Podcast #4: BC Medical Doctor Shares His Success Journey with Telehealth

Here is Cortico's fourth podcast from our own Ashley and Kelly, with special guest Dr. Singhal discussing how he discovered and has engaged with Cortico Health Technologies.

You can access the podcast audio here.

Kelly 0:00
Hi everyone, and welcome back to the fourth episode of the podcast with Ashley and Kelly. Previously, we were joined by Surpreet, a medical office manager to discuss seniors in the world of virtual health. Today we're shifting gears to investigate Dr. Singhal's journey in discovering Cortico Health Technologies. Dr. Singhal is a very reputable family doctor from West Steveston Medical Clinic in Richmond, BC, who has been practicing for over 25 years.

Ashley 0:34
So thanks for joining us today. Dr. Singhal. Could you tell us a little bit about yourself?

Dr. Singhal 0:38
Sure. I've been in medical practice for, as I've been reminded, for at least a quarter century, so that seems like a little bit of time. I'm a family doctor and I used to do different areas of consultancy GP called GP consultancy practice in different areas. And at least for 21 years, I've been running a group family practice and walk-in. And so we've always been a very busy practice. We have multiple doctors, and we cover for one another, we see each other's patients, and we do longitudinal, long-term care and provide, hopefully, best practices. As a principle physician, I've supervised a few physicians [...] so yeah, we took very good family practice and a group of us and we've adapted to the new changes with the pandemic and how we've come about to do things.

Ashley 1:49
Dr. Singhal, I just wanted to say thank you for providing such quality patient care throughout the years. You just mentioned the pandemic... can you tell us a little bit about some of the challenges that your practice in yourself has faced during these difficult times?

Dr. Singhal 2:06
Yeah, you bring back a lot of memories. Now, we had just ended a lease with our practice, we had about 1200 square feet for 656 practitioners, and we had another space where we had midwives. And that was a very small space, and we ended our lease January 31 2020. So for February 2020, and potentially March 2020, we were doing everything we could to see patients, and some of us would be in on a Saturday, some of the others on Sunday, three of us would be in on a Monday and three of us would be in on a Friday. So we could just use the space we had. So, we could just kind of all use it. And in addition to midwives, there were about seven-odd practitioners using this small space. And then the lockdown happened, where it was, you cannot conduct visits face to face, you must do telehealth, and I have to actually commend the Doctors of BC, they've done just a tremendous, fantastic job in encouraging telehealth, developing tools, giving us the wherewithal to, to kind of... "this is how we're going to have to do it, and with good reason, so that we could keep the COVID numbers down" and this sort of thing while seeing patients. And the reality is that a large part of medical diagnosis is asking the right questions and taking a proper history. And yes, we do need to do physical exam at times, we do need to see things at times, and touch, and feel, and listen, and what have you... But I think other tools have developed from then until now that have allowed us to do that in a safe way. Now at this stage, in November 2021, there is some lifting [of restrictions], and over the last number of months, we are seeing patients more in person; but definitely telehealth is a large percentage of how we see patients. So it was a lifesaver in terms of our practice, in terms of the only silver lining of this awful pandemic, was that this small space we had could accommodate so many practitioners because of telehealth, and we're developing some other office space. We will have that soon. But it's due to those construction delays, and it's got us through all of this.

Kelly 4:37
Yeah. It's interesting that you brought up the timing of when the pandemic started, because as the pandemic started in the beginning of the year things are probably... many, many clinics and other companies as well are rolling out new things, but it kind of interrupted from the get-go and so I wanted to get to know a little bit about your first experience using telehealth. Was it at the start of the pandemic? Or have you been using telehealth prior to the pandemic?

Dr. Singhal 5:10
That's a really good question. So let's go back two years; two years ago, November 2019, I would have done zero telehealth. In November 2019, prior to the pandemic. And I don't think many were doing it at all. I mean, there were some, but really not a lot. The pandemic was a great catalyst for telehealth, if anything positive can be said about it. So initially, we started with Doxy.me, and then the Doctors of BC, advised us, "Hey, we've got encrypted Zoom for you," so a high-end, sort of Zoom. So we certainly started to use some Zoom. Although, I was very comfortable on the telephone. I mean, I've known patients for 20 years, and I've known the families for a very long time period. So it wasn't a large kind of undertaking to just listen to the intonation of a tone on the phone, and I can picture a facial expression by listening. So I mean, largely just from a from an ergonomic perspective, the phone is an easier tool. And I guess there's other things that have rolled out. So just that the practicalities, so in other words, I don't even use... Initially I was using a phone with *67 so that people wouldn't know my personal number, then it was Fongo Works. So we're all on Fongo Works, a voice-over-internet protocol with a message on it. So if the patient misses your call, they can dial that number, but they won't be calling you personally, which would be very interruptive and not practical. So, they will have our office number and our staff will then be able to speak to the patient. So there's a bunch of things there technology wise, that occurred very quickly. The Doctors of BC also encouraged us to use SR Fax. So we've used that and integrated that with our EMR. So we can fax prescriptions, fax requisitions, and do all those sorts of things that you would think, initially, well, "Hey, you have to be in person, we have to hand that to you..." Also, for dermatology things, for instance, emailing your photos, or emails of different sorts of things are uploaded into the chart. If we couldn't use Zoom, if we couldn't, for whatever reason, and we wanted multiple pieces of information, that started to happen. I have an app now called Dermcam, where it's like a text. If I call you, and you're wondering how can I assess your dermatological issue, or your cosmetic issue, or whatever? How would you do that over the phone? Well, you do it with a text, and you can take a picture, or I can Zoom call you, or whatever... Or you know, other platforms within Cortico, which I have yet to use, but hopefully will be using at some point. But it's about all those sorts of things that have been allowed. If you'd asked me two years ago, "How would you do it?" I would have been wondering how would we do it. But, within really a very short time period, probably two to four months, all these tools have been developed, where it's just, "Hey, this is the new normal of how we do things," and it's surprising just how much can be done through telehealth versus in-person. And it's largely the patient who may not get it, that, "I've got some condition and I need to be seen in person..." Well, yes, and no... You can't do procedures over the phone, you can't do you know, a digital rectal exam, or PAP smear, or breast exam, over the phone. But for a lot of the other things you can. And of course, if something isn't measuring up, then you want to bring them in anyways, if you really have to. You'll do that for others' safety and so on. We work in a group, so we do have the luxury of having a doctor on-site, in-person, every day. So, if we do need to see someone in person, we have that ability to do that.

Ashley 9:21
So, that's really good to know, Dr. Singhal. Now, not every single doctor can be tech savvy, and there are a number of practitioners all over Canada that are still kind of hesitant on using telehealth. Are there any words that you could say to encourage these practitioners on starting to use telehealth?

Dr. Singhal 9:46
Oh, yeah. The feedback that we get... I have practitioners who are 12 years older than me, and 12 years younger than me, and all in between, and the learning curve isn't that steep. I mean, it's not that difficult. I think the days of the solo practitioner are going the way of the dodo bird. I mean, they're not going to be... If they are out there and doing it, I don't think that's going to last long. You need to have a group where a lot of technical... and you need to have the right kind of tools, like with anything. And the tools that are in existence are not, it's not rocket science to learn. I would say, within two to three months, our infrastructure was reasonably set, in terms of being able to do some degree of telehealth. The practitioners who are not doing that... I just wonder what the hesitancy is, or what is the roadblock or stumbling block to get there? Some of it... Go ahead, sorry?

Ashley 10:52
Do you think Dr. Singhal that, Is it more of a security thing? Or is it more so that... Is it more so that the their patients, like I mean... there's geriatric doctors worried about their geriatric patients not being tech-savvy, so there's some hesitancy on that as well.

Dr. Singhal 11:14
That's very true. The patient base has to also be comfortable with the whole concept. And so, it's a two way street, right? I mean, you both have to feel comfortable. So a lot of patients will ask, "Why weren't we doing this 10 years ago?" I mean, when we say we have great access of health care in Canada... Yes, and no. We do, but you have to take half a day off of your work, you have to go find parking, you have to wait in a waiting area... Whereas, for a lot of things, you could be called on the phone, and a lot of what you need to do could be done without interrupting your whole day. And I think there are times, like with anything, that, you know, you can't have everything perfect all the time. I mean, it depends on the type of practice you do. If you're doing a geriatric practice, and you want to do a complete physical exam? Well, yes, you've got to have that person in front of you, as for many things. And there are technical tools that allow you to, you know, listen to the heart sounds and things like that. We don't use them, we don't incorporate them. They were around when a previous company was trying to do this years ago, to have virtual care, which never really took off prior to the pandemic. But with what we're doing now... The hesitancy has to do a little bit with the patient and a bit with the practitioner. And I think, again, if you'd asked me two years ago, I would have been saying something entirely different. But after two years of kind of doing a lot of this, and developing more tools, things like Dermcam and other things, where we're not compromising safety... The feedback I get is largely, over 90%, that telehealth is what we should have done before. And that's from the patients. And from the physicians, it's also, "Hey, this is really a good thing. Why haven't we been doing this sooner?" There's times I think, where of course with the pandemic as another variable here, where the the adaptation of how you used to do things to how you're doing things now might be a little different as well. Whereas, if someone's right in front of you, it doesn't take much to say "Well, okay, let's examine this or this," right? And when you're doing it remotely, or from telehealth, you have to try to think a little bit and coordinate to see somebody to examine them. And that's probably a little bit of a workflow difference. And I would hope, and I think, we're not compromising anything in every scenario by coming to that decision point that "This can be done in a virtual way, and this cannot be done in a virtual way." So, a good example is for dermatological things, where many will think, "Well, how on earth can you do that over the phone?" I used to initially use email to get pictures sent, because the phones now, that everybody has... Almost everybody has, there might be like a handful of people who don't have email, a handful of people who don't have a smartphone, and for them there's other ways if it were... But the vast majority of people do have email and smartphones. So Dermcam at point-of-care, "Text a picture to me right away." And cortico does have a video link as well, that can be helpful, or Zoom, or whatever that can be used. And then, if not, "Well look, I need to see you in person." And we do have to actually have you come in, or one of my colleagues will see you. If it's an emergent matter, we'll see it today or tomorrow, in-person or in whatever setting that may be.

Ashley 15:10
Kelly, do you want to ask how long he's been using Cortico for and how it differentiates from other platforms?

Dr. Singhal 15:17
You have to remind me how long I've been using it... for like half a year or so, or how long?

Kelly 15:23
Arun was saying half a year or so.

Dr. Singhal 15:25
I heard in the background here...

Ashley 15:28
Yeah, we can ask this question

Dr. Singhal 15:30
He's the on who brought me tea, on top of my coffee, one second here...

Ashley 15:35
So then Kelly, I'll wrap it up.

Dr. Singhal 15:36
I'm a caffeine junkie, I think... Here you go. Okay, thanks. Okay. Go ahead.

Kelly 15:47
Yeah, perfect. So how long have you been using Cortico, Dr. Singhal?

Dr. Singhal 15:53
I believe it's been about half a year now. And, it's a very, very nice tool. And what we were using prior... the online booking has been really, really, really nice. The workflow that I would have, is typically when I see a patient, and I need to do a follow up, I would physically, as a practitioner, move the patient, and say, "Oh, I'm going to book... Let's book you in here." The feedback would often would be, well, "I've got dance rehearsal that day in that time," and, "Can I move it here?" Something like that. It's so much... I mean, that all adds up. And so, it's nice also, for our staff not to go through that process, to kind of have a patient, just to say, "Rebook within two weeks," or something, "Just go to our website, and go online and do that." And so that saves the practitioner's time, and it saves the staff's time. And it's just an exceptional use. It streamlines things very well.

Ashley 16:58
Dr Singhal, what differentiates Cortico from some of the telehealth services that you were using in the past?

Dr. Singhal 17:09
You're talking about for booking online? Yeah, so the nice thing about Cortico is that, what we were using prior required staff to 'Okay' the patients, so there'll be a tremendous staffing issue. So Cortico is much easier as patients can do everything themselves. And they don't have to have the staff 'okay' it, and so that's a huge bottleneck with the previous sort of scenario. And the patient can register themselves with Cortico, which is even better.

Kelly 17:46
Yes, that's correct. So any booking of appointments, cancelling appointments. And also, like you said, if they're new patients, and they want to start a new file at your clinic, then that is definitely an option as well. Another thing that I wanted to mention was, do you think Cortico is a customizable platform for your clinic?

Dr. Singhal 18:12
I think it is. We've got a psychiatrist with us, and then a family doctor who is part of a program... a government program, where they book patients differently, called a "PCN" or primary care network program... And the needs are different for them, compared to the regular fee-for-service family doctor. And even there's subtle differences between myself, who's usually fully booked with appointments, and my colleagues, who might have more openings, and might have more of a walk-in basis, or can absorb the walk-in practice. We just have different styles, and different things that we're doing. And so, I guess, to an extent, the things... So to reflect those needs, I believe we work with Cortico to try to come to more customized solutions to those issues.

Ashley 19:05
Did you want to ask about the streamlined communication?

Kelly 19:07
Yes, I wanted to ask about... One last thing I wanted to ask was regarding... You were just saying that, you know, especially with virtual health, communicating with patients is very, very, key because you can't really see them in-person. So, what do you think about the streamlined communication that Cortico has to offer?

Dr. Singhal 19:33
So I mean, I think there's a few things. I think some things are a bit in development, in terms of the email... At a practical level, what you'll want to do in your workflow is often you'll want to get some type of assessment, and the first thing is ask "Can you do that without seeing somebody?" Therefore, telephone or what have you, the oldest telecommunication, then the decision is, if you want a video which, so you can see someone through video through the Cortico platform, or, or whatever, there's other video platforms that can be incorporated, but one platform will be better than six platforms that you're working with in the day. So what I really find exciting is the email development, in terms of emailing requisitions. So that would be X-rays, lab requisitions. I fax things to the hospital, like CT scans, MRIs, etc. It would be nice also to email patients those requisitions and whatever, you know... But that we will fax there, so that if they have it, then if they want to follow up, they can follow up. So our staff, you know, that sort of thing. And so that's... I'm looking forward to the email components really working better, or being developed, rather, to work in a workflow pattern. And that's exciting. And I hope that comes to fruition. So what else am I thinking here? The video parts of it, and maybe Kelly, remind me some of the other components that we might be thinking of here...

Ashley 21:22
All the bells and whistles, Kelly, let him know! So Dr. Single, you know, some clinics that are not using Cortico, are there any encouraging words you can say that can encourage clinics to start using Cortico?

Dr. Singhal 21:39
Yeah, I mean, we've been very happy. I think there's a lot of services that Cortico offers that... and in the marketplace, maybe is positioned to do things in a certain way, that would be very beneficial... I'd mentioned about the online booking, first of all, which is the bread and butter. And not every EMR system has an online booking system. And we've had that with previous EMRs. We changed providers, and then with the other provider it was not their forte, and it was a fairly... there's only a few Oscar service providers right now. But, Cortico has really, fairly robust ability to lessen staffing, and staff involvement. So when a patient can book themselves, move things around, that frees up staff time to do other more important things, if it were. Hopefully, to make the telephone appointment booking a thing of the past. If we can free up our staff to not answer the phone, not go through, you know, 5 minutes, 10 minutes of just trying to book an appointment... someone looking at their calendar, flipping the pages open, and what have you... That's a win, right? That's a win for everybody. And so, right off the bat that can be accomplished. and accomplished well, with minimal staff involvement, minimal time, that's what the advantage of cortico would be. It's saving staff time and saving practitioner time. That's a win on all fronts. And then, the tools that are involved with Cortico being integrated with the EMR, sending requisitions, doing things that automate the system... So the current system would be a lot of practitioners, especially for multi practitioner offices, would rely on the staffing that they would be sending a tickler or a message, "Can you email out this and this and this to the patient? Can you follow up on this, here and here?" That takes a lot of staffing time, and that interrupts a lot of the workflow as well. So if that can be automated, and function well, that's a no brainer as well. That's kudos to Cortico as well, because that does allow staff to do other things that they do, that a lot of practitioners don't see. It's good to know what staff are doing. There's a front-end work, there's the back-end work... I'm speaking like a manager now... But, the front-end work is what people see... You know, what are you doing? You're answering the phones when patients are calling, you're emailing or faxing requisitions, you're trying to book an appointment. In reality, a few clicks of a mouse ought to take care of a lot of those sorts of things.

Ashley 24:44
Dr. Singhal, do you think that... I was looking at some statistics recently with Kelly, and there's a high percentage of staff burnout, MOA burnout, frontline workers burnout... And it's taking a toll on a lot of people's mental health. Choosing Cortico, do you think you prevented a lot of staff-burnout for your front staff?

Dr. Singhal 25:10
I think it's definitely helpful, because in terms of lessening the day-to-day challenges, I mean, it piles up, right? Stuff piles up. If there's five, six practitioners, and they're all asking staff to email this or fax that, that becomes 300 requests. Or to book appointments, and that adds up as well. So I mean, the key word, I would say, is 'asynchronous'. If we can make things from synchronous to asynchronous, meaning we don't have to have 20 phone calls on Monday morning, 9:00AM, or maybe 50, or 100 phone calls at 9:00AM, if you can spread that out, like, "Look, this is not urgent or emergent. Can we do this by email, or other means?" Or do a few mouse clicks, it adds up. If it can't be done today, it can be done tomorrow, when there's time to do it, when there's not a busy phone rush or busy in-person session; that's just good management. And that's good use of time, and use of the staff time. And so I would say, aim towards making those tasks more efficient and more asynchronous. When we don't need to do synchronous... We don't have to have it all synchronously done, if that makes any sense. So Cortico is a good tool to try to hopefully achieve that.

Ashley 26:32
Awesome. So, in the beginning, you mentioned practitioners should have started using telehealth earlier. What do you think the future has in hold for virtual health?

Dr. Singhal 26:45
Let's go back historically, a little bit before the pandemic. If there were billing codes to use telehealth, they were not well known. At a practical level, the billing codes were such that in-person visits were much the norm, and the culture just wasn't there. The pandemic has been a catalyst to show us, "Hey, there is a better mousetrap, there is a better way to do things." So the authorizing bodies or colleges or so on, have their own mandates in terms of the public, and there's certain members of the public will want, "Hey, I'm retired, I don't mind. I want to come in-person. And I don't know how any of this. I don't know how an email works. I don't know how to use a smartphone or what have you. And I just, I want to hand write a letter to you..." And I mean, the technology is there, where we don't... we don't use the telegraph anymore. We don't use smoke signals, right? We use technology for what we have. We've got emails, and even now we've got texts on our different apps that we can communicate, you know, images and things like that in an instant. So the reality is that technology is developed. We have the means and the tools that weren't around, maybe five years ago, even. And so I can't help but think, when technology has been advanced to this degree, why would we purposefully say, "No, we shouldn't use it in healthcare." So, we were one of the first to use electronic medical records in 2005, we had developed our own medical records system at that time. So that was different than any of the major producers. I mean, we had people who were doing it with us, but it was a customized electronic medical record system. And I think some people, they weren't familiar with it, they would need training to use it and things like that. But it was a no-brainer. I mean, this was a technology that was used in the airline industries, that we've used in banking, and all reputable industries. And why on earth were we seeing people using paper, and charts, and walls filled up with charting, and you need three people to find it and give it to you. So right from the start... 2005 I'd say, is when we started with electronic records, people would look at me funny. They'd say, "How on earth can you have two staff to support so many practitioners?" "Well, they're not hunting for paper records. They're not trying to file the papers in that way." You know, even when we were building our office, the architect was pointing at me and laughing, and saying, "Well, why do you have such little chart space? You realize that you need six times the amount of chart space?"

Ashley 29:57
You'd need a library!

Dr. Singhal 29:59
Exactly, and I was saying, "Well, let's make sure we have data jacks in every room. Let's make sure that we're networked." He'd say, "What's networked?", or something like that. But yeah, there was some laughter at the beginning. But now, of course, everybody is using electronic medical records. And it would be unusual... I mean, we see it still, there are practitioners who are using paper records, who have just started retiring, who are sending their paper records to us, because we take on their patients. And yeah, I would say, going back historically, sometime in 2007 is when we started shredding all the paper. So, whatever little space was there - the architect might have been partly right, because they were starting to get filled up - but we scanned it all, and then shredded it all. And so we cleared it all out. And so we had more than ample space. And now, a lot of my colleagues wonder, "How do you have practitioners with this much space?" Well, it's all computerized, it's all digitalized. And, you know, there's robust backup systems, there's all these sorts of things. But everyone, I think, is now doing it, it's not a foreign concept to have electronic medical records, I would say 80-90% are doing it now. But there are other tools now too, and including online booking, including other automation. And you're right; the frontline workers in health care are burnt out. It is a challenging job. It's a very challenging job to be a medical office assistant, and anyone who says that's "brainless work" or "easy work" or whatever, doesn't know the system. Patients are very demanding, they're very worried, they're very... And maybe they should be, maybe shouldn't be... but the communication levels between practitioners, patients, and it all somehow moves towards the medical office assistant in terms of that worry. And so the tools and systems have to be in place to efficiently and reasonably communicate with patients. And, I kind of touched on this, if there's 50 people trying to call 9:00AM, or, you know, with some urgency on their mind, if that can be done in a much better way, where it can be asynchronous, and we can address their concerns through communication... Whether that be, "Here, you can book an appointment this way, speak to the physician, just with a few mouse clicks," and their issue's being resolved or assessed. You know, that's lessening the burnout of the staff, as well as the practitioners and, you know, it reduces tension. And it makes them more harmonious, it's an easier way to function. So I hope I'm answering your question, am I doing so?

Ashley 32:58
Yes. Kelly, you're gonna wrap it up, right?

Dr. Singhal 33:02
Yes. By all means, ask a follow-up if I somehow evaded the questions.

Kelly 33:06
No, no, no, it was great. You're doing good. Yeah, I just wanted to add that, definitely, technology and all these innovations are... It's kind of like a blessing in disguise... Because in terms of building more of these technologies, that means we are bringing more efficiency. However, we need to kind of pay attention to the mental health and well-being of these frontline workers, like you, and the staff at your clinic. And so, from the era of phone appointments, and now to video appointments, and more of these appointments are growing... Cortico really, really values a healthy clinic environment. So, reducing the number of phone calls, which we believe that reduces stress on MOAs, and doctors as well. So, creating a manageable clinic environment where it's... I think even these phone rings and phone calls affect patients as well in the waiting room. So definitely all these things really add up in creating a healthy or unhealthy clinic environment. And so yes... Ashley, do you have anything else to add?

Ashley 34:46
No, I think that Dr. Singhal covered all of our key points today. And I just wanted to say thank you for taking the time to sit down with us today, to discuss virtual health, and Kelly did you have anything to add?

Kelly 35:02
No, I think we're good! It was a pleasure speaking with you, Dr. Singhal, and thanks to everyone for watching, and see you in the next podcast!