Telehealth Best Practices: Vikram Savkar of Wolters Kluwer On How To Best Care For Your Patients When They Are Not Physically In Front Of You

Take advantage of what many in the space are starting to call “digital therapeutics.” There are so many tools in the market now that can monitor patients’ glucose levels or medication levels, and so on. These tools must be vetted carefully by clinicians as they are still new and likely will be regulated, but the reliable ones can make a huge difference in patients’ lives. Instead of having to take a day off of work or find childcare in order to have their readings checked by their doctors, patients can have their information sent automatically.

One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?

In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing Vikram Savkar.

Vikram Savkar is the vice president and general manager of the medical segment at Wolters Kluwer’s Health Learning, Research, and Practice business. In this role, Vikram is responsible for driving innovation in Wolters Kluwer’s key product lines in medical research, medical publishing, and medical education, including a recently launched product suite in telehealth consulting.

Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?

Like many people who work in business, I switched stories midstream. At one point in my life, I was focused on becoming a physicist. I had a real passion for math and theoretical physics and was fortunate to study under some of the groundbreaking physicists of the second half of the twentieth century. But as I got close to the moment when I’d have to commit to physics at a graduate level, I realized that for a variety of reasons I’d be happier in industry than on the academic side. After a few really interesting intervening roles (that’s another story) I started my career in the information industry, focusing initially on science and math but broadening out over time to several other areas. Each role gave me good opportunities to stretch myself and take on more responsibility, and for the last several years, I’ve been running businesses in fields that range from life sciences to law to, now, healthcare and medicine. I’m really thrilled to be working in the healthcare space now because it’s so core to our societies and our lives, never more so than during this pandemic.

Can you share the most interesting story that happened to you since you began your career?

One of the people who originally inspired me to study advanced mathematics and physics was Benoit Mandelbrot, the French-American mathematician who was a pioneer in fractal geometry and helped spawn chaos theory. I spent a lot of time in high school working on what are called “Mandelbrot sets” on an ETA supercomputer my high school happened to own (that’s another story, and yes, I recognize this is a nerdy anecdote). I would have loved to have met him in those days, but that never happened. Fast forward years later, well into my business career, I found myself running the global science education division for Nature Publishing Group, the publisher of Nature magazine and other prestigious science journals. One day, in the course of business, I was set up for a dinner meeting to discuss a collaboration with one of NPG’s most prestigious authors . . . Benoit Mandelbrot. My wife and I had a lovely dinner in Cambridge, Mass. with his wife and him. I had gone into business believing I was leaving physics and math behind, but then business led me back to some of the people I had admired most when I was young. He has passed now, but I still treasure the memory.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

One of my favorite proverbs is “a stitch in time saves nine.” It refers to mending clothes: it’s better to fix a small rip in your jeans today, which will take five minutes and a few stitches, than to ignore it today and watch it develop over time into an enormous rip, which will take hours and many stitches to repair. I think of the phrase often and it’s had a significant impact on my life. In business, it means I try to think structurally, architecturally, systemically, and with an eye to the future right from the beginning of any strategy or initiative, rather than pursuing easy success now and then worrying about how to scale it later. This does mean you have to push yourself and your team to think through business ventures in extremely thorough ways upfront and there’s some overhead involved in that; but I’m a believer that you’ll thank yourself years from now for doing it, when the business is going smoothly, and you don’t need to spend ten times the overhead to fix whatever strategy debt you’ve accrued.

None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?

Everyone’s career progresses in small movements over time but every now and then there are step changes. Whenever that happens, there’s always someone in a position of power who made that possible for you, who took a chance on you. One of the most significant step changes for me was when I left the publishing company where I had been since the beginning of my career and took an exciting role starting up a brand new global science education division for Nature Publishing Group. This was a leap upwards and onwards in every sense, and I know there were many other candidates in the process who had much more experience than I did. I landed the role because someone named Annette, who ran NPG at the time, took a risk, bypassed the other candidates, and gave the opportunity to me because she saw something. It took courage and imagination. I’m not even sure I would have done the same thing in her position! The rest of my career has flowed from that opportunity and I’m eternally grateful to her. I try to remember this often as a reminder to myself to give similar opportunities to the next generation. Often, of course, you have to hire for experience, but sometimes it’s important to take a calculated risk on a new talent. Without that, the system becomes self-circulating in some sense; breaking the mold is what makes room for fresh ideas and new approaches.

Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?

There are so many benefits to the traditional mode of face-to-face consultations between clinicians and patients. A lot of diagnosis is very tangible: doctors look at rashes, or test eye movement, or take a pulse. There’s also the relationship aspect: the clinician works to build trust with patients through conversation, body language, and humor, which ultimately helps the patient accept and make good decisions about treatment options. And there’s the ease of rapidly moving from consultation to testing or complementary medical services. A doctor can send a patient down the hall to get a blood exam or a scan, or to work with a mental health specialist. All of this is obviously more challenging without face-to-face contact.

On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?

All of what I described in the previous answer is more difficult via telehealth. But beyond this, there are challenges that are very specific to this new mode of telehealth. One is the “digital divide.” I frequently hear people talking about how telehealth expands access to healthcare. This is true in some ways, but in other ways it can exacerbate issues of equity. True face-to-face telehealth, for instance, is only workable for patients who have a smartphone or a laptop with good Wi-Fi, while patients — from rural or low-income communities, for instance — who may lack these things can only participate in phone-based or some other simpler form of telehealth. Safety can be a concern as well. While doing research for our telemedicine product suite, we heard a story from one our advisors, a cardiologist, about a patient who fainted while he was conducting a telehealth consult with her. If she had fainted in his office, he could have treated her immediately. Since she fainted in her own home, at first, he was at a loss. Fortunately, because his hospital had robust training in telehealth best practices, he knew the protocol, which was to confirm her current address and call 911. (She got the appropriate care and was fine in the end.) There are other aspects of safety that are challenging in telehealth contexts. In many kinds of in-person consultations, for instance, the clinician will ask patients whether they feel safe in their home and with their family, which can sometimes help the clinicians recognize abusive domestic situations. But that can be difficult to do in a telehealth consult when the patient might be sitting in their living room next to their spouse or family.

Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need To Know To Best Care For Your Patients When They Are Not Physically In Front Of You ? (Please share a story or example for each.)

The good news is that hospital systems and clinicians have responded to the explosion of telehealth during the COVID-19 crisis with extreme creativity and dedication, and the solutions to many of the challenges inherent to telehealth are already circulating as new best practices within the community. I’ll outline a few of these emerging best practices based on research we did when launching our telemedicine product suite. (And I want to thank Rebecca Schmidt from my team, who designed that product and shared many of these insights with me.)

First, build a relationship with the patient through an explicit focus on what is being called “webside manner.” The web can be awkward at first, but clinicians can absolutely build a trusting relationship with a patient over the web. All of us are doing this every day now during the pandemic with each other, whether in business, education, or other walks of life. Relationships are not about proximity but about dialogue, listening, humor, questions, observation, shared history . . . all of this is possible via telehealth. It’s important not to ignore the “presentational” aspects of webside manner as well. Clinicians should dress for a telehealth consult in the same way that they would for an in-person one. No clinician would show up to a personal consult in a t-shirt or a baseball cap and shouldn’t for a telehealth visit either. (We heard plenty of stories about this during our research.) Lighting, camera angle and so on are also important. Patients do tend to judge the credibility of their clinician based in part on their presentation over the web.

Second, take advantage of the amazing opportunity that telehealth provides to analyze broad determinants of health, including social determinants. In an in-person consult, clinicians will ask their patients about their diet, and patients will give answers that may or may not be accurate. (I would think we are all guilty of that.) In a virtual context, though, clinicians are discovering that they can ask their patients to walk over to the fridge and show them what’s inside. They can see directly whether the patient’s diet includes vegetables or not. Telehealth provides a unique opportunity for clinicians to see aspects of a patient’s home life that can help to inform decisions on overall treatment and care. Similarly, clinicians can sometimes form a much deeper sense of a patient’s mental health and well-being through telehealth than in person. One doctor we talked to noticed that a patient to whom he had delivered difficult news seemed to be outwardly calm but repeatedly picked up and petted her dog throughout the consult. He realized this was a coping mechanism for extreme stress and was able to recommend mental health treatment.

Third, take advantage of what many in the space are starting to call “digital therapeutics.” There are so many tools in the market now that can monitor patients’ glucose levels or medication levels, and so on. These tools must be vetted carefully by clinicians as they are still new and likely will be regulated, but the reliable ones can make a huge difference in patients’ lives. Instead of having to take a day off of work or find childcare in order to have their readings checked by their doctors, patients can have their information sent automatically.

Fourth, know the regulations. Telehealth is different from in-person consults, and the regulatory framework can be confusing. Is a doctor in Pennsylvania licensed to treat a patient from Delaware who used to drive into the office but now engages via the web from Delaware? This was a real-world question one of the doctors we spoke to during our research encountered. How long do you need to be on the phone in order to submit a consult to Medicare for reimbursement? One of the doctors we interviewed described how after wrapping up a 7-minute phone call she discovered that the minimum to bill in her state was 8 minutes, which means one missing minute cost her practice an entire billable session. As more and more of healthcare shifts to telehealth, it’s crucial for hospitals and practices to make sure that clinicians are always aware of the (shifting) answers to regulatory questions.

Fifth, be resourceful about diagnosis. Despite all of the advantages of telehealth, which I have outlined above, there’s no question that it’s still difficult to perform some activities that are routine in the office, like a cranial nerve exam or an eye exam. But what we heard from the clinicians we have been working with is that there are resourceful solutions to almost all of these challenges. One doctor mentioned performing a cranial nerve exam virtually using household items: coffee to smell, ice cubes for sensation, a standard flashlight for visual acuity. Another clinician described assessing gait by asking a patient to stand up and walk around the room but using a family member as a companion in case of falls. We’ve heard similar stories about nearly every kind of diagnostic activity. I’m sure there are limits, but we can do much more via telehealth than it may seem.

Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?

This is what’s exciting: there are many ways in which telehealth will move us forward as a community. The most obvious is the ease of access. For those who do have the technology to participate in telehealth, a telehealth consult is much easier than the time and disruption involved in traveling to a doctor’s office. This should help people be more comfortable using telehealth frequently, which over time could help address our societal challenges with chronic diseases like hypertension. We heard from a specialist in opioid addictions in Massachusetts that, anecdotally, substance-use disorder patients in that state have missed 90% fewer appointments during the pandemic than previously, because of the ease of telehealth. Beyond this, as I mentioned earlier, telehealth broadens the data points that clinicians can take into account when diagnosing a patient to include, for instance, diet, family dynamics, home hygiene, and more, which leads to higher quality care plans and stronger outcomes. Finally, what may be most impactful in the long run is the way that telehealth can help connect patients with specialists and experts that they would find difficult to reach otherwise. Not everyone lives close to MD Anderson or MSKCC, for example. But telehealth can improve access to that specialist expertise.

Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?

I don’t think that the heart of what makes a telehealth visit successful is advanced technology tools that create a sense of “being in the same place,” such as virtual reality environments. The straightforward modes of interaction that we see throughout the economy now — Zoom, Microsoft Teams, WebEx, and so on — are all adequate for the basics of what clinicians and patients need to do together, which is talk, listen, and arrive at a common understanding of diagnosis and treatment. What does make a difference is the degree to which the collaboration software supports critical nuances such as live captioning, which is important to the hearing impaired. Though it’s also important to note that most of the responsibility for supporting accessibility during a telehealth consult lies with the clinician, rather than the technology. Clinicians may need to speak slowly and clearly, for instance, or ensure that their face is clearly visible to the patient.

If you could design the perfect Telehealth feature or system to help your patients, what would it be?

Again, I think the core interaction between clinician and patient can be handled well through common technologies, though it is important for healthcare providers to have a range of platforms that can support patients with different levels of technological access. What must be layered around that core interaction is a broad set of telehealth enablement tools: communication software that allow doctors to easily and securely send accurate patient education materials (in multiple languages) to their patients as a follow-up, that automatically send reminders to patients to confirm and set up their next consult, that surface data from the patient’s digital therapeutics so that the clinician can assess up-to-date information while conducting a telehealth consult without juggling multiple browser windows, and so on.

But technology, by itself, is only a piece of the ideal telehealth system. I recently read an article that emphasizes the importance of having staff at the hospital who can serve as “digital health navigators,” helping elderly patients or patients with disabilities or poor English skills successfully take advantage of telehealth options. And even when we do focus purely on the technology-enabled interaction, what makes the difference between a successful and unsuccessful consult is still not the technology, but the clinician’s resourcefulness and webside manner. I don’t imagine there will be a one-size-fits-all telehealth solution that health care providers can buy and implement. Just as hospitals combine different electronic health record systems, email systems, and other technologies to digitize their in-person workflows, their telehealth ecosystems will involve a variety of components from different providers combined in ways that are particular to each hospital. There will be work and complexity involved in arriving at a successful integrated implementation, which certainly introduces some friction in our society’s transition to telehealth. It also is the raison d’etre for companies like my own, that have a range of technology solutions — addressing medical research, telehealth training, patient education and clinical decision support — designed to help facilitate this and other healthcare transformation initiatives.

Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?

Being in the home can sometimes help a patient answer questions more thoroughly than they are able to in person. For instance, the doctor may want to know how much of various medications the patient takes each day, which can be difficult for the patient to remember in person and is also difficult for the doctor to look up if multiple clinicians are prescribing from multiple networks. At home, by contrast, the patient has the ability to show rather than to tell, which can help the doctor make a fully informed diagnosis. If there were one piece of advice I would give to patients, it would be to take advantage of the doctor’s ability to make a holistic assessment by being as transparent as possible about the full social context of their lives. I would also remind patients that they don’t have to be at home to participate in telehealth; it’s possible to do it from the office, for instance. Personal healthcare outcomes are better when we can minimize disruption and friction that disincentivizes care.

The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?

I’m very excited by the potential of VR/AR in general, but, as I mention above, I don’t see telehealth as the first place where these technologies will and should make an impact. I do see a lot of possibilities for VR/AR in training clinicians. There are medical schools today (such as University of Texas at Dallas) that are starting to train students for real-world clinical activities through interaction with virtual patients. It’s easy to imagine how this could significantly expand educational possibilities by making it easier for students to familiarize themselves with a broad range of ethnicities and personalities, for instance, or by exposing them to high-pressure, critical care situations early in their medical training, long before their clerkship and residency.

Is there a part of this future vision that concerns you? Can you explain?

Of course there is no replacement in the end for real contact with real human beings. It’s always exciting to think about how VR/AR and other advanced technology could make certain kinds of educational experiences more scalable or more diverse; but it’s important to remember that healthcare will always be patient-centered, and there is no way to become expert at patient-centered care other than by spending immense amounts of time with real patients.

Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)

What comes to mind when you ask this question is a simple tenet I hold — I think of it as the “5% rule.” I believe that if each of us were just 5% kinder every day, the world would look very different. For each of us as individuals, a 5% daily stretch towards kindness beyond our normal mode is a very small difference. A few kind words, a little thoughtfulness, a note to someone we know in need, a small donation somewhere . . . these are easy to give. But in the aggregate, if we all gave an extra 5%, the world would be transformed. I try to live up to this vision in myself as consistently as I can. I wish I could say I succeeded all the time, but sometimes I do. I always try.

How can our readers further follow your work online?

They are certainly welcome to take a look at some of my posts on LinkedIn . . . though I admit I’m less active about that than I should be! They can also participate in our monthly Expert Insights webinars, where I interview thought leaders in medical research and education speaking about their groundbreaking work. I will be blogging regularly starting later this year on what I encounter in the healthcare marketplace on Electronic Health Reporter, so readers who are interested can look up my thoughts there. And of course, they can take a look at our product suites, which is really where I embed the most valuable insights that we discover in our work in global healthcare markets.

Thank you so much for the time you spent doing this interview. This was very inspirational, and we wish you continued success.