Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.
Dr. Allison “Alli” Williams: I'm Alli Williams, one of the pediatric hospitalists here at UPMC Children's Hospital of Pittsburgh. And today, while I am without my co-host, Dr. Agnihotri, today I am so excited to be talking with Dr. Ken Nischal, who wears multiple hats. He not only is the chief of the division of Pediatric Ophthalmology and Strabismus, as well as a professor of ophthalmology, but he's also the medical director for Digital Health. And that, I believe, is the hat that we're going to be talking about today. Thank you for being here, Dr. Nischal. I am so excited to be talking to you as the medical director for Digital Health.
Dr. Ken Nischal: Thank you so much for inviting me. I really appreciate the opportunity to come and talk to everybody about what we are doing at Children's Hospital with the digital footprint and the digital space.
Dr. Williams: I feel like digital health is newer these days. So can you kind of talk to us about how digital health or even that term evolved?
Dr. Nischal: Sure. Um, as we all know, we went through this terrible pandemic and lockdown and we suddenly realized that there were patients who needed to be seen and we couldn't see them. So we pivoted at Children's from doing 500 telemedicine visits in January 2020, sorry to by the end of May, something like 19 and a half thousand.
Dr. Williams: Oh my goodness.
Dr. Nischal: And so that was a tremendous amount of effort, both by the IT team, by the doctors themselves. And we were able to do this because of the public health emergency. This was a declaration that said you can deliver care. You didn't have to be in the same state because we had patients who used to drive into Pennsylvania from other states, and now they couldn't. Right. So we had to get rid of that barrier. We were able to see patients at home, which we couldn't do before. The public health emergency has, has ended, ended in May 2023. But thankfully, some of the changes we saw then are continuing and allowing us to deliver healthcare. Now, there is the actual visit, right? The telemedicine visit, and you need to have a good Wi-Fi. Cellular data is not so good in doing a face-to-face. So you need good Wi-Fi.
And then what you need to do is to make sure that you've booked your appointment. And what we're doing at Children's is we're offering, uh, parents the opportunity to book online. They can book online for a schedule, a digital appointment in the comfort of their own home. So the whole thing about telemedicine is that it's part of digital medicine, digital health, which encompasses not only the actual visit and the exchange of information, but it also encompasses parent education, patient education, and the education of the providers so that we can together deliver a much better service. And, and I can, maybe I can give you a couple of examples of that. Would that be okay?
Dr. Williams: Yeah. Oh my gosh. I would love to know more. Cuz whenever I think about digital health, I think about a virtual clinic appointment. But it sounds like there's more than that.
Dr. Nischal: There is. So imagine that you have a patient coming in for a procedure or even just a test. Some of the time we spend is explaining to parents what we are doing, and that's face-to-face time. If we could utilize that time through a digital appointment so that an APP, a nurse practitioner, could explain to them what the test entailed, why we were doing it. You as the provider have saved that time in clinic and perhaps allowed an open slot for a patient who's a new patient who perhaps previously may have had to wait several weeks. But now, because we freed that time up is a, you’re able to see a new patient sooner. More importantly, what we found is that parents love the digital exchange because they get information sent to them digitally. They understand what's going to happen.
Somebody explains it to them. Now they come into the hospital and they're not strangers. They know exactly where they're going, why they're going and what they want. And the error rate of getting the wrong test is dropped. So, all of this sort of, if you like, bolsters what we were already doing. Now imagine a situation where you have a family who they find it difficult to come to the hospital, but they find it easy to get somewhere that's relatively close and is a UPMC facility. Well, we can do a telemedicine in that UPMC facility with testing that can be done on that site so that the provider has the information they would've had, even if they were there, here in the main Lawrenceville site. So now what we've done is we've expanded our footprint and allowed parents to choose what's convenient so they don't miss their appointments.
Dr. Williams: And it sounds like you've gotten a lot of positive feedback from this too, because it reduces the fear for families and they have all of the knowledge before they come in as opposed to coming in kind of blindsided.
Dr. Nischal: Totally. And the thing is it, I wouldn't say that it's been easy for providers because we've had to change our mindset, right? We were brought up to see patients, you know, this is how we were supposed to do it. They, they come in, we have a clinic the whole day, but now we are finding that providers are beginning to pivot. So if they know that they've got three empty slots, because parents rang and said we're canceling, they're now saying, well, maybe I can put in a couple of telemedicine visits because I was supposed to give so and so the results of their MRI scan. And I can do that face-to-face, tell them what's going on and what the next step is.
So we are finding that providers are going, well, actually I can save time for the parent and myself and just get things going. It's becoming a little bit easier. Still a lot of steps to take, but becoming easier. Imagine a situation where, and we are there right now actually, where we can have an application, a software application that pulls in all the data for one of our patients. Let's say a patient who's diabetic. And the patient who's diabetic got an app to take home that they play with in a pictorial way that tells us what they're eating every day. So it has candies and meat and vegetables, and you find that the candies are being hit on more often and then they get a blood test done, or they're getting constant monitoring that can happen now.
This software that we have called Xealth, we already have it at UPMC on the Epic side. It can draw all of that data and send a report to the provider before they see the patient and say, by the way, all this is what's going on. These are the tests we recommend they get as they come into the clinic. The patient goes and gets the tests, but by the time they see you, you've got all the data. So now instead of having to go back and forth, the patient's visit becomes more coordinated and more concentrated. So you're doing what you're good at – advising and planning and treating.
Dr. Williams: As opposed to taking all the time to ask the questions where parents feel like or patients feel like they've answered the same question over and over again.
Dr. Nischal: Absolutely. Absolutely. Now imagine, let's take digital health to another place. What if we have a wayfinding app? Imagine you've got an appointment at 10 o'clock in the morning and you live in Butler, Pa. And the wayfinding app alarms and says, “You should be leaving right now because the traffic conditions are such that you're gonna miss your appointment if you don't leave in the next 15 minutes.” Patient leaves, gets here, and gets told, “Oh, doctor's running a little late.” On the way to the clinic, these are all the places where you can sit and have a cup of coffee or a bite to eat if your child is hungry. They come in and they're told, “Oh, because of the tests we did last time, you need to get these tests. Away you go and the wayfinding app tells them, just like they do on Google Maps, this is where you walk, go and get the test done, and then come back.
Dr. Williams: I feel like that would make things easier.
Dr. Nischal: Right? So we are actually in negotiations at the moment about getting wayfinding app like that. And the wonderful thing is Children's Hospital is the only hospital in the UPMC system that already has the routers in all the spaces, including the car parking. Imagine if you were getting close to the hospital that says don't go to that parking space because it's full. You need to go to the other one. You're changing the whole journey. Now that's a convenience issue. But in 2023, the easier we make it for our parents, the more likely they're to turn up, the more likely the children are going to experience a good journey, the more likely we're going to get a good outcome. We're also working with a company where a child can make its own avatar. And then it can place that avatar in the surroundings that it's in. So imagine for the oncology children that this avatar will talk them through and say, you're gonna have this IV drip put in, but the child can project the avatar on its bed so it doesn't feel alone. The digital space can really make us provide an experience that is so much better, but more importantly our access can improve. And one of the things we are doing, see there are so many doctors in so many specialties, we don't always get to talk to each other.
Dr. Williams: No.
Dr. Nischal: So in the beginning of May, we had a meeting of all the division chiefs at Children's about what we are doing and what we're able to do.
And we uh, appointed a point person in each specialty who was going to be the digital point person. So if something changes legally, for example, with the PHE, the public health emergency or something changes with how we can bill or what we can do for telemedicine, they disseminate that information. We're taking that one step further.
At the end of September, the School of Medicine is helping, uh, develop a Digital Health Summit. So every specialty in the school of medicine can come and present how they utilize telehealth, digital medicine, both for the patient, parents, and for the trainers and the providers. And we are going to be able to sort of get some joint up thinking about how we can all collaborate or use other people's ideas to help our own patients. The last thing that's really important is that with all the data we are gathering, we are gonna be able to do some really robust research.
And if at UPMC everybody's talking to each other and we have this data, the NIH, when they give out grants is more likely to give grants to places like us, then other places which are disparate or disorganized. So the Digital Health Summit I see as a real starting point, um, to help people showcase what they're doing and how we can further what's happening to our patients. You know, everybody thought that digital health would reduce inequity and inequality. It hasn't. If you only have a cellular data plan because you can't afford Wi-Fi, the chances of you getting a good quality telemedicine appointment are lower. So we need to identify that. And then we need to change the state law to say, “Hey, basic Wi-Fi for health should be a basic necessity.” So let's concentrate on putting some money into that, into infrastructure of the digital platform rather than other things that you might think are important.
Let's put that on that space for discussion. So I kind of feel that UPMC Children's is really helping drive this forward, that UPM C as a whole is really interested in developing the digital platform and digital health, but it's not just focused on the one-to-one visit via audio visual communication. It's interested in the whole thing. And the more automated we make it, the easier it's gonna be.
So for example, right now if I schedule somebody for a surgery, I'm an eye surgeon, when that schedule occurs, Xealth automatically sends the parent the customized information that I want them to know about for the day of the surgery, what the procedure is, and what the complications are. So when I meet them, I don't have to go through all of that verbally for 20 or 30 minutes. I can just say, did you read the information we sent to you? And if they say yes, okay. Was were there any questions? Is there anything? And I find that my conversations are much more informed.
Dr. Williams: Well it gives parents the time to process too before they come in for these big procedures in which you're already stressed about having them. Exactly. And it gives you a chance to really process and then ask appropriate questions to their providers.
Dr. Nischal: Exactly. And the other thing that we are getting providers to do is to make videos of what, what it's like to walk into their clinic and who to expect to see. And we are gonna send those out as links so parents can, it's just, you know, fear is such a tremendous anxiety producer and children exhibit anxiety in different ways. They won't let you examine them. And so the, what was it booked for a 15 minute appointment drags out and then everybody else is waiting. But imagine if you can take away some of that anxiety. You could never take away all the fear or all the anxiety, but if you can blunt it, everything starts to work in a different way. And it's like, like somebody once said, didn't they? They said that, until you create what you need between now and that point, the only thing you have is faith and hope. We have more than faith and hope we have a tremendous amount of talent and infrastructure here and we are really hoping to utilize it.
Dr. Williams: Yeah, it sounds like, I mean when I first was reading about kind of this digital health, I was literally thinking just about the website we have you know the MyUPMC app that patients use and it sounds like it is like that, but on steroids and so much better.
Dr. Nischal: And you know, the thing is it's, it's already here. Everything is there. It's just a question of plugging everybody into the right spots and then they can get the information they want, including the parents. But, you know, online scheduling, it just is. I mean, how many times do we online book our restaurants, you know, or online book our seats. Right? So why can't we do an online scheduling for an appointment if the slot is there, it's there. We can go online and we can, we can book it.
Dr. Williams: And I think it's important too that, you know, you mentioned this the digital health summit, that's gonna happen in September. And that's a place where we're gonna share ideas so that we're not building it from the ground up, but coming up with working together and how we can make this productive for everyone without reinventing the wheel. That was for providers and like families as well could go to that?
Dr. Nischal: No. So the first one's going to be for providers. Then we are going to do one for nurse practitioners, nurses, apps, MAs, PAs. But we felt that we would try because nobody's done this before. In fact, if you look at any other health system, nobody's done a digital health summit for their own staff. So we thought we would try it out, work out where the, uh, the problems arose, any iron out, any kinks, and then do a bigger one for all the other staff who frankly are probably more important than the providers. But if we have the providers on board, then there'll be someone for them to turn to and say, what is this about? And they go, well this is how it works and it'll give you a great opportunity to showcase what you're doing. Um, there are a lot of people who are, who want to create digital applications, apps to help their patients. They just don't know how. Right. And so we're gonna have people who've done it successfully, uh, to show people how to do it and how they can get the help.
Dr. Williams: Do we have a date or time right now for that summit or we'll have that information later that we can put with the episode now?
Dr. Nischal: That will be, so it's the last Friday, September and it looks like it's gonna be at the University Club. Um, and there will always be the very impor and this is very important, hardworking, um, reception in the evening with drinks.
Dr. Williams: And I assume that information will come through for providers or there'll be a website that we can attach to this episode exactly when it comes out as well.
Dr. Nischal: Exactly. So what we will be doing is that the, uh, call for abstracts will go out, each chair from each specialty will be told about this and expected to disseminate the information down to all of their providers. And I think they'll be a little bit of healthy competition cause people want to show that they're doing more than others. So we are looking forward to a, a big abstract, uh, submission.
Dr. Williams: Well, I am so excited to learn about all of this growth that we're having at UPMC Children's Hospital of Pittsburgh. And I cannot thank you more for coming to share all of this with us.
Dr. Nischal: Thank you so much. I really, really appreciate the opportunity.
Dr. Williams: Appreciate it. And thank you all for listening to That's Pediatrics.
Voiceover: You can find other episodes of That's Pediatrics on Apple Podcasts, Google Podcasts, Spotify, and YouTube. For more information about this podcast or our guests, please visit chp.edu/ThatsPediatrics. If you've enjoyed this episode, please be sure to rate, review and subscribe to keep up with our new content. You can also email us at podcast.upmc@gmail.com with any feedback or ideas for topics you'd like our experts to cover on future episodes. Thank you again for listening to, That's Pediatrics. Tune in next time.
Ken K. Nischal, MD, FAAP, FRCOphth