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Dr Sheila Lakhoo

April 10, 2020

For our inaugural episode we sat down with Dr Sheila Lakhoo – a family doctor who leads the Telemedicine Impact Plus clinic at St Michael’s Hospital. Recently she has also been the Medical Director at Union Health (a new clinic owned by Telus Health utilizing their own telemedicine app called Akira) and practices lifestyle medicine at One80Health – an integrative clinic in Yorkville.

Her take on the current situation:

  • OHIP Billing codes now covering telemedicine through 3rd party apps (like Telus/Union Health’s Akira app)
    Physicians across Ontario are using a multitude of video conferencing software options (including Facetime, Skype and Zoom) to offer care because of the restriction lifted on HIPAA compliance with this pandemic
  • Until this pandemic the Ontario Telemedicine Network (provided by the publicly funded provincial healthcare system) was the primary means of conducting virtual consults and was mainly used for complex cases which may involve remote patients who didn’t have direct access to doctors in person
  • Most doctors across the province may not have every used telemedicine at all leading up to this pandemic
  • A lot of the online consults she is conducting include education about Covid and symptomatic diagnosis as well as how people can stay healthy whilst isolating

Vision for the near future:

  • If not a single platform emerging as ‘the best’ virtual care app, some form of unification of options may come in a new standard being developed and enforced at a platform layer
  • Better tools will emerge to save time and make processes easier for doctors using artificial intelligence and systems integrations – for example, automatic transcriptions of patient charting with virtual care (telephone and video conferencing) built into Electronic Medical Records systems
  • Some walk-in clinics may not be able to re-open post-pandemic
  • A large number of Ontarians who may not have regular doctors (typically who use walk-in clinics) may shift to primarily using Virtual care as their main interface with doctors
  • Doctors may choose to work online instead of in person where its more lucrative and efficient for their schedules
Podcast Transcript
[intro music] 0:00
impact of COVID-19 we all knew this was going to be a tough time. We need to wrap our minds around a painful truth. We’re in the early stages of what is going to become a series of cascading crises.

[intro music] 0:23
Getting back to extraordinary the successful country and economy that we’ve had, that we built over so many generations however long it takes

Qasim Virjee 0:43
Welcome to start Will’s podcast featuring innovators and entrepreneurs working through challenges which the global pandemic is presenting them. I’m Qasim and for this our inaugural episode, I sat down with my wife, Dr. Sheila lukou. She’s a family doctor who leads the telemedicine impact plus clinic at St. Michael’s Hospital, and recently has been the medical director at Union health which is a new clinic owned by TELUS health, utilizing their own telemedicine app called Akira. She also practices Lifestyle Medicine at 180 Health integrative clinic in Yorkville.

Sheila Lakhoo 1:19
So I’ve been at a clinic called union health for about the last year. I was hired as the clinical opened in April of when did it open 2018 As a medical director, it is a joint venture between right health and tell us and now fully own TELUS clinic. And what’s interesting about this clinic is that we are using the Akira telemedicine platform to deliver virtual care to our patients, not only our patients but Canada. Why 24/7?

Qasim Virjee 1:49
Is that something that since you began work at this new clinic that the practice has involved Akira or have they been separate things

Sheila Lakhoo 1:58
so they’ve been a slightly separate in the sense that as most of you probably now know. Family Physicians were not able to use multiple telemedicine platforms and Bill Oh hips. So patients could buy memberships to platforms such as maple, and Akira Babylon, for example, for a set fee, but it wasn’t covered under Oh hip. And what’s happened due to the COVID pandemic is now physicians are able to use other private platforms that have been developed and built Oh hip and see their patients virtually. So that’s what’s changed over the last few months. We were using a cure on the past but our nurse practitioners were developed delivering care primarily through that platform.

Qasim Virjee 2:39
So doctors weren’t specifically using it until this pandemic exact change the the accessibility of these platforms exactly

Sheila Lakhoo 2:47
because we were able to build a hip. So essentially, yeah, with this new billing system in place, we are now able to use any telemedicine platform or any platform actually, that is deemed, I guess safe and HIPAA compliant. And in some cases, not even HIPAA compliant. So I know some physicians are using platforms such as Skype, Facetime, and zoom, if they don’t have access to other platforms to deliver care.

Qasim Virjee 3:14
So I guess traditionally, you’ve seen the development a little bit in the last few years of virtual care being something that is being adopted in Canada. What have you seen to do with the, let’s call it the I don’t know if it’s federally or provincially or otherwise, provided systems for telehealth in Canada? You know, how have those developed? And how are they relevant today compared to all these products like Akira that you’re using as a family practitioner,

Sheila Lakhoo 3:44
so generally, Canada has been slow to adopt a lot of these platforms. If you look at the healthcare system in the UK, in the US, for example, there have been telemedicine platforms available and in common use for many, many years. I’ll tell you a bit about my background. I come from an academic practice at St. Michael’s Hospital and I was practicing there for about 10 years. So I started there in 2010 and just left in 2018 after the birth of our daughter has, you know, of course. So, during my practice at St. Michael’s Hospital, we did use telemedicine, but telemedicine was used mainly for complex cases and cases that involved I guess, patients in remote rural settings that didn’t have access to specialists, for example. So the OTS has had telemedicine around for many years. So ot N stands for the Ontario Telemedicine Network,

Qasim Virjee 4:37
but it was built it sounds like primarily to, you know, use the internet to reach people who can come into a clinic not as a supplementary service or replacement for in person

Sheila Lakhoo 4:47
care. Exactly. So it was primarily developed, I believe, to service remote patients that didn’t have access to care specialists would have, you know, special telemedicine clinics. And that was what was primarily used. It has also been used in the last few years to develop or to as a platform for multidisciplinary clinics. So one of that is called the telemedicine impact plus clinic. The tip clinic, which I am the lead for at St. Michael’s Hospital, and we use o tn, to develop deliver multidisciplinary care to patients that require more complex assessments. And those are for patients in Toronto. I believe o tn, and I don’t know about the dates a few years ago, decided to open up their platform to certain pilot groups of Family Physicians, and allow them to bill through OTs, and see their patients virtually. And as far as I know that adoption was fairly slow, I believe at St. Michael’s Hospital. Adoption wasn’t very good at all. And a few of those reasons might have been that the technology was difficult to use, the interface might not have been easy for patients to access as well as physicians to use and I believe the adoption of that was very slow, right? So it’s interesting, if we look at most of the family health teams within Toronto, Ontario, in Canada, very few of them, if any, are using telemedicine as a primary way of delivering

Qasim Virjee 6:18
or anyway probably, like, I’m sure the majority of doctors across let’s call it Toronto, just because that’s where we’re sitting. I’m sure most of them until this pandemic hit, and they were scrambling to figure out ways to connect with their, you know, with their patients. They never use telemedicine before. Yeah,

Sheila Lakhoo 6:37
very few. And that’s probably also because we were not able to bill Okay, right. So a lot of our patients that couldn’t afford extra memberships to platform such as, you know, a Kira would have no way of accessing their physician through telemedicine because they would have to pay privately.

Qasim Virjee 6:55
And again, just for our listeners, overseas or outside of Canada, outside of even the province of Ontario, the way things work in Canada is we have a socially provided or a government provided health care system subsidized through our taxes, the government funds, which directly pays doctors, and, and so until kind of these codes that you’re mentioning, were introduced, doctors weren’t being able to be paid for consults on telemedicine unless someone paid out of pocket, which is difficult to ask for husband difficult to ask for, because people already feel like they’re entitled to this government provided health care system. So this is really interesting to see that, you know, the payment model has been the limitation to a technology being adopted that could actually help people. So what have you been, you know, your experiences, kind of with Akira, I know, it’s been like a couple of years that you’ve been working on this kind of new technology platform that has a bit of a better interface and allows people to use it. If you could speak to some of the kind of use cases you were seeing before the pandemic and before a cure, I became something that patients understood doctors to be able to use. And now have you seen a transition?

Sheila Lakhoo 8:09
Yeah, so I was one of the first physicians as a consultant on a cure. And this is when Akira first started when was this like 2015 2016?

Qasim Virjee 8:19
Yeah, it’s been that long, I think.

Sheila Lakhoo 8:21
So this is what I worked at St. Michael’s. I actually also did a few days a week as a consultant on Akira. And at that point, it was very slow at Kira just launched. And you know, there were a few people that came on and paid for their family memberships. Since then, a cura has grown substantially and there are many companies that offer the platform to their their employees, a lot of insurance companies and now it is 24/7. So even before I guess this pandemic hit Canada, platforms like maple, Babylon and Akira has been growing a lot. And primarily people would have access to it through their companies. And the theory behind that is is obviously if you have great access to virtual care, there probably will be less sick days less trips of the physician unless you needed it in person visit because we do know that telemedicine has limitations. But since I started in 2015 to now the volume of patients specifically on the cura platform have increased substantially. We’ve got now multiple nurse practitioners and physicians working 24/7 And the amount of patients we see are probably oh my gosh, I don’t even know what to say 10 times the amount well not more. Mind you I haven’t been practicing on Akira for the last three years I started you know in 2015 took a break and now started again after we were able to build through the ministry is interesting

Qasim Virjee 9:48
because with this kind of like huge. Let’s call it kind of market response to the provision of care being digitized in just the last few weeks, it’s such a new phenomenon, I’m sure, you know, cases leading up to recently, where people were paying out of pocket for the services were more for that additional comfort level of knowing that they can reach out to a health care professional if they need it. So, you know, families like ours with young kids where, you know, parents want to kind of like, quickly, they don’t have time, we’ve got a couple of kids that need to find out if this runny nose is really something to worry about. And they don’t have time to go to a doctor. But now, have you I guess, let’s launch into this kind of like how you felt in the last few weeks as a practitioner using telemedicine. And and let’s clarify, it’s not just audio connections, but also video that you’re using.

Sheila Lakhoo 10:42
Yeah, so they care a platform is text based and and video, and it’s fully HIPAA compliant. And I use it in my clinics. So at Union health, all our patients have access to it. So when I’m actually in the clinic, I book slots as virtual appointments and use that Akira interface. And when I take care of shifts, I’m seeing people throughout Ontario. And, you know, it’s interesting to see how many patients really need the service right now, because many of the walking clinics as you know, are probably closed, right? A lot of their family, if patients have family physicians that might not have access to technology, not using virtual care technology, or clothes. So these patients have nowhere to go. So the amount of you know, cases of anxiety, depression, mental health uncertainty, along with COVID type questions around themselves and their families is, is pretty much what I’m seeing. I am seeing a lot of, you know, general coughs, colds, your tract tract infections, things like that, but the majority of it is around COVID. And in a lot of anxiety around that, and what’s going to happen,

Qasim Virjee 11:54
right, I think I’m guessing or I’m reading into this, but I’m thinking a lot of people are kind of like anxious about whether they have, you know, COVID Yeah, so what exactly so,

Sheila Lakhoo 12:03
you know, they’ve got cough, you know, runny nose, and they’re wondering if they need to self isolate. So there’s a lot of guidance, and reassurance that has to go in and education that we’re providing for these patients. And even though there’s a lot of online self assessment tools, and a lot of reading that people can do online, sometimes they want to speak to a practitioner just to make sure that they are doing the correct things under this circumstances. So it is a lot of education and reassurance. And the other thing that I’m doing a lot of is, you know, counseling around keeping yourself healthy under these circumstances, because we know that this is going to be a set amount of time, we don’t know when it’s going to end. And that’s a question I get commonly is when can we get back to normal life? Fortunately, no one up, none of us know that. So all I can do is talk to patients about boosting their immune system, you know, having some semblance of normalcy in their day. And you know, doing things that are not COVID related in the sense that, you know, watch a movie, read a book, engage in hobbies that you might not have had time to do. Look at artwork and creativity, cook with your family. And yes, go for walks, I know, there’s a lot of mixed messages about self isolation, what you can and cannot do. And, you know, this is not a podcast on you know, COVID You know, I guess guidelines, but as physicians we do say unless you are in quarantine or you know, immunocompromised, you should be going for walks just taste safe and go in areas was not a people people need sunshine, people need exercise. It is very hard for people that are cooped up in small condos, for example, or Right. Right, you know,

Qasim Virjee 13:41
or even shared living, you know, shared housing, where, you know, they’re feeling trapped because they’re around other people. And they don’t know whether that’s something to be afraid of. Yeah, there’s a lot of fear

Sheila Lakhoo 13:51
right now. And part of our role as physicians, I believe, is to help dispel some of the myths around what self isolation actually means and what is safe and what isn’t safe.

Qasim Virjee 14:03
So let’s kind of look into the future a little bit from you know, your perspective of what you’re seeing, even though it’s just been a few weeks with your backdrop of kind of looking at telemedicine, applicability in society and also as a doctor how you use apps like Akira to interface with your patients. This isn’t going anywhere telemedicine seems to be somewhat of a new standard, if not the de facto or what will become the de facto triage mechanism. If anything else, it seems like

Sheila Lakhoo 14:35
Well, yeah, I mean, it’s been a long time coming in the sense that we’ve been pushing for the ministry to allow physicians to use multiple platforms to bill for virtual consults. So this pandemic basically just jumpstarted what was going to happen. And I think it’s here to stay. There’s no way now that the ministry can remove kind of virtual codes, I think it would be a step backwards. virtual care has a lot of potential And definitely I want to say that patients still need to come in. And we still need to examine patients in person. But there’s a lot of things can be done virtually. And it can save the healthcare system a lot of money. And it can access people that don’t have time to come into the physician. And, and I think it’s here to stay. And the great thing is now that there’s multiple platforms, it’s not just the OT M platform, there’s going to be great competition on how to make the streamlined and perhaps is gonna be one that stands out and gets adopted.

Qasim Virjee 15:31
Interesting. Yeah, it may lead to a unification or some sort of a platform standardization, they all have to, you know, it sounds like maybe up until, really up until the last couple of months, within the industry, from what I’ve heard, people had been talking about HIPAA compliance a lot, right. So some sort of like safety standards in medicine compliance. So maybe it could be a return to the standards that all of these platforms adhere to. But something bringing them all together to make the experience of care online, not unique to a particular practice or platform.

Sheila Lakhoo 16:07
Exactly. And looking at how to integrate the platforms into the EMR system. So I know TELUS is doing a lot of work around that. And even on the Telus platforms like med access, we are now able to do virtual consults right through the platform. And this is something that’s just been launched with EMR to the EMR itself, I still have to test it out, I think, a patient next week that were tested out for but if we’ve got EMRs that have built in virtual technology, we don’t having to use three different platforms. It’s all built in and it’s all transcribed into the EMR. Because right now, you know, I’m using Akira as the the platform I’m communicating and then I’m having to type the notes into the EMR, right. So it’s double the amount of work, or so I know TELUS is working on this. And I’m sure in the next couple of months, it’s going to be launched where you can actually just do virtual care through your EMR

Qasim Virjee 16:52
well, with what we’re seeing in terms of audio transcription, automatic audio transcription, enabled by machine learning and artificial intelligence. That whole process is done so good. I’m sure in the next six months, no matter or three months, no, no, no, like any of these platforms, will will enable doctors lives to become easier in that transcription process. So for any of our listeners, unfamiliar with kind of doctors and how they work, I guess, Sheila, you could tell us a little bit about this, how it works, someone comes typically in the old school, someone comes into your clinic, you see them? And then how do you make notes? And where do those go?

Sheila Lakhoo 17:30
Well, it depends on the electronic medical record that you have. But essentially, you would type in their notes. There are some software’s like dragon that do auto transcription. Most physicians don’t use that just because of the cost and implementation. So most physicians will just type into the EMR.

Qasim Virjee 17:47
So that’s a whole process after you see someone to remember what happened, accurately, transcribe it, or write it down,

Sheila Lakhoo 17:55
or write it as you go along. But that, again, takes away from the encounter when you’re speaking to someone and having to type at the same time. So every physician has their their own way. But yes, it does take a lot of time to have to chart and then make referrals and do that. So there’s a lot of paperwork involved in an actual patient encounter.

Qasim Virjee 18:13
So it sounds like, you know, with the adoption of virtual medicine across the board, there’s going to be a lot of positive impacts on the flow, the work rules for doctors. What about what do you see as the implications for how physical clinics are used through this period and looking into, you know, the new normal?

Sheila Lakhoo 18:35
Well, it’s interesting. So at our clinic at Union health right now, we have four physicians that work there. And now during this pandemic, we have I guess, one physician per day, that’s able to see patients and we’re keeping it to a minimum in terms of the patients that are allowed to come in. But we are using spaces to still do our virtual care. So there might be three physicians in each room in separate rooms, sorry, seeing their patients virtually, and then one physician bringing patients in. So I think it’s it’s gonna be interesting in the way clinics, it. I don’t know how it’s gonna pan out, because as I said, we still need to see patients in clinic. But it might be that there’s a model for physicians working together in a virtual space in a space doing virtual consults. Right, and then having a separate space for, you know, the physical exams, I don’t know if it’s actually going to change the way most primary care practices are run. I think it’s just going to be the adoption of virtual care into their practice.

Qasim Virjee 19:33
Of course, earlier, you mentioned walk in clinics being closed. What do you think the, I don’t know, lasting effects of this will be for walking clinics, retail level street clinics.

Sheila Lakhoo 19:46
So some of them might not be able to, you know, reopen depending on the cost of those clinics. Now. They are and I’m not sure because I haven’t worked in walking clinics for many years. And I wonder if some of those clinics are adopting virtual care technologies because everyone is allowed to do it, any physician should use that platform. But because walking clinics don’t necessarily have their own patients, they might not have that ability to retain people to come in. And also, right now, during the pandemic, patients might be scared to go to walk in clinics as well. I know we have, as physicians group together, and the ministry has created an OT and virtual clinic to allow physicians to provide virtual care to patients that don’t have physicians. So that is one initiative that has been started. And I wonder if that’s going to continue. Where physicians can actually use this platform and connect with patients that don’t have a physician. So that might be something that that continues ongoing.

Qasim Virjee 20:47
Right. And then yeah, I mean, it’s very interesting because a flip side of this, of course, you come from proximity to Akira as a platform to provide telemedicine, but many other doctors are going to be looking for platform and connecting those people with not only platforms, but patients make sense when we’re seeing this kind of like you said, 10x demand, and just a month from patients looking for care.

Sheila Lakhoo 21:12
And we were talking about how we see maple signs everywhere on buses, billboards, you know, they’re definitely recruiting a new Babylon. I’ve got tons of emails from them recruiting physicians to join their platform as well. So it’s going to be interesting because renumeration is fairly good for these online platforms. So I wonder if this is going to change the way physicians actually want to practice. And they might cut down their hours in the clinic and say, You know what, it’s more lucrative to work for a company like Babylon or maple, or Kira, and I don’t want to necessarily, you know, see 40 patients a day in my clinic.

Qasim Virjee 21:50
If If access to medicine and medical care become something that is more pervasive through this adoption of technology, and people have less bias about sickness and their need to go into a clinic at the worst possible time. Do you think there will be some sort of mass benefit to society? How do you think this will affect people’s psyches? If they know that they can push a button and either validate concerns or get the medical care that normally they kind of seem to wait, you know, push off going to the doctor? What do you think this will change in society?

Sheila Lakhoo 22:33
Well, I think it actually has a lot of benefit in the sense that, you know, people need a lot of counseling in the end, a lifestyle advice and I don’t know if I talked to you about the other clinic that I’m working at, which is called 180 Health, which is an integrative clinic, in Yorkville. And what I’ve been doing there over the last couple of months is doing primarily lifestyle medicine. And what that means is I look at the four pillars of health being sleep, nutrition, movement, and mindset. And we know that if any one of those things in your life is skew, you’re not going to feel well, overall. So right now, generally in medicine, we look at people when they’re sick, and try to help them recover. But I think with this pandemic, and what’s been happening, or last few years is there’s a shift towards keeping people well, and looking at holistic and alternative treatments. And things like movement and nutrition to help people’s immune system keep people’s mental health, you know, working well, I guess you could say people are suffering from a lot of anxiety at this point in time. And that’s a whole other topic on why people are feeling like this. But the work that I’m doing at 180 health, for example, can all be done virtually right. So if I’m consulting with patients on how do we improve your sleep, how do we improve your nutrition, a lot of these things, people don’t have to come into clinic so they can take an hour out of their day sit in their office. And we can go through all of this. And I know a lot of naturopaths are doing virtual clinics right now. So I think it’s going to help people to connect more easily and not feel like they have to take an hour outside of the day to come in and talk about their sleep that they’ve been pushing off for months and months and months. Because they’re busy, they’ve got kids and they’re working full time and probably get the help that they need quicker. Most people are turning to online resources anyways right now. And it’d be great if there’s a physician that can help summarize all the research and bring it down to the basics because right now we’re in a society where there’s just too much information even with COVID right now, you know, I don’t listen to the news very often because it’s just too much information that changes all the time. And I think right now more than ever, we have to bring it back down to the basics and the basics are fundamental in terms of eating clean, keeping yourself you know, moving making sure your sleep is optimal. Doing things that make you feel well and using a creative part of you that you might not have been using for the last you know, number of years working getting the job you are. So things like meditation, breathing, things like that is what I talk about supplements to help boost your immune system. And I think there’s a lot more shift around that. And people are seeking alternative care. Because they don’t, don’t get that from the primary care system right now. Because we are so used to dealing with sick people and helping them feel better. So I think this is a great opportunity for us to look at, you know, humanity as a whole. And you know, how vulnerable we are, and how we can take ownership exactly, and how we might need to make fundamental shifts in our health, in our way of thinking and our way of consuming in the way of looking after each other and an environment we live in. And so I think it’s a great opportunity for physicians working in primary care especially to look to support their patients in that way. And also, you know, work with other allied health care professionals, I’ve learned a great deal from, you know, a naturopath that I work with closely Dr. Lera specter at 180 Health about you know, natural supplements that can help people and about how to improve people’s sleep and energy and anxiety in a really holistic way. So I think things like that are gonna come forward more than ever at during this time.

Qasim Virjee 26:17
Excellent. It was a pleasure speaking to on the mic. And for anyone who’s listening that wants to reach out. We’ll have some contact information posted with this in the digital magazine at start well.co There’s a link in the main menu