Podcasts about so abby

Fish is food, right? Well, it hasn't always been treated that way in policy dialogues and development funding, according to a recent paper in AMBIO. Fisheries management practices and policies most often treat fish as a natural resource or a trade commodity, rather than an important contributor to food security. At the same time, food security policy and funding have focused primarily on agriculture instead of fish. This podcast is part of a series on fisheries and nutrition and a movement to bring fisheries into international food policy and programming. Interview Summary Welcome to "The Leading Voices in Food" podcast. I'm Sarah Zoubek, associate director of the World Food Policy Center at Duke University. My co-host today is World Food Policy Center alum and Michigan State University Fishery Social Scientist, Abigail Bennett. So today we're also joined by two guests. Belinda Richardson, agricultural development expert from the Gates Foundation and International Coastal Programs expert, Elin Torell of the University of Rhode Island. We've asked Belinda and Elin to push and pull on ideas from our recent paper on fisheries policy published in the journal, AMBIO. So Abby, can you help us lay the scene here before Elin and Belinda jump in? How could fish not be treated as food? So in our paper, we describe how fish and food security policy are disconnected from one another. Let me give a couple of examples for our listeners. The UN sustainable development goal number two on zero hunger doesn't mention fisheries or aquaculture by name or outline specific guidance for them. The global nutrition report that tracks global nutrition commitments every year only mentioned fisheries for the first time in 2017. And the World Bank, a big player in agricultural development funding, has allocated only around two and a half percent of its agricultural portfolio to fisheries and aquaculture over the past decade, although this has ticked up to above 5% in 2018. So Belinda and Elin, why do you think fish has been so disconnected from the food policy arena and do you see this changing? Elin: I would say that a major reason why fish has been a bit disconnected is because it's a common property resource. Fish doesn't have boundaries, it moves around. It's not as easy to manage as agriculture for sure. And there's so many different fish in the oceans, everything from our precious coral reef fish to small pelagics and large pelagics and so forth. So it's very, very complicated. I would say that for aquaculture, it's been really contentious both from an environmental perspective and I would say also from an equity perspective. Belinda, I'd love to hear your thoughts. Belinda: The Gates Foundation is a relatively new donor coming into this sub sector of agriculture. The agricultural development team at the Gates Foundation began looking carefully at fish and aquaculture for its potential to impact poverty and nutrition only very recently in 2017. And we were surprised, frankly, at the size and the dynamism of the sector. So it's the fastest growing food sector, 10% annual growth per year. Demand for fish is growing fastest in South Asia and Sub-Saharan Africa and it's very important nutritionally. An estimated 3.3 billion people get at least 20% of their protein from fish. And as the nutrition community starts shifting from counting calories to tracking dietary diversity and the nutrient density of foods, fish becomes a very important source of essential macro and micro nutrients. And I think part of the challenge as a data-driven organization was really the lack of data and the complexities around data quality and availability affecting low middle income countries are not necessarily specific to the fishery sector. The data are particularly sparse for small scale fisheries and aquaculture. And so I think as more data become available through public and private investment from different innovations, we can see a bit more clearly how many people depend on fish for food, for livelihoods and nutrition and the sectors' impact on food security. And if I can just make one last point here, I think importantly as climate and the environment keep climbing on the global agenda, as Elin said, aquaculture's been very contentious. I think aquaculture and fisheries have their sustainability issues but fish is the most efficient animal protein, so it can really help to alleviate some of the pressure on land agriculture. So as we start to grapple with how to produce enough food within planetary boundaries, fish is going to be a necessary part of that story. Thanks, Belinda. And you've mentioned funding development projects around fisheries and I'd like to drill down on that a bit further. So have the both of you seen the funding landscape for fisheries and aquaculture, or the narratives and dialogues around fisheries and aquaculture in the funding landscape change in the last 10 years? Elin: The University of Rhode Island has been implementing international fisheries programs in developing countries since about the mid-1980s. And I would say that until about 10 years ago, our fisheries work was really under the umbrella of marine conservation to protect coral reefs and other important habitats and charismatic species and global marine biodiversity. But over the last 10 years, there has been an increased recognition of the importance of fish for food security in many countries but especially in West Africa and Asian countries like Bangladesh, the Philippines, Vietnam and this has opened up some possibilities for us to work on fisheries from a food security perspective. And to some extent, we are dealing with a different type of species under the food security umbrella. We're looking at small pelagics and other fish that are incredibly important for food security in many countries. And we've seen the US government and USAID fund multiple projects. I'm also involved as the deputy director in the Feed the Future fish innovation lab and there we do fisheries for food security programming in many countries around the world. I think another really cool shift is increased recognition of women's role, both as harvesters of fish and their roles in value chains and the importance of empowering women to participate both in fisheries management and in the production. We do know from our research and implementation of fisheries work that women are critical in the harvesting of fish and in feeding their families. So you really need to have women involved. Those are a couple of the shifts that I've seen. Now, I'd love to turn it over to Belinda. Belinda: I can really only speak to the last three or four years since we've been exploring aquaculture at the foundation but we were actually really surprised to see the increasing interest in investment into the sector from both the public and the private sector. So it's increasing on countries' agendas, planning and prioritization. That means countries are either allocating money from their national budgets or they're taking out loans against those priorities to develop the sector. As Elin said, looking at not just food security but also economic growth and then adjusting policies to incentivize investment by the private sector. Investment by private sector itself has really been another signal. Industry's responding to the strong demand pool from consumers. So as populations and incomes are rising pretty much across the board, now with some setbacks due to the pandemic but hopefully that trend will get back on track. The demand for fish is also rising and while most of the innovation for high value species like shrimp and salmon has come from the private sector, these companies are really starting to recognize the importance and the opportunity in low and middle income countries and that includes large and small producers who rely on lower value species like tilapia, carp and catfish which we could consider more staple commodities versus like salmon or tuna, which are kind of the champagne of fish. And these lower value species and production systems could really benefit from the innovations that private sector brings in genetics, feed, aquatic animal health. That could boost productivity and profitability and supply more fish. Thanks, Belinda and Elin. It's really interesting to have both of your insider perspectives on how some of that funding landscape has been changing recently. Are there challenges in development projects that are unique to fisheries and aquaculture, especially as compared to agriculture? Elin: The fact that fish is a common property resource is definitely an issue because when you think about the geographies and your stakeholders, you know some of the sardinella, for example, in West Africa may swim across five or six countries. So how do you get all the right stakeholders and all the right people to the table? Not only decision makers but private industry and fishers and gear owners, boat owners have to come to the table. So that makes it very complicated. The second issue is the tension between conservation and productivity. We know that we need to have a sustainable fisheries in order to feed future generations. But in order to reach that sustainability, we may need to make some sacrifices in the short term through closed seasons or quotas or total allowable catches or whatever it is. And we could call that a delay in production and during those stoppages, people that are really dependent on fisheries for their livelihoods and for food security may be suffering. So that's a challenge I think we need to look at. How do we address that? What is our arsenal of solutions, whether it's through conditional cash transfers, through importation, private sector engagement? Those are some challenges that we need to address. Now, I'd love to turn it over to Belinda. Belinda” So from the donor perspective, increasing investment into the agricultural sectors, you always run the danger of unintended consequences but because we've hit or are approaching the carrying capacity limits of our oceans and freshwater bodies, which basically means that over 60% of the world's fish stocks are now over-exploited beyond their biological sustainability limits, there's an instinct to say that we can fill that supply and demand gap with fish from aquaculture which at first glance is true and mathematically, the calculation works out but there are two challenges I want to flag. The one is nutrition and the other one is environment. There are a lot of challenges when we talk about sustainable intensification related to fisheries in aquaculture. You've got effluent hormones, antibiotic use, farmed and wild fish disease interface. But one in particular is the specific environmental trade-off around the fishmeal debate. So, fish for feed versus fish for food. 22% of fish landed in captured fisheries according to FAO is destined for fishmeal. The vast majority of that is human grade food. So if we're looking at the whole system, can we do a better job balancing this equation of where fish is coming from? And also, what are the more nutritious species? So from a nutrition lens, if we look at this problem, smaller marine or indigenous species that people might eat whole, for example, they've got calcium in the bones, vitamin A in the eyes, these are much more nutrition-dense than like a filet that you would eat from a salmon, for example. So just thinking a little bit more holistically about the nutrient content of these fish where they're coming from and the environmental limit. Elin: I 100% agree with your comments about this debate between pitch food versus people food and where does the fish go? And I think that's why there's a lot of research going into alternate feed for aquaculture as well. And there's also multiple efforts to think about how we can use some of that fish that would go into fish feed and turn it into products that may be used for pregnant women and children in the first thousand days of life. So I think it's always good to follow up a discussion on challenges with some successes. So I'm curious, what are some of the measurable impacts of the recent funding efforts that can already be seen or that we might be able to soon see from these investments in fisheries and aquaculture sectors? Elin: I'm really, really proud of the work that we've been doing in empowering women cleaners. This is something we've been working on throughout the world in West Africa, East Africa and Southeast Asia. Some recent successes has been in West Africa, in the Gambia and in Ghana, where we worked with women who were harvesting oysters to both work with them to protect their oyster resources through establishing no-take areas or closed seasons and we've seen some improved stocks. We are seeing that the oysters are coming back and the women we are working with are really encouraged and they're continuing to renew their closed season on their own. We do see that economic empowerment is incredibly important. Some of our research in Malawi found that women who were generating an income from the fisheries sector have a higher negotiating power within their households. And they're more able to participate in fisheries management. And this is something we've seen also again in the Philippines and in West Africa. And our work in West Africa is starting to evolve now, moving from The Gambia and Ghana to other countries in the region. Our work with the small pelagics and a broader ecosystem approach to fisheries management is a lot more complicated. And while we're very hopeful that we're going to see good improvements in fish biomass over time, for now, I feel like our biggest wins have been at the enabling conditions and policy governance sites. For example, our work in Ghana. The government of Ghana has adopted a national fisheries co-management policy. And at the more local level we have community-based fishery school management plans that we feel comfortable that we've contributing to really set a base for seeing great measurable impacts, even though we haven't seen them yet. So Belinda, I'm curious for you - what are some of the measurable impacts of recent funding efforts you feel like we can already see or that we might soon see in fisheries and aquaculture? Belinda: So from the Gates Foundation perspective. There are some great technologies and innovations in aquaculture, specifically. We've seen technologies and innovations in aquaculture generate real results for productivity and profitability, even for very small scale producers in field trials. Looking at those technologies, that's really something that we'd like to build on. Take these innovations to scale, create sustainable market linkages for small scale producers, so hopefully increase livelihoods and nutrition. So just an example, with breeding and through new genomic tools, genetic gains result in fish with faster growth rates, more feed efficiency, more disease resistance which will be important with climate change as you get intensification. If you think about the large amount of small scale producers in low and middle-income countries and their low yields currently and then you multiply that by the productivity increases from these technologies, that's a huge potential. So hopefully, if countries can do this well, that translates into income for small scale farmers and better nutrition for a range of consumers. Along that impact pathway, The Gates Foundation is looking to these technologies and innovations to pick those up and disseminate those to small scale producers. Thanks, Elin and Belinda. It's really exciting and encouraging to hear about those pieces of progress, ranging from technological developments, all the way to setting the policy and governance stage for these things to have impact on livelihoods and food security. So I want to end on a question that's a bit forward-looking and ask what are you most excited about that is on the horizon for fisheries and aquaculture? Elin: I am really excited about working more on fisheries in ways that strengthens the role of women and youth in marginalized groups. I feel like we've made some headway on gender and I would love to bring some of those experiences into also including youth and marginalized groups and really try to find win-win initiatives where we can promote synergies between food security including nutrition, of course, and conservation outcomes. Belinda, I'd love to hear your thoughts on this as well. Belinda: Adaptation to climate change is quickly becoming a top priority for fishing communities and fish farmers. The people who depend on fisheries and aquaculture for livelihoods and nutrition and the majority of which are in these low and middle income countries and often the most vulnerable to climate change. This underlying vulnerability makes them particularly susceptible to the stressors and impacts from climate change. So if we think about this challenge also as an opportunity so everything that Elin mentioned around gender, some of these initiatives where you can have a win-win for nutrition and food security and also conservation and environmental sustainability, this seems like a really opportune time for fish to be getting more of a spotlight. The paper we've discussed is available on the website that the Duke World Food Policy Center and the title is "Recognize fish as Food in Policy Discourse and Development Funding". Our guests today again are Gates Foundation's Belinda Richardson and the University of Rhode Islands' Elin Torell. Bios Elin Torell Elin Torell is the Director of International Coastal Programs, Evaluation, Livelihoods and Gender at the University of Rhode Island Coastal Resources Center. She provides programmatic direction and selected technical support within her main areas of expertise: monitoring, evaluation and learning, livelihood development, gender mainstreaming, population and environment, civil society, fisheries management and environmental compliance. Elin has more than 15 years of experience providing technical assistance and leading complex and interdisciplinary projects in East Africa and South East Asia. She is an expert in project management and developing and leading strategic planning, monitoring and evaluation systems that foster learning within projects as well as across multiple projects. Elin has a Ph.D. in environmental studies, an MsC. in human and economic geography and a bachelor's degree in social science. Belinda Richardson Belinda Richardson is a Fellow at the Bill and Melinda Gates Foundation, having also worked as a technical consultant for the World Food Program and as a teaching assistant at UC Davis, where she completed a Master's Degree in Agricultural Economics and International Development.

In a recently released January 2021, paper, scientists urge global policy makers and funders, to think of fish as a solution to food insecurity and malnutrition, not just as a natural resource, that provides income and livelihoods. The research team argues that fish can play a larger role in addressing global hunger and malnutrition, but fisheries governance would need to change. Welcome to the leading voices in food podcast. Our guest today is lead author, Abigail Bennett, an assistant professor of Global Inland Fisheries Ecology and Governance at Michigan State University. Interview Summary So let's dive right in. I've got a clarifying question. The paper is titled: Recognize Fish As Food In Policy Discourse and Development Funding. So what do you mean by recognized fishes food? Isn't fish already a food? Yes, that's a good question because we do consume most of the fish that we produce. We consume 88% of fish that we produce. So fish is a food, but what we want to say in this paper, is that fish can do much more to, meet the challenges of global malnutrition and food insecurity. So why do you think that fish is underrepresented in food and nutrition security policy and in funding priorities? This is something that people who are working on fisheries and issues of food security have been saying for a while - in big global discussions on food security and malnutrition that fish doesn't come up as much as it should. And policies don't deal with the contributions of fish to these issues as much as they should. What we did in this paper is analyze some food security funding and policy discussions, to actually try to discern is that the case, is fish actually not being discussed as a food, as much as it potentially could be. We looked at funding priorities, by the World Bank and regional development banks. And we wanted to know how much of, funding that's directed towards food. So agriculture or fisheries, aquaculture is targeting fisheries and aquaculture specifically. And so what we found is that the, World Bank on average has allocated about 1.8% of its agricultural funding to fisheries and aquaculture. And that's gone up a little bit, in the most recent five years in our dataset. The regional development banks have allocated a bit more, but again, in many years, those banks don't allocate anything to fisheries and aquaculture. And instead all of their funding goes to terrestrial food production systems. So we think that there's some room there for perhaps more, development resources to be targeted towards fisheries and aquaculture and their potential to meet food and nutrition security goals. We also looked at some high level policy discussions, around fisheries and aquaculture to understand to what extent were those discussions looking at fish as a food. And so we analyzed the committee on fisheries, reports. The committee on fisheries is a meeting of FAO member countries that happens about every other, year to discuss major policy issues in fisheries and aquaculture. And we analyze the text of the reports from those meetings. And what we found is that issues of food and nutrition are marginally discussed in those meetings, and other issues are emphasized much more such as, economic and trade issues and environmental sustainability issues, which are of course important, but fish doesn't seem to be considered as, a source of food and nutrition in those discussions as much as it potentially could be. So those are just a couple of examples of, the types of venues that we looked at to try to, really ask this question in an empirical way of, is fish being considered a food in these high level policy and funding forum? So Abby, it sounds like there's, a great role that fish could play in addressing global hunger and malnutrition. And certainly you need to work on, a financial resource support piece and the policy dialogue. What are some other steps that could be taken to advance the role of fish in addressing global hunger and malnutrition? Yes. So really broadly, changing the way we conceptualize fish to thinking about it as a food rather than just a natural resource that's important for economic development or, something that needs conservation policy can, really lead us to a number of concrete research and policy actions that, I think can kind of pave the way to, raising the contributions of fish to food and nutrition security. In the paper that you mentioned, we laid out four pillars of, how we might be able to do this. The first one that we discuss, is the need to improve metrics around the contribution of fish to food and nutrition security. Key metrics, information and data that we're missing, include information about the nutrient content of many species of fish. We need metrics to influence policy because we have to be able to demonstrate what the potential impact would be, if we focus on fish as a, contributor to food and nutrition security, and implement policies that target that. The second pillar that we explored in the paper, is to promote nutrition sensitive fish food systems. This builds off of efforts to improve metrics and understand the specific nutrients and micronutrients that are contained in different fish species. It could allow us to do things like tailoring fisheries and aquaculture production systems to meet specific nutrient deficiencies in specific places or specific populations. Promoting nutrition sensitive food systems also encourages us to, look at the whole food system. And so looking not just at, how fish is produced and, its economic benefits, but also looking at, how it travels through a value chain, how it's processed and what that does to its nutritional properties, issues of food safety and hygiene. And then right down to understanding, how households are able to utilize fish, and actually consume it. By positioning food in this lens of nutrition sensitive, fish food systems. I think there's an opportunity to uncover a lot of different types of policy interventions that can utilize fish that's being already produced, to better meet nutritional needs of specific populations. Another pillar is governing distribution. Right now we don't know a whole lot about, what happens to fish once it's harvested. We know a bit about the dynamics and direction of, international trade and fisheries, but at sub national, and especially at local levels, we don't know a lot about where fish is going and how the benefits from fisheries are distributed. The final pillar is to situate fish, in a food system's framework. And the emphasis here is bring fish into this, broader discussion about global food systems, which focuses on meeting the dual goals, of achieving human and planetary health. Ultimately people don't just eat fish, they eat a variety of foods that come from both aquatic and terrestrial food systems. And so trying to see these holistically, I think is the best approach to being able to, ensure planetary sustainability, but also make sure that people, get nutrients they need, especially in places where, who vulnerable to hunger and malnutrition. Are there any examples from you or your colleagues, that you think represent really promising new directions? One of the things that my lab is working on currently is mapping the distribution of fish and the nutritional benefits from fish after it is harvested. And so what we've done for example in Malawi is, actually followed fish from the Lake where it's harvested, to fish markets throughout the country. And we've done this for two different species of fish and actually found that their distribution networks are quite different. These fisheries are serving the nutritional needs of, somewhat distinct populations within the same country. And if you couple that with knowledge about the different nutrients, that these different species contain, then you get these really distinctive profiles of how different fisheries are meeting different nutritional needs, throughout a country. So we know generally that fish are really high in, micronutrients and polyunsaturated fatty acids that are crucial for proper development and growth, immune system, lowering cardiovascular and noncommunicable disease burdens, right? But for many species of fish we don't know what their nutrient profiles or, what the content of nutrients that contain are. And this limits our ability to make specific recommendations about the role of fish in meeting food and nutrition security, and also of meeting specific nutritional needs of particular populations. There are a number of researchers right now who are, working on compiling information about the nutrient content of different fish species, and developing some models to try to infer what the nutrient content of fish species are for which we don't have data. And that work is proving to be really powerful in communicating the importance of fish. Some findings that have emerged from that work are this prediction that 845 million people or 11% of the, global population might experience deficiencies in vitamin A, zinc or iron, due to decline in capture marine fisheries, for a variety of reasons. Another really interesting study, has translated global fish yields, of different fisheries around the world, into the nutrient yields that they provide. And, this study is really interesting because it highlights, that different species are yielding different types of, nutrients. And that some fisheries yield a lot of Omega three fatty acids, other fisheries yield a lot of different micronutrients. And this doesn't correspond directly to, the volume of fish that's being produced. And what this tells us is that there's room there, for us to look at these different fisheries, and understand their specific contributions food and nutrition security. This study also highlighted that, there are many fisheries that are producing ample, nutrients, but that coastal populations adjacent to these fisheries are still experiencing, deficiencies in the nutrients that these fisheries provide. This raises some interesting questions about, distribution. Great Abby, and let me ask you one final question. What do you see as the next steps for fisheries management? It's a really interesting question. I think that we can ask ourselves the question of, how would fisheries management or fisheries policy, look different, if we thought about fish as a food, and try to govern fisheries to better meet food and nutrition security. One thing that may end up changing is we might focus on, managing different fisheries and investing in the governance of different fisheries, right? So fisheries governance is expensive, and we have to think what are the economic costs and benefits, for a country to invest in the governance of fisheries. By looking at the food security benefits, and highlighting those, I think that can provide another justification and basis for investing in the governance and sustainability of fisheries. Not just high value fisheries that may, for example, go to export revenue generation, but also small scale, fisheries that are important for local food and nutrition security. I think also that fisheries governance, that takes seriously this fish as food lens, would also look at connecting, this realm of fisheries production, and managing the fish stocks and production methods, right? The fishing methods, and connecting that to, the value chain and how fisheries is distributed and, thinking critically about issues of, property rights, and markets and the distribution of benefits. So that fisheries can better, serve the nutritional needs of people who need them most, within the limits of sustainability. Bio Abigail Bennett is assistant professor of global inland fisheries ecology and governance. She studies the role of fisheries in livelihoods and food security around the world. Her research examines how processes such as governance and trade shape the connections between fisheries and human well-being. For example, what kinds of governance arrangements can mitigate negative social and ecological impacts of global trade pressures? How important are fisheries for addressing hunger and malnutrition globally? And, how can we enhance fish value chains to increase access and benefits to women and the rural poor?  

Live from my personal Facebook page, I welcome Dr. Mark Milligan, PT, DPT from Anytime.Healthcare as he discussing how we can implement telehealth services into our physical therapy practice.  In this episode we discuss:  * How to set up a telehealth platform * How to perform an initial eval and follow sessions * How to bill (at least what we know right now) * The paperwork you need to start seeing patients today * And so much more!  Resources:  Anytime.healthcare Doxy.me Connected Health Policy/Telehealth Coverage Policies State Survey of telehealth Commercial Payers Telehealth Paperwork   For more information on Mark:  Dr. Mark Milligan, PT, DPT, is a board certified, fellowship-trained orthopedic physical therapist. He specializes in the intelligent prevention and treatment of all human movement conditions. He is a full-time clinician with multiple patient populations and is the Founder of Revolution Human Health, a non-profit physical therapy network. Helping others create the best patient experience and outcomes through his continuing education company specializing in micro-education is also a passion. His latest venture is creating the easiest pathway to access healthcare for providers and patients with Anywhere Healthcare, a tele-health platform. He is an active member of the TPTA, APTA, and AAOMPT and has a great interest in the pain epidemic, public health, population health, and governmental affairs. Read the full transcript below:  Karen: (00:07): Welcome to the healthy, wealthy and smart podcast. Each week we interview the best and brightest in physical therapy, wellness, and entrepreneurship. We give you cutting edge information you need to live your best life, healthy, wealthy, and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now here's your host, dr Karen. Let's see. Hey everybody. Welcome back to the podcast. I am your host, Karen Litzy and in Karen  (00:40): Day's episode. I am sort of re airing a Facebook and Instagram live that I did last Wednesday with dr Mark Milligan all about telehealth. So a little bit more about Mark. He is a board certified fellowship trained orthopedic physical therapist. He specializes in the intelligent prevention and treatment of all human movement conditions. He's fulltime clinician with multiple patient populations and is the founder of revolution human health, a nonprofit physical therapy network, helping others create the best patient experience and outcomes through his continuing education company specializes specializing in micro education is also a passion. His latest venture is creating an easy pathway to access healthcare for providers and patients with anywhere. Dot. Healthcare. This is a telehealth platform. He is an active member of the Texas PTA, P T a and a amped and has great interest in pain epidemic, public health, population health and government, governmental affairs. Karen  (01:41): I should also mention that he is also on the PPS coven task force. So if you want to get the most up to date information on how the coven pandemic is affecting physical therapists in private practice, you can find that at the private practice sections website. It's all free even for non-members. All right, now onto today's podcast. Like I said, this is a recording from the Facebook live that we did last week. And in it we talk about what is telehealth. We talk about how to set up telehealth, how to implement telehealth, how to conduct a telehealth session for an initial eval or for a followup. We talk about how to get paid for telehealth and this is the information that we knew at the time. That was last Wednesday. Like I said, things are moving really, really quickly here. So the best thing to do in Mark says this is to check with your individual insurance providers, check with your state things are moving really, really fast. Karen  (02:45): And of course finally we talk about answer a lot of viewer questions. So a big thanks to Mark and I think this is really timely and I hope that all physical therapists that if you're listening to this, that you can set up an implement your telehealth practice ASAP. Thanks for listening. So today we're talking about how to implement telehealth into your physical therapy practice. As we all know, the COBIT 19 virus is causing a lot of disruption in healthcare and we're hoping that telehealth can help at least mitigate some of that interruption for the sake of our patients, for the sake of our own practices and for our businesses and for our profession. So Mark, what I would love for you to do is can you just talk a little bit more about yourself, where you're coming from and why we're doing this interview. Mark  (03:34): So Mark Milligan, Austin, Texas physical therapists board certified fellowship trained, but also for the last few years have stepped into a telehealth space and have anywhere healthcare, which is a digital platform for delivering healthcare. It's agnostic to provide her, so PTs, mental health providers, anybody that needs a HIPAA compliant platform to connect with patients. So the current situation is it's pretty mind blowing, right? We're seeing a, a world changing epidemic that will change the landscape of healthcare as we know it today. For several reasons. One is that people will be now exposed to a delivery of care method that they weren't otherwise are supposed to before. So telehealth and tele PT and tele medicine had been out there for a long time. Teladoc started in, in 1987, somewhere in there. So it's been around for a long time, but a rapid adoption of telehealth has really occurring right now for physical therapists. Mark  (04:30): What we need to know and what are the most important things right now are how it applies to us in this landscape. How can we be the best providers to meet our patients? Demand to help quell fear, doubt and an anxiety for our patients as well as, as providers and our businesses. And so stepping into this space is, it's been a little bit overwhelming. It's been a nonstop 70, 96 hours really. And so everything that I say today may or may not be true and four hours or smart [inaudible] because of how fast things are changing. So yeah, I think that tees it up. You want to kick it off? Yeah, Karen  (05:10): No, I think that's, that's great. That's perfect. So let's start out with, we got a number of questions from people from different therapists from around the country. And I think let's start with the number one question is how do you actually set it up? Totally basic one Oh one. So let's start with that, Mark  (05:33): Right? So the first thing you have to make sure is that you have patients that want this. And right now everybody wants that, right? So patient adoption of technology can be challenging, especially especially generational. So the issue with in, yeah. Pre COBIT has been adoption by, by therapists and by patients just because of ease of use. Now it's a, it's a forced adoption. So now we're in a set up where we, where are going to want this regardless of whether or not they want it. So first thing is patient population. Second thing is you need to look at your business, right? You need to look at your patient workflow and your business flow. So you need to have the appropriate from a business standpoint, you need to have a liability to make sure that you're covered in the telehealth space. So in my experience over the past few years, almost every liability insurance cover, it doesn't see telehealth as a, is a different delivery mode for physical therapy. Mark  (06:26): But with everything changing rapidly, it would be real. It would be highly advised that you contact your liability insurance provider and make sure that tele-health is approved as, as in your cupboard. All right? So that's logistics. Secondly, you need paperwork, you need onboarding paperwork for digital visits. You'll need a telehealth consent form and you'll need the digital release form. And if you're recording visits, you need to have a very specific form that that allows you to record patient visits. Some States don't allow recording some. And so you have to be very mindful of that. So onboarding paperwork, it's, it's good to have in fillable PDFs so that a patient can fill it out and then send it back to you digitally. Making sure that that transmission is is secure. You can also have E faxes, right? So they can electronically fax to you over a secure portal as well. So just basic things that we haven't really thought about as providers we need to adopt as mobile providers. Right. So, Oh, go ahead. Karen  (07:24): I know, I was going to say, so when we're talking about who is the best, what is the easiest way for us as a clinician to get that paperwork Mark  (07:32): Right? So they can email me. I've gotten a tele-health consent. I've got I've got that. So they can just email me at market anywhere. Dot. Healthcare. And I can send 'em I'm been sending that out over Facebook. I'm happy to share that with people. And of course you need to make sure and adapt it for your state in your practice. It's a word doc so you can switch out the logos and everything, but I'm happy to provide that for people. They can pass that that step. Karen  (07:57): And then one more question on paperwork and things like that. So when we are calling our insurance, our liability insurance carriers, aren't there specific questions we need to ask them or like what is the best way to have that conversation with our liability insurance providers? Mark (08:16): Right. Just say in this facing time that we're starting to provide care digitally. Am I covered for providing telehealth as a physical therapist? Simple. Straightforward. Karen (08:25): Okay. And so you may already be covered in your current policy, it might be part of your current policy, you just don't know it and then you're not, is that then added as a rider to your yes. Mark (08:38): Typically it's a very inexpensive writer. Okay.  Karen (08:41): All right. So before we set everything up, we get our liability coverage covered and we get consent forms, which can email to you or you can share them on under this post. It's whatever you feel more, most comfortable with or what might be easiest. And then we do what we got the paperwork covered. Now what? Mark (09:06): So you're sending that out to the patient. So they need to agree to be treated digitally. Right now it's really an interesting space. The CMS has waived temporarily a HIPAA privacy with when it comes to digital communication. I'm can't stress this enough that this is a temporary wave in, in the absence of mass abilities to communicate or HIPAA compliant platforms that patient that people are able to communicate via other means of non HIPPA compliant video software. So right now Skype and FaceTime are considered and what's the other one? Zoom and zoom and those well-known platforms are, are open, enable all those zooms just increased their prices yesterday. Yeah, so I would argue that you could use the, what's free and what's available right now in preparation as you prepare after this is over, you'll need to go back to HIPAA compliance. So in the immediacy video platforms are readily available across all. You cannot use public facing video platforms like tick talk or other things that mass put out your video. Okay. Karen (10:22): Instagram live or Facebook live. You can have your patient video, you can have your patient treatment sessions over live video, Mark (10:30): Right. That it means sounds, it sounds obvious, but you never know where people will do right by a group session. You can just do a giant group session. I'm going to train everybody on the East coast of America on a Facebook live. Karen (10:42): Yeah. Okay. All right, so good to know. So no one social media lives like we're doing right now, but for the time being during this outbreak, we can use face time, we can use zoom, we can use Facebook, zoom, Skype, Mark (10:59): Right. Totally. And you need to make sure that in your notes and documentation for your intake software or your intake paperwork, that you are waiting, that the patient is waiving their HIPAA rights during this time due to the COBIT outbreak and you are using this unsecured software and you will return to it as soon as possible. Right. Okay. This is a window. This isn't something that will last. And you need to note for your own CYA that you are, you acknowledged the existing coven scenario and that you will prepare for post that with, with my platform. Yeah. Yep. So technology on the technology side, it's really easy because you can plug and play as long as you get someone's if they have an iPhone or if they have Skype, easy set up, you can connect technology there. So once you get the form signed, you have the informed consent, the HIPAA, the HIPAA included waiver as well to sure that they understand that they are on an, they have to understand and agree to an unsecured network. Mark (11:58): Even though you can provide it, some people may not want it because FaceTime, that's all easily hackable. Right? So so they may not, or may, they may, they may not want to agree to that. So just have to be transparent with them in the, in your services. Right. So once you get that, I mean, it's really a matter of getting the patients, depending on your system, everybody's so different. So if you're, if you are a concierge PT and you're practicing out there for a fee for service cash base, you handle all your own scheduling when it comes for their time, you just flip them and you just call them on FaceTime, right? You collect their face, their number and you connect that way and you do your treatment, which we'll talk about in a bit, some other scheduling systems. You may have to, you know, type in a telehealth visit and your scheduling system or have some type of a demarkation for a telehealth visit versus an in person visit. Mark (12:47): And so work with your scheduling software, work with who you work with in order to make sure that that's appropriate so you can have the right amount of, or the right type of scheduling so you know where to go and what to do and how to bounce it. A billing, again, for the concierge practices out there, this is fee for service. Tele-Health doesn't take as long as normal to as normal PT. So I have my hourly rate broken down into 15 minute increments because it's roughly about 15 to 30 minutes. Is it an average tele-health followup evaluations in the last 40 to 50 minutes? But it just completely depends. So fee for service, it's really straight forward. You just charge per time, per minute, dollar, dollar, dollar, $52 a minute to 15 minute depending on your price point. Karen (13:29): Okay. All right. So now let's get into, so knowing how to actually set it up. So we've got a lot of these different things. What are some other platforms? I know anywhere. Dot. Health care. Doxy.Me. Mark  (13:46): Yup. Doxy.Me co view. So anywhere. Dot. Healthcare is the platform that I created. It's straight forward. Right now I'm offering you a $10 a month, unlimited use for anybody for three months while onboarding everybody. So to, to help people get to see patients doxy dot. Me actually has a free version where that's a, a room where people meet. So you can actually sign up. The patient is sent a link, they click on a link and it drops them right in a meeting room. Super convenient, super easy. There's no bells and whistles and it's free right now. So you can do that. I think a couple of other platforms I've seen throughout the Facebook live of Facebook groups that I'm in a few platforms are pushing out a free entry level software right now. So it's everywhere. So I think Karen  (14:31): We'll use G suite Mark  (14:32): D suite, right? So G suite, if you have a BA with, with Google, you can use Google meet. Right now actually with the, with the HIPAA waiver that's happening right now, you can actually use Google hangout. That would be another appropriate thing to use as long as the other person has the G suite or Google doc, a Google suite downloaded on their computer. So there are lots of, there's literally lots of options now there, there are other companies that offer other features, right? As you get into anywhere that healthcare, not only as a platform, but also as a billing feature and a scheduling feature. Doxy dot. Me if you upgrade to the higher levels, has a scheduling feature, a messaging feature, all types of stuff. So it really looking for different platforms. You need to be, do your due diligence and test them out to see what fits your practice best. I mean, some, some have exercises that are completely a part of the package that you can just have an HTP that sends right out from the program. Some have an actual, a range of motion measuring system so people can move their arm or their body in front of them. The then they can actually measure range of motion live on camera, which is pretty cool. So it just really depends on the need for your, your practice and also the practice size. Karen  (15:44): Got it. Yeah. Okay. So that's a lot of options for people going from free to low priced too. Mark  (15:52): $200 a month for co for HIPAA compliance zoom. Karen  (15:55): Right, right. Yeah. Yeah. Okay. So lots of options there for people. So we know we need some onboarding paperwork and we need to call our liability insurance carriers to see if they cover telehealth. Presently. And if they don't, then we need to ask them to put an addendum on and you can, they can do that immediately. It doesn't take like 30 days for that to happen. Right. Should be immediate. Okay. And so once we have all of the right paperwork and everything we decide what platform we're going to use and you just gave a whole bunch of different platforms that people can use. So all of those platforms are pretty easy to set up. And like you said, you send a link to the patient, they'd drop in and boom, there you go. And at this time we can use Facebook and Skype and, and not Facebook, sorry, Facebook. We can use Skype, regular zoom face time, all that. Okay. All right. Now Mark  (16:58): You may need other equipment though. You may, depending on the situation you may need. So some people, a desktop versus a computer are versus a tablet versus a phone all matter, right? So a desktop computer tends to be really well for you to have good communication and see the patient really well. But it's also very challenging for me to move my desktop to show somebody how to get on the floor and exercise, right? So the part of being a a digital physical therapist is that you have to be able to move and your equipment has to move with you. So some people use, I, you know, some people use a selfie stick to demonstrate exercises, right? Some people have one of those little iPhone holders that can be multiple or wrap around something so they can have different angles or show people at different places. Mark  (17:41): So understand that desktop can be good for this face to face interaction and the, and the immediate subjective interview. But maybe moving towards the objective exam or, or showing the exercise parts you may want to find or have a different device that's more mobile. So just thoughts for that. And you also need to think about your area or your headphones, your microphone and your lighting that can all add or take away from the experience of the digital experience. So making sure that you have those things. I use, I'm old school. I just use the old wired ear buds. They, when you're on the computer a long time, the wireless can die, right? And then all of a sudden you don't have new headphones. So I'm always a fan of just good old fashioned things that won't die on you after a long day of work. Mark  (18:26): So something to think about. You also may want to get a tripod to hold up your computer or you can get a standing desk. So there's lots of options in that space. But also you have to be considered for your backdrop. I love your backdrop that you have there in New York here and with the, with the cherry tree, that's all. It's very Boston's. That's awesome. I just have a plain white wall. Just be mindful of the environment that you're delivering this care in, right? You don't want you to be distracted. You don't want the patient to be distracted. You need to connect with the patient. Some of the key things that you need to think about are the connection that you're going to have with a patient. Something you can do easier face to face. It's challenging to get the connection and to have the emotional connection with the patient by a digital care. So setting up the environment for not only you to feel safe and, and that you feel comfortable that you're, no one's going to bust in, but also your patient needs to feel safe in that space too, so they can communicate to you in a free way that their patient information isn't being broadcasted to other people as well. So backdrops, microphones, computers, tablets, all have to be taken into consideration while you're doing this, while you're doing this intervention. Karen  (19:32): Okay, thank you. Those are great tips. How about cats that could, that could help or hurt you. Right? People love a cat. Great. If not, it can be a problem Mark  (19:44): Or at least they're not allergic to it. They're alerted to it. It doesn't matter. Right? So Karen  (19:47): Right. So pets can help or hinder, just kind of depends. Okay. So we've got, let's say now everyone has a better idea of how to set it up. And then the next question I got was how, Oh, they said this is great. Sound isn't great. I don't know why this sounds not great on, on Instagram, but, well, I mean it's going to be out on it as a podcast as well. So we'll, you'll be able to hear full sound tomorrow. At any rate, I dunno what to do. I could get my earbuds, but as we just said, what if they time out on me? Yeah. Okay. So let's talk about let's talk about how do you, what was it? How did, Oh, how do you actually execute a session? Mark  (20:40): Yeah. So once you've got somebody on the line, once you've got a patient in front of you, right? We know from our PT and our PT exam that about 80 to 90% of your differential diagnosis occurs in the subjective. So you go back to your old way of being, you shut up and you listen to the patient. Right? So, you know, so this is also assuming that you're doing an evaluation via telehealth, right? So most people at this space have patients that they'll flip from brick and mortar or in person into telehealth. So that's a different beast, right? So that's followup. That's exercise progression. Those are obvious things, right? That you're going to show them. You're going to talk them through their progression and talk to them about what they need to do next. Maybe show them a few new exercises when you're, we're, we're going to get, what we're talking about right now is the new patient that you'd never met before and what, how do you gain information to get them treated? Mark  (21:33): So subjective is key, right? You need to have your differential diagnosis hat on. You need to ask the next best questions, their intake form. You should have looked over, created your hypothesis list and make sure that you have a good idea of what you're trying to discover. It's your responsibility as a provider. I know it's written in the Texas legislation that if you, if the patient is not appropriate for digital care, you have to get them to an in-person provider, right? So doing your, you still have to do your red flag screens, you still have to do your due diligence and your differential diagnosis and make sure the patient's appropriate. Right? This is, you have to consider a digital visit to be no different than an in person visit. You have to take every precaution that you would take. I'm minus taking vitals unless the patient has their own, you know, portable, vital kit. You're gonna have them do that. But you have to take every precaution you would from an initial evaluation perspective as you would in a digital space. So going back to forms, you also have to have your intake form and consent to treat in there as well. That needs to be signed off as well. Karen  (22:31): So the, the same sort of forms that someone would have if they were coming to you or if you're like a mobile practice like me, you have them sign that initial paperwork regardless of whether you're seeing them in their home, in your clinic or, or via telehealth completely. Mark  (22:48): This is, you cannot be this any differently. Right? So take it, having all the consent to treat forms, signed all your intake paperwork done, differential diagnosis, red flags, you know, your three tiers. Are they appropriate for physical therapy or are they a treat and refer or they refer. You have to have that, you have to have that hat on. And so if they're presenting with sub with symptoms that aren't musculoskeletal and presentation, you need to be mindful of that and get them to the approved provider, right? So you have to be a triage at this point. So once you get through and determine their appropriate for intervention, you have to get your thinking hat on, right? This is where, this is where things change. And as a mobile PTM, I know that you have walked into somebody's house and been like, huh, how are we going to do PT in here today? Mark  (23:32): Or you have to completely be a problem solver. Think about being a problem solver on steroids when it comes to digital health. Right? Because you didn't have, at least in someone's physical environment, you can see what they have available. Right? If you treating me right now, all you would know is I'd have a white wall behind me. You don't know what chairs I have. You don't know what equipment I have. You don't know anything that I have. So asking them about what equipment's available is important. I take all my patients, depending on what they have, if they have, my most common thing I treat is, is back pain. So most commonly about 20 to 40% of patients, that's 20 to 30% of patients will fit into some type of directional preference when it comes to low back pain. So I take them through an active range of motion our digital active range of motion to see what exacerbates or relieves their symptoms. And if, and if repeated extensions and standing it relieves their symptoms, I go why? Clear out other things, but I go right into treatment. Right. So you can use progressive movements, repeated motions right in your treatment from the get go the same way you would do in the clinic. Mark  (24:35): Some of them prior, Karen  (24:36): It's New York. I don't even literally grown even here at anymore. It's just did with something there. Is there the engine going up, I don't even hear it. Anyway. Mark  (24:46): White noise. White noise. Yeah. So you have to go through your objective range of motion in your objective measurements just like you would in home or in the clinic at home. So knowing your physical exam and having a musculoskeletal screen is super important. So if I have somebody with radiating arm pain that I'm treating, where's my arm on my camera? If I have somebody with radiating right arm pain, I'm going to take them through cervical active range of motion. I've actually even had people do over pressure to themselves. Right. To see, I've had somebody to do their own spurlings to see if it's ridic. So you have to get really creative teaching someone how to do a UNL TT a on camera is because you have to back up. Right? That's another thing. You have to have visibility and you have to have the ability to see what the patient's doing and also correct them while they're doing their motion. So I take my patients, do as many physical exams that they can do on their own without, without me being present to do it. Karen  (25:45): Yeah. So I think it's important to note cause my good friend Amy Samala said, can you do this for brand new patients in your practice or is this just to be used for existing patients? So I think Amy, I think we're covering that right now, that yes, Mark is sort of taking us through how he might do an initial evaluation with someone via telehealth. Mark  (26:05): Totally. Totally. Now I think we should probably circle back to billing again and payment. I think we, we've, Karen  (26:12): Yeah, yeah, yeah, yeah. Let's definitely talk about that. And one other thing that I, I want to make people aware of, Mark, is how using you want to have space. So not only you want to make sure that not only your patient has space or depth, but that you do as well as a therapist because you may need to step back to show them something and then come closer. Mark  (26:33): Right. And I've I often, so I have a flat couch in the back, so I have this couch that's right behind me so I actually use that. I pushed my chair of the way and I show repeated extensions and prone. It's a six or seven foot long couch and I show double needs to test and I sh if I mirror exercises for patients. So you cannot do everything verbally, you can't. Could you imagine telling somebody, okay, I'm going to walk you through a double a single knee to chest with words only. It becomes extremely challenging. So you get up and you move. I just hop on the couch. I'm like, all right, so you're going to lay on your back. You'll grab both knees. You see my hands on the outside of my knees. Knees are slightly apart. We're going to pull that all the way up until you feel a big stretch in your back and I show them. Mark  (27:13): I walked through the exercises with them. Same thing with, same thing with nerve glides, right? If I'm doing a U L T T a I'm going to say, I'll bring your a shoulder all the way up. Like you're going to put those little, or you CC that you're going to put the little ion right and then you're gonna lift your elbow up and see if that changes it. Right. And so you have to walk them through. It's easier for them to mirror you than it is to say, okay, you need maximum shoulder flection with external rotation. NOLA deviate. Like you can't do that. Karen  (27:39): Yeah, we know jargon doesn't work. Yes. You can never say that in an NPR. If you are face to face them, you would never just sit there with your arms folded and be like, okay, flex your arm to hear externally. Like if you just want to do that, you wouldn't do it. I think it's important to know that we can still certainly in well versed in strong verbal communication in this space. Oh, that's nice. From work. Yes. Or there was a delay. Oh, okay. So I think we're good. So Amy said, yes, sorry, there's a delay. She's all the way in New Jersey, so forgive the Jersey part. Yeah, New Jersey. Okay. all right. So I think people get an idea that yes, this is how you can set this up. You just want to make sure that each of you have enough physical space to do everything that you want to do. That yes, you can do your initial evaluation. It's all about the subjective, in my opinion, in that initial evaluation anyway. Definitely. and then once you see them for the initial evaluation, as you start progressing them, like you said, it would be like any other exercise progression you're just not putting hands on, but it can be done. Mark  (28:51): Definitely. Definitely. If you think about the interventions that we do in the clinic that you can apply to home. So I work with people that you know, that don't, they may not have good balance. So safety is a, is a concern in that space. Right? So I talk people in a corner, I show them what it looks like to get into a corner with a chair in front of me or in front of my couch or the chair in front of me and teach them how to do single leg stance while having my fingertips on the chair. Right eye. You have to physically show people what to do so they understand that better. And so like you said, it's about being able to show and speak at the same time, right? Because a lot of the field like nerve tension testing, a lot of times it's, you can feel the tension before the symptoms ever get there. Mark (29:34): So you have to educate somebody that has a really angry nerve that's a, it's a hot nerve and say, look, we're just going to take this up until you barely feel it. Right. We're just going to touch it. And then if you feel it there, just bring it back down. Right. You, you can't rely on your hands to feel that tension anymore. Not that we can reliably feel it anyway, but we want to make sure that we prime the patient for success. Right? Communicate expectations. Like we're going to do some discovery today. We're going to walk through a lot of different movements to see what's happening with your body. See if we can figure out ways that we can help you feel better through movement. Cause that's what ideally what we're going to do, right? We need to make sure that we enable patients and make them feel safe and comfortable that we're going to help them. We're going to take them through this. We just need to, we need to communicate to that. This is going to be something that I should be completely comfortable with. Yeah. Karen  (30:24): Perfect. All right. Now let's get to the part that everybody really wants to know about billing. Someone. let's see. Oh, Mark Rubenstein also New Jersey. He had kinda some of the same questions. No, I have nothing against New Jersey, New Jersey. So he kind of had the same question I had before we went live. He said but Medicare will only pay now for existing patients as per info yesterday. So this is the info, I guess on that evisit versus tele-health. So can you kind of give us, cause I know just for background, Mark is a part of a PPS task force and he is really being updated a lot. And I'll let you kind of talk a little bit more about that and, and how you are helping to work the billing aspect of things and the difference between an evisit and tele-health. Mark  (31:20): Right. I'd like to first shout out to the PPS members, Allie shoes and the I and alpha are our lobbyist for the APA. We are meeting for hours daily and we are, so everyday we have scheduled calls on this task who have a task force. We're pushing out content on the APA plus the PPS site. So there are 18 to 20 people that are hard at work to get, to gather information, to interpret it and then to question it and then make sure that it's legal. Right. Because there's information that comes out that it's great information, but it may not be legal for us to do based on practice act. So there's, there's a federal level, then there's the, then there's the PTA level, then there's the state level, then there's your individual insurance levels. So there's a, there's so many different paradigms. It's not just a cut and dry situation. Mark  (32:06): So right now, some of the biggest things that we're working on behind the scenes with this PPS task force are really are defining out what it means from Medicare as it relates to the visit ruling. So E visits technically are not telehealth. Medicare is not calling these eVisits tele-health. They're calling them eVisits because they derive them from the medical, from the MD coding as, as a bra, a brief and abrupt follow up to a situation where the patient is in an engaged patient. So imagine somebody who may not be feeling well after seeing, having a doctor's appointment just to follow up to touch. So the visit codes right now can only be billed based on time, so their cumulative time and there are three levels. The max level is 21 minutes to be billed one time over a week. And so you add all the time for one week and over 21 minutes is the third code. Mark  (32:59): And that can only be a build a once every, well in seven one time in seven days. There is a question right now about whether or not that code can be repeated the next seven days. That information has not been gotten yet. We have not had a clear answer on that. So please be patient while we investigate whether or not that code can be repeated the next week. So right now, currently we are still working on whether or not now that these eVisits have come out, the question is now whether or not CMS sees us as telehealth providers, which upfront does it look like they do. But we still haven't gotten for Bay. We still haven't gotten the, the appropriate word from CMS whether or not we are. We are providing tele-health, which they said we're not. So we can assume we can assume anything. Mark  (33:49): But so they said we're not providing tele-health, but we think they will. They won't include us in the, as a telehealth provider, which is extremely important because if they don't consider us Medicare providers, then we can, well, I'll wait about Medicare billing Medicare patients, we'll, we'll wait to hear what happens. I'll have to have an update on that. And so right now we are not approved providers for telehealth, for Medicare. And we can build he visits with an established patient that has to make contact through a patient portal to the provider to request their evisit. Now it's been clarified that you can notify a patient that they have the option of that type of care. You can tell the patient, Hey, you know, we're not treating people in person, but you do have the option for an evisit. Here's how you do it. If you choose, if you were to choose to have an E visit, you would go to this part of our website to our port, your patient portal and request a visit so you can prime patients to go utilize that service. Whether or not you can only do that for one week or multiple weeks, that's in question. Karen  (34:52): Okay. And a patient portal is not Skype zoom face time or any of the telehealth platforms that is not a patient yet. Mark  (35:04): Well, some platforms have a portal, some, so it has to be a patient portal. So it has to be a place where a patient can log in and request a visit. And so we're still also waiting for a clear definition of a patient portal. But for our understanding the patient, it's a place where the patient goes to get their information or connect or message their provider. Right. So right now that's still being clarified through CMS on the other private payer front and medicate well, so Medicaid is being rapidly adopted by payers all across the country. Right. So we've seen, I know Louisiana is about to release a wording today at some point. I know that I think Minnesota, I think that a few others have already, Medicaid has already blasted that inflammation and that are, that are, that there are approving and paying for telehealth or physical therapists, payers on a national level are all over the place. Mark  (36:00): So if you are a, in the work provider, you need to call your payers and ask very specific questions and we have people working on this across the country. You have to ask them if your patient has tele-health benefits, you need to ask them if those benefits are payable to a physical therapist. So if a therapist is a PT, a paid as a payable provider of telehealth services, if they need any modification codes, right? So like an Oh two location code modifier, right? That needs to be asked and then what CPT codes they reimburse for. Okay. Right. So manual therapy is not going to be one, but neuro, our neuro they're ex their acts home care, self care, all of those codes should be available. And it just depends on the, on the payer and the carrier. Okay. I have a Google doc that we can link that I'm trying to collect that data from across the country. Mark  (36:58): So people can have open access to it that I can send you that link here and it's on a couple of Facebook pages. But we're trying to collect that data so people can see because, and you don't put any reimbursable fees, don't breach your contracts, don't talk about a fee per schedule, but where you're scheduling fees or your fee schedule. But I'm just put whether or not they pay if it's parody, right? Some States out parody. So here's the kicker. Parody States doesn't miss it necessarily mean payment, right? And this is a, this is a very confusing, a very confusing thing. So somebody says, Oh, we have parody in the state so that, and then we are going to get paid equal in person as we do digitally. Just because you have parody doesn't mean to pay your pace for telehealth, right? They may pay for physical therapy, but they may not pay for tele rehab, right? Yes. Check. Karen  (37:47): Why can they just not make this easy? Mark  (37:50): Right? So you can have parody in a state and you could have a parody law and then the payer not even pay for telehealth. Right? So there's nuances upon nuance, on nuance. And in some States, some carriers have contracts with larger telemedicine providers and their members can only have telehealth through that tele provider and they may not have tele, they might not have tele PT. So then they had no tele-health, physical therapy option for that payer. Does that make sense? Karen  (38:28): Okay, so I'm going to just do this. So for example, I'm just going to take a for example, and tell me if I heard you correctly. Oh one more thing. So Rina said, we're talking about the visits, that's all specifically for Medicare patients only the egoist. Yes, yes. Mark  (38:46): As of now we have, we are unaware. I am unaware. I'll say that of any payer that's adopted the evisit policy and that's as of our Medicare Copa. Our coven call ended at noon today. So I don't know. That may change. Karen  (39:02): Okay. So let's talk about your individual. Let's talk. Oh, somebody said, Oh Mark, can you bring your microphone closer to your mouth? But you've got the ear buds in, Mark  (39:13): Right? So I have my phone a lot. Loose ear buds are going to the computer, but now you see if you can bring the microphone closer to your mouth, then they see my giant fivehead here and I'm like, I mean, how about if I go, that's fine. We'll do that. Karen  (39:32): We'll do that. It's fine. It's fine. Okay. Oh, so here, let me just ask some, get some of the questions. So Kim wants to know, she's in New Jersey also. He lives in New Jersey, but her practice is in Brooklyn. How do we find out if our state has parody? Mark  (39:51): So again, I, the, I will link you guys to the center for connected health policy and I also have a link to the parody in the different States. So I have links to both of those that I can give you, that we can add to this. Karen  (40:07): Yeah, we can put that in the comments under this Facebook under the live here. Mark  (40:12): So where, and so the, the commercial parody book is only 150 pages of nice, easy light reading. Where should I go for Facebook live? Karen  (40:23): Just go, if you go to my page, just go to me and then you can put it in. You'll see, you'll see us. You can put it in the comment section or we could put it in the comments section. When we're done with the live, we can add it in as well. Mark  (40:35): Oh, there we are. All right. So I'm dropping it in the, yeah, Karen  (40:37): You can drop it in right now too. Mark  (40:38): There's the parody laws. Here is the fact sheet on the UpToDate. This is a live document on what's happening in the world right now. As far as tele-health policies and procedures across the country. So those two documents should have a lot of information. But here's the kicker. Just because the state has a parody law doesn't mean that, that, that the payers have a policy that reimburses tele PT, Karen  (41:08): Right? So parody and, and just to be very clear parody means because you, you can do tele-health because you see them in person. So it's like Mark  (41:20): No. So parody only means parody only means payment. So parody means if they have a parody law and they both reimburse for inpatient physical therapy and for telehealth benefits, they paid equal. Karen  (41:32): Say again Mark (41:33): If the, if the, if a payer say let's let's say blue cross blue shield, if that, if that patient has a blue cross blue shield policy and they have a physical therapy benefits and they have tele-health benefits that a physical therapist can provide, they pay equal. Right. Okay. So it's the same face to face as the say. So because a lot of insurances will the 75% or 50% of impersonal versus digital. So it's literally a payment equality clause. Karen (42:02): I see. Okay. Okay. But you have to call blue cross blue shield because they may not actually, that patient's policy might not include tele-health. Mark (42:13): Right. And then even if they have a parity law, you're not getting paid for it. Karen (42:17): Got it. Right. I got it right. It's okay. Kim. I hope that my inability to understand help you. Dah, dah, dah, dah, dah. Can hear Mark fine. I'm physic. Oh, Deborah joy Sheldon. She said, is there a particular language that needs to be included in the documentation? So when we document the visit, how, so? Let's say we know how to set it up. We have the visit, how do we document it? Mark (42:47): Right? So you typically documented as a telehealth visit. So there's no you, your billing will coat it with an OTU location modifier, but you need to denote specifically that it was a digital visit. Okay. Yeah, that's the, Karen  (43:02): Because we just got a question on what's the location coding for telehealth and you just answered it. So Abby, I hope that that helps you. And [inaudible] can we skip insurance and just bill cash or has this new E health stuff messed that up? Mark  (43:26): So that's unsure right now. So the visit has, it's not considered telehealth by early information. That's not considered to be telehealth. We are still not telehealth providers by Medicare. So that should not impact that. That's my, that's my personal uninformed or relatively informed opinion. Please don't take that to anybody else. We're still discovering that. And private payers still do not, are not adopting that yet. That we've heard of. And so you should, Mark  (44:01): If you are currently billing or having people pay cash in there and they do not have coverage, then you should be able to continue doing that. Does that make sense? Okay. Right. I mean, you need to check your contract language. Where we get sticky is, is this considered a non-covered service by a policy? Right. So this is where the sticky sticky comes in. Okay. Is tele-health considered physical therapy just delivered in a different manner, not a non-covered service, right? Yeah. Yeah. Well that V that opinion varies. And so if it's a non-covered service for Medicare, you can, they can, you can charge cash for that service. Right? And so, and that also applies to other payers. Correct. So if, if your payer has a policy that considers telehealth to be reimbursable by PTs, you wouldn't be able to pay, have them pay cash. But if Karen  (45:03): Your individual patient's insurance does not cover telehealth right, then can you charge the patient cash? Mark (45:12): I'm not a healthcare attorney. But we're doing that. Karen  (45:16): Where the heck, I know she's on here somewhere here in Jackson. I know she's watching, I saw her log on, Karen  (45:23): Come on or Jackson answer that question for me Karen  (45:25): Or an answer that question please in the comment section if you're still watching if not, maybe we can ask her or care Gaynor through the APA might be able to answer that question. So again, that question is if Aaron's still watching is if your patient's specific policy does not cover telehealth, again we'll use blue cross blue shield. So they have blue cross blue shield, they do not cover telehealth. Can you charge cash to that patient if they don't have it covered on their policy? Mark (46:02): That is a good question. Yeah, that's a great question. And I think, I mean I, I think I know what my answer would be but I cannot speak as Karen (46:12): Brought any information to anyone or misleading information. So maybe that's something we can ask Cara Gaynor on Twitter. Maybe she can answer that or if Aaron is still listening, maybe she can pop that into the comment section at some point. So Mark (46:28): And having amazing people that are listening that can help. Yeah, exactly. Taking, cause this is a, this is a mad house right now when it comes to legislation and information. So it's all over the place and apparently so yeah, it's just all over the place. We can't information that was [inaudible] I did hear that. Some of the bigger things for Rhode Island and for Pennsylvania this morning, that the governor, the governor assigned legislation that would massively require all payers to pay all providers for telehealth. All right. Yeah. Yeah, yeah. Okay. One other big question that comes up is location for these for, for billing. Right. And so the word from CMS is the, the, the POS code is the location of the billing practitioner. So in the case where remote services are rendered it does not matter where the corporate address of the billing provider is either, nor does it matter what the beneficiary's address, it matters where the services was rendered. That is where the biller is located. Okay. All right. So when that happened, Karen (47:43): Put that into like example. Mark  (47:45): So when that happens, let's say yes. So if you are, New York has parody, right? Or you got to know you guys have compact revolution, right? Correct. I thought you did. So let's say you're a large provider and you have multiple States that you are in charge over that or multiple States. You treat patients and you're billing Medicare that the, the, the service in the, in the billing, in the service location code is the place where the provider is located. Karen  (48:18): I see. So like for example, if we use something like Athletico like a big gigantic company or maybe someone like, I think Michelle Kali has some places in Rhode Island. I think she just went to Massachusetts, but the headquarters is in Rhode Island. So if you're a therapist in their Massachusetts office, you're using Massachusetts. Mark  (48:40): No, you're using wherever you are and delivering the code. Deliver. Karen (48:43): Where do you get where you are? Okay. Mark  (48:45): Okay. Yup. Karen  (48:46): Okay. and then Michelle Townshend said, how does this work with EHR? Ours? Mark (48:55): Yeah. So eeh Karen  (48:57): So she is looking at a separate telehealth provider from our EHR who also does our billing. Mark  (49:04): Right. So EHR is, there's only a handful of the HRS in the physical therapy space that offer tele-health as a part of the platform. I think PT everywhere is a platform that has that has it built in. And self doc is another ER EHR that'll be live and in the next couple of weeks they'll have a platform within six weeks. But most of them are stand alone freestanding. So you just have to find the best system that are set up that can work simultaneously with your other systems. There's really no way to unless the company has an integration with your EHR, which the HRS don't like to integrate with people because that's patient data and it's a, it's a whole hot mess. So most of these are just freestanding side by side. So you'll have your EHR on one side and you're in your camera on the other. So you just do, and that's what I did with anywhere healthcare, it's just basic connection so you can document everything ever somewhere else. Okay. Karen  (50:03): All right. And then Debra says, Mark, my state has parody related to my hospital being F, Q, H C I do not know what that means. Any insight on that? So what does FQHC mean? Any thoughts if not, maybe Mark  (50:25): It's a federally qualified health center federally. Okay. So they have parody. I don't think I understand the question. Karen  (50:33): Yeah. In my S my state has parody related to my hospital being FQHC. Any insight on that? Mark  (50:40): Oh good. So she Oh, she said they have parody. Karen  (50:43): Yeah, they have PR has parody. Yeah. Mark  (50:46): I'm unsure on that. That has to parody is I've, I linked that doc into the live on Facebook. I can look up parody by state and by organization. Okay. Yeah. Karen  (50:59): Okay. Let's see. Let me we already touched, so I'm just kind of, what paperwork do we need? We talked about that. Oh, what if you're not a Medicare provider? Gosh, all right. Dah, dah, dah. Oh, we are usingG suite and doxy.me. This is from,uKelly Dougan, I think. Yeah. But haven't started officially yet. We have an ABN and I wanted to have liability form as well. So those liability forms, that's something that we can, that you can maybe share also on this link here and people can make it their own. Is that by liability? Like the patient has to sign off on saying yes, I'm okay with having telehealth. Mark  (51:51): Is that of course for me. Yeah, I would assume that what she's saying. Yeah. So I'll, I'll create a, I'll create a Google drive folder and drop a link in to the chat Karen  (52:05): And then one other, we've got two other questions. So to clarify for service location code, so that you said that, is that like the OTU code? Right. Okay. If I or any of my PTs are in their own home while tele-health with patient, is she using her home address? Mark  (52:28): Oh, that I can't answer that I haven't gotten, yeah, that would be a billing question. That hasn't been brought up, but I, we have a meeting tomorrow morning and I'll ask that question. Karen  (52:39): All right, Kimmy, we will get to that. Mark  (52:43): We're saying the PTs can just stay home and bill from there. But Medicare has specific guidelines on origination sites. And I know if origination sites apply to eVisits versus telehealth. That very question. Do origination, do originations, I'm writing it down so we can ask this to origination sites. Apply to eVisits. Yeah, cause that's, that's a game changer too. Karen  (53:11): Yeah, yeah. Oh, sorry. She said, sorry, I meant to say service location. Did you clarify for service location address? If I or any of my PTs are in their home while doing telehealth, do they use their home address or does she use her address? So Kim, like lives in New Jersey, her practice in Brooklyn. So that's a really good question. So, Kim, maybe we can get back to you with that answer. Mark  (53:33): And is she a Medicare provider? Karen  (53:35): Kim, are you a Medicare provider? I think so. We'll see. We're on like a 22nd delay. Mark  (53:43): Yeah. So I'll ask, I'll ask service location for employees versus brick and mortar versus mobile provider. Karen  (53:52): Perfect. And then Sarah Catman says, if you are licensed in more than one state, but only practice, may single state, can you only do telehealth in the state you practice in or can you do, hello, hello, hello. Telehealth and States you are licensed in. Mark  (54:12): Yeah. So that's where it comes to state rules and regs and yeah. So everywhere that you have a practice reciprocity or you have a licensed in other States, as long as they, you are allowed legally to practice tele-health in that state. Yes, you can practice telehealth in that state. I mean it's, but you have to sit, you have to make sure to abide by the rules and regs when it comes to our the licensure compact of the rules and regs of the state that the patient abides in or they live in. Right. Cause that's just compact language. So like I can do tele-health and Missouri, but they don't have direct access. So I would still have to have direct access or I'd have to have a referral for that patient if I want to open Missouri. Right. So like example. Yeah. so I think, yeah, so we have to make sure that you abide by the laws of the state that the patient resides in. But yes, you can do tele-health across the country. That's the beautiful thing about the compact, right. Compact allows for us to practice across this country with with little, with, without a lot of that a lot of restraint or not restraint, but a lot of challenge. Karen  (55:20): Okay, perfect. All right, so we're at about an hour, which is as long as I think people's attention spans are, and I think we have an apparently as long as Instagram will go live. So if anyone has any other questions, please you can keep adding them into this feed here and we'll try and get to them as, as best we can. Thank you Mark for dropping that stuff into dropping those links in here. And again, we'll get some of the, the onboarding paperwork from you and maybe can drop it in here as well, or you can point us to maybe where it's been put in other Facebook Facebook links. But yeah, everybody, you're welcome. You're welcome. And Mark, thank you so much. This was above and beyond. I think what you had to do but I think we all appreciate you so much because we're in a time where there's a lot of uncertainty and tele-health is at least a way to one, keep our patients healthy and moving and to kind of keep our practices going as best we can in these times because we don't know. Mark (56:38): Yeah. We don't know. Karen  (56:41): Okay. Mark  (56:43): Yeah, I think, I think, I think as a profession we need to remain calm and PT on, right? Like there's a lot of things happening right now. There's to be the, the future is unknown for us as a healthcare profession. All I do know is that it's going to be changed on the other end. This will no longer be an exception to the rule. This will be an expected method of care. People will, will now grow to understand that digital health is a real opportunity in every aspect, not just in, in telemedicine. So I think if I can say one final thing is just be prepared to adopt this and, and, and set up your systems for the long game. Not for this short, immediate, even though the immediate needs to happen. We have things in place like the waiver for using different platforms just to make it happen while it is, but set your practice up, set your systems up for a long game to provide digital care to your patients. Because that's where we're going to go. Part of it is so yeah, but be patient with each other, love each other be kind and wash your hands, Karen  (57:49): Wash your hands and don't touch your face. Yeah. And be mindful of the people if you are still, if your offices are still open, be mindful of the people coming into your office. If you are a home health therapist, be mindful of the people that you're that you're going to be treating because they may be in that vulnerable population. And because we, there's so much that we don't know, just be very mindful of how you're doing that and utilizing telehealth is a great way to have that extension of care for our patients, so. Mark  (58:27): Right. And feel free to reach out to me market anywhere. Dot. Health care. I'm here as a resource. I'm trying to be as available as I can. I have to go to the bathroom occasionally or drink some water, eat some food, but I'm trying to be as available as I can in order to help help us transition and get through this, navigate this time. Karen  (58:45): All right, well Mark, thank you so much. Got it. You've got everything there. Check out. Also, check out Mark's platform anywhere. Dot healthcare. I'll be happy to give a plug for that of course. And thank you so much. I really appreciate it. This is everyone else on this, on this call, so thank you. Mark  (59:01): Beautiful. Thank you. Karen  (59:04): Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram  and facebook to stay updated on all of the latest!  Show your support for the show by leaving a rating and review on Apple Podcasts!

Our exercise series continues as we highlight the benefits of Pilates with PDX powerhouse, Abby Parker! Settle in as she shares her story of strength and resiliency, culminating into a love for fitness. Before we jump into the show I want to make sure to remind those of you in the Portland area to come out and see me at Athleta in the Pearl District! I am doing an awesome workshop event there to help you embrace the power of your mind for fitness. It is February 17th at 8:30 AM and you can click this link to RSVP on Eventbrite. Abby is here today helping us continue our exercise series to expose us to the amazing variety of options we all have for moving our bodies every day. It’s all about finding something we LOVE to do, something that feels good and feels right to our bodies. Abby is here to help us understand a little more about pilates and to help us see the true beauty in this exercise. You HAVE TO head over to Abby’s Instagram and check out her photos. They are incredibly inspirational...you can’t help but feel motivated to get moving and find commitment to daily movement when you see her beauty! Abby's Road to Fitness Abby’s fitness journey is truly amazing. She is a New Jersey girl and reflects back on her mother enrolling her in dance lessons at the age of 13. Ballet quickly became all consuming for her. She would stretch and practice daily, head in to New York every weekend to compete and be exposed to other dancers, and at 17, decided she wanted to pursue dance professionally. After many terribly critical dance auditions for professional companies, she was finally accepted to the American Repertory Ballet out of Princeton, New Jersey. Though she loved dancing full time, she quickly learned the harsh realities of the profession when all the female dancers were lined up in front of the mirror and told to pick out everything that was wrong with themselves and to dedicate themselves to “slimming down.” Abby is 5 foot 8 inches tall and only weight 118 pounds but was told to lose 15 or 20. She went to extreme dieting and cut herself down to 108 pounds in 3 months. But her energy levels showed the damage and she ended up in the hospital after collapsing in a rehearsal. She was told she had to begin eating again and as a result, ate excessive amounts of food but would feel extreme guilt and throw it all up. These two years with the company were full of big changes for Abby, but in 2015, at 20 years old, she discovered Moxie Contemporary Ballet whose tagline stated, “We support healthy bodies in dance.” She packed up everything she could fit in a suitcase and flew to Portland, Oregon to practice with this company while staying in a dorm room on the campus of Portland State University for 4 weeks. At the end of that period, it was time for the director to select 7 out of the 100 dancers to stay with the company. Little did the dancers know, the funding fell through and the director chained up the doors to rehearsal and fled the state. So Abby began frantically searching for a job, staying on the couch of a friend, and doing everything she could to make herself marketable. She finally got a job in a call center in downtown Portland and was less than thrilled about the work she was doing. But Abby didn’t give up on her passion. She still worked out every single day, did deep research into dance opportunities in the Northwest, and she wouldn’t let her dream die. She even joined PDX Contemporary Ballet part-time to continue dancing while working. In March of 2016, her mentor and superior at her job was murdered and the call center was shut down and she was out of a job once again. She knew with her dancer mentality to be her best, that she had always loved fitness. So she was faced with a blank page on her computer and typed in, “What are the top 10 fitness gyms in Portland, Oregon.” And she clicked on one of the middle results...Firebrand Sports. She sent them a shot in the dark email letting them know she was great at answering phones, doing clerical duties, and that she really needed a job. She got a response that they didn’t need anyone answering phones...but they did need an instructor for Barre. Abby was completely caught off guard. She wasn’t even sure exactly what Barre was. She met Sarah, the owner of Firebrand Sports and they immediately connected. She auditioned, was hired, and became a certified Barre instructor. As she was doing that, she walked past another room at Firebrand, saw the Megaformers, and desperately wanted to know what that was and how she could do it. After trying a class, she immediately LOVED it and went down to California to become certified in Lagree. Back in Portland, Abby started teaching more and more while supplementing with other jobs and finally, Sarah thought she should become more involved with the runnings of the business. Throughout this process, she met her best friend Katie, who encouraged her to push herself to her full potential. They began working out a 6 AM together and became fast friends. Abby is continuing her career in fitness and is proud to see a bright future ahead of her despite the setbacks in her past. Abby’s story is a fantastic example of what it takes to make a true lifestyle change...support from the 4 cornerstones of fitness: Daily Movement Good Nutrition The Power of the Mind Community Connection Abby’s story is a beautiful example of the amazing change that can happen when these 4 things come together. It shows us the importance of releasing our obsessions with body shape and embracing body appreciation, health, and wellness into our lives. Fitness helped Abby get through some of the most difficult part of her life in a positive light. So what is Pilates exactly and what can a first-timer expect from giving it a try as a new way of moving their body? Abby explains that the Lagree Fitness Method is what Firebrand specializes in, which is a form of Pilates. You are using a total body fitness machine, or Megaformer, to enhance your movements and exercises. Lagree is a high intensity workout with low intensity on the joints. You can move all parts of your body in just 45 minutes. The beautiful thing about using a Megaformer is that you can modify any workout for more or less intensity. So regardless of your ability or experience level, you are able to feel fantastic. For those of us who have never experienced Pilates or Lagree before, Abby gives us a little insight into what the Megaformer machine is actually like. At the basics, it sort of looks like a bed with many springs and many different things to grab on to and adjust. You are always either pushing or pulling at all times and YOU control the springs of resistance on your machine. There are over 500 different moves that you can do on a Megaformer which gives both the instructors and the students loads of creative expression and flexibility in their workouts. “You have the ability to create a whole beautiful symphony of movements in your workout.” The resistance and intensity of the workout helps to target all those tiny little muscles that are difficult or impossible to reach with other workout methods. Abby says it isn’t just fantastic for strengthening your physical body, but also for strengthening your mind. These workouts challenge you in new and innovative ways and leave you feeling fantastic at the end. For both veteran and new Fitlandians, Christa focuses intensely on the power of the mind with Mind Zoning. You can work to create new neural pathways and thought patterns to change what we believe we can do and to build on our health and wellness simply with our subconscious mind. Pilates is great not only for your physical fitness but your mental fitness as well. Still not sure if Pilates of Lagree Fitness is a good fit for you? Abby offers a complementary class called Lunge and Learn to help you learn modifications, get started slowly, and learn more about the exercises in general before you drop in on a full class...so be sure to check that out! Also, if you are in the Portland area, be sure to check out a Lagree Fitness class in person at Firebrand Sports! Abby’s last minute tips for getting started: Just GO for it! (Starting is the hardest part!) Try a workshop to get started and feel comfortable Grab a friend for support and motivation Stay inspired and push your boundaries! Thanks to Abby for sharing her incredibly inspiring story with us and for giving us some insight to the world of Pilates and Lagree Fitness. We are so grateful to you and look forward to seeing you in our Fitlandia community in the future! Subscribe to the show, rate us and leave a review on iTunes or Sticker. We'd love to hear what you got out of the show!   

Niklas Lollo interviews Vickie Ly, of the NASA Ames Research Center, about her work with NASA Develop: an applied science capacity building initiative. Her work weaves remote sensing, watercolor videos and environmental problem-solving to improve the Navajo Nation's drought monitoring and water management efforts.TRANSCRIPTSpeaker 1:Method to the madness is next. You're listening to method to the badness, a biweekly public affairs show on k l x Berkeley Celebrating Bay area innovators. I'm your host, Nicholas Lolo. And today I'm going to be interviewing Vicki Lee and her science researcher and science communicator at NASA Ames Research Center in mountain view, California. Welcome to [00:00:30] the show, Vickie. So you work at the NASA Ames research center and in particular you work with the NASA developed program. Mine explaining what the NASA developed program is. Speaker 2:So NASA developed is a program within the applied sciences and what we do is be partner with other organizations, non-governmental governmental, um, different agencies and we partner with them to utilize NASA earth observation data, satellite data, and we apply that to different environmental concerns [00:01:00] and issues that they have. What are some sort of environmental concerns that you might apply it to? So for example, one of the main projects I've been working on is with the Navajo nation. And what we've been doing is figuring out how we can use NASA satellite data, precipitation data, and apply that to different drought monitoring efforts that they have. And it's, it's a really arid and dry place. It's located in the four corners of, um, Arizona, Utah, New Mexico [00:01:30] and Colorado. People may be familiar with monument valley. Yeah, that's right. Yeah. And so when you're driving out there, you're just seeing these big red rocks, blue skies, beautiful country out there. Speaker 2:Um, but it's also a lot, there's also a lot of challenges and um, in particularly it's looking at water, it's looking at water availability and it's looking at how you monitor water. And this has been a challenge [00:02:00] in the past and with climate change it's potentially going to be more variable and more difficult for monitoring water. Yeah, definitely. I think, um, I think the biggest challenges in the Navajo nation is how to, how to monitor water and how to monitor drought on a continuous scale and with spatial continuity and spatial coverage. [00:02:30] Why is NASA working with these communities? Speak about that, that tension. Um, was it difficult to approach them or did they approach you? Um, how did the connection start? Yeah. So how this partnership started between NASA and the Navajo nation was through Cindy Schmitt, who was a longtime researcher at of NASA Ames in mountain view, California. Speaker 2:And she's been working with different end judge Digitas groups for over 10 years. Um, she put us in touch [00:03:00] with this gentleman by the name of Ramsay, um, with a Navajo technical university. And then we started talking to the Department of Water Resources and then we started talking to them about different issues that they're having. And um, one of them was looking at how, looking at how they collect water and looking at how they collect precipitation, um, data in specific. And with that, how do they calculate, um, [00:03:30] something called the SPI or standard precipitation index, something that tells how wet or dry and area is and sort of how severely, um, or sort of it's a gauge at looking at, um, drought and whether an area is experiencing drought or not. So I want to take a step back here. Satellites can capture precipitation data. Yeah. So satellites can do all types of things. Speaker 2:Um, I think that what [00:04:00] most people are most familiar with in terms of satellites is looking at land cover, looking at land cover change, um, or just looking at maps of the places that they want to go and the places that they do go. And they do that by taking a bunch of high resolution images or low resolution depending on, yeah. So it kind of depends on um, sort of the frequency that you're looking at and sort of the range in the electromagnetic spectrum that you're [00:04:30] looking at. Maybe you're looking at red, green, blue, what we all look at in images and pictures that we see with our naked eye. Um, I e maps that we use on line like Google maps, but in other cases you can also look at near infrared or infrared, um, or other parts of the spectrum to get other types of information that you wouldn't be able to with your, with all near your eyes. Speaker 2:How have they been collecting data before this? They have rain gauge [00:05:00] stations and re-engage rain gauges all across the Navajo nation and that sort of just like a bucket collecting water. And then they're recording the observations on any given day essentially. Yeah. So they have, it's essentially like a, a bucket and then, um, it collects rain and then every single, every single monthly, they go out on a certain day of the month, then they go out and drive to all of the rain cans and then, um, [00:05:30] measure what is, what has been collected for that month. So they were collecting data in buckets and having to drive around once per month. Why was that not sufficient? They actually still do that. They go out and still collect all of the rain gauge data monthly. But you know, one of the things is the Navajo nation is the biggest native territory in the u s and both and size. Speaker 2:I mean, it's the size of [00:06:00] West Virginia to drive out and collect all of that data takes a lot of time and um, to maintain those places. And some of those places are so, um, rain stations, weather stations. And so, um, to maintain those also takes a lot of upkeep. So the utility of using satellite data is that it is continuous and regular and [00:06:30] it doesn't, you don't have to go out and get it. You just go onto your computer and download it. And it can be more precise too. Yeah, I mean it provides spatial, um, coverage versus having like one rain gauge and having just one point, you'll can look at entire areas and you can look at precipitation and how it covers all this area. And then you're able to take that precipitation [00:07:00] data, compare it to, um, a historical average and be able to say much more about a whole territory, a whole area than you are from a single point or sort of interpretating from different points. Speaker 2:And can you describe a bit how the tool actually works? Yeah, so there's three main steps, um, within d sat. The first is to calculate an SBI. So you choose the type of SBI you want [00:07:30] to look at, uh, one month, six month or 12 month. Um, all of those correspond to different types of drought that you're looking at, agricultural, immunological, and then you choose the starting day or starting month. And the starting year and ending year. So that sort of gives you a range of time that you want to look at and calculate your spis for. Um, then in the next step you, um, are able to take what you've calculated [00:08:00] those spis and um, be able to look at statistics of those. So you are able to look at, you're able to look at statistics for a certain boundary. So you choose, um, the data that you've processed. Speaker 2:And then you choose a certain boundary that you want to look at, for example, like agencies. And then within every single agency you're able to look at the statistics for that agency. So you can see, um, [00:08:30] the mean SPI for from April, 2014 to current. Um, and then the last step, which is really the, um, jazz hands snap, it's the, I don't know how to just the time lapse animations. Yeah. Yeah. So, um, the [00:09:00] last step is sort of the shiny step, sort of the, you're quoted as saying it's the bread and butter and the Cherry on top. Speaker 2:Yes, it is both the bread and butter and also the cherry on top. Um, and within the last step you're able to visualize the spis. So, um, sort of addressing that issue of having spatial continuity [00:09:30] and coverage. Um, you're able to visualize SBI rasters, um, on a map and you're able to overlay different boundaries on top of that. So you can look at the Navajo nation political territories, watersheds, eco regions, um, on top of that and, and over time as well over a seasons or years. That's the sort of get in, get a sense for the history of drought or [00:10:00] rain in the area. Yeah, that's right. So based on the time that you selected in the previous step of the calculate SBI, um, then you're able to look at the time range and um, you're able to sort of run through time and see the changes seasonally. Speaker 2:Um, and one other feature that is in there is plot analytics, um, which allows you to look at a certain area, um, within a boundary [00:10:30] and you identify that area and then it breaks it down of how much, what percent of that area is experiencing, what type of droughts it really wet, um, a really dry and everything in between. Okay. So you come in with a lot of this technical expertise and these sophisticated instruments. Is it difficult or was it a challenge for you to not appear like you're just imposing your ideas [00:11:00] on this community that has been working on monitoring its own water resources? Yeah, I think that, um, that's definitely a really big consideration. One. And when working with the Nova nation and with different indigenous communities, because you know, a lot of people are very interested in working with different indigenous communities. Speaker 2:Um, and there's great need, but a lot of groups also go in and, [00:11:30] um, create something and then sort of depart. And in that, in trying to create a project, it was also how to create a partnership. How do you create a longterm partnership and how to really think about how this project is a stepping stone for other projects to come. And so how did you eat better, create that partnership? How did sort of approach them? I know you made some videos. Were those helpful? Yeah. So to better build some of those at [00:12:00] partnership. Um, one we had lots and lots of telecoms, which is always a lot of fun because you get to talk to people without seeing their face. That's a teleconference. Yes. A seller conference. Speaker 2:So we had lots of telecoms, but in addition, um, we wanted to make some videos that sorta explained our project and something that we could use to explain our project, but also they could use to explain our partnership and [00:12:30] where we're going. And so one of the things that I wanted to do with the videos was to sort of take out our narration as much as possible and to use more of their narration. Um, because no one can really describe problem more than the person and people that are actually experiencing it. So, um, I hopped on the phone, I asked Theresa show one of the principal hydrologists if I could interview her. And at first she was like, um, [00:13:00] you want to what? And I was like, can I interview you for a video? And she's like, you're making a video. And I was like, just trust me. Speaker 2:It's all gonna work out. She's like, does my face have to be on it? And I was like, now your face doesn't have to be on it. Um, I think you should explain the videos a little more because they're very creative. I guess the idea came, I remember trying to think about how we could create a video and what it would look like. [00:13:30] And I was thinking about like how we could get imagery, um, what type of images we would use and video and all of that. And in thinking about that one, the thing with youth with remote sensing with using satellites is that, uh, remote sensing implies that it's remote. So you actually aren't there. Like we work in California while the nomination is mostly in Arizona. So I was trying to think how could we collect data, how could we collect film, how [00:14:00] could we collect sound, how could we get these sort of technical details of a video. Speaker 2:And I was kind of hitting a wall because I'm like, well, we aren't out there. We won't be able to make it out there just to shoot anything. Um, and that would take a lot of time to and resources that we don't have. And um, at the same time, um, one of my friends, Abby van Mucin was teaching a decal, um, here at [00:14:30] UC Berkeley and a decal is a student course. That's right. It's a student led course and she teaches this decal decal on how to take notes and how to illustrate your notes. So you ended up making these like beautiful watercolor videos. And this was inspired by Abby [inaudible]. Yeah. So Abby does these really great water color videos and it's sort of in, everything's in motion. So you're watching this hand move across the screen [00:15:00] painting all of these different images and transitioning from one scene to another. Speaker 2:I was really inspired by her work because I thought it was a really great way to one, explain something because you're watching this blank canvas turn into something and then at the same time you're also watching one idea transform into another idea, transform into another idea, transcend, formed another idea. So in a way it was like how do we connect all the dots [00:15:30] in a project? You know, how do we explain the issue? How do we explain what we're trying to address? How do we explain what we are trying to develop? Um, the tool that we're trying to develop, how do we explain the technical things without being too technical? One of the solutions is make it pretty right. Nobody can refuse it. Pretty pretty picture. And when the viewer watches the picture of pier, they get a better sense of how [00:16:00] everything is connected. And I think we have a bit of the audio to share here today. Of course the listeners won't get the full experience for that. They can go on youtube and check out the video at NASA, develop beyond a shadow of a drought. Speaker 3:If you leave on a half Pinko monitor water. If you leave 45 with a rock area, you have to drive all the way over to five hours. How many sites, and you know they do that every month. [00:16:30] We would like to cut back to where we could manage a few of the site and some are going to be managed by [inaudible]. If we could get some of our data remotely and religiously, it would help our program tremendously Speaker 3:from one of the things that we wanted to do is to show the Navajo leadership. That's when we get emergency drought dollars. Where do we concentrate the leaf or [00:17:00] the way it is right now? Every time we have a drought, drought mitigation dollars get equally stripped at 110 chapters. You want a big shirt that's dropped. Mitigation dollars goes into chapters that we did the most with our tool. Water managers like Robert and Teresa, and better understand which agencies are in a greater state of drought. They're using NASA earth observations, drought mitigation resources [00:17:30] can be focused in the places where they're needed the most Speaker 4:[inaudible]. Speaker 2:It really is a work. Did you find that useful for your project to have to integrate it with a storyboard and with the music? Yeah, definitely. Um, [00:18:00] it was really helpful because that storyboard served for our outline, for our papers. It served for an outline for our presentations. Um, so you took the video storyboard and then turned it into a academic paper. Yeah. And then we just filled in like technical details and all of the other stuff that we needed to put in there. Wow, that's a pretty good idea. Yeah, because you're drawing, you're literally drawing out all of the details and [00:18:30] if you can explain it to somebody that's walking down the street and that street being the Internet, then you can explain it definitely to any of your peers. And so this really helped me with the community, um, with the Navajo nation to help them understand your abilities at NASA. Speaker 2:Yeah, I think so because, I mean, one of the things is people are always asking, well, what's NASA doing here? Um, I've had the [00:19:00] fortune of traveling some with Cindy Schmitt to, um, another reservation, the patchy reservation. And I, I don't think I've ever been asked that in my whole life. Um, the number of times I've, Vanessa, like, uh, so what's NASA doing here? Um, and it was a way that, um, for the video to be used in a way the video could be used by our partners in the Navajo [00:19:30] nation to explain what they're trying to use the tool for. Um, two different people that are visiting the Department of Resource Water Resources. It's a really easy and shareable medium and it takes not a lot of time to watch. So now that you've sort of built the partnership, um, or at least establish some measure of, of partnership, what has been the give and take, like on the project of improving their [00:20:00] water monitoring, when you're creating something, you want that give and take because you want to improve it, you want it, you're creating something for an end user. Speaker 2:And so in these later stages of the project, um, in these later stages of the project, I've mostly been working with Carl McAllen who's a senior hydrologist. And, um, he's actually the main going to be the main person using m d PSAT, the tool that we're developing. [00:20:30] We'll show him like, this is what we've been trying out, this is what we've been testing, how does this look? Um, and then he'll say, that looks great. Or he'll, we'll be installing things on his computer or walking him through installations, um, or troubleshooting things on his computer with him and I'll screen share his screen and, um, we'll just sort of have this back and forth and we meet pretty much weekly to do so. [00:21:00] Well, so what have you been learning through the partnership? I think what we've been learning is how can this tool actually be used. Speaker 2:You know, we go through the ups and downs of like, is this going to be used at all? Is all of this effort even going to be worth anything? Um, and then we go through these highs of like, oh, this is gonna change everything. And you know, Carl Avon says that too. I'll be like, this is going to be like historic and so why [00:21:30] is it going to be so historic? In his words, it's going to change the way that they do things. The ideas that will change the way that they'll be able to calculate those SPI values and report does SPF values indicating how dry in areas or the degree of trout that an area is experiencing so that you can tell the difference between one area and another area and be able to send drought relief dollars to one area versus another [00:22:00] area. How have they been allocating Jabil leaf dollars before this project? Speaker 2:So that Navajo nation is split up to agencies which are equivalent to states and they divided equally amongst all of the states. So you can think of that in the u s that wouldn't really make sense because certain areas are inherently more dry and inherently more wet. But um, areas are going to experience way more drought than other areas. And so it's the same thing in the Navajo nation. We want to be [00:22:30] able to look at where areas are experiencing the most drought. So you'll be able to target the dollars exactly for those areas that need it most. Yeah, exactly. And that goes back to one of the main things that we wanted to address in this project is the ability to, um, say that one area is drought is experiencing more drought than another. Um, these, besides collecting rain gauge data, the Navajo nation currently uses, um, [00:23:00] SBI values calculated by the western regional climate center. Speaker 2:That's really long mouthful, but basically that only splits the Navajo nation up into three different values. So you're having three values to explain, um, an area that's as large as West Virginia and those values are explaining what degree of drought in each area is experiencing versus having any finer detail of splitting it up by agencies [00:23:30] or chapters or watersheds or any other boundary. So is the Department of water resources retaining any of its old methodology, um, or how is it integrating what it has previously been working on with the new DSM in taking the next steps? That's sort of what we're thinking about. How do, how does this tool fit into the current methodology? And, um, so does it make sense to keep on using the western regional climate center calculations? Does it [00:24:00] make sense to use duset in what context? It doesn't make sense to use it just for monthly. Speaker 2:It doesn't make sense to use it to calculate statistics. Does it make sense just to use it, the raster map. That's sort of something that we're trying to figure out right now in these later stages. And it's, it's really interesting because I feel like we're finally getting to a stage where it's becoming a little bit more real. You know, it's, it's being tested, it's being used [00:24:30] and the next step is really well how is it going to be used? How is it actually going to be implemented and how it will sort of the downstream effects change because of that. It's kind of interesting cause I think it's going to be kind of a lot of trial and error from here on out. Um, and it's going to take some experimentation and, but there is a lot of promise. One of the exciting things that this project will be a part of is a larger indigenous [00:25:00] people's initiative. Speaker 2:I'm working title acronym to be created. Um, that is a partnership between NASA and, um, different indigenous communities in that initiative. Um, the idea is really to, to create a space where NASA can be come a facilitator with different communities. How do we bring tools, how do we create projects together? How do we create these longterm partnerships, [00:25:30] um, where we're educating, um, the youth, we're educating, um, college students, we're engaging community members and creating projects that are meaningful, culturally significant, sort of environmentally important. So not just drought. You might be moving on to whatever is relevant for that particular community. Yeah, definitely. I think that there's a lot of opportunity to expand much more and the idea sort [00:26:00] of to get coverage across the u s so having the southwest pocket, um, with the Nava nation and the Paci and working in the southeast as well as in lake country as well as in um, the Pacific northwest. Speaker 2:All of these different areas are experiencing different types of environmental change. And so with that brings a lot of opportunity for us to be involved and um, [00:26:30] to create different projects and collaborations. So y'all at NASA develop, have tried to, you know, make this very accessible I guess and a, a, a great user interface which maybe scientists don't typically develop. Um, and having open source code put up on get hub. Um, can you tell me a little bit more about those projects and what was the motivation behind creating open source code? Yeah, I [00:27:00] guess, I mean the idea behind NASA capacity building and a lot of the initiatives that we have in applied sciences is working with the public and serving the public. And um, in that, I mean the idea when we're creating this is how do we, how do we get this in other people's hands? Speaker 2:How do we, how can, how can we, can we use this in other areas? I mean, so many different parts of the world are experiencing drought [00:27:30] and if that can be used in other areas more the better. Yeah. So you have it. An open source and coated in the program language are [inaudible], which is also free and open source. And that's sort of that. One of the ideas too behind it is, is working when working with different communities, you want to make things available. You don't want to create things where you have to have certain software programs that may be more expensive. Um, [00:28:00] so one of the intentions behind that was what can we use out there that is free and open source and virtually anybody anywhere could download it and be able to use it. Speaker 1:Thank you so much, Vickie, for coming in today. So great to hear about your project. We're excited for where we're incented. Speaker 2:Thanks Nick. Speaker 1:And if you'd like to learn more about NASA develop in their other projects, you can check out their youtube page at NASA develop or [00:28:30] you can visit their website at develop dot l a r c. Dot nasa.gov. See acast.com/privacy for privacy and opt-out information.

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