Telehealth in Integrative Medicine in the Covid-19

Era Rashmi Mullur, MD, has been an endocrinologist with UCLA for three years. Prior to joining UCLA, Dr. Mullur has worked towards advancing integrative medicine for Veterans at the Greater Los Angeles VA. She has pioneered several clinical programs using integrative medicine techniques for the management of chronic disease and is a national leader on the use of integrative medicine for patients with diabetes. She has published on the use of experiential learning modules to residents about integrative medicine, and has written several educational curricula in integrative medicine. Her clinical interests include the use of yoga and mind-body approaches for diabetes, integrative approaches for stress management and fatigue, and the judicious use of herbal and micronutrient supplements in chronic disease.

As the education director of the UCLA Health Integrative Medicine Collaborative, Dr. Mullur works with senior leadership and the medical director to coordinate educational efforts in integrative medicine across the campus. Her expertise in medical education and integrative medicine will be integral to developing our program with academic rigor.


Alternative Therapies in Health and Medicine (ATHM): Today we’re going to talk about your presentation at AIHM about Telehealth.

Dr. Muller: Yes. Telehealth, and integrative medicine specifically.

ATHM: Okay. Maybe start off with a little bit of, just a brief background about yourself.

Dr. Muller: Yeah. So I’m an integrative physician who’s been practicing for over 10 years with a focus on endocrinology I’ve led educational efforts at UCLA in integrative medicine and for several years, I’ve also innovated in telemedicine for chronic disease management, started the tele-yoga program at the Greater Los Angeles VA and the tele-diabetes program there.

ATHM: You primarily focus on telemedicine for chronic health issues?

Dr. Muller: Predominantly, yes. Telemedicine has been used widely since the pandemic, And I helped expand telemedicine use at the Los Angeles VA across ALL specialties, including in primary care and even in tele-urgent care, but longterm, telemedicine is best suited for helping people manage chronic disease.

ATHM: And which diseases do you think are most effectively utilized by telemedicine?

Dr. Muller: The data for supporting telemedicine use, the data is predominantly before the pandemic, and the data really supporting its use is in diabetes, high blood pressure, hypertension, as well as heart failure. And, as well as mental health disorders, primarily mood disorders, depression, anxiety

Those are the areas where the VA was really focused on providing its care because the veteran population does have multiple comorbid disease and wanting to make sure that we can provide adequate care and increase access, and decrease cost.

ATHM: Do you find compliance issues with patients participating in telemedicine

Dr. Muller: Patients like using telemedicine.  They have less burden with travel and it can increase access to care for our rural and disabled veterans.  The challenge is that we need the infrastructure in place to make sure people have access to digital health equipment, smartphones, and broadband access.  Also, in the virtual setting we have to rely on patient’s reports of their vital signs, as well as patient reports of their blood glucose measurements, et cetera. We often use a mix of the patient’s own health equipment (scale, a BP cuff, etc), and at the VA we have the infrastructure to provide digital tools for the patients. We can get as advanced as a digital stethoscope for our patients heart failure. Also, many of our blood glucose meters can be remotely monitored or downloaded. So there’s a lot of opportunities we have to still get the health data that we need to provide care.  We have trained both patients and providers on feeling comfortable in using the virtual medical exam room.

ATHM: And what types of challenges do you see there?

Dr. Muller: It’s interesting because there are challenges, but there’s also real benefits and opportunities. Beyond access, which is a very real challenge for our vulnerable patients, the main challenges in telehealth for integrative medicine surround the physical exam and establishing connection.  Many integrative providers, whether it’s acupuncture or other approaches, they really do prefer to lay hands upon patients, and that is not an option in the virtual space.  There is also some concern about establishing that rapport and connection. And so that can be a little bit of a challenge with the screen—whether its delays in connectivity and speech, patients who are hard of hearing, or just the fact that we need to be more mindful of our “webside manner” or “netiquette.” But I think, those minor hurdles are overcome, and then the benefits of integrative medicine are really key, especially benefits of tele-integrative medicine are really key.

So, it returns the care to the home. So I can see a patient in her home, evaluate their home environment, especially integrative care when we’re trying to provide whole person care, to see a person in their home and provide that, and be able to have that 360 view of their life, gives so much more information. It helps us care for not only the patient, but also if a patient has a caregiver, helps us also provide a look into the caregiver’s life, and offer support there.

It’s also a really nice way to incorporate mind, body techniques, whether it’s group-based classes or remote apps that allow patients to use mindfulness, or yoga and Tai Chi, as long as the patient has had some exposure, these are nice ways of sustaining these practices.

And then finally, it allows us to really explore with these new digital health tools, the benefits of integrative medicine and the new way, right? So if I have a patient who is using a remote blood sugar monitor or a remote blood pressure monitor, I can see the effects of these integrative modalities in real time with the use of these digital tools. So, it’s really kind of an interesting landscape, and I’m excited to see where this will develop into the future.

ATHM: Do you find that the patients who participate in telehealth visits with you are more likely to participate in other sessions that maybe your clinic offers?

Dr. Muller: I certainly have seen that. I have the good fortune of working at the VA. One of the things I will highlight in my talk is the VA really had a confluence of innovation in both telehealth, as well as integrative medicine, kind of establishing these programs and establishing the infrastructure around these programs well before the pandemic. So once we got into a situation with the pandemic where we needed telemedicine to just see patients, and the use of integrative medicine has grown in popularity because we now understand the burden of stress and trauma and grief so much more with our lived experience.

ATHM: Have you seen a spark for integrative telemedicine as a result of COVID?

Dr. Muller: It really just got everyone to really scale up telemedicine. I mean, prior to COVID, telemedicine was something that was looked at by large health systems like the VA and Kaiser, to try to take care of a multi-morbid disease population to predominantly decrease cost. But once COVID hit it became a necessity, it really then started a lot of innovation in this area. And what we found, since COVID is that patients really love this. Patients are happy to have telemedicine. They don’t necessarily want to go back to full in-person care.

And I think what we’re going to find, as we move forward, is this model of blended care. Telemedicine is certainly not going to replace face-to-face visits in traditional care or an integrative medicine. We’re still going to be seeing patients in our clinics, but with telemedicine infrastructure now in place, and access improved, we can now have increased contact with our patients without the burden of travel, and we can incorporate other providers into this care.

Part of the regulatory landscape that changed with COVID is that there were more people that could bill for telemedicine. It used to be only physicians but now we have nursing, social work, physical therapists, dieticians, who can now get paid for services delivered via telemedicine, which increases your ability to provide these services for several patients.

ATHM: We’ve talked a lot about the patient experience. How about the doctors? How do they relate to being able to do telemedicine?

Dr. Muller: It’s a learning curve. I spend a lot of my time in education, and so one of the things that we’ve really had to do is provide education and training to our physicians on how we best utilize telemedicine. There’s patient factors, like we talked about, there’s also patient diseases that make telemedicine easier, and we’ve educated providers on that. We also had to kind of walk them through, just kind of what we call netiquette. Like how to frame yourself in a visit, what are the do’s and don’ts of a telemedicine visit, whether or not you have to have a chaperone in the visit. These are things that we have developed training tools along the way. And certainly that provider comfort is increasing. I think, when you have a younger generation of physicians, who has been online for a long time, it’s less of a hurdle. Certainly the physical exam component has been one of the biggest barriers. These digital peripheral tools that we have do make it easier.

ATHM: What about reaching out with follow ups?

Dr. Muller: Absolutely. Yeah. Especially in diabetes care. So much of what we do is guiding the patient in self-management. if I make a change, I may not see that patient in the clinic for another three months, just because of the challenges of getting a patient into clinic. But, if I have the option to do a video visit, I can have either a nurse from my office, or a diabetes educator from my office, or myself, do a quick check-in with the patient, just to follow up on their blood sugars. And the ability to remotely transfer that data for interpretation is also becoming easier, and the fact that you can bill for that now, and actually get credit, per se, for taking that time, makes providers more involved.

ATHM: To wrap up can you summarize the goals of your session?

Dr. Muller: I think the key points that I’m going to make sure that I mentioned at the talk are that integrative medicine modalities can definitely be delivered via telehealth, it’s feasible and effective. And I’m talking primarily about mind, body programs, yoga, Tai Chi, things like that. And the use of those modalities with already established pre-COVID and pre-this landscape as being something that’s useful in the management of chronic disease. We knew already that yoga was good for blood pressure, and mindfulness was good in diabetes and multiple medical conditions, et cetera. As we all pivot to kind of a blended telehealth, face-to-face kind of medicine there is an opportunity for integrative medicine to be more integrated into care.

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