointment or able to take 20 to 30 minutes, connect with me on the video and

get the same service as they would if they were coming in the office to see me.

So if anything, to me it seems like

patients have had less medical needs, though, since

the beginning of the pandemic that require an in office evaluation.

So I'm not sure why exactly.

I think, like you had mentioned, a lot of people are just afraid to come out and

into the community and maybe not really sure about the whole telehealth thing.

So they just choose not maybe not to contact us with a concern.

You know, one of the things that I maybe we're taking better care of ourselves.

You know, I had for instance, they said there was like no flu.

I have not seen any flu yet this year.

And just think about how you would have been busy with the flu had we.

And it's not just the masks and the social distancing.

It's we haven't been going anyplace.

But I think in some ways, for me personally, I've tried to really take good

care of myself because, you know, you don't want to go home alone.

I didn't want to be sick with covid.

If you don't end up in the hospital, who wants to be home alone with that?

So, yeah, we haven't seen any flu this year.

Knock on wood. That's great.

Amazing. Yeah.

So good. Good for all of our listeners who have

done a good job of taking good care of them.

Yeah. Well, you know, that leads me to this

question. I mean, do you think telehealth has helped your patient stay well and stay

on track with their whether it's health care, maintenance or maybe even beyond?

So I really think telehealth can go either way.

Some people really love the ease and accessibility and they're happy to hop on

for a quick visit rather than taking a big chunk out of their day.

Others maybe don't have Internet access at home.

They don't have a smartphone or the technology to connect with us.

We still do some telephone visits if needed, although those are a little less

useful since we can't actually see the patient.

We have unfortunately had some patients,

though, who are so scared to seek out medical care

in the community or even go to the emergency room when it was recommended

to the point where they've we've unfortunately had some patients who have

passed away or died at home because they're afraid to go get medical care.

So I think that just really highlights the

need are the importance, really, of treating anxiety and depression.

It's nothing to be ashamed of.

It's a medical condition, just like high blood pressure or diabetes.

So if you're suffering from depression or anxiety, I would encourage you to connect

with your health care provider for treatment.

One of the things I noticed when I was

looking at where the instructions were for all of the different health care systems

is that there's information in there on how to find a hotspot.

You know, if you don't have the Internet

access at home, if nothing else, to be able to do your phone in your car, you

know, on a hot spot, on a hot spot on the various campuses, or I sort of was

laughing because they were saying one of the hot spots at issue is on west campus.

So you're literally a mile from the hospital, but you're sitting in your car

because you don't want to go to the hospital.

Right. OK, so.

Yeah, good. So.

So, Stacy,

it sounds like telehealth is here to stay.

Do you see this growing?

Do you think it'll come back or or pull back after covid?

And what can we do to help old, particularly

older adults dealing with the technology of telehealth?

So I think Telehouse here for good.

It's made access of care better than ever.

I think the question moving forward when

we're out of the pandemic is what will insurance companies allow or

what types of visits will they allow us to perform the telehealth?

So a lot of that may be dictated by

commercial insurance or so that's always a barrier,

which right now there during the pandemic, really the the.

Doors are kind of wide open and they're allowing us to do anything we want on

telehealth, but I don't think it'll be that way after the pandemic is over.

I would I would think insurance companies

would want it because it's got to be cheaper.

The billing is different, I think is cheaper, increases access to care.

So you would think in general your

patients would be getting better care via telehealth.

But

again, depending on the illness. Right.

And what has to be seen

right now, they may only allow it for a certain set of conditions like anxiety,

depression, mental health, diabetes, follow up, blood pressure, follow up.

But they may not necessarily allow it for

things like shortness of breath, chest pain, which

those types of people might need benefit better from an in-person evaluation.

So I think the elderly, though, remains a

challenging population when it comes to telehealth.

So I will say, though, most of the time I

feel like we are still successful in doing a telehealth visit.

However, a large portion of the time, they have a family member there to assist them

or else with three way calling them, which has been helpful.

So it seems to, for the most part, just work out even for our elderly patients.

Well, you know, the we've always talked

about the fact that that as you're getting older, transportation becomes more of an

issue, particularly when your family physician health care provider says, no,

you shouldn't be driving anymore and telehealth would take

care of that, if not eliminates that barrier, right?

Yeah. So exactly.

You covered the bases.

I mean, and it's funny, we were going over

questions in our mind about how do what do we ask in the insurance what the big

things like insurance is going to be the driver of this, whether how it remains

with us after we don't necessarily have to have it 100 percent like we do.

So I think you were right on with what we were thinking, too.

But it's just still an open door, right?

You know, it's in our future, we're going to see telehealth for quite a while.

I think it's not going to go away.

It's not going to go away.

Any good words of advice to folks who are listening?

They haven't done telehealth.

I would just try it.

It's a lot of people are so nervous when I get connected with them.

Sort of like I was nervous to talk to you guys today.

But I tell them it's it's not hard.

If you are not connected at your

appointment time, I will call you on the phone.

I will talk you through it and tell you how to get connected.

And if you can't get connected, I'll just

call you on the telephone and we can we can talk about what's going on.

So

it's not scary.

We're here to help you.

So if you need an appointment, just try it out.

Stacy, thank you. This has been wonderful.

We are welcome. We appreciate your time.