Our next speaker is going to be Dr. Jonathan Edwards who I have known since 2015 when I joined his program at the Medical University of South Carolina where he is a professor as well as the department chair for the Department of Neurology. He is a past president of the American Clinical Neurophysiology Society. He has worked closely in leadership with ABRET and he's received numerous awards for teaching, research, and patient advocacy. Today he will be talking to all of us about access to epilepsy care in the post-pandemic era, something I think all of us are learning more and more about. Dr. Edwards. Good afternoon and thank you Dr. Schmidt and Dr. LaRoche for inviting me to speak. It's an honor to be here. We'll talk a bit about epilepsy care in the post-pandemic era. I have no disclosures relevant to this talk. We will review some significant changes in practice that have occurred that were triggered by the pandemic but are still going to be part of our practice today. And I'm also going to talk about some practical strategies to help optimize care in the post-pandemic era. The structure of my talk over the next 20, 25 minutes or so, I'm going to focus a bit on the post-pandemic era. I'll also talk about the role of telemedicine, which as you know, took off during the pandemic. And I'm going to talk a bit about remote work and epilepsy care. We talk about the post-pandemic era. First of all, do I mean that COVID is over? No. COVID is not over. So if anyone comes away thinking Jonathan Edwards thinks COVID is over, it is not. But the pandemic phase of it has settled down. Compared to the initial waves of COVID, we are seeing lower hospitalizations. We are seeing lower death rates. And that's a good thing. And one of the questions is, why are things going better now in terms of COVID? Well, one of the big factors, of course, is vaccination. Another factor is prior exposure. And the other also is just natural mutation and evolution of a virus. If you look at vaccination in the United States, data that were published this summer, about 677 million doses of the vaccine have been administered in the United States. If you look at the vaccination map, it does look a lot like a political map. But I won't talk about that further right now. If you look at the people in the United States that have had at least one dose, the good news is, if you look at seniors who are very vulnerable to getting much more severe or deadly COVID, about 95% of seniors have had at least one dose of the vaccine. If you look at the general population, about 80%. If you look at adults, over 90% have had at least one dose. In terms of completing the primary series, again, almost 95% of those over age 65 have completed the primary series. About 80% of adults, and about 70% of the population of the United States completed the primary series. The concept of seroprevalence means that between various different methods, we have some degree of protection. That could be because we've had COVID before. It could also be because we have had the vaccine. And in many of us, it's because we've had both. About 75%, 77% of our population now have had COVID. And the seroprevalence between those that have had COVID and those that have been vaccinated is now up at nearly 97%. So that's good news. But I need to remind you that viruses change over time. In fact, the things that viruses really do, they infect, they replicate, and they mutate. And that's really all they do. They don't have any hobbies, they don't cook, they don't fish, they don't play golf. They infect, they replicate, and they mutate. And as viruses mutate, mutation can make a virus more infectious or less infectious. It can make a virus more resistant or less resistant, and it can make a virus more lethal or less lethal. And the photo that I'm showing you here is not a photograph related from our COVID pandemic. This is a photograph from the influenza pandemic of 1918 to 1920. Remember that that was not the first ever outbreak of flu. Flu has been around for thousands of years. But this variant of flu led to about 500 million cases worldwide and killed, most estimates say around 50 million people. But this was not the first ever outbreak of flu. But something was different about that flu that made it devastating. So as we talk about the post-pandemic era, the federal public health emergency was declared ended on May 11th, 2023. But it is not the end of serious outbreaks of COVID. Our seropositive should help, but remember, it's important to remember, our immunity wanes over time without a booster. When I showed you those excellent uptake of how many people have been vaccinated, about 7% have had the booster. How many of you would consider yourself vaccinated against flu if you last got a flu shot two years ago? COVID-19 also, interestingly, will not be our last pandemic. It's the first one that most of us have had to deal with as healthcare leaders. But it's not the first pandemic and it's not going to be the last. I don't know what the next one's going to be. But hopefully the lessons that we have learned should help us prepare for the next. So for example, here's where I live. Right here, okay? And we live in Charleston. And every time we say, oh, we live in Charleston, people go, oh, I love Charleston, what a beautiful place. I love Charleston. Yeah, I do too. And it is a beautiful place to live. We're very, very fortunate. But every so often, mother nature speaks up and says, there's a downside to being on the coast, Jonathan. And that downside is hurricanes and tropical storms. And we don't get a lot of direct hits in Charleston. Fortunately, we're in a spot that doesn't take a direct hit very often. But we always, in any given year, could. And every year, we have to prepare ourselves for a storm that as we're tracking it, really could hit us or at least could have a devastating effect. We've gotten pretty good at preparing for those. We've all gotten good at preparing our homes, getting our families ready, and we're very good at preparing for these at work. And thankfully, most of the time that we prepare, we don't take a hit, and it doesn't have a huge impact on our operations and on our patients and on our families. But every time that we have one of these exercises, we do a debrief. We do this in our department with our senior leadership. We do this at the hospital administration level. We go, okay, what did we do well? What communication worked? And most importantly, what lessons did we learn the hard way? My recommendation is that you have not yet done, if you've not yet done so, think back to the pandemic and work with your leadership team and say, what did we do well? What communication worked? Like one of the things I hope everybody learned is that sending one email about something is not sufficient communication. In a crisis, you need to over-communicate. Nobody reads every single email that comes to them, so your critical information can't have all just been in one email. You need to over-communicate. What did you do in terms of operational readiness that kept your program going and maintained access of care for your patients? What innovations did you come up with? We came up, for example, we bought an iPad, and we bought a stand that the iPad could go on. I bought it on Amazon for like $35. It looks kind of like an IV pole, but your iPad can mount on it. We bought a little charger that you can clamp to the iPad that you can plug the charger in overnight, and that provides lots of juice for the iPad for the day. You can use that to round. At the height of a pandemic, when we don't have a vaccine yet, we were able to, instead of having to go with 12 people at a time and from one patient's room to another, because we've got medical students and residents and fellows and nurses, we went with a small group, just two or three of us, and everyone else was on remote. They can see what's going on. They can ask questions, and it was the next best thing to everyone being there. Now, do we use that now? No, but we remember how we did it. We've still got the equipment, and we could use that again in any other disaster that you could think of when everyone else can't be there to try to maintain the education of our team. But all of your centers probably have different innovations, and importantly, what we often don't do after a disaster is, okay, what lessons did we learn the hard way, and I recommend writing those down, recording them, so next time you don't have to start all over again as if you've never done it before. With the pandemic came the rise of outpatient telemedicine. Now, we were already good at inpatient telemedicine. At MUSC, we've had a stroke network that provides access to stroke care in almost every hospital in South Carolina. A lot of places have been doing this very, very well, but on the outpatient side, it was kind of dragging way behind. This is a press release from March of 2020 from CMS. Beginning March 6, 2020, Medicare, administered by CMS, will temporarily, an emphasis on the word temporarily, pay clinicians to provide telehealth services for beneficiaries residing across the entire country. That was in 2020. Overnight, we converted over to telemedicine. We were able to still see our patients. The patients learned how to use it, and it really made a really big difference. About 90% of our clinic visits during the height of the pandemic and before we had vaccines were provided by telemedicine for those few months. And interesting, this is a study from the CDC looking at 90,000 participants, and it was published about a year ago, looking at the previous year, and among 90,000 participants, 37% had used telehealth the preceding year. And interesting trends were actually seen. Telehealth was actually embraced more by women than men, 42% compared to 32%. I remember being in meetings with our hospital administration talking about launching our telehealth platform, and I remember one person after another person after another person raising the concern, like, yeah, but what are we going to do about the seniors? I mean, seniors aren't very computer savvy. They're going to struggle with this technology. We'll probably have a bunch of millennials logging in doing telehealth visits, but what are we going to do about the seniors? That was everyone's preconceived bias. But interesting, when you look at the data, we often, for like the seven billionth time, we find out that our preconceived biases are wrong. Actually telemedicine use was used the most by people over 65, second most by age 45 to 64, and the least by patients, by adults that were 18 to 29. The exact opposite of what we expected. There was a significant trend in telemedicine use by education. Those with the highest amount of education, college grads more so, and the ones that were non-high school grads were able to use it the least. And importantly, there was a trend with family income. And if we look at income as a percentage of the federal poverty level, those with a higher income access telemedicine more. Now, why is this important? Because part of the focus of this symposium and part of the focus of the way a lot of us are focused right now is, how do we improve health care disparities? How do we get to those that are less fortunate? How do we get to those with less resources, those in rural areas? And if the plan is just, we'll roll out telemedicine, telemedicine is actually disproportionately used by those with more money. But I will address that in just a minute, how we may be able to make some step forward on that. If we look at telemedicine use at MUSC, as I mentioned earlier, at the height of the pandemic and pre-vaccination, more than 90% of our outpatient visits were by telemedicine. And I looked at our data from MUSC across our entire health system, all specialties, not just in the Charleston area, but all of our hospitals. There are about 16 hospitals in South Carolina now that are MUSC hospitals. And I also looked at our Charleston data, too. It has been rock solid at 10% of outpatient visits within our system have been by telemedicine. And it has varied by like a half a percent to 1% month to month to month, absolutely steady at 10% for the last 18 months. So that seems to be the trend that we're on. In neurology, we're a little higher. It's about 15%, and it stayed very stable at 15% for the last 18 months. Psychiatry, if you're interested, is the highest at MUSC. It's about 40% of their visits are by telemedicine. In my opinion, this is my opinion, epilepsy is very well suited for telemedicine. Now, why do I say that? Well, the examination tends to be stable between visits. Contrast that to multiple sclerosis or myasthenia, where the exam is very different from visit to visit. The exam tends to be stable. EEGs, MRI, and labs can be reviewed remotely. And also from the patient perspective, driving is a common limitation. At a level four epilepsy center, you see a disproportionately high number of patients with refractory epilepsy. In South Carolina, if you've had a seizure, you cannot drive for the next six months. In some states, it's three months. Some states, it's 12 months. But either way, transportation's an issue. So now not only does my patient need to miss an entire day of work to get to Charleston, somebody else does too in order to get them there. And many patients that are treated at level three and level four centers live at a distance. It is not uncommon for us to see a patient that traveled four or five hours to come for a clinic visit. In my opinion, does it make any sense at all for someone to travel four hours both ways to get a refill of their lamotrigine? No. If you were starting over designing our healthcare system and that's what you proposed, you would be laughed out of the room. But what's the future of telemedicine? As I said earlier, when we had that proclamation by CMS that they were going to cover telemedicine visits for outpatients, it was temporary. And the coverage of telehealth visits in the patient's homes is set to expire December 31st, 2024. There is an exception for rural emergency hospitals of which there are many. And they will still be eligible as originating sites. So if you're thinking about a potential strategy where you might want to try to get care to underserved areas, partner with these rural emergency hospitals. A lot of these hospitals are really struggling. Some are going under. They are dying to make partnerships with tertiary centers. And if the patients can go there, there are patients across South Carolina that can get to a rural emergency hospital in no time at all, 20, 30, 40 minutes, but it's four hours to come to Charleston. This makes sense for the patients. And this is actually a carve out with the current proposal as it is where the patients will be able to do that and it will be covered. So if you've not started thinking about looking at partnerships with rural hospitals, this would be a good time to do it. You got 12 months and 29 days to get on that. Oh, and also, so what do I think is gonna happen about that expiration on December 31st? I promise you, I don't have any inside knowledge on what's gonna happen. There are a few possibilities. Possibility one, which is quite likely is it's gonna expire December 31st, 2024. Possibility number two, CMS could change its mind. They sometimes do, but usually not that often on something like this. Possibility three is they could publish a new code, which almost certainly would have a significantly reduced reimbursement for the facility part of that visit. I really don't know which one of those three things is gonna happen, but it's a good time to start planning ahead for the high likelihood that this will expire. The last big trend that came out of the pandemic was remote work. There are a lot of advantages to remote work, both for the employer and also for the employee. For the employer, some of the advantages, if you are at your center, if you have too much space, too much office space, too many offices, raise your hand. A single hand. Nobody has too much space. Everybody has not enough space. That's been the case everywhere I've ever worked in my medical career. And so if your group are working remotely, say 30% of the time, that's 30% less office space that you need for your staff. It's less computers that you need. And also, if someone gets sick, they're less likely to get everyone else in the office sick. It also, employees tend to like it. And there is a benefit to having happy employees. There really, really is. From the employee standpoint, why is remote work so good? Well, for many different reasons. Commuting is a big part of it. We live in Charleston, and most people, despite the fact that it's just a medium-sized city, it is not uncommon to have a 30 to 45 to one hour commute. My friends in New York would go, one hour, that's nothing. And that's kind of wasted time. And if you're an employee and you finish at five o'clock, you get to see your kids at five o'clock, okay? Not six o'clock. So there's that wasted time away from your family when you're really not able to be very productive. But also, it's less of a hassle to get started on work. I'm sure almost everyone in this room has done tele-visits before. Raise your hand. Well, I won't ask you to raise your hand. But I bet many of us have, at least once, had visits where, on the camera, you're dressed very professionally, but actually, you're wearing gym shorts and sweatpants. I won't ask everybody to admit if they've done that. I'm probably the only one. But there are a lot of advantages for our employees also. What are some of the trends in the workforce? This was a study published this summer, studied by McKinsey & Company, of 25,000 U.S. workers. And in healthcare, almost half work remotely, at least some. 31% of those, it's full-time, 14% part-time. But if you look at healthcare practitioners, not just support staff, practitioners, 43% work remotely, at least to some degree. 27% full-time, 16% part-time, with an average of half of the week being remote. This is a huge change in our work environment. So I mentioned some of the advantages of remote work. What are the biggest concerns about remote work? Really, the biggest concerns that I hear again and again about remote work are about productivity and getting the job done. Are they actually working? Some people are really good at working remotely. They get a lot done. And let's just be honest, some people are not. The other question is, are they working exclusively? I've seen several articles about some people who take a second job, because nobody knows they're doing that. That might explain why they're being less productive in the job that you're paying them for. The work quality, timeliness, responsiveness, and distraction can be an issue. If you've got someone who's really distracted in the office, they're gonna be a train wreck working remotely. Also concerns about HIPAA and other privacy issues. Very important. It's easier to control that in the environment within your office. It's very hard when you open it up to all that many people's homes. There are technical challenges that we've all experienced working remotely, and also security issues. And our IS people, they look at how many different points of vulnerability this opens up when your network is now opened up to that many different homes and people with various different levels of sophistication in their home. It's also a burden sometimes for those in the office. Those that are remote say, I can't do that, and they pass it on to someone who's there in the office. That sometimes causes some ill will in the office. A real concern with people working remotely is a bit of a disconnection from the team, and also with newer employees, a loss of learning and mentorship opportunities. But the reality of remote work is that our workforce has changed rapidly, and ignore those changes at your peril. It is hard to deliver cost-effective, effective care when you don't have your staff. A couple of insights, so I was talking to our department administrator, David Chandler, who's wonderful. I asked him, in the last two years, when you think about staff that have applied for jobs in our department that have gotten as far along as an interview, how many of them have asked for at least some of their time to be remote, and that that would be a critical part of them deciding whether or not they'll take their job. In the last two years, all but one. All but one in two years. And he was in another meeting recently with all the other department administrators, and several of the administrators were saying, we're probably gonna eliminate remote work in our department, and the medicine administrator said, okay, you sure you wanna do that? Because if you don't allow remote work, your best workers will soon work for me. And the reality is, if you don't embrace these changes, you're gonna be short-staffed. So what do I recommend? I recommend allowing remote work if it's possible. Obviously not for a job that can't be done remotely. But you need to have a clear, transparent, fair remote work policy that spells out in advance, what is remote work, what is sick leave, what is personal time? That helps eliminate a lot of misunderstandings down the road. You need to emphasize quality with timeliness and responsiveness, exclusivity of that time that they were working for you. HIPAA and privacy has to be assured, and technical and connection requirements. Any limits that you place, like you say, okay, we will allow each of our folks in this category to have two days working remotely. If someone wants a higher amount than that, it should be based upon performance. It shouldn't be based on personal decisions or your own biases. And also, given the fact that it does tend to fragment teams you should create new opportunities to engage and develop your team. Remember that disasters can greatly accelerate needed change, and in just four years, our workforce has changed tremendously. The way that we deliver care has changed. And it's gonna continue to do so. Do not fight those changes. I recommend that you embrace them and find ways to help your program and your patients thrive. Thank you.

epilepsy care

telemedicine

remote work

COVID-19 pandemic

healthcare practices

economic disparities