How a Nurse Practitioner Is Using Telemedicine to Treat Patients

Virginia Allen /

Medical practices have been forced to quickly adjust the way they care for patients during the COVID-19 pandemic. In just one week, Dede Chism, the co-founder of Bella Health and Wellness in Englewood, Colorado, successfully shifted her practice to see half of patients using telemedicine in an effort to keep patients and doctors safe during COVID-19. 

Chism joins the podcast to explain how telemedicine works, whether or not it is here to stay, and the benefits of antibody testing. Listen to the podcast below or read the lightly edited transcript.

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Virginia Allen: I am joined by Dede Chism, the co-founder and executive director of Bella Health Natural Women’s Care and Family Wellness. Dede, thank you so much for joining me.

Dede Chism: Oh, it is so great to be here this morning, Virginia.

Allen: Now, you have spent decades working in the medical field, and today I’m just so excited to talk with you specifically about telemedicine and how your practice has so quickly adapted to meet the needs of your patients during COVID-19.

To get started, can you just tell me a little bit about your practice, Bella, and how you all have navigated, really, how to practice medicine in this very, very unique season of life?

Chism: Sure. It’s actually a great question.

My daughter and I actually opened our practice about five and a half years ago. We’re both nurse practitioners and we both came from a hospital-type setting, but what we wanted, even back then, and it took us about two years prior to that to get open, but what we wanted was a different kind of practice that was highly relational.

It allowed us to give the patients time, enough time, so that they could tell their story, because everyone has a story, and we really believe that if you just take a minute and listen to people, they will actually tell you what they need.

We started by opening a women’s clinic. Initially it was Bella Natural Women’s Care. And right from the beginning, we had this huge response, like a hundred new people a month joining the practice, registering and being a part of the practice.

Within a very short amount of time, we had men saying, “Well, could you just take care of me, just today? Could you take care of my sore throat?” Or, “Could you help me with my hormones?”, or whatever.

So that started, and within less than two years, we had set up and made plans and we became Bella Natural Women’s Care and Family Wellness. And then over the next few years, we just continued to grow and having, again, this continued response of many, many people registering every month.

So then, back in 2019, which seems like a long, long time ago, we were registering 150 new people a month. The trend was not going down at all, it was going up. And so as we were going into 2020, we actually softly rebranded to kind of tighten up that name and became just plain old Bella Health and Wellness, and as that is launching, so is COVID-19.

It was the craziest thing. I mean, it did seem like just yesterday that we were ringing in 2020, and yet everything in our life and everything in our world has really, really changed.

Regardless of how people feel about the severity of the virus and the response of the media and the direction and all that kind of stuff, despite that these are the cards we’ve been dealt and we needed to respond to that, our patient numbers had grown, and we had registered in January over 200 new patients.

Now, as we’re hitting into COVID-19, we’re in an interesting situation because so many people wanted to stay home and yet we had this huge demand to see people as well. So, it was this crazy kind of “push me, pull you” sort of situation with people wanting to be safe.

We honestly didn’t know at that time in early March how this virus was going to play out, what it looked like for the majority of people, and how it was going to run its course.

So we’ve had nearly 500 people register in a six-week period of time. The numbers have been crazy, but the need to be able to see the people who are well and balance it out still remained. And so literally overnight, we made a decision. I mean, it was a Monday and we just looked at each other and it was like, “If we are going to see patients, if we’re going to help people be comfortable, we need to do telemedicine.”

Literally, I got a health care Zoom account that night. It’s a lot more layers of safety when you have a health care account. And so I got a health care account that night. We started telemedicine the next day.

Allen: Wow.

Chism: Within one week, we were over 50% all telemedicine.

Allen: Wow.

Chism: In many ways, we had to learn how thorough we could be on telemedicine, which is actually pretty darn amazing.

Obviously, I have talked with patients on the phone after hours or in the midst of concerns and worries and different types of triage for 30 years, but in this moment in time, actually being able to see people on the computer screen … I mean, I had people send me all kinds of pictures of all kinds of things you probably don’t want on the air, and I’ve done FaceTime with patients when I’m trying to determine what’s going on with them. But now that we’re at this new level of actually having an appointment, a virtual exam with a patient, it’s a new, interesting take on that.

You actually can sit and talk with your patient about what they’re feeling, capture their history, review any labs, because we may have had some labs drawn and we can review labs or chest X-ray findings. Even just looking at a person, especially … right now during this [time] of COVID-19, influenza, strep throat, common cold, you have these acute upper respiratory infections but … you can learn a lot just by looking at somebody. You can tell a lot about their color.

Myself and my colleagues at Bella, we all agree that COVID has a certain color and you can capture some of that by looking at someone on the screen.

You can see how they’re breathing. You can see kind of around their collarbones if they’re retracting and really trying hard to get air.

So yes, it’s not the same as listening to somebody’s heart and lungs, that tells us so much, but it’s definitely a place to start and it’s a place to be able to say, “Gosh, I’m concerned about what I’m seeing here. I really feel like I need you to come in. I need to put my hands on you. I need to listen to you.”

In that case, at Bella, what we also started when we started telemedicine is we started a drive-thru clinic for the sick and we had the healthy patients come inside the clinic. That way we were making sure that people weren’t exposed to other people’s germs, especially when we have so many different viruses going on, but that we’re keeping the healthy, as healthy as we could by having them have masks, be screened at the door, and then be seen inside the clinic.

But then, actually, see people in their cars, like listen to their heart and lungs, bang on their kidneys, look down their throats, and certainly doing swabs for strep, swabs for influenza, swabs for COVID-19.

Our office also does rapid antibody tests for COVID-19, checking for the immediate antibodies, which are the IgM antibodies and the IgG are … what we hope to be the permanent immunity antibodies for COVID-19.

So we can do a lot in the car. It’s amazing.

I had a pregnant mom who was getting close to term, but she was sick with COVID-like symptoms, but she also needed a non-stress test, which is a test to monitor the well-being of the baby. So where we listen to the baby’s heart, we also watch for contractions in the mom, but this mom was sick.

I needed her not to come [into] the clinic and, crazy, when we’re in the midst of this COVID-19, hospitals, seriously, they don’t want anybody to come in. They don’t want anybody on their unit if they got symptoms. It’s this kind of fine line, you have to be super sick for the hospital to want you. And so the hospital didn’t necessarily want to monitor this mom.

So we just had her recline in her seat and we brought the fetal monitor out into the parking lot with an extension cord and strapped her up and we’re monitoring her baby. And … we could also evaluate her and her upper respiratory infection at the same time.

But the telemedicine has served a great purpose for us because it can cue us up and it can help patients to know, do you need to come in? Is it OK to stay home?

For a lot of routine things like diabetic follow-ups or hypertension follow-ups, medication follow-ups, following up on labs, it’s been a way for people to not have to come in and be exposed to any kind of contagion and yet have a good touch-base with their provider, and talk about how they’re doing, talk about their hopes and their goals, and make a plan, refill medications. It’s been a very, very effective tool.

Allen: Yeah. It’s amazing to see how you all have so quickly implemented telemedicine and seeing patients in your parking lot.

When you consider these things, do you think that COVID-19 is permanently shifting the way medicine is practiced to where telemedicine really might not disappear and seeing patients in sort of a drive-thru manner might be here to stay?

Chism: That’s a great question, and I’ve actually submitted some of those questions to our state when they’re reaching out to us. There’s a subset of clinics that are not federally qualified health clinics. We don’t receive money, but we do take care of a fair number of indigent. In Colorado, that’s called the safety net clinics.

In Colorado, there’s 42 of us that are not federally qualified health clinics, but we do not turn away anyone because of their ability or inability to pay.

For us, before going into COVID, … about 1 in 5 patients did not have the money that they need to pay their bills or for their health care. And … we are seeing that number go up.

Now, the interesting thing with telemedicine, it is self-limiting to a patient’s connectivity, right? So if you’re trying to make that for kind of like a generalized first step in seeing people, or in some circumstances, sometimes it’s just not possible because of lack of connectivity.

Now, most people have connectivity with the telephone or their cellphones. So during this COVID-19 period, there has been a lift on restrictions for telemedicine so that patients could actually have an appointment on their phone. And it doesn’t necessarily have to be like a Zoom conference, or a FaceTime, or a WebEx, or however they were going to do their telemedicine platform.

I do not think that will continue to stay because there’s a very important aspect of the care of a patient, which is actually face to face and laying eyes on and seeing a patient.

So the one thing that we are somewhat strapped to in medicine is that we still need our revenues and revenues actually are not great. And on telemedicine, they are horrible.

So you could have a 30-minute visit with somebody—this was just recently, I had the same thing, I had a 30-minute visit and went through the multiple problems, had clinical decision-making of medications and lab orders, imaging orders, and our reimbursement on that was $45.

So if you could imagine any doc’s office, you can’t pay your bills with a $45 reimbursement for a patient being seen.

So I think that when we look at obstacles to telemedicine, it’s going to lie in the connectivity of the patients, but it’s also going to lie in the reimbursements by the insurance companies.

Now, granted, the government has really, really encouraged insurance companies to reimburse similar to a patient being actually in the exam room with a provider. That’ll be awesome if they can actually pull that off. We haven’t seen that yet.

Now, insurance companies are saying that they’re going to go back and they’re going to fix these things in their system. So we do hope that that’s going to work out in the long run. And I do hope that we’ll be able to use telemedicine and that there will be some things that can remain lifted from the restrictions. One of those being taking care of somebody who’s in another state.

So, giving an example, we have patients who could be maybe in Louisiana, or in Texas, or Kansas, or wherever because they went home to be closer to family during this COVID-19 period. Well, if that patient was pregnant or perhaps that patient was trying to get pregnant, or maybe they were following up on labs or medications, right now, what they would say is that the provider needs to have a license in the state where the patient is.

Again, that’s been lifted during the COVID-19 time, but I don’t know how that will play out. I’m not sure … if a patient has been seen in your actual clinic at sometime, if there will be some lifting of those restrictions.

Another thing too that was a restriction and that the insurance companies would like to see happen is that, if you’re doing a telemedicine visit, you’re not doing it with a patient who is at home, you’re doing it with a patient who is in another medical facility. Perhaps they’re in a clinic that is a lower specialty or of a clinic of some sort.

That’s one of the things that the insurance companies … also set up, is that … the patients needed to be in a clinic and the provider had to be in another clinic, physically, in that facility in order to do the telemedicine.

Now, clearly, that doesn’t make much sense. It doesn’t make sense for, especially, what we’ve all learned during the COVID-19 time.

We’ve learned that there’s a lot that we can do in caring for patients. There’s now apps for patients who need to be seen regularly, who need to have their vital signs monitored, there’s apps that connect in blood pressure and weight, and oxygenation.

I think that we’re going to see a growth in those things and that the patients will find that they will invest in their home monitoring system so that they can have better convenience … Again, we’re talking about more limited needs, and yet it’s still important [to] follow-up.

But it keeps patients out of the clinic. It keeps, perhaps, patients who are immunocompromised or are more susceptible to catch germs and catch illness, it would be an opportunity to have those patients who are otherwise stable be monitored and managed at home.

I think that telemedicine should be here to stay, it should be here with many of these restrictions that have been lifted to remain lifted. And when it’s taking a provider’s time, it’s taking a true assessment, it’s involving clinical decision-making, the providers should be reimbursed in a similar way as to when the patients were in the office.

Allen: Yeah, yeah. Thank you, Dede. One of the things that you mentioned earlier was the antibody test, and we’re hearing quite a lot about this antibody test and who should receive it. Could you just tell us a little bit more about it? Is this something that you think eventually everyone should receive? Is that not necessary? What is kind of the best practice here?

Chism: Great question. The antibody testing, people have been talking about it. Actually, if we look at it, people have been talking about antibody testing for a couple of months, at least in the United States.

But the countries China, South Korea, Indonesia, many of these countries, they were right on board and ready with antibody testing from the beginning. And I think a lot of that is what did slow the spread of the disease.

Now, China did a lot of antibody testing. South Korea, man, they were out of the gate with antibody testing.

Granted, I’m not a fan of the tracking system. You get your antibody test and there’s this app that goes onto your phone. And if you’re positive, it’s going to track everywhere you’ve been, and it’s going to continue to track you.

I just feel like that is, it doesn’t seem very constitutional in our privacy. And I don’t think that tracking is the right thing, but I do think individual tracking to be able to find out is important.

Let’s talk about the antibody testing itself, the pros and cons of it. … The [con] is that there’s been a lot of tests that have come out. And just like anything else that comes out on the market, especially when it’s a lot of one thing that’s similar enough, you’re going to have some that work well and some that do not work well.

When you have anything that is based on medicine and it’s giving you the wrong answer, whether it’s telling you something is a false positive or it’s telling you it’s a false negative and you’re trying to make decisions about that, like going back to work or taking groceries to grandma or whatever, it’s pretty important that that’s dialed in.

I know that the powers that be are trying to test, the [Food and Drug Administration] is trying to go through and test lots and lots of these different antibody testing, especially, we’re talking specifically about the rapid antibody testing that is done at clinics such as mine, at the county level, university level.

Johns Hopkins is doing a big study right now where they’re comparing many of the different rapid antibody testing and seeing which ones are the most consistent, with the least falses—false negatives, false positives.

We talk about antibodies, the IgM antibodies are the antibodies that come on the scene as we get sick.

We’re going to start to get—let’s use chickenpox as an example. A person gets exposed to chickenpox, and they’re exposed and they’ve never had to get pox before and their body is starting to respond and we can’t see anything. We don’t see any dots or anything, but maybe that person is feeling a little lethargic, maybe a little bit feverish, just not feeling themselves.

And then you start to see some spots coming around. And then, those spots start to get that kind of classic look of chickenpox, which is kind of a little bit of a pussy type of a bump. Then, as that progresses, those open, they break, they get hard, and then, they start to go away.

Well, as we’re … several days into that, from the time of exposure to the time that we’re getting the first dots, and then they’re starting to get more prevalent and more pronounced, around the time they’re getting pronounced—which could be somewhere around day five, six, seven, maybe even eight, nine, 10—that’s when the IgM antibodies are coming on board, they’re coming on and they’re starting to fight and they’re starting to lay ground of where they are.

The IgMs are coming on board when you’re in the midst of your illness. So when we’re doing an IgM antibody test, it’s telling us [if] someone [is] actively ill.

In the world of COVID-19, where we’ve all been so surprised is when someone—remember I told you, in my office, I have my sick people outside, I have my healthy people inside, but when we have someone who is otherwise entirely healthy, no symptoms that they can perceive, no symptoms by vital signs or anything that we can perceive, and we’re talking and maybe because of history or places they’ve been, we choose to do an antibody test and we test that person and they have actively strong IgM antibodies.

Now, I have every reason to believe that that is a true test. Now, what we would do in our office is we would back that up with the swab and send that to the lab and see if the lab also shows them having active antibodies. …

Active disease, where you have the RNA, that’s the kind with the nasal swab. The problem with that is if somebody doesn’t have any symptoms, that could be negative. But nonetheless, we have many people who have zero symptoms and they are positive on their antibodies.

Then we repeat those antibodies in a couple of weeks and the IgM antibodies are very, very weak. And we see that the IgG antibodies are now very, very strong and IgG are the antibodies that come in when we are past the disease, the active disease part, those are the ones that are coming in. … It’s like the little army that lays throughout our body and says, “I am not letting this disease come back.”

So with chickenpox, you’ve got all of those chickenpox that harden, almost all of them are gone now, you may have a couple. Your IgG army has arrived and they have laid down all of their … weapons already and they are not going to let the chickenpox virus come back into that body because they are going to fight that. …

On a rapid antibody test, we would see that just in a little line where the IgG is on the little consent. In the laboratory, they can actually measure that quantitatively in house, how strong are your antibodies.

So anyway, when we’re looking at antibody testing, it is very important because we can have people who are asymptomatic—they don’t feel anything at all, or have something mild. And they’re just being a part of life where, and if we can capture that, we can at least let them know, let’s repeat and get a negative.

When you have a negative, that’s maybe [when] you could be around grandma, you feel like you’re safe to be around people. Or in some cases, there’s a lot of studies that are going on where people could donate plasma that can actually help people who are very sick from the virus.

So antibody testing has a big role. I feel like it is what has been successful in curbing not only this virus, but other viruses in other countries.

So I think that we’ve learned a lot from China and South Korea and some of the other countries in being aggressive.

Now, I don’t feel like we’ve done great about getting good antibody tests that we could rely on across the nation. We’re very blessed here at Bella because we did get us a really good antibody test that is consistent. That test time after time is validated by the labs. So we feel very confident in the product that we’re using, but I know not everybody is that way.

I think that within the next two weeks, I would guess we’re going to have a pretty good idea of which are the best tests. And it seems like there’s pretty good availability for the antibody tests. So I don’t think we’re going to have near the issue with getting those out. I think that there’s a lot of product, it’s just more a matter of getting them in the right hands so people can more widely test.

Allen: Dede, thank you. That was such a helpful explanation and just great to hear that background and the whole picture unfolded.

We just so appreciate your time today and all the work that you’re doing at Bella and how you’re just setting, really, such a good example for the medical community of how we can adjust and how we can still be meeting patients’ needs so well and effectively even during COVID-19. So thank you so much. We just really appreciate all the work that you’re doing.

Chism: Oh, it’s just been a joy to be with you guys. I love everyone and all the work that’s done at The Heritage Foundation. I was just there.

I’m in Colorado, but whenever I’m in D.C., I do like to stop in and I do have enough opportunities and people that I know that we can end up having meetings there.

You guys are such a great … spoke pulling all of us together in all of our different places to make our country strong.

Allen: Well, thank you. We love to be a resource for people like yourself all over the country.

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