Public Health Insight

Virtual Healthcare Technologies: Telemedicine & Patient Satisfaction

July 20, 2021 Public Health Insight
Public Health Insight
Virtual Healthcare Technologies: Telemedicine & Patient Satisfaction
Show Notes Transcript

The ongoing pandemic has disrupted many of our routines, including the way we engage with our healthcare providers. According to a national survey commissioned by the Canadian Medical Association, Canadians who connected with their doctor virtually during the pandemic reported a 91% satisfaction rate, which was 17% higher than in-person emergency room visits. This raises more questions as access to broadband high-speed internet connection and mobile devices remain a barrier for many populations. 

In this episode of the Public Health Insight Podcast, Dr. Keith Thompson joins us to speak about telehealth, the various ways in which it can be delivered to serve patients, and how the pandemic has influenced the availability and uptake of telemedicine services.


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The following tracks used in this episode were all produced by Lukrembo:

  • Daily • Bread • Biscuit • Bored • Chocolate • Onion • Holiday
Gordon:

The ongoing COVID-19 pandemic has disrupted many of our routines, including the way we engage with our healthcare providers. According to a national survey commissioned by the Canadian Medical Association, Canadians who connected with their doctor virtually during the pandemic reported a 91% satisfaction rate, which was 17% higher than in-person emergency room visits. This raises more questions than answers as access to broadband high-speed internet connection and mobile devices remain a barrier for many populations. In this episode, we'll be speaking with a special guest about how telemedicine and other virtual care technologies can be leveraged to provide healthcare access to hard to reach populations in a way that does not exacerbate existing health inequities.

Sully:

This is the public health insight podcast.

Gordon:

Hello everyone. My name is Gordon and welcome to the public health insight community conversation podcast series. And I'm joined with my fellow co-host Leshawn.

Ben:

Before we move on is important to note that the views expressed in this podcast are our own and do not represent any of the organizations we work for or affiliated with.

Gordon:

Our guest is a primary care physician based in London, Ontario. He is the chief medical officer for I tele med Canada telemedicine group, and is an adjunct community faculty member for the department of family medicine at Western university. He is also a working group lead for the I E standards association. Tele-health icy virtual care lexicon as part of a team to recommend standards, to increase the accessibility of digital health for remote and rural low resource regions. He is early into exploring the work within WHL, private sector, collaboration and innovation for digital health. He has a deep network within stakeholders in the private and public sector and enjoy sharing his knowledge, facilitating connections, and encouraging others, willing to tackle issues of health inequity in Canada and the rest of the world. Please join me in welcoming to the public health inside podcasts, Dr. Keith.

Leshawn:

Welcome Dr. Thompson.

Dr. Keith Thompson:

Thanks so much Gordon Leshaun, uh, really excited to be here with you today. You know, as I said before, we started, uh, this has been a journey for me, right. To I'm a late comer to a virtual care. And I jokingly say further along in life, I think that maybe some of the guests and yourself, so I don't have a lot of time left in life. So, uh, you know, if I'm going to learn as much as I can, let's learn fast and, uh, certainly excited to be here. Really appreciate the opportunity to talk about virtual care and its implications, right to general population use, but also marginalized populations and, uh, kudos to you guys and, uh, public health insights, some amazing work. Uh, I had banged into Gordon, uh, through a, uh, pitch event for a social innovation around opiates and, uh, learned that the work you're doing through that and really quite awesome and, uh, really, uh, inspired by the network that you're creating. And so thanks for this opportunity.

Gordon:

So Dr. Thompson tell us more about what you do and the organization that you represent.

Dr. Keith Thompson:

Yeah. So I'm a family care physician, family practice here in London, Ontario, uh, solo practice right now, but a fee for service. And, uh, we can talk about physician reimbursement, maybe on another podcast, but, uh, uh, D really my journey has been, uh, into virtual care and as applications into primary care, and really at least staying centered within that, which is publicly funded. Uh, yeah. Uh, through that journey, discovering that, uh, you know, there's some issues obviously in terms of equity and we've seen that, uh, greater disparity, certainly during COVID, um, along that journey, you know, you learn of other people and organizations working in this area. So I imagine faculty at Western, uh, doing some co-investigator work under Dr. Bridget Ryan, and several of the family docs within the faculty department of family medicine, uh, researching what is best practice and, uh, what will the guidelines be for virtual care? Pre COVID. We didn't really know we were slammed with this great pandemic and we were in survival mode and certainly most of the encounters we do or by telephone, uh, because we have the relationship, we know the patients and that's probably easiest for workflow and probably easiest for patients in some ways. Um, but my other affiliation is the I triple ESA tele-health industry connections is what the IC stands for. And that organization formed recently has, you know, I triple ESA creates those standards around electronics and information, communication technologies, uh, you know, what's the basic standard so that your toaster doesn't shock you when you turn it on. Uh, but they realized. In terms of tele-health, uh, in terms of virtual care, uh, they really hadn't turned their lens on to that area. So this whole organization, uh, which is open to any members by the way. So I'd encourage anyone. Listening is thought about wanting to offer their expertise, uh, as a volunteer, uh, as sweat equity, but really important work that they decided to focus on. And how do we create a. Infrastructure and ecosystem, that's going to allow access regardless of regions and how do we improve connectivity and what are the security and privacy issues that we need to keep in mind? Because we may be able to get easy connectivity into a community, but is it going to be equitable in terms of privacy and in terms of security? So that has to be considered. So that's where I Tripoli is in the world health organization, again is a kind of a new gig for me. It was merely a round table discussion that I was invited to, and it was able to participate still ongoing, uh, but a fabulous network, uh, met some innovators doing some work in Africa, uh, and remote regions in Africa and Kenya. And we can talk about that as well, but certainly a really great examples right. Of how to do a lot with little. Um, so that's kind of the background on my organizational participation. Locally here at home, bringing it to that Ontario perspective. As you know, we're moving towards Ontario health teams and it is getting us to think as primary care beyond the person in my office, in front of me, but as a collaborative our whole population. So not just the one diabetic that I'm meeting on a virtual visit or telephone or office face-to-face visit, but all 200 patients in my practice who are diabetic and likewise as a region, those thousands of patients who are diabetic, uh, and there comes a challenge I think, and equity and access because, uh, within London, uh, the estimates. So I'm hearing, I'll say Western Ontario health region, we have up to F 70,000 patients without primary care access. Uh, and. Scratched down a little bit into that. And what are those limitations of access, uh, and what is creating marginalization? That's preventing access. It may be geographic and maybe, uh, those social determinants. Uh, and that's my last comment. And I really appreciate being here is, uh, as I started to scratch deeper into this realizing that digital divide really equates with the social determinants of health. So many of the things that are creating poor health really, uh, are also similar to what is preventing access to our digital health ecosystem or virtual care as we call it.

Leshawn:

Yeah. no. Fantastic. Thank you for sharing that. And, um, I was wondering if you could share a bit more about I tele med Canada from a more of a operational perspective and your role as the chief medical officer.

Dr. Keith Thompson:

Yeah, absolutely. Totally. So I tell them it was formed as a non-for-profit, uh, and financial conflict of interest declared on the chief medical officer would, uh, declare revenues if I had any, uh, it has been sweat equity to this point, uh, really, uh, deeming to stay within the publicly funded guidelines, which pre COVID OTN was pretty much the only way to access virtual care for patients that was funded. So you had to be a physician registered with OTN Ontario telemedicine networks One of the largest, uh, virtual care telemedicine networks in the world, actually. Uh, so some phenomenal work that they have done. It's clunky as a hard workflow. It doesn't easily adapt. And so that really outside of OTN where these private systems, right, you had maple dialogue here, all of these companies springing up providing virtual care, telemedicine care, video chat, and counters that wasn't funded. So it was a direct to consumer or through employer based program, whereas OTN was publicly funded. So I tell them it has really been looking to stay publicly funded and leverage in the system. Uh, what is. All of our patients in Ontario. Right, right. Not just those that have ability to pay, uh, COVID has changed as a little bit. So we're seeing now that under the Ontario health guidelines we have, oh, I think last count five or six vendors, uh, maple, uh, uh, doxy me, uh, uh, several of them that have applied for verification, which what that means is when we reach a point that the ministry of health may pull the plug on these temporary fee codes, uh, to encounter our patients by video or telephone, these other vendors will likely be able to say we're approved. Uh, we meet the requirements. And so any physicians who use our platform will be allowed to bill for that service, uh, whether that will address the issue. Equity of access, you know, it would be a whole other discussion, but, uh, that's really how we differ perhaps somewhat tonight, tele med, uh, versus, you know, the other systems that are out there. So, um, we're doing some work with participation house, uh, here in London, uh, and those are very, uh, high needs individuals, wheelchair bound, congregate living to bring them to the office is, you know, uh, an endeavor unto itself, two to$300 actually in costs for attending care, getting them to the office or a physician would have to take time at the end of his day, uh, which is usually after hours. Uh, and the premiums and feet codes to do that can be in excess of 120,$140. We can do that visit virtually in many cases for 45 or less dollars. Uh, and we're still on an uphill battle. Uh, just so you know, to get the allowance for the virtual house, uh, call fee code, uh, we're allowed every other fee code virtually, but we really been fighting to try and say, guys, you know, this is really an issue of access for highly complex patients. Can you allow those encounters to happen? Which in our case, we're using a stethoscope and the equipment to examine. So it's not just a video encounter. We're going deeper into that encounter with a patient, uh, as close as you could get to a bedside exam. Uh, and that's still, as I said, still a challenge to find funding for that type of program.

Gordon:

Right, right. And that's that segues us perfectly into our next thing we wanted to talk about. So you've been practicing as a primary care physician for a number of years now, and we know that telemedicine has emerged as a tool to help providers provide healthcare services to their patients. Ah, and it's super impose onto COVID of course, because people are less able to move around and with the lock downs and the restrictions and closures. So, uh, before we get into it, we're hoping for you to share with us clear up some terms for us. I'm not sure if they're interchangeable, we've come across terms like digital health, telehealth, telemedicine, virtual care. So we're just wondering if you could situate us a little bit.

Dr. Keith Thompson:

Yeah, for sure. And I think we're fortunate in Canada because there's a great working group under digital health Canada, actually that created a, a lexicon, uh, that was really meant to try and define some of these terms. And why is that important? First off, let me say that as we develop standards around this, and that's the working group within I Tripoli, as we're looking to license and create standards, uh, creating standards around terms is a challenge. And, uh, honestly, no one's been able to do this. There did a lot of talk and wrestling with it, uh, but we often kind of get mired down in the clinical applications. Whereas those that are in the technical side of it are looking at this as an industrial or information communication tech standards. Uh, so merging those two worlds has been a challenge. Certainly in Canada, what's been done as we talk about virtual care and that I think of it as the umbrella or all encompassing term for all things, digital health, uh, that the platforms that are used when you go down into the clinical encounters, uh, we can speak of concepts or domains was a terminology that was used here in Canada. And the concept or domains would be the ways in which you engage with the patient, the general term. So telehealth telemedicine, e-health consumer health telemonitoring, telepathic. Tele-psychiatry just by those terms alone, you can kind of. You get an implication, what's going, oh, teleradiology absolutely looking at x-ray ultrasound, telehealth telemedicine. Uh, so telemedicine traditionally implies a term where a physician or allied health professional is engaging with a patient and treating them remotely. So again, virtual care, just to clarify, as other than face-to-face and tele-health might be all other aspects of that. It may be, uh, an email, a text. It may be an exchange of information between provider to provider, provider, to patient, uh, between sources of information on the patient, uh, you know, would be all within that domain. We get into capabilities. And then that is the more specific specifics rather of the tools that you would use. So, uh, the. Execution of it can be synchronous like we're talking right now live okay. Or it could be asynchronous. I could record my symptoms and findings. I'm a nurse provider getting the parameters on a patient, upload it. And the physician comes in later and encounters or the patient uploads their blood pressure or their blood sugar and throws it into my email or my, uh, uh, my inbox is a digital in, in, and I look at that later. But the capabilities would be again, telephone messaging, texting peripherals, uh, was the one that I was able to kind of be like, Hey guys, you gotta include, do an exam, right. Equipment to look and, and provide that, uh, gets included patient education or eConsults right. So I'm creating a parameter and sending it to a specialist. So virtual health. Concepts or domains of platforms, the interacting on and the capabilities, that's the way digital health Canada defined it. And that's a pretty good generic, and I think it's got potential and we're bringing that forward to I Tripoli. And they were inspired by this. What we need a little bit more definition around is the population health aspects of that. Right. And that really hasn't been addressed because there's a lot of stuff where today talking public health, you guys are the heroes during the pandemic. Right. And so population big data, regional data. Right. And what does that look like? And that's still, uh, within a domain, if you think of it as virtual care. Uh, but the capabilities may be different. Maybe it's going to be an AI analysis of data and say, look, our STI rates in this region are very high. We need to address that or our TB rates. Right. So it might be regional. So that's how I think we think the definition. Break it down the platform we in your act. And that may be digital e-health amHealth I would tend to just group those all into one. And then the actual means of engaging with those patients are more kind of the clinical specifics.

Gordon:

Yeah.

Leshawn:

Right, right. Cool. Yeah, like you, speaking of the like specific populations or just populations in general, there was a survey done in 27 countries that really found that one in 10 respondents had tried telemedicine before and four in 10 indicated that they would try it if it was available. So under normal circumstances before the pandemic, what was the uptake of virtual health care in Canada? And in your experience, have more patients been using it as an option during the COVID-19.

Dr. Keith Thompson:

Yeah. So, uh, again, pre COVID, I think the uptake. There was trajectory. We were gaining, but it was still probably very small. And I would don't have the exact stats in front of me, but I'm guessing it was probably less than 5% there, boats. Uh, and COVID was just a great accelerator. It was literally, if you look, it's like the switch went on, right. And boom, it was zero face-to-face or very near zero and everything was virtual, virtual being telephone. Email or video chat videos, a small percentage, even still, if you look at the work being done in primary care, we have the advantage of knowing our patients longitudinally. And so that's why a platform like telephone or text messaging even for that matter works well because we have the history on the patient. We've got years of, uh, you know, encounters and information on that person. If it was a new encounter, I would hazard to say, it's maybe not going to work as well on there's some risks associated with that, that episode encounter using virtual. Right. So I think if you look at the CMA did a study and what, where we're going to go during, or post COVID is about a 60, 40 split. Meaning if you had a new problem and you had to encounter your physician, how would you prefer to do it? And it's roughly 60% are saying face to face. If 40% would be okay with a virtual encounter. So that's interesting, right? There's still that therapeutic need or desire for that face-to-face or maybe just something there to satisfying or gratifying to the patient, uh, that maybe we need to understand, uh, what we can and cannot do in that regards for virtual.

Leshawn:

specifically for your practice, for example, did you use a lot of tele medicine, pre COVID and now that you shifted more, I'm assuming to more telemedicine, what are some of those nuances that you figured out or had to work through, um, with this kind of influx of people using this.

Dr. Keith Thompson:

So, uh, again, probably, uh, a disparity between those of us fee for service and those of us that are in capitated models. So just to define that, uh, that means in Ontario, I'm paid per visit. I'm paid per patient. There's good. And there's bad about that. And we can leave that for another day capitated model, here's your population, X dollars per head, whether you see them once or 20 times doesn't matter. So workflow is extremely important and those of us in the fee for service and I was definitely starting to explore using OTN. In fact, it was November of 2019, that OTM said, okay, for those physicians registered, you can send a link to the patient. They open it up and you can video chat and you can build. For that process. So that was a first, because prior to that, we had to engage patients only if they are at, I recognize OT and end point, which was typically a hospital or clinic. There was some private providers out there doing it, but, uh, pretty much that's the only way. So it was working. The patients loved that it was convenient, but it was clunky because you had to send the link. The patient often didn't understand. They would call my front desk who became my tier one tech support. And again, I can't get it right. Uh, so, uh, when COVID hit it certainly telephone became the lifesaver when they released those fee codes. Uh, and I have to say the patients, most of my feedback, and this is anecdotal from data on this, but I think the surveys would support that patients like telephone. Uh, I mean, as soon as they connect bang, we're right. Right. There is no loss of time to figure out the video, or is the sound working as a connectivity, good, et cetera, et cetera, for telephone. Most people work when we get into the marginalized populations. That's interesting as well. Uh, because there are some folks that video and wifi is not an option. I mean, they only have telephone. Uh, so, you know, virtual care adopts very well to that. So I think still we're seeing about 80% from what I understand, you know, it would be a telephone, uh, and maybe the other 20, a mix of email, uh, and, uh, video chat

Gordon:

Andrew.

Dr. Keith Thompson:

or text messaging and video chat. Yeah.

Gordon:

Interesting. That makes me curious about, you know, you talked about the logistics of telemedicine, uh, fee for service versus capitation. And I wanted to hear from you then telemedicine is meant to expand the geographical boundaries if you will, through which medicine or healthcare can be delivered. So are there any barriers in terms of where a physician is registered in one province and what are the limitations to serving people in other jurisdictions or

Dr. Keith Thompson:

Yeah, no, definitely there are. Right. So yeah, as an Ontario licensed physician, I'm limited to engaging, uh, my patients within the province of Ontario. Now, if they are residents of Ontario and they're outside of the province and they're my patient, I can still engage with them virtually. But to go outside of that is a concern. And, uh, you know, one company that's done very well in this regard, certainly maple, uh, was able to grow and scale their physician pool. So if you think of it, that they were able to get physicians, uh, registered across many provinces. So, uh, to cover the late evening hours in Ontario, It means recruiting physicians able to, uh, visit from say BC or vice-a-versa into the Eastern provinces. Uh, so that was really a, I think a sweet deal. Right. And getting that cross or provincial coverage. But for me as an N of one, it's just not practical to really go and apply to multiple provinces. Cause I'm just not going to get those, uh, many of those encounters.

Gordon:

We know that there's a lot of push for physicians to service these underserved communities in rural regions. So, given the fact that I, as a physician have this option, rather than moving there in person, is there a danger then that eventually there'd be less physicians and healthcare providers in those regions available for in-person interactions.

Dr. Keith Thompson:

Yeah. That's a very good question. And I think in COVID we've seen in the Northern communities, physicians adopt virtual care the same as within the Southern regions because of that risk of face to face contact. Prior to COVID the question is, or has been, and certainly OTN has done some work in this is how do you bring those encounters? How do you bring those services into the Northern, in Ontario, for example, Northern regions under-serviced or indigenous communities? How do you bring those services in other than face to face and converged will be a supplement to that care when the physician is not there. So. It's complex because, you know, as I hinted at earlier, that longitudinal relationship is most important and depending on which, uh, you know, population we're dealing with, if it's indigenous, for example, uh, it's extremely important to have and build trust. Uh, and one of the challenges has been, and physicians tend to serve and Northern communities because it's mandated by, you know, their undergraduate training or maybe they've done, uh, international medical graduates. They've come in and done extra training here or had a stipends. I think there was a program to promote physician setting up in Northern Ontario region. And as soon as that two, three five-year requirement is. Bang they're gone. Right. Uh, and so it really does leave those communities in a constant sort of turnover rate. if the telemedicine services allow for greater support to that primary care, which is really what OTN I think was built upon bringing the specialists into those communities and help prop up primary care when there was uncertainty around diagnoses or treatment, uh, then it could be a value add to retain physicians that don't feel like they're working totally alone. They have that expertise to draw upon. And I think really, uh, that's where this type of technology may be a win, a win, how it's or will it, you know, uh, Enough of a value add to attract physicians to serve in those regions? I think still needs to be discovered. You would say the potential. Is there, uh, can I be a physician in Southern Ontario, uh, and have my patients, uh, and I'm the MRP, which means most responsible physician. Can I be the MRP for somebody that may only see face to face once a year when I fly to that community to come in and establish, right. And I think there are some regions where they say, if you provide that care remotely, it's required that, you know, X number of times per year, per month, uh, provide face-to-face as well. Uh, and I think that's wise because really it's, it can't all be done by, uh, by virtual care telemedicine or remote care. You've got to have some face-to-face encounter.

Leshawn:

Yeah. no, totally agree with that point about, you have to have that face to face encounter, And it seems that based on the results that you presented earlier, 60% do prefer that having that face-to-face contact as well. I found some other survey results from Abacus data poll. and it was commissioned by the Canadian medical association, like you alluded to earlier. It showed the 91% satisfaction rate when working with, or interacting with virtual care. Other kind of interesting tidbits where 46% preferred virtual as their first point of contact and 45% of people saw this to improve their access to specialists. And with that, I'm like you already mentioned 41% also think that this can increase, improve the timeliness of healthcare services, but just in general what are some of the benefits of telemedicine? Like we hear about things like tele triage to assess and decrease the volume of in-person visits. We talk about the potential for, uh, mental health services and stigma that may be a barrier in person. Is there concrete evidence that this does improve patient care and you kind of alluded to cost earlier. Does this actually limit or control costs?

Dr. Keith Thompson:

And that's a great question. I think honestly, those studies are ongoing. I know of one, at least here at Western is looking at, uh, utilization. Uh, and as we have the virtual emergency rooms set up across the province as a recent, uh, funding, uh, using, uh, virtual encounters for those patients that maybe are lower acuity and don't need to come to the emergency room as a face-to-face. Uh, so I think that that is still being clarified. The benefit is you would hope the benefit for patients ease of access, certainly. Right. Not having to take time off work, drive to the office, get a script, go to the pharmacy. You know, all of those parts of the encounter can be virtualized or, you know, just electronic transfers. Uh, the downside is there's going to be some visits that require a face to face. And some of that may be patient determined. Uh, I think in one other, uh, interview, I referred to the work by Ian McWhinney. What drives patients, uh, coming to the physician. It's that limit of tolerance. They just can't stand the pain anymore, the itch or whatever. Uh, the limit of anxiety. They're just so worried. Oh my gosh. I think it's cancer. I'm really concerned. Uh, the ticket. Uh, they want to come for a new script, but have a door knob comment. Oh, can I talk to you and talk about my alcohol use or whatever, uh, and administrative duties they need to know they need a clarification on something. So thinking of that as the primary driver, uh, which of those parts of the encounter can be met virtually, and I think for mental health, for sure we can probably achieve, uh, satisfaction with that. And I think that there may be studies that would support that. I can't quote them off the top of my head without doing a little bit of digging on it. Uh, utilization is a huge concern. And I think that that is still being, uh, looked at and the reasons are pre COVID. I'll give you an example. A patient goes to a virtual health center and they're encountered the, physician assistant registered. Does a bit of an exam looks in your ears, takes a history, dials up the physician. The physician comes on for literally a one or two minute encounter says, oh, it looks like you have, according to the nurses, ear infection, I'm going to give you a prescription and off they go. So I've experienced firsthand. Some patients come away not feeling satisfied, obviously whether it's the anxiety or limited tolerance just wasn't met. So the next day, you know, they're in my office seeing me because I don't know doc, like it was a video encounter and not surely they didn't listen to my lungs, right? So there's a double dip, right? That, that two times first filling virtual. And we ended up with another face to face. Uh, and I, I know all the early studies that were done, Wellington, Waterloo, uh, that enhanced access to primary care. One of the concerns in the rural regions was primary care docs working in emerge, working in the hospital, dial up how the encounter with a patient. It's a video or it's a telephone. Oh, I'm here at the emerge. Come on. Right. So it kind of uptick to a face to face. When is it needed? And I don't want to criticize my colleagues and not knowing all, but you can see those would be examples where you could optimize the billings right around virtual care, uh, similar to, you know, methadone. I always pick on those guys, but physician services, huge million dollars, right? Uh, for providing methadone, it's a needed service. Don't get me wrong. I understand that. But if I'm a patient with COPD or diabetes and I come and I get my methadone and I want to talk about my chest, my cough. Oh, sorry. Not my problem. You got to go see, well, I don't have primary care. You're it right? So that million plus dollars. And if you look at the data, is it's, I know they even drop the fees, right. To try and kind of throttle down some of this utilization, the danger is will virtual care be used that way? Is there a potential really to optimize billings? And it becomes a coaching for the docs, but not providing a value or service. Uh, and that gets into the whole arguments around reimbursement, right. And, uh, individual, uh, services versus thinking as a collaborative. Uh, and where you in public health or looking at a whole region, you you've got the sky view, you know, where we're hemorrhaging, right. And where services are being utilized. Uh, and now how do you engage with primary care or hospitals or providers in the community to do a better job to focus in on that? And so thinking along that lines, that's really where I think virtual care. Has to aim, I think, and I don't know that we're there yet. Uh, and, but I think that's hopefully where we'll go.

Sully:

You've just heard part one of Gordon and LeShan's conversation with Dr. Keith Thompson, chief medical officer of iTelemed, med, Canada. About what? Tele-health. Yeah. The various ways in which it can be delivered to serve patients and how the pandemic has influenced the availability and uptake of telemedicine services. Join us in the next episode, as Dr. Thompson shares his thoughts on the digital determinants of health and how telehealth can be leveraged to reach marginalized and isolated populations. Thank you for listening to the public health and say podcast, you would go to space for informative conversations, inspiring community action. If you enjoy our content, I would like to stay up to date, follow us on Instagram, Facebook, Twitter, and LinkedIn, to learn more about our community initiatives and how you can support us. Visit our website@thepublicofinsight.com joined the Phi community and let's make public.