Narrator:
This is a DarshanTalks Podcast. Before this weeks interview with Doctor Emmanuel Fombu on COVID-19's impact on telemedicine, Darshan will introduce this episode with a recap for the week of Thursday May 14th, 2020.

Darshan:
So this has been a bit of a slow week. People have been talking about COVID and people are starting to get restless, but I've done a bunch of different podcasts and the big takeaway has been that COVID is affecting how we're going to do business. I can think of three very clear ways COVID is going to affect business. All of them are not necessarily game changers as much as COVID has accelerated the direction of where we're going.
Number one, I think we're going to end up with more virtual working. And that means that your employees may not be sitting out of your office anymore, they may ask... No, no, no, they may demand that they sit out of their own houses, do their own work at their own time. So that, it's the end of your traditional 9:00 to 5:00 because little Johnny still has to go to school and he comes back at three O'clock and the mother or the father taking care of them wants to take that time off, take care of little Johnny, get him settled in and then go back to work.
The second thing we're looking at is an acceleration into decentralized trials. I've had a bunch of different conversations, and the big takeaway has been that decentralized trials are here. The question is, will they say? And I think that there's an argument to be made, that based on the investments that are taking place, decentralized studies will start making more of a footprint. I would be surprised if the decentralized trials go as quickly as people are expecting, not because they don't mean as much, but because all the investments aren't completely there yet, which means that, it becomes a nice add on, but I don't see it becoming a here-to-stay for the next year to two years at least.
Stay tuned and reach out to me if you think that I'm wrong about this. I could be wrong, leave a comment. The other thing that I think will be here to stay is this idea of patient centricity. And patients have now started looking online, and we've always been looking online for information, but patients are now going to say, "I want to be able to handle my life in the way that I want to handle it." And with that comes the concept of telehealth, with that comes the idea of how does one reach out and be understood by your clinicians, by your clinical trust staff in a way that meets them on their own terms. So, those are my big three take aways.
Another sort of bonus take away, is the fact that Zoom meetings, GoToMeetings, the other different formats out there on connecting virtually are likely here to stay. Companies are already talking about reducing their office footprint, companies are already discussing what are better ways to engage? Jeff Morgan actually came on here and said that they were going to reduce their footprint.
So if all that is true, the big question is going to become, how do I look professional when I'm in my own house? How do I make sure that my walls are clean? How do I make sure that my outfit doesn't clash with the Zoom background? How do I make sure that I stand out and look professional? There have been instances where people walk away from their Zoom meeting without their pants on, and that's obviously problematic. So, there can be a whole discussion on that as well, but I just thought that was an interesting tidbit that I've been following over the last couple of weeks. If you disagree with me, if you think that I missed out on where the next direction is for life sciences, for health care, feel free to reach out to me, and stay tuned!

Narrator:
This is the DarshanTalks Podcast, regulatory guy, irregular podcast with host Darshan Kulkarni. You can find the show on Twitter @darshantalks or the show's website at darshantalks.com.

Darshan:
Hey everyone. Welcome again to another episode of DarshanTalks, as usual we have one of the premiere speakers in the area of health tech, in the area of health IT, in the area of health itself. He's been recently featured in Fox News New York, where he spoke about COVID-19. He has his own radio show on Hot 97. We have Doctor Emmanuel Fombu. How are you Emmanuel?

Manny:
I'm doing great Darshan, thanks for having me.

Darshan:
Thank you for coming on. Emmanuel would you like to introduce yourself? Talk a little bit about what you're doing? Before we started talking, we had a very brief conversation about the type of work he's into and I thought it's going to be a good setup for us to talk about some of the things we want to get into.

Manny:
Sure. So, my three year studied in clinical medicine, and through working on ePharma, worked at [inaudible 00:05:31] and recently Johnson & Johnson and now I spend my time as a deal professional, doing a lot of medical set acquisitions of financing of companies whereas in bio-pharmacy side or latex side on digital heath and advising companies about what direction the industry is going in. And how best they could position their companies to be successful.

Darshan:
So that really speaks to... What you have is a front row seat to what's happening. And interestingly enough we're going to talk about COVID because that seems to be on top of everyone's mind. And everyone's talking about how the world has ended and it's the start of a new world. And you and I had this very brief discussion of... When I started talking about how the world was ending and you were like, "No, no, no. We're talking about the start of a new world." And you raised some interesting points and do you want to talk a little bit about what you hinted at?

Manny:
Correct. So, the COVID-19 pandemic has really, literally hit a restart button on our lives, right? No one expected this, this really came out of nowhere, and this has literally destroyed everyone's plans for 2020. Whatever business strategy anyone had has completely changed. The idea of telework is the norm. Students taking classes online, has become the new norm, right?

Darshan:
Yeah.

Manny:
Telemedicine has become the new norm, the idea of remote patient monitoring has become the new norm, and now vaccinations and infectious disease area has become a hot toping in health care, which was not really the hottest topic. I remember in January, being at J.P. Morgan come to the San Francisco with a lot of investors and a lot of companies, and the discussion was not around infectious diseases, right? It was more focused on [inaudible 00:07:39] disease, oncology and kind of areas of opportunity. But now you look at every major player in the industry, is literally scrambling to dig to the biggest solution, whether it's a cure or a vaccine for COVID-19.
So, the world is completely different, we all are quarantined in our homes. And basically this is the point of something I called the new normal, right? So that new normal is what we all have to do together.

Darshan:
So that really raises the question of the new normal, is this a new normal during this COVID-19 crisis, or do you see that carrying over after the crisis is over? Do you see investment dollars going into infectious diseases? I mean we all know that... When was the last antibody that came out? It's been forever. And the reason is because it's a short period of time, someone gets better and the drug's never used again until the next time you get it. And that's not great for stable revenues for a company. Do you see that changing?

Manny:
I see in a short term, I see there would be a lot of interest. I mean, right now I see everyone and their grandmother has a new product that works for COVID-19, right? So there's a lot of noise in the space right now, certainly. I don't see new investors necessarily in that industry is jumping in and taking that risk, but there's certainly a lot of products in the market. I think the big players are already in the space, that we're already touching on vaccine players. If you look at [inaudible 00:09:12], you look at BMS, all these companies that are already making moves for cure. So, I hope that that is something that hits the market within 12 to 18 months from now from a vaccine angle, right? But it's also the idea of also until the vaccine gets here, what do we do?
So up to then we have to actually try to cure the disease and manage the disease, right? And so you've heard every other kind of drug that supposedly cures COVID-19 infections, but that's up for grabs, so there's a lot of interest there. But I don't necessarily think it's a hot investment market, because a lot of drugs that people are talking about are generic drugs.

Darshan:
Correct. And [crosstalk 00:09:50].

Manny:
So it's good that research is being done in those areas, but I don't think it's a hot area for investors. The interesting piece of what is happening in the industry now is, if you look at hot areas for investments like gene therapy, oncology, Reye disease. These patients that are supposedly part of the studies, are actually at a higher risk of being infected, right? Or dying from this particular infection. So they are staying away from hospitals, non-essential medical procedures, for example are being stopped. I think recently this week in New York they might open up some, where people can have electric surgeries, for example. So think about it, if any ongoing clinical study was taking place in cancer patients, those studies are probably on hold right now.

Darshan:
Yeah.

Manny:
Right? Because you don't want to expose those patients going into a healthcare center to go take part in the trial. And so, those things are being affected on a massive scale, and so this has literally changed the way we think about doing clinical research in the future. I don't think that mindset is going to change, I think it's a rebuild on the way we all think. I think that going to concerts, going to the airport will never be the same. And a great way of likening it to is 9/11. Before 9/11 we could go through the airport, you didn't have to take off your shoes, you didn't have to get your bags screened, you didn't have to literally go through X-ray, body searchers to go through. But that became the norm, and we adapted to that, like going to the airports for example.
I see the current world and the post-COVID-19 world being exactly that, where temperature checking before boarding planes for example could be the norm. Showing the fact that you have been vaccinated against COVID-19 or you have antibodies to COVID-19 for you to get into a restaurant or a concert hall or a nightclub or a bar. So I see that as a new norm of what would just become part of life.

Darshan:
But don't you see that as being something during COVID-19, next year when it comes around it will be another version of COVID. A COVID-22 or whatever it is, I'm making up numbers here. But if that happens, aren't we always chasing what the new version will be? I mean that's literally what vaccines look like for pneumonia, right? So every year they come up with a new version. So I guess the question I'm asking here is, if we're going to change the world to fit this new paradigm, how does that work when the paradigm itself is unstable, if you will?

Manny:
Correct, which is very interesting here. I mean, the discussion about pandemics has been something that a lot of public health officials have been talking about for a long time, right? So if you look at... There are multiple cases of people like Bill Gates talking about this in a TED Talk several years ago, right? We have President Obama talking about this several years ago. A lot of global public health officials will be talking about this. We've had SARS, we had MERS, right? We had H1N1.
So the idea of having these kind of flu pandemics is nothing new, but having a new virus such as COVID-19 in a global world where people travel and the ability for this to spread and the financial losses that business and countries have suffered will permanently engrave our minds and we'll not forget this, right? This is the first time in our generation where we've seen something this big that happens globally.

Darshan:
Right.

Manny:
You really cannot escape to anyplace.

Darshan:
Right.

Manny:
Because everything is on standstill, planes are flying empty. That says a completely different kind of mindset. And going forward, the next thing might not be COVID-22, it could be something else.

Darshan:
Right, exactly.

Manny:
Right. But we know that this is real, and that something like this could happen. And so, we will forever become more proactive about this as opposed to being reactive, because every business owner knows, that if something like this should happen again, we will not be able to withstand this.

Darshan:
Interesting, so you're seeing it more from a societal viewpoint, if you will. Which is, how is society going to adapt, whether it's the temperature checks, and maybe business planning. I mean I know for example, I'm general consult for one of the companies for startup, and one of the big things was we reached out to the insurance provider and we asked them, do you guys cover this type of business stoppages as part of our insurance coverage program? And insurers are having a really hard time basically saying, "No, we don't." And their argument is, we didn't cover COVID-19 and it's kind of hard because a lot of insurance companies come out and say, "We'll cover SARS-like symptoms and SARS-like infections."
So it's going to be interesting for the next few months and years, but I don't think too many insurance companies can absorb this type of loss. And if it was going to absorb this type of loss, they would have to do this in an unprecedented way. And everyone's insurance cots will go through the roof for it.
So it's interesting that you're talking about just at that societal level and you sort of then zoom in on healthcare. You talk a little bit about how everyone's not moving which means everyone's staying home, which means we're talking about telework, we're talking about remote patient monitoring. What are you seeing in those spaces?

Manny:
In those spaces I'm seeing a couple of interesting things, right? And so one of the most interesting things is around new teletechnology called nanotechnology and the company is called NanoVapor Biotech where they actually have a product that you can spray on a surface that actually kills viruses and bacteria for a long period of time. Which is very different from our traditional way of disinfecting things where you use just an alcohol based or a hydrogen peroxide based cleaner.
So you see new technologies come out that kind of arena. If you look at the idea of telemedicine in general, Teladoc. I mean, Teladoc when it went IPO their stock initially went up and then it was on this downward trend and you could hear everyone talking about, "Oh, telemedicine is something of the past." "People have tried telemedicine and it didn't work." But now with COVID-19, the demand for telemedicine services have skyrocketed.
For telework, if you look at Zoom, if you look at all these other companies that are providing this telework kind of services, Microsoft Teams, right? And Facebook is giving in to the idea of telework too, right? Because [inaudible 00:16:24] worked for live stream platform on Facebook to do this. So everyone is getting to this space. If you look at things like Instagram they're hosting conferences. Especially in our industry, if you look at your [inaudible 00:16:34] at this particular point, I'd probably be on a plane flying to some conference to give a talk or medical companies and happenings. But guess what, all that is on standstill now.

Darshan:
Right.

Manny:
Now though we will communicate, now it's through online technologies, right? Conferences are going virtual, everything has going virtual, something that we didn't think would actually happen from an experience point of view, but we're all doing those things now. So that is picking up. The idea of virtual clinical trials is also picking up now where for a long time, I've made that argument and many people have made that argument that we do clinical trials for example if patients live far from the clinical trial site sometimes. Justification was the major issue. But yet, well, this is a really major thing, the burden was drawing the patient. But today going forward, everyone that designs a clinical trial will take that into account that, "Yes. It's possible to remotely monitor patients."
And with that being said, it's a new industry booming around companies that could have devices that you could actually measure vital signs at home. So those kinds of companies now are popping up because if you do telemedicine, well, it's you tell a doctor or any other platform, what happens is you just still need to collect the vital signs, right? So the doctors looking at you, they still have to take some kind of objective measure, blood pressure, heart rate, ETGs. So you need those kinds of datasets. And so there's a big boom of investments coming into those kinds of companies that make hardware that could actually collect these vitals right at home.

Darshan:
That's kind of interesting to me, you brought up two different points that I want to dig into a little bit further. One is you talked about the rise of telemedicine and the second is you talked just virtual clinical trials. And we'll talk about both but let's start with the telemedicine.
Obviously there are areas where telemedicine makes a lot of sense, but I speak to a lot of friends of mine who are in healthcare, who are PAs or MDs and their big thing is, I don't get all the information I need, it's very impersonal, it takes longer than you would think, people think that it's a shorter period of time but now the daughter walks into the room, the dog comes up, I don't get the attention I need to be able to make the decision and move on. I can't see all the patients walk, even if I do see the patients walk I can't fully evaluate what that looks like.
So all those bits and pieces, I'm wondering if telemedicine is going to have a roll, but it doesn't actually replace the physician-patient relationship. Does it become, or augment what mid-level practitioners use? As apposed to replace what physicians do, what's your take on that?

Manny:
Correct, I think a lot of telemedicine work could be done by nurses and physicians assistants, even doctors as well. If you look at... From multiple aspects, so this argument prior to COVID-19 was one of the reasons why telemedicine was stalled, that's one. Two, the reimbursement rate for televisits were lower than an in-person visit. So clinicians were not incentivized to do a televisit as imposed to an in-person visit.
If you look at... But today's it could be different. CMS will reimburse, a lot of insurance companies like to reimburse the same fee for face-to-face visits as they do for televisits. So the incentive is there to have adoption with a provider site. The next piece of evidence is, I can't remember the last time anyone said, "I can not wait to go to my doctor's office and sit there for hours and hours just to see a doctor." Or a nurse.

Darshan:
Right.

Manny:
Right? The typical days you have an appointment to see a clinician literally you have to take half the day off work or take an entire day of work. With telemedicine, you literally can just book a time and have the conversation either for manual or physical. So I think near volume or gain here, where a lot of people would like to be checking in with doctors, and have more preventable approaches to healthcare, as apposed to going to an emergency room when things are [inaudible 00:20:38].
So I think people need to become more pro-active in healthcare and help the providers become more accessible, that you could talk to. So, that's one advantage of that particular system. And I think that the incentives aligned with that particular element of things. Yes, I do agree that a faced-to-face interaction like any other interaction is fantastic. I would love to be with you right now in the same room having this conversation, but we still have an effective conversation through your podcast, right?
And we have a lot of listeners right now that will learn and contribute more to society and to our environment and can share this dialogue virtually and we do not need face-to-face, right? When we are face-to-face we can have a much deeper conversation and build a much deeper connection, but it doesn't prevent us from actually communicating and moving forward with what we need to get done. So I will argue for the fact that we need to adapt to this kind of way of doing things and move forward with it.

Darshan:
So, I guess I'm not disagreeing with you, I'm agreeing with you. What I'm wondering is, putting on that fortune tellers' hat, do you see a future where both become necessary? I think we both agree that that's probably going to be true. That both forms, both live and in-person and this electronic telework, telepharmacy kind of thing becomes a real thing. My question is, what is the niche that telepharmacy occupies? Or are you saying it might encroach quite significantly on the common practice of medicine? I use the word encroach not to say replace, but yeah.

Manny:
Correct. So, yes. I see... So which one is cheeper to begin with, right? If we say, okay what's going to happen in the future and we are looking at what will happen even in the post COVID-19 world, first of all, players realize that it's way cheaper to do televisits than it is actually showing up in a doctor's office or showing into the emergency room, right?

Darshan:
Right.

Manny:
That's way cheaper. And so I see a lot of investment and I see a lot of interest in pushing that, pushing for remote patient monitoring. Because today actually I just say an article this morning about the United Healthcare being interested in possibly acquiring a remote patient monitoring company or a telehealth company able to. And a deal is about a half billion dollars, in the deal.

Darshan:
Quick question for you though, quick question.

Manny:
... Making moves in space, right?

Darshan:
Quick question for you. You said something which I'm trying to understand. A few minutes ago we talked about how the reimbursement was not the same, and therefore the doctors were hesitant to use tele-options if you will. And then you just said that it's cheaper for insurers, could you explain how both would be simultaneously true?

Manny:
Correct. So previously the reimbursement was not the same, right? But today the reimbursement is the same for face-to-face visits. And so, yes they're the same for face-to-face visits, same as if you do telemedicine so that's incentive for clinicians to participate.

Darshan:
Sure.

Manny:
And then I said that it's cheaper for insurers to actually focus on telemonitoring and remote patient monitoring as opposed to patients going into the emergency room.

Darshan:
Oh, okay.

Manny:
If you show up in an emergency room... Yeah, correct. Because that's where people go. When people get sick, so if they have a cough or they have fever or something, they go straight to the emergency room, right? Which is very expensive. That's why the last several years you've seen urgent care centers popping up around the place because they're cheaper than actually showing up in an emergency room.

Darshan:
Right.

Manny:
When you show up at an urgent care center or emergency room, it's more expensive for the payer than if they actually for a face-to-face visit just like you pay a primary care doctor when you just go into the office. When people get sick, you don't walk into primary care doctor's offices usually, you have to make an appointment to go, but if you have a fever today, you can't get an appointment with your primary care doctor, you go to an emergency room.
Majority of people don't have a private care doctor that they actually go see on a regular basis. So that's why company's like Zocdoc for example, with the a platform where you could go and book appointments on a short term basis to see a doctor. Otherwise, the emergency rooms are being flooded with people. And that's why if you look at the whole [inaudible 00:24:55] about [inaudible 00:24:56] admissions and trying to keep people away from the emergency room, there's been a big movement towards that. The Affordable Care Act was specifically designed around that. To keep people away from that.
And so, you see with this movement that people adapting to this and clinicians being able to use this, patients are being comfortable with using technologies for work, for school, to talk to your doctors. So that mindset has already changed. And innovation now it's really said, it happens when we have our backs against the wall, we don't have no choice but to adapt.
And that's where we are today. We have not choice but to communicate through the phones, FaceTime, doing concerts on Instagram or on TV and watching other concerts on TV, that's the norm. Watching sports on TV is the norm. The discussions today about the Yankee's opening up the baseball season or the NBA opening up and people are going to... There'll be no fans and audiences. Everyone watching TV. So that is becoming a norm.
And so people will get used to this kind of idea and the idea of virtual communication will not be that strange after all. And don't forget, the social distancing society we're living today is going to continue way into 2021. And so the idea of us putting masks today looks strange, but by the end of the summer or it goes to December, it will become the norm. Because we'll be wearing masks, right?
Today you can't go to a grocery store in New York without putting on a mask, it's required. So everyone puts on a mask, keeping free distance between people is the norm, going to restaurants and being able to sit far apart from each other will be the norm. Jeff Bloom just announced yesterday that starting in May, May 21st, every passenger must put on a face mask. So you see a new world where we're adapting to because we are forced to.

Darshan:
Right. I mean, there's so many questions that have come out of this for me. The first thing that really strikes at me is obviously COVID in this case is spread by droplets, so mask get us partially there, but aren't you still spreading it with your hands? So from a clinical perspective, what's your take on that? That's a short question but I'm just curious about it.

Manny:
Yes, that's a very interesting piece of it that first it was put on gloves and wash your hands, but we know that this droplet lives in the air, it's airborne, just how people get infected, right? And there are many studies that have shown that it actually goes beyond six feet.

Darshan:
Right.

Manny:
So the best idea here... You're correct. I think we're doing the best we can to just mitigate risk, but I don't think it's the perfect solution to what happens. I don't see a society where we walk around being distant from each other. I think probably the side effects of that is probably worse than actually being close to each other. I think physical contact between humans is actually very important. So I actually like the term social distancing as apposed to physical distancing. I mean, as humans, we need to be around each other in the general sense of things, keeping that space but yet finding ways to communicate with each other is actually the best way to go.

Darshan:
So I'm going to pivot a little bit now. I'm going to start talking a little bit about virtual clinical trials. By the way, just so you know, this conversation is going way longer than we expected so thank you for your patients of staying on. You talked about the idea of virtual clinical studies and obviously we've been talking about virtual clinical studies for a long time. [inaudible 00:28:29] done one a long time ago and we've had some learnage from it, it sort of peaks and ebbs and flows, ebbs and flows. I've done some interviews with sites and they talk about some a lot of things.
My big takeaway... Let's sort of take a step back from virtual and start with the first piece which is, as you mentioned, a lot of studies have stopped because no one wants to expose your oncology patients to the hospital environment where you might get sick. How are you going to start that again? Do you think that they're going to start virtually and go from there, or do you see them sort of starting at a scenario where you come back and we sort of catch you up? Will the protocols have to change? How do you see this working in the immediate term after COVID?

Manny:
Correct, I see a lot of protocol amendments happening to take away some of those in-person visits to virtual visits. Or have them amended in such way where we actually send a healthcare provider or a nurse to the patient as apposed to the patient coming in to see the clinician. So I see a lot of protocol amendments happening.
Imagine doing a study today, looking at quality-of-life measures, right? [inaudible 00:29:45] studies in the past looking at qualitive life. Multiple studies have quality-of-life as an end point. And which is what is most important to the payers, right? So quality-of-life measurements today we've looked at... If you look at devices, look at activities. How many steps did you walk last week? Were you active? Were you able to mow the lawn? Were you able to go grocery shopping? And all those things, right?
In a sick-patient population where we're telling them to stay home and get groceries delivered to you, don't put yourself at risk if you're a high-risk patient, and we know that patients with [inaudible 00:30:16] conditions are actually at a high risk of mortality. If you look at patients with diabetes, COPD, asthma, heart failure, they have a higher mortality rate than the average patient population that has COVID. And so those patients, we ask them to stay home.
So imagine you had a study ongoing right now, and those patients are now allowed to move. Their entire endpoint is done, you can't study that. So the way of defining what you meant as quality-of-life is completely different. Prior to COVID-19 and what is happening today, because patients are restricted. So that study can not go on. So you have to completely amend those or put those studies on hold.

Darshan:
And you'd just restart them at that point.

Manny:
Yeah, correct. And so what happens with those patients if... So they basically take their drug to the regular time interval, and if they do, what exactly are you measuring. So, so many studies will have to be scrapped, some other studies have to be re-done all over and redesigned to be launched. So the impact of this to the industry is massive.

Darshan:
I agree with you 100% I think the impact's massive, I think the cost once this is all figure out is going to be catastrophic, which is really interesting and I'm sort of going off on an off-shoot here but they're already talking about how the stock market's coming back and it's only 16% off from it's all time highs. And the all time highs were like what? A month and a half ago? But, while all that is happening, I can't even understand it. We have so much uncertainty, so many studies that were stopped, so many plans... And I'm just talking health, and there are obviously multiple other industries that are affected similarly. That's not counting industries that have just plain stopped like the restaurant industry. But I wonder how this is all going to play out in the stock market in the long term. As an investment banker, do you have any thoughts about that?

Manny:
Yes. In the long term, everything is going to work out. If you look at the current stock market situation, the stock prices are down, but it's not necessarily because of the economic problem. If you look at 2008 for example, we had a financial crisis but that was because the banking infrastructure in general was not strong enough. We had bad lending practices, so that's why the system was down.
Today we have a situation in which a pandemic is actually disrupting businesses. The core of those businesses are strong but customers are not allowed to actually engage with the businesses. Like you mentioned the restaurant business for example, if you look at [inaudible 00:32:58] business or even Uber businesses, all these businesses, groceries, retail, all the shops are completely locked down.
Everyone is at home, so look at retail general, people are not buying new clothes to go out, makeup, barbers, everyone is down, right? But when it opens, I think there will be a big rush and demand to people to get back to taking care of themselves and getting back into society. So that is another interesting piece of it. So I think that we will definitely rebound, this is a global thing and so it's not focused on one particular industry.
But what will change in general is that for the first time, healthcare is going to be in the backbone of every single industry, regardless of where you are. Before talking about health and the interaction about health care was a luxury kind of thing that businesses were not necessarily interested in, it was not in their core business, but just like terrorism was that put fear in every single industry going forward and safety around that, I think healthcare and making sure we are safe and being proactive about healthcare will be at the center of every single business, regardless of what business you are in. Healthcare will be at the forefront of this.

Darshan:
I agree. It's interesting, all I've heard is the doom and gloom version of, no one's considering all these things, we're going to see two, three quarters of impact, of financial impact and I really like the take you have, which is, that may be true but you're going to see a major boom in work once we come back. Because the world's going to basically restart, which I think is so understated. So I appreciate you saying that and it's that glimmer of hope that I haven't heard personally in months, well weeks. It just feels like months.

Manny:
Right. Darshan, you're a regulatory guy, right? And so one of the biggest challenges being in this industry for a long time, especially healthcare, was that, healthcare is a heavily regulated industry. Getting things like telemedicine work done in the past would have been a massive challenge because of the regulations around it, doctors could not see patients across state lines in most instances. And so, there was a big challenge there, on how you do that. Getting drugs quickly approved has been a challenge in most cases.
But in today's COVID-19 world, we've realized that some of those regulations have been downgraded a little bit to spur innovation and to spur adoption to this things. Which could be a catch-22, right? And so I am happy to see that some of these regulations have been down, but I'm sure you probably have a different take on that.

Darshan:
I do have a little bit of a different take on it. You and I, just before we started this talk, you raised this exact issue. And I totally understand where you're coming from because I think there's something awesome about the world going, "We'll stand up and we'll take this disease head on." My concern in doing this in a "normalized world" is, I can't even trust my Fitbit to tell me the number of steps I took. I literally every single day get a different number of steps from my Google phone and my Fitbit. If that's true, how do I trust some kind of remote monitoring system to tell me what my blood pressure and my pulse is?
In the end, my experience is that, not only are the systems in most cases flawed because they're often created this... A lot of medical devices work off of the way Google and Apple and all of them work which is, start with an imperfect version and keep creating slight modifications over and over and over again until you get a robust, great system.
Healthcare works very differently than that. Which is, you need to get it the first time. And that fundamental difference and philosophy is hugely problematic. So in the same way... So I certainly don't believe that the tools work as well as they should. That you need a fundamental change in philosophy to make that happen.
You take the second piece of that and you talk about physicians working across state lines. As a concept, I love that, that sounds great, except you'll end up having different bugs, you'll end up having different standards of care when you cross state lines. Someone working in Arizona and someone working in New York almost definitely have different ways they treat patients. Not because the patients are different but because the standard of care is different.
So they're exposing themselves and the patients to a variant form of standard of care, and as a concept is that the worst thing in the world? Maybe, maybe not. But you're going to get different results because of it. Now, how do you know which results are better? I don't know. You take the... Go ahead, you want to comment?

Manny:
Sure. And I agree with you, I think we should have some regulations in place, some kind of a guideline in place that I think that every company needs to hit some kind of bare minimum kind of elements, right? But addressing that particular area of clinicians being able to see patients across lines, state lines. I think the same issue will apply even within the same state. So look at New York for example, where in Manhattan you have significantly more people that tested positively for COVID-19, yet the mortality rate in The Bronx which is literally across the river, the Hudson River, has twice the mortality rate of people dying from COVID-19. So the access to care, even within the same state is completely different.

Darshan:
Without a doubt.

Manny:
If you are in Manhattan and you have access to a New York [inaudible 00:39:15], you could go down to Mount Sinai's main hospitals. You have great service, you can go down to The Bronx. But if they have testings available to those areas, right? In those poor areas. So it is the same thing within cities, and the doctors are practicing the same thing within state lines. So is it possible if a doctor in Wisconsin for example, that was in an environment where they're not flooded with patients with COVID-19 and not overwhelmed could interact with a patient out in The Bronx. So if you look at the cost-benefit analysis of it, is it not worth it to give me that shot?

Darshan:
So, I'm not necessarily opposed to the shot, I guess what I'm wondering is... For example, I'm making this up, right? But a patient comes in and says, "I have a cough." Today it is, I have to go to my local doctor and my local doctor will write a script for Keflex for me, I don't know if that's right. But yeah, and you are taking it four times a day. On the other hand, if I go to Arizona they go, "You know what? We don't have the same bugs, we're going to go with a slightly different... Some other drug."
And the question that I ask at that point is, if... And the way I see this working, is this is not going to be just a random doctor, right? What will probably end up happening is you'll come up with... What's the word I'm looking for? Some kind of phone centers or some kind of that, where you've got 10, 15, 20 doctors sitting and they just keep taking phone calls. And now that you've got these 10 doctors in Texas dictating care across the entire country, for areas that may or may not know. And that difference may be fundamentally problematic.
Okay, maybe that idea is a weird situation, we shouldn't talk about infectious diseases in that specific way, maybe we need something different for that. Okay fair enough, then let's take something like heart failure. And the treatment for heart failure in I would guess rural Wisconsin, is very different from the treatment of heart failure in New York City. And the question I start wondering is, does it make sense for say 15, 20 doctors sitting in New York City because that's where your hub is, telling a farmer that, "You know what? You shouldn't wake up at 5:00 in the morning, you can't take the stress. Is there a different form of stress that we simply don't understand because we're not in the same place?"
So, again, to me it's a question of... And I recognize your point, which is, don't we already have variance of standardized care? And I think the answer is, yes, we do have variance, but at least we're working with the same basic sets of knowledge, if you will. I think you risk the chance of health disparities, the risk of greater health disparities by causing unregulated telehealth. But obviously I think your point is right and maybe there are better ways to organize this than we've considered. Are we on the same page? Or I don't know if we're saying the same thing?

Manny:
The point you're bringing up is interesting. So if you look at... I mean, if you're a physician in the United States, every physician took the same exam.

Darshan:
Yeah.

Manny:
Everyone took the same exam. When it's a drug available to treat a particular disease, the guidelines mandate that every single patient in the US should be treated on those particular therapies. That's why you go to the FDA, you get them pull for a drug in a given patient population. So it should be standard.
It is true that the affordability question actually influences how people get access to care, but I think it should be standard. I think if a patient with heart failure in Arizona's and a patient is in New York, wherever you are, if you fit the same criteria of what was studied in a clinical trial, and the drug was approved for it, you should be able to get access to the best therapy that's available. And so if I'm a physician in New York and I decide to move to Florida, a patient of heart failure is a patient of heart failure.
I do understand that certain details about a patient might change, right? There are certain diet restrictions based on the local thing that people eat that will be different nationally, globally, but let's not forget that was set for the last several years. If you look at radiology as a practice, a lot of MRIs and X-rays have been read by doctors outside of the United States, at night time. When the radiologists of US are in bed, those images are being sent across country lines. And other physicians outside of the country that have never met you are actually reading this and sending reports back-

Darshan:
But I think those doctors still have to be licensed in the US if I remember correctly.

Manny:
Sorry, what did you say?

Darshan:
Those doctors still have to be licensed in the US. So if that's true-

Manny:
Correct, yeah.

Darshan:
... Would you still say that Dr. Smith prescribing in New York, should also have a license in Arizona, or are you saying that that's not necessary?

Manny:
I think there should be a simple way to get a doctors license in every state. I mean, there are states today that will show-

Darshan:
Reciprocity?

Manny:
Reciprocity, right. Where you have a license in one state and then you're also able to practice in other states. Like California is not one of them, or you look at Texas for example. What is the difference if I took a national exam and I'm certified as a physician and then I have to go down to California to apply to a new license and then wait months and months and months? I mean it's a fee based on a model. So I'm not saying that what you have are people that aren't qualified to practice medicine in places, I'm saying these are people that are already licensed in a state that could help other people where they are overburdened.
If you look at New York City right now, there's a lot of intake from nurses and doctors from outside of state to come into New York to help people in the city [crosstalk 00:45:16] work are overwhelmed. Just recently, you have suicide rates among clinicians and nurses that are taking care of these patients when you're going up. So it is a big impact to mental health. So how do we as a country decrease the burden and pressure on health care workers? And I think doing something like this where you could open up that [inaudible 00:45:37] clinicians to practice across state lines actually helps improve healthcare.

Darshan:
We could keep talking about this for so long, this is such an interesting topic. But I think we're past the 40 minute limit. I'd love to be able to continue this conversation if you're open to it and love to have you back again, but I think we should stop here and organize another meeting if that's okay with you.

Manny:
That's definitely okay. It was great having a good conversation with you. Great discussions.

Darshan:
This was a great discussion, thank you. Again, thank you for coming on Dr. Emmanuel Fombu. And Dr. Fombu where can they reach you if they wanted to reach out to you?

Manny:
They can reach me on my website, emmanuelfombu.com or doctormannymd.com.

Darshan:
Sounds great. And thank you again for coming on and we're excited to have you back soon. Take care.

Narrator:
This is the DarshanTalks Podcast, regulatory guy, irregular podcast with host Darshan Kulkarni. You can find this show on Twitter @darshantalks or the show's website at darshantalks.com.