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The Geriatric 5M Approach to Telemedicine Assessment: A Podcast with Lauren Moo


On todays podcast, we have Lauren Moo, a cognitive behavioral neurologist who has been doing video visits well before the COVID-19 pandemic to decrease the need for travel and to decrease the agitation in older adults with dementia that commonly occur when a clinic visits disrupts the usual routine.  

Now with COVID among us, Lauren talks to us about her recently published JAGS article titled "Home Video Visits: 2‐D View of the Geriatric 5‐Ms."   In the article and on the podcast, Lauren walks us through assessing the Geriatric 5M framework: mind, mobility, medications, multicomplexity, and what matters most.  

Lauren gets very practical with us about how she does things like a cognitive assessments in this new medium of telemedicine.   One thing I'd like to note that we didn't talk about in our podcast, but Joe Ouslander wrote in the accompanying editors note to Lauren's article:

"I recommend that you discourage patients and families from using the backgrounds of outer space, peaceful woods and lakes, or other fancy pictures that are available on Zoom, Webex, and other virtual meetings. Doing so will hide what could be extremely valuable information when assessing the M’s of geriatrics."

So take a listen and maybe even sing along to Alex's version of "Video Killed the Radio Star".


  


You can also find us on Youtube!

 

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TRANSCRIPT

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have on our Zoom GeriPal Podcast?

Alex: Today, we have Lauren Moo, who's a cognitive behavioral neurologist. I believe she's the first cognitive behavioral neurologist we've had on GeriPal. She is at the Massachusetts General Hospital and at the VA in Bedford, Massachusetts. Welcome to the GeriPal Podcast, Lauren.

Lauren: Thanks so much.

Eric: Lauren,, you had a wonderful recent paper in the Journal of American Geriatrics Society, JAGS, on home video visits, 2D-view of the geriatric 5Ms. Love to talk to you about what you're doing as far as assessment and a little bit more about the article. But before we do, you have a song request for Alex.

Lauren: I do. I'd like Alex to play Video Killed The Radio Star.

Alex: Can you tell us why?

Lauren: Well, it seemed it's a song about video taking over the older modalities and it's actually an interesting song. It turns out that that video for the song was the first video that was broadcast when MTV was new.

Alex: Really?

Lauren: Yeah. So it's really all about shifting paradigms in terms of media and approaches.

Alex: I didn't realize that was the first. That's awesome. Here's a little bit of the beginning.

Alex: (singing)

Eric: Lauren, I'd love just a little history. Before February, March of this COVID year, were you doing a lot of video visits, telemedicine?

Lauren: I was. I've actually been doing video visits for dementia management with video into the home since 2013. So I was an early adopter.

Eric: Wow. And how was it going prior to COVID as far as doing your visits and what do you do during your visits?

Lauren: So, I have again pre-pandemic, most of my visits were dementia followup visits. So seeing patients who had already been established to have some kind of dementia either by me or somebody else in person brick-and-mortar clinic. But then the subsequent sort of management visits were by video into their home just because there was a lot ... Well, first, I thought it was cool, but also families seemed to think it was more convenient and easier for them instead of having to come into the clinic, especially because a lot of the visits were talking. There was not lots of hands-on assessment after the initial diagnosis.

Lauren: So talking about how somebody is doing in terms of their cognition, their behavior, their mood, home safety issues, had there been any wandering incidents or falls? Have they had any problems with sleep disruption, incontinence, what kind of status they're in regarding ADLs and IADLs and stuff like that? Essentially, find out how they're doing and depending on the patient's stage of dementia that would either be a conversation largely with them, with the sort of a family member by their side or half and half or in later stages, often it's mostly an informant telling me.

Lauren: But really not very different than an in-person visit in terms of the content.

Eric: Did you see any benefits of doing these video visits over having them come in besides just families liking not having to go to the clinic?

Lauren: Definitely from the family point of view, it was convenience regarding travel. And again you said I'm in Massachusetts, so weather. Most people with dementia, their primary family caregiver is a spouse. Usually, the primary care giver is also an older adult who having them travel in inclement weather is challenging as well.

Lauren: But other than that sort of convenience factor, one of the other main things that families told me their reason for liking them was a decrease in how much the routine of the person with dementia was disrupted that getting ready to ... It wasn't just to literally the travel but the planning for travel, having to wake up early, being sort of agitated about the visit, worried about the visit from the part of the person with dementia, that that would really throw off sometimes the day before and the whole day after the visit.

Lauren: So it was really disruptive to come in, in terms of how the person with dementia would behave. And so families really appreciate it. There was less disruption because it was just half an hour in their house. So that, from the family point of view, was the other main benefit that they reported to us.

Lauren: From my perspective, I really like the idea that you can see people in their behavior potentially in their actual contexts. Sometimes, people are on better behavior when they're at the doctor's and they don't display some of their behaviors that they really do at home. And they might display those behaviors that the family is describing but that they don't do when they're in the clinic if you're in their house with them even virtually. And I think that ... I also have seen things and family dynamics that I don't think you see again in a clinic.

Lauren: People comport themselves better when they're officially in a doctor's office. I think they do, than they do at home. There's that as well.

Eric: Much different kind of picture. Even before COVID, as a clinician going into their homes virtually, what kind of challenges were you experiencing?

Lauren: The biggest challenge is by the far our technology challenges. Partly early on, we're talking way back especially in 2013, 2014. We sort of tracked who we invited to try the video visits and who the client and a lot of the people which declined, the number one reason back then was lack of having a computer or internet access at home.

Lauren: Those numbers have gotten somewhat better and I think certainly with the pandemic, people are motivated to get a device when they can afford one. And certainly in the VA, there's also a mechanism for supplying people with connected devices, so that has helped as well. But that's all newer.

Lauren: But lack of access to the technology or lack of comfort with the technology, I think, are still some of biggest barriers. Other people are just not comfortable with the idea or even if they want to try it, they don't access. I think that's the biggest barrier.

Eric: Historically, one of the issues around access too is that the technology was a little bit cumbersome as far as it wasn't just sending somebody a link to join. They had to do a couple of hurdles. What was it like for you? What kind of platform are you using?

Lauren: So, early on, until I think a couple of years ago, I was doing most of my video visits through the VA where the platform was much comfier to do home visits. And that made it challenging not so much for me but for the family. They had to have a unique email for each visit and they had to copy a password from that unique email into a completely different platform and the password was one of those gobbledygook email passwords.

Lauren: And then we had to make sure ... Sometimes I would have a successful visit and then I'd go to do another visit a few months later and they couldn't connect and it turned that they're ... For example, their computer was set to have remembered the password. And so it stored the password from three months' ago visit and now, they couldn't get on just by pass, all sorts of problems.

Lauren: It's much better with the current software. And the same thing is true at Mass General, because I was doing video visits pre-pandemic there as well. And the platform we had was also much comfier, and has become much more streamlined now during the pandemic. There's a while where it was very chaotic everywhere when everyone was scrambling.

Lauren: But I think at this point, it's come out the other side much easier from the patient and provider side in terms of essentially just clicking on a link.

Alex: Yeah, that's terrific. For our listeners who may be interested in specific software platforms, what are you using now? Are you using Zoom or Citrix? What's opened up from the working and what platforms have you been frustrated with?

Lauren: So, at the VA we now used something which I think is proprietary to the VA called VVC, which I think is Veteran Video Connect. And that is launched from an email that they get. So from their perspective, they literally just click on the link in the email and it is launched.

Alex: That sounds good.

Lauren: Which is much better and they don't have to have multiple windows opened ... I mean, before, they had to have multiple windows opened which is hard for anybody.

Alex: Right. That sounds like Zoom. You just click on a link and boom, it's there.

Lauren: Now, I know, Mass General has changed platforms during the pandemic. We now have Zoom integrated into Epic. And so right in my schedule for the morning, there's a video camera icon next to each patient's name and it turns green when they check in and I literally click on the green video camera icon and it launches my Zoom.

Lauren: But there's concerns because back at the beginning of the pandemic, they were allowing people to use almost any platform. And as we know, there were issues around privacy and stuff with Zoom and other platforms which they've now addressed. HIPAA compliance and-

Alex: You've never had a Zoom bomber interrupt a confidential-

Lauren: I haven't, but for example, the Harvard default for all of the Harvard hospitals with Zoom is now that you have to admit people in from the waiting room. There's not an option to even undo that. Just a little challenging when you're having a research meeting and you have to admit every single member of the team but definitely, I understand why that's the default now.

Eric: Now, as we go into the COVID era and specifically, maybe we can dive down into the practical aspects of how you're thinking about assessment. You wrote this paper in the Journal of American Geriatrics Society on using the geriatric 5M framework. So the 5Ms for our listeners are mind, mobility, medications, multi-complexity and what matters most.

Eric: You wrote a really wonderful paper on kind of how you also think about assessing the 5Ms using video visits. Is it okay if we kind of dive down into that? I'd love to start off with how you're thinking about the 5M framework starting off with mind as far as when you're on those video visits. What are you actually doing?

Lauren: So, I think the mind part is obviously as a cognitive behavior neurologist, that's sort of my principal focus in general. But you might be surprised to find that my approach is actually not very ... It's not super standardized perhaps because I'm a neurologist, I'm not using necessarily a formal screener. I'm not just screening people with a tool like an MMSE or a MoCA usually.

Lauren: But certainly, I have those tools in my toolkit. My approach is actually, in part of it, maybe because I'm old enough to pre-date the MoCA and other tools that people now used as their only mental status tool. I generally do a large part of my mental status evaluation just talking to the patient, what they think. It's almost like the equivalent of chatting with them on the way in from the waiting room, just checking in and seeing how they're doing and asking them how about the Red Sox or whatever.

Lauren: I think that their interests, if I know them already what they're interested in, I find it a lot of ... You can tell a lot if you just pay attention to how people are doing. Are you talking or they're deferring to the person with them? Are they answering my questions or are they evading them? If I'd say, "Oh, how have you been spending your time since I last saw you?" And they are very vague, I try to pin them down.

Lauren: Can they actually discourse on what they claimed to be interested in? Because often, I'll find people who just sort of say something like, "Oh, well, I don't really follow sports anymore," once they've said that's what their main interest is. And then you say, "Well, what do you do with your time?" And they say, "Well, I pretty much just watch TV." Then, I'll say, "What do you watch?"

Lauren: Essentially, trying to not just let that be chit-chat but using it to interrogate them without them knowing it.

Eric: It's kind of like when I think about falls in a gait assessment. I feel like one of the best assessment is actually just watching your patient go from the waiting room into your clinic. And you can learn so much. It sounds like similarly you'd hear like as an intern, you always learn like A&O x3, which is like the worst cognitive assessment out there.

Eric: But rather just having a conversation, you can learn so much more about what's happening with your patient. Is that right?

Lauren: Right, and that is one of the things that, again even outside the context of videos, I try to emphasize with trainees is that even if you don't do something formal, if I were to quiz you on what ... Was he fluent or was he not fluent? Was he oriented or not? Did they seem to have word finding problems? You probably know that if I just ask you.

Lauren: So it's really just a question of stepping back and realizing that if you increase your powers of observation and be mindful of their responses during your sort of chatting, that you actually are getting a fair amount of a mental status exam or at least clues that there's maybe something up that you do need to assess more deeply.

Eric: And when you're assessing this, this could be, as you're doing the assessment, potentially emotionally challenging for the patient and if there's a caregiver. Do you ask for the caregiver to be there? And how do you balance talking to the caregiver, talking to the patient, like seeing how if there's disagreement or agreement?

Lauren: Yeah. I'd say that's potentially trickier in video. I think in person when I'm, say, doing something more formal like if I'm actually doing a pen and paper sort of standardized tool like a MoCA. I'm anti-MSSE, so I will not use that as an example. I used some body language to make it clear that the person accompanying them is not to answer. I will say, "Please, I'm just trying to ask Mr. Jones these questions. So if you could keep quiet."

Lauren: I have to say that much more explicitly in a video call because they're both sitting there next to each other on the couch. I can't sort of turn my body and essentially use body language to exclude the other people in the room the way you can in a clinic visit.

Lauren: So I'm much more explicit, as I said, about this is just ... I don't want the other person to help. Those issues also come up if somebody is potentially going to ask for help. If you are testing somebody in your office, you can see if they're looking to the side and asking for help. Or if they're writing words down and you're trying to have them learn words, you would see it.

Lauren: I have yet to have that happen, but I have some of my neuropsychology colleagues have had people where they realized the person was writing stuff down or looking over at a calendar or the clock for orientation questions. So there are nuances to doing it in video, and you have to be somewhat mindful of them.

Eric: Yeah, I spend most of my time in an in-patient setting and there's like a clock usually right on the wall. I'm always impressed how nobody actually ever looks at clock when they're drawing the clock. And that's a sign like, "Oh, they're talking to the side. This is pretty good. They know there's a clock there."

Lauren: They're resourceful. They're resourceful if they do do that, right?

Eric: Let's say you do want to do a little bit more of a standardized cognitive screen, how are you doing that?

Lauren: So, if I wanted to make it standardized, I guess I would say I do sort of small, medium and large in terms of standardized. My most informal is much more the sort of chitchat version and if they seemed okay or about the same as they were last time I saw them, I might not go any farther.

Lauren: I sometimes do sort of just an on-the-fly mental status exam where I will sort of assess naming and learning where if I just ... Honestly, I'll hold things up that I just have in front of me. I don't like pens usually because that's a very high frequency word that's too easy to name. But right here on my desk at home, I can ask people to name things. So, I just held up a stapler, for example.

Lauren: So that you can just grab things, scissors, stapler, things that are on your desk, body parts. I ask people to name things and point to them, obviously, ones that are visible on the screen. But I have also prepared, and again, I don't know that everyone needs to do this, but I have actually prepared little PowerPoint presentation that I will do a share-screen.

Lauren: It's just sort of the first part of roughly parallel to the MoCA but it's not the MoCA since you're supposed to be licensed to do the MoCA, which I am but not everyone is. But I have things like a picture of a cube to ask them to copy. And then I have instructions for drawing a clock sort of written out and I ask them after they do things like that to just hold it up to the video camera. And I do a screen shot.

Alex: So you would ask that they draw it on a piece of paper, and then they hold that up to the camera? You take a picture of it, and then so you can look at it in more detail later?

Lauren: Yeah. And I sometimes incorporate them right into my note, a picture of the bad clock they drew or something. Obviously, they do it perfectly. It's not worth copying into the chart. So, I've done that. And then I have some line drawings of things again from sort of high frequency easier words up to somewhat moderate frequency words which are harder to name. And they just name these.

Lauren: And then the other things are just verbal. You can ask people to learn lists and to do many of the other element, do abstraction or serial sevens or all of those kind of things. Those are all just verbal. Again, potentially having to worry about people cheating but again I have not had that so much in a dementia context so far.

Eric: Like you said, that indicates resourcefulness which is a pretty good cognition for that.

Alex: Was that the robust assessment?

Lauren: I would say that's a robust assessment. Again, most other things, if I'm going to do more, most of them probably have more time to do them than a primary care person. But again, I can do a full digit span, not just a screener version but until people can no longer name the digits forward and backwards. You can do all sorts of things.

Lauren: I actually have some other sort of parietal lobe screening tools that I'm a fond of. I have a little paper on from fellowship about doing things with interlocking finger figures, which again, you can do by just ... You just make sure that you're holding things up into the camera so people can see. You can do more than you might first think you can do, I would say, for cognitive assessment, although that may take some planning. But if that's part of what you want to do, a small investment in time, I think in practice, you will realize that you can do a lot more.

Eric: You mentioned the JAGS paper potentially thinking about using like the MoCA version design for blind people.

Lauren: That version is minus visual things. If you don't want to spend the time to have people to develop something where you put up a cube so that they can copy it and do the clocks and stuffs, then you don't need to do that. But I think anyone could ask somebody to do the clock drawing without putting up visual instructions and just ask them to hold it up. You could have them hold it up at each stage, the circle, the numbers and then drawing in the hands. Clock drawing is a very sensitive task, so that's a pretty good assessment.

Eric: And any other practical advice for our listeners on assessing the first M, mind, whether it'd be mood or mental state?

Lauren: I think the other aspects are similar to in-person and that you ask if people have felt sad lately, tearful, et cetera. I think one wrinkle that's a little different is sometimes people are ... In some of our clinics, we have the person with dementia separate from the family caregiver who's the informant for part of the visit so that the family member can describe some things that would otherwise be upsetting to the person with dementia. And that is you have to sort of orchestrate that ahead of time in a video visit in a way that you don't always have to in-person in clinic.

Lauren: I have a number of family members who would like to tell me about certain things about, say, delusions or violent outbursts or new incontinence issues, certain issues that come up in dementia management that they're not that comfortable talking about in front of the person with dementia. And so, I have made it clear to most of my patients that if they want to do that, that at the time of the supposed start of the visit, it can be just me with the family member and that they can then go get the person with dementia to join us for the later part of the visit.

Lauren: That's also easier in the house. By doing that virtually, the person with dementia may be sitting in the other room watching TV and that family member just goes and says, "You know, the doctor is here on the computer for you now. And in fact, we've been talking for 10 minutes."

Eric: Has that worked generally pretty well for you?

Lauren: That works very well. And a lot of times, if it's a 30 or 40-minute visit, the person with dementia depending on their stage is not ... Their attention span is such that they don't want to sit there for that long anyway. I haven't had any of my patients with dementia push back on that. Again, they're fine with just seeing me for 20 minutes and not 30 minutes.

Eric: Then I guess also from a behavioral disturbance's perspective, you probably got a sense of actually what the home environment looks like as far as thinking about how to address some of the behavioral disturbances that we see in dementia and potential triggers for that. Is that right?

Lauren: Definitely. So often, the person will ... They may get distracted and wander off and you can kind of see what's distracted them or they may be very ... I've had patients who look actually more calm than they do in the clinic, again because they're a little agitated by being in the clinic. And yet on the video, they're sitting there and they are, say, petting their dog or fiddling with something that makes them more comfortable or they get up and go to the bathroom and come back. They're not worried about not knowing where it is, for example, because they're just at home.

Lauren: I'd also get to see their environment in terms of other elements that are important for dementia home safety issues. For example, knives in a knife block on the counter behind their head.

Alex: Oh, boy.

Lauren: Right, which a lot of people have a knife block in their house, which is fine, but in certain settings and stages of dementia, we worry about that, grabbing a knife out of the knife block. Or you can see a lot of clutter. I've had who ... The burden of caregiving is such that they're not able to keep up with housekeeping as well and it just sort of snowballs to the point where their house is very cluttered, and now, it's also fall risk and is adding to the tension in the room and the home too.

Alex: I really appreciated how in your JAGS paper, you started off with a story of this person who ... Through the challenges of video and the two-dimensional screen, you got a sense of what's important to him when he wandered off the screen and came back with a painting from his art flats. And so, this idea of trying to understand like what's meaningful to patients and their caregivers and the ability to elicit that in the home setting better than it might be in the clinic.

Lauren: Also, there's another patient I didn't mention in the article who I think of who was one of my earliest patients whose wife ... I've seen them a number of times in the clinic first. So then I was transitioning to trying the video at home stuff. And he'd always come with his son, and his son didn't live with him. His son lived nearby but he brought him to all the visits because his wife, who was a primary care giver was in a wheelchair.

Lauren: So I'd never met the primary caregiver until I then did a video visit with them and now, because it was so much work to bring the wife also in the car to the clinic, now I was able to have a direct conversation with the wife. And I could really see these sort of dynamics between this quite physically spry person with dementia, and this quite cognitively with it, but physically limited wife in this really interesting complementary partnership that they had that I would not have appreciated in just our in-person clinic because I never met her.

Eric: Let's talk a little bit about maybe some practical pearls on the other four of five M's. So, you already talked a little bit about mobility and the advantage of seeing what the home looks like. Are there slip rugs, other things that could be an issue of mobility? Any other pearls that you have as far as when you're looking for that mobility M?

Lauren: Again, I think if they're getting up to go get something from the other room or I have had them asked, excuse themselves and say that they want to go and do something. And I'm fine with that partly because I do get to see them walk. I can see, do they need to use their arms to push up from the chair? Do they just stand up? Do they need somebody to help them get up? Do they have to be reminded to use the walker? You get all that in the home in a way that ...

Lauren: You can get some of that in the clinic, but some of it is actually, again, [inaudible 00:30:52] in the home because if they're in your clinic room, their walker is one of the only things there. They're less likely to forget it, right there in front of them, but if it's among the things ... If you want to do more of an assessment, I have checked people for tremor and stuff. Again, you can just have people hold their hands out, check for tremor because as you know, there's a lot of Parkinsonism that comes in later stages of many forms of dementia. It's not perfect. I definitely think that that motor exam is not as good as in person.

Eric: Yeah. I'm thinking back to med school. The only time in med school I was ever taught about a gait assessment was in my neurology rotation. Any tips as far as, because I can imagine like seeing somebody's complete gait on like a Zoom camera maybe difficult because you're only seeing a part of it. Any tips for assessing gait on Zoom?

Lauren: I confess I have not tried as much, but I think you would ... Depending on their home orientation and where they're going to go get something for you or entering the room, you may only see a little snippet as you said. I think if you're concerned about their gait, you have to ask them to position the camera such that you could see if they walk into the next room and back or down the hallway or something, which bring up a lot of doing these video visits into the home, there is no tech. You are the technologist. You're advising. You are essentially trying to coach the family in doing some of the tech.

Lauren: We have helped getting them set up initially with the technology but I do a lot of coaching about how to unmute or how to adjust the lighting so that [crosstalk 00:32:44]. You have to be prepared to do a little of that tech troubleshooting on your own.

Eric: Real quick, other M's, we're going on to medications, any pearls around assessing the medications?

Lauren: For me the big pearl is that they have all their medications there at their house somewhere. You could potentially do a more thorough medication reconciliation in the home than you might be able to do in the clinic because there are all those PRN meds that they don't mention to you and over-the-counter things and vitamins.

Lauren: I've had patients who say that they're taking some kind of naturaceutical or Chinese herbal mix or something like that, and I don't know what it is. I don't know it by brand and they will say, "Hey, I'll go get it," and they bring it back and they can either read it to me or at least show me the labels so I can google it and look up what it is that they're taking. Where if in person, you wouldn't have known. They would just say, "Oh, and I'm taking something that my healer gave me," and you don't really know what it is.

Lauren: Those are some additional benefits, I'd say. You can find out what that new prescription that somebody in a different medical system network gave them where they just go get it.

Eric: Last two, multi-complexity. You gave a couple of stories including in your JAGS article, including the opportunity to meet a patient's adult child with special needs and learning that it's not really making future plans for the patient with dementia but also her daughter as well. I love that thinking about multi-complexity, not just like somebody with lots of organ dysfunction or comorbidities but like what everything around them may be complex.

Lauren: A complex social network. Most people, it's not just them and their one caregiver they live with or something like that. There's a whole complex network of people and financial burdens that they suffer. And I think you sort of see that writ large in their home. You get a sense of what that network is and what some of those other challenges are. Again, if you look.

Eric: And last one, last M is what matters most? Any practical tips around assessing for this?

Lauren: I think that a lot of what you see in their home can be good conversation starters, if you will, to ask them about what matters most. Is it living longer because of their granddaughter's upcoming wedding? Or is it about being able to continue with that hobby that they really love because they just came and showed you this model both that they've built or whatever? It really is sort of entree into those conversations that's I think are little different than in the abstract again in a kind of clinic or hospital setting.

Lauren: And I do feel like I've visited their home by visiting their home through video in a way that is more personal, and that I think many of them appreciate that it's almost like a house call, like you've really gone into their house. And so having that conversation again doesn't feel quite as clinical. It feels like a real conversation with another, not that we're not humans but just I'm in their home so that that conversation is in the context of not just scary clinical setting.

Alex: That's such an optimistic and refreshing and encouraging view of video visits, which at first watch, you're like, "Oh, my gosh, I have to meet this person through a screen," as you described, a two-dimensional view. And yet you're talking about how this opens up a level of relationship with patients that is similar to making house calls because you're invited into their home, because you're seeing them in their closer to natural state outside of the clinic setting. And because of that level of intimacy of being as window into what's happening in the home setting. It's such a fascinating contrast.

Lauren: And obviously, I don't want to paint a picture saying it's all roses. I think the technical technology challenges are the flip side of that. That's really been ... There's audio lag and video lag and challenges with access. And so as much as I'm painting a rosy picture, I also feel bad that not everyone can necessarily do it. But I would say from the point of view of clinicians, I do hope that people realize that if you just think of it that way and open your eyes to what you can observe and some of those opportunities that they can be really rich.

Eric: Okay, one question. If you had a magic wand, you can make one change as far as what providers do or potentially from a policy perspective or healthcare system's perspective to encourage use of virtual home visits, do you have an idea what that would be?

Lauren: I would make it so that everyone has access to high quality broadband and geriatric, shall we say, friendly devices. I guess I think that a lot of our technology has become so ... I mean these smartphones are just so complicated and everything is just so complex and so many people don't have access. So, if I could make ... I don't know if that's even beyond policy. That's a sort of [crosstalk 00:39:33] thing but I would love if everyone had ... If the technology was not the limiting factor and it was ... I really think that that would be my dream.

Alex: Here's my last question. I hosted a session for UCSF alumni. We'll put a link to this in the show notes about, will video visits and telemedicine endure beyond COVID? And I'm interested in your perspective on this like, when this madness is all over and of course you're doing this beforehand, what's the landscape going to look like?

Lauren: I think that there's going to be a lot more video visits. I think that people have now crossed that threshold of people were afraid to try it, we're sure it wouldn't work or we're biased about who they thought could do it. And this pandemic has forced people to challenge those notions and to try it and that now the genie is sort of out of the bottle. I don't think it's going to replace in-person visits but I think it would, will and should replace some visits.

Lauren: Again, I usually suggest that people ... If you start somebody on a new blood pressure medication and it's part of a comprehensive visit and then instead of making them come in for a blood pressure check and to tune up that one medication or you just started an anti-depressant or whatever, that three-week check or whatever could very easily be a video visit. And that a video visit is richer than a phone visit and is not as burdensome as an in-person visit.

Eric: I got to say we can't rewind, we've gone too far.

Lauren: I agree.

Alex: Good tie-in. [laughter]

Lauren: There you go. [laughter]

Alex: All right. I have a little bit more of the song, here we go.

Alex: (singing)

Eric: I love that last line. We can't rewind, we've gone too far. I think that's a great song choice for this session. Lauren, very big thank you for joining us on today's podcast.

Lauren: Thank you. This was fun.

Eric: And to all of our listeners, thank you for joining us. Please share us. One social media share out there on Twitter, Facebook or anything else that you're listening to. And a big thank you to the Archstone Foundation for their continued support. Good night, everybody.

Alex: Good night, everybody. Thank you.

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