 and welcome to the latest episode of Telehealth in Hawaii. My name is Vikram Acharya. I'm the host of Telehealth in Hawaii, also the Chief Executive Officer of Cloudwell Health, Hawaii's all-digital physician-founded telehealth organization. This is a very special month, important month, in terms of healthcare and wellness. It's National Nutrition Month and also National Kidney Month. So to talk to us about the importance of these two events is Dr. Neal Chowhan. Dr. Chowhan, welcome to Telehealth in Hawaii. How are you today? Hi, thanks for having me. I'm doing great. How about you? I'm doing good. I'm doing good. You have a very extensive background in telemedicine. Talk me through all your experiences and how you've gotten to this point, working as a physician and serving the residents of the state of Hawaii. Sure. Yeah, long story. So my background is family medicine, and I did my training in England, where I can now practice for a good few years post-presidency. And then I did a stint in Canada for about a year and a half. And my now wife, we were doing long distance and we finally decided to announce the right time to be in Hawaii, which is where she was. And it was very serendipitous. As I moved here, I was asked to get involved with a telehealth company at the time. This was about seven years ago, so way before COVID. And I was very involved with this startup telehealth company. And I'm still working with them and we're the biggest telehealth company in Europe. And it's just been a very interesting journey, you know, pre-COVID during COVID and just how this whole area of medicine has evolved. And it was going to do that experience. And then coming here to Hawaii, seeing the kind of health care challenges that we have and seeing how telehealth could help the community. And that's how we started up Clarenville Health. Definitely. Definitely. That's a great story. Now, you're a physician. You see many patients with diabetes, you know, high cholesterol, high blood pressure. Now that it's National Nutrition Month, what are some steps that residents of the state of Hawaii can take to improve their health when it comes to their nutrition? Yeah, that's a great question. And it's something that, you know, us as a family have suddenly been thinking a lot off through this month as well. And, you know, we have a young two-year-old and, you know, prior to having a kid, you know, busy professionals and nutrition probably wasn't the most important thing on our heads. And now having a kid and thinking about your health and kind of wanting to stay healthy as you get older and so on is definitely a pretty significant priority. And so it's a great month for really people to be able to spend some time to think through how to improve their nutrition, their food intake and how the right building blocks can help for the future. And, you know, as a family, just to bring it back to that, we've been kind of trying to think of ways that we can work on improving our diets, how we can kind of try and reduce the amount of processed foods, the vast foods we eat and so on. And it's just so easy, right? You know, if you're tired, if you're, you know, running around, you tend to grab the easiest, quickest thing you can, right? And if you're kitchen or fridge is full of not the healthiest of things, well, that's what you'll go for. So we've kind of been trying to make this, you know, diligent effort to, you know, try and keep only healthy things in the fridge as snacks or keeping things like, you know, fruits and vegetables and making sure we're drinking plenty of fluids. A lot of the times this is a bit of a revelation for me is sometimes you think you're hungry, actually just thirsty, you need to kind of drink some fluids and kind of making a contented effort to get the right amounts of fruits and vegetables. And I was looking at some really amazing statistics out there, something like 60% of our food intake is from outside in terms of, you know, restaurants or, you know, fast food takeaways, processed foods and so on. And so trying to make an effort to kind of have home cooked meals easier said than done, right? But I think it all comes down to planning. So we've kind of been trying to do food planning for the week, trying to kind of figure out what meals we'll be having. And then, you know, a step from there would be, what are we actually going to be shopping for? Whereas before that, it was kind of chaos, you know, go to the supermarket and grab what I can think of that we need. And God forbid you go in hungry, right? Then you pick all the terrible stuff. So for us, it's definitely made a difference through the month already in terms of having that kind of schedule, carving out time to actually do the kind of prep and meal planning. And it's actually been really nice. I mean, you know, for us, for my wife and I, it kind of gives us some time, some down time almost, just to be able to talk through things and some time in the kitchen together. So it's been enjoyable. And then the other thing which we're trying to set up is kind of exploring more cultures of different foods. And so, you know, we have an extensive network of kind of friends and so on here locally, you know, people from different backgrounds, different countries. And so we're setting up a soccer club where we try and be as healthy as possible. And once a month we meet up and everyone brings a dish and, you know, just a way to feed to get to enjoy different things that you might not have had before, but kind of ensuring that it's tomorrow in the healthy side. Yeah. You know, what's interesting about Cloudwell is that not only could I get access to a Hawaii board certified physician in less than an hour, but there's also something called a telephysical. And you have a lot of experience in telemedicine. You know, how does the telephysical connect back to nutrition? You know, if I were to have a telephysical, how does that work? Yeah, so the telephysical is something that we launched as part of our primary care model. So, you know, we do urgent care, telehealth, and we recently launched primary care, where you're looking at a patient's kind of journey, you're looking at preventative health, trying to keep people as well as possible, and kind of prevent diseases from kind of moving forwards or progressing. And the telephysical, and this is something that kind of I spearheaded in our kind of UK platform, is a way of always getting a snapshot of a patient's kind of well-being at that time. So it's looking at a holistic approach to the patient. We call it biopsychosocial. So, you know, from a medical standpoint, from a psychological mental health standpoint, and just what else is going on in life, what things can we think through to help? And so nutrition is a big part of that, kind of knowing, you know, how much, you know, how much are we exercising? How much are we kind of, what are we eating? How much are we eating outside? You know, weight, body mass index, things like that can really, you know, small adjustments can make a really big impact, especially as we kind of get older. And so part of that, which I'm really proud of is our technical coordinators who help kind of get patients booked in. And so we actually kind of train them all to be health coaches. And so a big part of that was nutrition and healthy diet. So, you know, when they have an understanding about it, they're able to help kind of talk patients through that, you know, prior to the patient speaking with a physician and kind of ongoing care, they're able to kind of help with their input and advice there. So I can see a physician and then also get ongoing coaching with one of the coordinators who's certified to help me improve my nutrition. Yeah, exactly. So they're able to kind of give advice. And that telephysical is there to help us moving forward. So, you know, if it looks like it's appropriate, there'll be kind of blood tests that arrange things like checking cholesterol, your kidney function. And then after that, we can kind of create a plan to kind of get you to your fitness, to your health. Now, there's a big subject right now that due to the unfortunate effects of the COVID-19 pandemic, a lot of people can put off care. They didn't see a doctor for at least two years, sometimes even more. Are you finding when you're seeing patients right now that many are coming in with unexpectedly high blood pressures, cholesterol, some things that maybe weren't looked at over the past couple of years, and now all of a sudden it's become an issue? Yeah. I mean, I would say it's significant both here in the US and with my work I do in the UK. That's true. You know, people, you know, haven't necessarily accessed care as regularly as they would have done kind of pre-COVID. And I think it's also been challenging for patients to get in to see someone. So in terms of things like routine blood tests, checking blood pressures and so on, you know, those things may not have happened as frequently. And then there's also, you know, if patients were noticing a niggle or something, I think a lot of people put it off during the pandemic. And so, you know, sometimes unfortunately those things can progress. And we do see that. So when we're kind of seeing patients doing telephysicals, checking things, sometimes we're noticing, you know, issues that, you know, you can still manage and it's great that we're kind of picking them up. But, you know, I think in another time may have been picked up earlier. Now, if I see you and you're concerned, based off what I tell you, that my diet is not very good. I eat a lot of fried foods, a lot of sweet dishes. And you want me to get my labs done. How does that work in a telemedicine model? What would the coordinator walk me through on the phone? Yeah, so, I mean, we try and keep things as kind of simple and easy as possible. So, you know, if it's flagged that certain blood tests would be appropriate to check like the sugars and kidney function and so on, then, you know, those are arranged by the clinician, the physician. And then the coordinator helps figure out with the patient where the closest lab is to get that done. And then once we have the results, the patient is contacted, invited back for a follow-up to kind of go through that. So, you know, the key is keeping these things easy. You know, sometimes there can be so many unnecessary steps or travel and kind of time sucks that you want to try and get rid of those so that, you know, one patient's more able and willing to do these things, but just try and make it easy. Everyone's busy, you know, everyone could do some convenience with these things. So, we know it's easy to see a doctor, you know, with just a couple clicks. Now, people always ask, is it the same as an in-person visit, you know, and it really is. And walk us through how it's the same. Yeah, I mean, it's been around long enough now that we've seen that. So, I think, you know, about 80% of what, you know, a PCP would manage in practice in a physical location can be managed with telehealth, which is the vast vast majority of things. And I think that's growing with the technology that we're having and then access to specialists and referrals and so on. I think it's really kind of becoming a significant kind of part of general practice in terms of kind of how we manage that. So, you know, there's intake in terms of patients booking in for an appointment, collecting some information to kind of see if it is safe. You know, if someone clearly has some very urgent pressing issue, you know, that they need to go straight to the emergency room for what that's flagged. That's picked up immediately. Patients contacted and they're kind of directed and helped to kind of get to the appropriate service. If all looks appropriate, then, you know, it's a matter of minutes in terms of scheduling an appointment, speaking to the clinician. And then there's a huge amount that they're able to do by video consultations in terms of examining and assessing patients, doing, being able to see, you know, past medical history, previous prescriptions, you know, you have the ability to upload images. So if there's things like rashes that need to be seen. And on the other end, you know, if investigations are needed, we're able to arrange all that. So things like imaging and blood tests, as well as referrals. And we're very fortunate here to have an extensive network of specialists. And so we're able to fast track getting people seen by the appropriate specialist. And what's nice is with the technology and the telehealth side, it's a very seamless process. It's as much for the waiting time. It's very easy for us to speak to the specialist so that they know exactly what the issue is and all the relevant information can be sent across. Now, if I do a telephysical, I get my labs done, and I see you again, and you think I need to see a kidney doctor, a nephrologist, how would that work then so I can get to the nephrologist as soon as possible? Yeah, so we have nephrologists, kidney specialists within our network. And so whether you have insurance or not, you know, we'd be able to kind of refer patients, but a step back would be, we would review the results. We would invite you back for that follow-up, go through what the results are. There's something that needs to be further looking into. And then a referral is made to the appropriate specialist. And our coordinators help kind of fast track that so that there's very little that the patient needs to do. We would kind of figure out when the next available slot is to contact the patient, let them know, you know, is that convenient for them and then make sure that they have all the appropriate information. And then usually the specialist clinic would contact the patient too just so that they kind of know exactly where and when to be there. I mean, that seamless access is really great. I mean, oftentimes, when somebody goes to their primary care doctor and they need to see a nephrologist or a heart doctor, for example, a cardiologist, they're often given a card or a phone number and you call that number. It can take months to be seen, but it sounds like with this process, much quicker. And then I think that's the key. It's easy for, I've been there, you have all the intentions of calling the number and booking something in, but other things get in the way and you get busy and sometimes you put that off. And this is just a great way of getting things done in that moment. It's all done so quickly and seamlessly that the chance to fall off or delay and so on is reduced, which is what we want. You just don't want issues to potentially fester or get worse. If you've got something that needs additional help or specialist review, obviously the sooner that's taken care of, the better for everyone. It seems like everything is interconnected. The better I eat, the better my potentially my blood pressure, the better my cholesterol levels, which then results in better kidney function. Is that kind of how it's all interconnected from your standpoint? Yeah, it's all connected. Nutrition is such an important part of our well-being and I always go back to preventative health. Having these building blocks of a healthy diet, a healthy lifestyle is such a significant part of being able to keep your body healthy. And on the other side, being able to access quick care when there are issues and getting to the appropriate place is so important to prevent things from worsening. Yeah, they refer to kidney diseases as unfortunately a quote-unquote silent killer. What do they mean by that? And what steps can be taken to try and make sure I have some healthy kidneys? Yeah, that's a great question. And you're right. It's classed as a bit of a silent disease. A lot of the times people won't know that they have issues with their kidneys because it doesn't come up with obvious signs or symptoms until much later in what we call disease progression. It's really common. Kidney disease I think is the ninth most common cause of death in the US. More than 35 million people suffer with what we call chronic kidney disease. And because it's silent in its early stages, it can be difficult to identify unless people are having kind of regular checkups and we're checking their blood pressure and the renal kidney function and trying to identify those patients that might be at risk. And I think you mentioned those that are higher risk are those that have diabetes, high blood pressure, heart disease. As you get older, there's a high incidence of kidney disease as well. In the later stages of things like chronic kidney disease, you can see symptoms of things like swollen ankles, fatigue, difficulty concentrating. Your urine can change in terms of appearance and so on. But there's still not the most obvious of symptoms. And so a lot of it comes down to good preventative care, making sure you're having your annual checks and so on. In terms of preventative measures, that's obviously the most important here. And so maintaining good general health, having a well balanced diet, avoiding high sodium, salt intake, making sure you're having lots of fruits and vegetables, exercising regularly, keeping your eye on your blood pressure. There's a clear link between blood pressure and kidneys. And so now it's pretty easy for people to have a blood pressure monitor. I know a lot of people have those checking their blood pressure periodically, which is great. I mean, I think doing those sorts of things can help identify things if they do crop up. The blood pressure that people can use, that's something that's used a lot in the telemedicine world, isn't it? Yeah. And I think people have got used to doing some of these things as part of telehealth and through the pandemic, checking your blood pressure. A lot of people bought oxygen monitors right through the pandemic where you put it on your finger. Those things have been really helpful. And I think there's no reason that patients can't check those things. Sometimes patients might not be confident they've never used it before, but that's the beauty of your consultation is where you can actually kind of talk it through with someone and have a doctor watching and checking. We use that a lot and we find that really helpful. Yeah. I've always heard these stories from patients. My primary care doctor tells me one thing and it's in one medical record. My specialist tells me something else and it's in a different medical record. Is there integration with medical records, with telemedicine in a way that it results in better communication and better care so that things are not disjointed for the patient and that everybody's on the same page? Yeah. And that's just such a critical component, right? There's information which is in different places and the PCP doesn't know what the specialist has said. That's where things can go wrong. Or it can delay potential treatment and so forth. So telehealth has definitely helped with that. It's all encompassed in terms of telehealth, ability to share records, electronic medical record systems. And it sounds so simple, but it's not always there in terms of you should be able to, as a clinician, write some notes and it should be visible for the next physician or the specialist and the patient should be able to see them. And that's where telehealth in Clarewell clearly does do that in terms of that seamless transition of information to those that need it. And what I love is the whole front-facing records that patients can see. With my practice in England, front-facing records has been pretty much always there since the advent of our telehealth services several years ago. And it does change your mindset in terms of writing things in a way that's easier for patients to understand. And I think it really helps patients to be able to see the doctors thoughts, what the plan is and actually have it. It's tangible. You can read it, you can review it and you kind of know what's going on. It's great to have something like a telemedicine service, especially in Hawaii, because especially throughout the state, there's a massive physician shortage and this can get you access to a doctor the same day and address things like potential kidney disease, how to eat better, how to live better in terms of health and wellness. People may live far away from a doctor, but they do have access to a smartphone and they can get the care they need when they need it and in a timely way for their overall wellness. Yep. And that's the key. I mean, that's why we wanted to start this in terms of, there's definitely kind of geographic challenges here in Hawaii. There is a shortage of physicians. There's going to be a huge number of physicians that retire as well. And you want to make sure that people have the best and easiest access to good quality care. And so I think telehealth really does help answer that. And you're right. I think just being able to use your smartphone or get on your laptop and be able to speak to a physician gets rid of a lot of those hurdles. And I think it's that access to expertise and information that's kind of critical. I'm sure you have patients when you counsel them on things like kidney disease, nutrition, that they may be a little bit hesitant to use telemedicine. Maybe it's their first time, but when they use it, they really like it, right? And they're like, you know, I didn't think it was this easy. I'll be back. Can you get a lot of that? Or you get more of them? Well, you know, I'm not so sure about this. Yeah, probably a mixture. I mean, you have some people, you know, who just aren't comfortable with the technology. I haven't used it before, but you're right in that once people have used it, they're then very comfortable with it. And I think I might be slightly off, but I think we have like an 80%, 90% retention rate. So if patients have used it once, they'll definitely be using it again. And I think, you know, if you were to just leave it to kind of patients to figure out from that tech standpoint, if it's something that they're not used to, you know, there's clearly challenges there if you're just not comfortable with it. But I think when you have coordinators that can help walk a patient through it, explain it, hold the hand through the kind of process and for it to already be easy and simple, I think then it's a mess of a challenge. So that's unique. So you have a coordinator team that actually reaches out to the patient before the appointment to tell them what to expect. Because I know a lot of companies actually don't do that, at least that more personal connection. Yeah. And that's what we do. And that's just something that we always thought was important, right? It's not about, you know, getting as many patients as you can through the door or kind of letting the automated services kind of take over. For us, it's still about being able to, you know, provide the best quality care. And I remember when we were first starting with this, it was about how can we provide the best bedside manner, right? And when you talk about bedside manner in terms of the kind of connection you can have with a doctor and how can we do that virtually? And this is what we realized. You know, you have to have those human contact points. You need to have someone that can help with the simple pieces and kind of, you know, having a contact point with a patient before they're booked or during the booking process and making sure that everything is set up. And if they have any questions, I think that's just a really important part. It's funny. Again, it just goes back to how everything's interconnected. Telemedicine provides a service that helps people get access to timely medical care. The better the customer service, the more people are going to use it, the more people are going to use it. It just increases better health, better wellness and basically a healthier society, isn't it? Exactly. I heard the nail on the head. It's about, you know, providing that easy access to care. So when patients need it, they get it. And by doing that, you can avoid what we call sequelae or progression of disease. And the aim, you know, the big aim is to try and keep everyone healthy, you know, prevent people from having to, you know, go into hospital or kind of unexpected illness progression or certain things like that. And I think if you have easy access and you're able to kind of speak with a doctor, you're able to keep on top of telephysicals and your blood tests and so on, you have a much higher chance of identifying any issues as early as possible. I think that's the key. Yeah. Yeah. And being able to identify things quickly with easy access just seems like a great differentiator. Thank you so much, you know, Dr. Chauhan. It's always a pleasure to talk to you, you know, your experience and telepathy and the excellent progress that Cloudwell is making in terms of providing just great care, you know, to the residents of the state. It's just making a significant difference. And I just really appreciate your time. Thank you for being on. Thank you. Yeah. Thank you for having me. Take care. Mahalo. Have a wonderful day. Thank you so much for watching Think Tech Hawaii. If you like what we do, please like us and click the subscribe button on YouTube and the follow button on Vimeo. You can also follow us on Facebook, Instagram, Twitter and LinkedIn and donate to us at thinktechhawaii.com. Mahalo.