Panel 4: Play like a Pro: Best Practices for Virtual Care Education

July 19, 2023

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00:00So the next session,
00:01this panel is called Play Like a Pro,
00:04best practices for Virtual Care Education.
00:06Here we thought we would immerse
00:07our learners in a little bit
00:10more of an actual sense of Okay.
00:12We've talked in theory about
00:13a lot of these things.
00:14Let's talk in practice about what
00:16works well and what doesn't work well.
00:18And we're very fortunate to have Doctor
00:21Toya James Stevenson here with us from
00:23Indiana University Health Physicians.
00:25Again, I'm I met her through this
00:28process and have been just very
00:30impressed with her role in the AA
00:33MC Telehealth Advisory Committee.
00:35What she brings to the table in terms
00:37of her understanding about teaching and
00:40learning in this telehealth environment.
00:42She is her clinical practices in
00:45GI and she's actually done a lot
00:47of work in virtual care access
00:49and quality as it relates to GI.
00:52And and so I'm very excited to have
00:55her share with us her thoughts
00:57as she moderates this session.
00:58So I'll turn
00:59it over now to her.
01:02Thank you, Lee.
01:03I appreciate the opportunity to
01:06lead this panel discussion on best
01:09practices for virtual care education.
01:12As we had spoken about before,
01:14we wanted to slowly progress
01:16into getting into the granulars
01:19of exactly how you would impart.
01:22Knowledge on to learners and so
01:26our objectives were to discuss
01:28some of the methods for educating
01:31and embracing website banner.
01:33And so we're going to use some
01:35simulations to exhibit this review
01:37approaches to structure the virtual
01:39delivery model and the environment.
01:41For learning,
01:42because there could be several
01:44different approaches that could
01:46fit within a practice,
01:48share best practices on team structure
01:50and integration while embedding
01:52the learner through role clarity,
01:54optimization of the role on the
01:57team and incorporating this into
02:00telehealth as we care for patients
02:02and incorporate their caregivers.
02:05And then also consider approaches to
02:08incorporating peripheral advices to enhance.
02:12The visit and the encounter.
02:14So as many organizations have come
02:19to rapidly integrate telehealth
02:24since the public health
02:26emergency was declared in March,
02:28what we are seeing is that there are
02:31gaps in the knowledge that we have as
02:34physicians because we weren't trained
02:36many of us in telemedicine and so
02:39we're having to rapidly educate our.
02:41Self educate our providers on best practices
02:45not only for interacting with the patients,
02:48but for incorporating learners
02:50into their environment.
02:52So next slide.
02:54So with that I'd like to
02:58introduce our panelists.
03:00Doctor Ronald Weinstein is the founding
03:03director of the National Awardwinning
03:05Arizona Telemedicine Program.
03:07He's an academic pathologist who was the
03:11department chair for over 30 years and is
03:14a pioneer in the field of telepathology.
03:17He received the American Telemedicine
03:20Association's President's Leadership
03:23Award and currently continues to work
03:26at the University of Arizona as the
03:29director of their telemedicine program.
03:31Doctor Neil Nyak is the is an
03:34instructor of emergency medicine
03:36at Weil Cornell Medical College.
03:39He joined the group in 2015 and practices at
03:44the Medical Center and in lower Manhattan.
03:47And he is the director of the Emergency
03:49Medicine Simulation Education and
03:51he's going to show us basically
03:55how he works to train the trainer
03:57through simulation techniques.
03:59Doctor Bart Demershock,
04:02who may may not be able to join us
04:06today because he is on telestroke call,
04:08is a professor of Neurology
04:10at the Mayo Clinic.
04:11He's the Medical Director for the Center
04:14of Connected Care and has had extensive
04:17research and clinical experience in
04:19Telestroke and Laura Christopherson.
04:22Works alongside Dr.
04:24Demir Shaw,
04:25where she serves as the Operations
04:27Manager for the Center of Connected Care.
04:30Kelly Wittebolt is an emergency
04:32medicine physician at Mass General,
04:33where she is public published extensively
04:36on the use of peripheral devices.
04:39She and Doctor Weinstein will help
04:41us to develop a better understanding
04:43of how telemedicine peripheral
04:45devices or medical devices can be
04:47used to augment the patient care.
04:49And so we will lead off with Neil who
04:52will share some simulation videos.
05:03Great.
05:07So thank you for that wonderful introduction.
05:09Thank you for having me here.
05:11So I want to start a little bit before
05:13we get into how we actually train it
05:15about how our program actually started.
05:17And it was simply with trying to get medical
05:20students and experience in in telemedicine.
05:24And so we started it as I'm a
05:26simulationist with giving them an
05:28experience by doing a simulation.
05:30And so we had them see a
05:32standardized patient over video.
05:34From a controlled setting and what ended
05:36up coming up in the debrief was less about
05:39the how to turn on the camera and how to,
05:43how to, how to navigate the system,
05:46but much more about the interaction itself.
05:49And what we realized is
05:51that the website manner,
05:52the the clinical corollary of
05:54telemedicine to bedside manner was
05:56what they wanted to talk about.
05:58And so as our program kind
06:00of expanded and developed.
06:01We realized that this was the
06:03crux of what we wanted to teach.
06:05And what we also realized is,
06:07as Doctor James Stevenson said,
06:08a lot of us have been thrown into this
06:10without any previous training in this at all.
06:13And so a lot of us were novices when it
06:16came to website manner or at least beginners.
06:20And so we were all starting
06:21kind of from the same space,
06:22the page whether we were already
06:25practicing clinicians that had,
06:26you know,
06:2720 years of experience or if we
06:28were the first year medical student.
06:31And So what we did is we developed
06:35this program for all comers who were
06:38interested in telemedicine to really
06:40understand the aspect of website manner
06:42and how to apply to their processes
06:44and their telemedicine practice and
06:46so the program that we developed.
06:49Starts with a flip classroom model.
06:51And so this flip classroom model
06:52is a module that goes over some
06:54of the basics and lighting,
06:55camera angles and some of the medical
06:58legal aspects of telemedicine.
07:00What is the Ryan Haid act and
07:02where do you need licensure?
07:04And this is basically to get
07:05everyone kind of on the same page.
07:07A lot of our learners are coming
07:09in with different experiences
07:10and especially post COVID,
07:12A lot of these experiences were
07:14just on the fly from home on zoom.
07:16And so we had to kind of you
07:18know before COVID,
07:18we had to convince people
07:20why this was important.
07:21Now it's we have to backtrack a
07:23little bit and make sure that people
07:24understand that once a lot of these
07:26regulatory relaxations go away,
07:27what do we need to know,
07:29how do we need to do it.
07:30And once they have that groundwork
07:32knowledge base, we bring them in, in person.
07:36Previously it was in a classroom,
07:37but now it's all virtual to do
07:40some experiential learning.
07:41And so we actually have them
07:43participate in simulations and
07:45do our long debriefs using the
07:47video from their simulations.
07:48And so,
07:49as was kind of stated in the last
07:52last panel, people being able to watch
07:56yourself on camera taking care of a patient
07:59is awful and awesome at the same time,
08:02but it's an awesome way to learn.
08:05And we have to get used to seeing ourselves
08:07on camera because that's the only way
08:09we get comfortable being on camera.
08:10And so we use these videos to
08:13engage in a discussion with our
08:15participants asking them about how
08:16what they think about their lighting,
08:18what they think about their framing,
08:19what they think about their
08:21website manner as it pertains to
08:23presenting themselves to the patient.
08:25And we talk about why that's important
08:27not only from a standpoint of you know
08:29in New York where a one party recording
08:31states your patient can record you at any
08:33point in time and post it on Facebook.
08:35Book.
08:35And so you want to put your
08:36best face forward,
08:37but also from a aspect of
08:41engaging with the patient.
08:43If we don't engage with our patient,
08:44if we don't reach through the screen
08:46and really make that connection,
08:48we're never going to be able to
08:50show that empathy that was that
08:51is also so important and so,
08:53so really understanding how lighting affects.
08:56That and how camera angles
08:57affect that aspect of it,
08:59How having a background that's
09:00not distracting allows you to
09:02take care of your patient and not
09:03be not have your and have your
09:05patient actually listen to you.
09:06You know,
09:07you can only imagine what it might be
09:08like counseling a patient on diabetes
09:10when you have a giant jar of cookies
09:12in your background because you're
09:13sitting on your kitchen table at home,
09:15right.
09:15And so we dive into this through
09:19this experiential learning process.
09:21And then.
09:22For many of our our practicing providers,
09:25we do an optional refresher in
09:27their environment to help them
09:29set up their environment to be
09:31optimal for telemedicine.
09:32But with their undergraduate and our
09:34graduate medical education learners,
09:36we do the first two aspects of
09:38this next slide.
09:42So how do we actually do this?
09:44Well, we play a video and
09:45this may be a pre video.
09:48Hi, tell me what's going on. Hey.
09:52I'm having this eye problem on
09:55the inner side of this bottom lid.
09:57It's been red, a little swollen
09:59over the last couple days
10:03and so we may ask the patient or we
10:04may ask the provider who did this.
10:06So if you were the if you were the patient
10:08and this is what you saw in camera,
10:11would you trust them as your medical doctor?
10:14And it's amazing how many
10:15different answers we get for that.
10:16Most people will kind of shy away and
10:19never never like themselves on camera.
10:21But if you start pointing out
10:23some of the redeeming qualities,
10:24you can also start pointing out
10:26some of the other aspects of
10:27it which they can improve on.
10:29And so using either some sort
10:31of debriefing technique,
10:32you can really start keying
10:34in on some of these aspects,
10:35such as your framing isn't optimal,
10:37so you're not the center of the screen.
10:39If you want your patient
10:40to really listen to you,
10:41you have to be front and center,
10:43so get yourself in the middle of the screen.
10:45Your lighting, right,
10:46causes this glare into the camera.
10:48So optimizing your lighting so
10:50that it's more uniform and not so
10:53spotlighting can really help with that.
10:54And having someone in your background
10:56may or may not be a HIPAA violation
10:58based on who it is and whether
10:59your patient's okay with it.
11:01And so discussing that with your
11:03patient or whether you're using a
11:04medical scribe is really important
11:06for that medical legal aspect.
11:07And so after our session,
11:10they may have a situation like this.
11:11Next slide.
11:14Hello, I'm Dr. Greenwald.
11:15Can you see and hear me OK?
11:17You can, yes. OK.
11:18Before we get started,
11:20a little housekeeping.
11:21Just confirm your name
11:23and date of birth for me.
11:24Joanna Flores,
11:2712/23/1995. OK. And what location
11:29are you calling from today? 50 W St.
11:32New York, NY 10006. OK, Terrific.
11:37Thanks for confirming that.
11:40And so as we do this iterative process
11:43of reflecting on your own videos,
11:45we see a lot of the students evolve in their,
11:47the way that they approach their encounters.
11:50They start asking,
11:52they start leading their encounters
11:53with some of these questions,
11:54these kind of housekeeping
11:55questions that are so,
11:57so important to the documentation and the
11:59medical legal aspects confirming that
12:01they have a license where the patient is,
12:03but just like bedside manner is
12:05not just that initial presentation
12:07and how you look on camera.
12:10How you look in person, website manners,
12:12not just how you look on camera.
12:14And that initial presentation to your person,
12:16It's about understanding the entire
12:18patient encounter and that art of medicine.
12:20And as we heard on the previous panel,
12:22empathy is a huge part of that
12:24patient interaction and understanding
12:25where the patient is coming from
12:27and how to provide care to them in
12:29the environment that they're in.
12:31And this is,
12:32I think where a lot of people get
12:34stuck with telemedicine and they try
12:35to take what they do in person and move
12:37it and block into the virtual realm.
12:39And we can't do that.
12:40We have to teach a different set of
12:42skills to actually care for a patient.
12:44And it's because the environment now,
12:45the room,
12:46the virtual care room is now
12:48half the patients and half ours.
12:50So we don't have as much control over it.
12:52The room isn't set up for us.
12:54We don't have this, you know,
12:55the bed located where it is and
12:57the Thalmascope on the wall and
12:59the lighting perfect in the room.
13:01For an encounter.
13:01And so we have to work with our patient
13:03to really set that up and engage
13:05them in taking care of themselves
13:07or helping us take care of that.
13:09We have to ask them to rearrange their
13:12furniture or rearrange their lighting,
13:14get to a better spot to make a
13:16better connection so that we can
13:18actually do an exam.
13:19We need to incorporate their hands
13:21as our hands in the exam to try
13:23to make sure we can reliably get
13:25an exam and we need to incorporate
13:27their home environment and what is
13:29accessible to them in their plan
13:31to allow us to take care of them.
13:32And so in the discussion we're able
13:34to cover all these topics and really
13:36kind of expand people's minds as to
13:38what it actually means to have good
13:40website manner over telemedicine.
13:42Thanks.
13:44Next we will have is Laura here. I'm here.
13:50I'm just waiting for my video to be enabled.
13:53Oh, OK.
13:56You can go ahead and get started, Laura.
13:57It'll kick in in a minute.
13:58Grab it, grab it. There we go.
14:00Hey, you're in the same office
14:02as the other person from Mayo. I
14:04know. I would like to use their background.
14:10Thanks for having us here today.
14:12So within the Center for Connected Care,
14:15we're Mayo Clinics home for telemedicine.
14:18We developed an education curriculum
14:20to educate our care teams and care
14:22teams and staff and accelerate
14:24our adoption and diffusion of
14:26telemedicine within our practice.
14:28So in this presentation,
14:29we're going to be offering
14:31our recommendations for best
14:33practices for structuring and
14:35delivering telehealth curriculum.
14:36That's really based on our experience
14:39and I will say lessons learned beginning
14:43with conducting a needs assessment.
14:46So to conduct the needs
14:48assessment with your learners,
14:49we recommend focusing on three key areas,
14:52curriculum content,
14:54curriculum design,
14:55and curriculum implementation.
14:57For our needs assessment,
14:59we conducted interviews with
15:00providers and other care team
15:02members within our practice,
15:04and we also included some support staff
15:06so our operations administrators who
15:09support those care teams to ensure we
15:12captured the full spectrum of needs.
15:14We did include individuals who
15:16had depth of experience with
15:18telemedicine and those that did not.
15:20We also interviewed residency
15:22and fellowship program directors
15:24to differentiate the needs of
15:27practicing physicians from those
15:28of trainees or student learners.
15:31So in the area of curriculum content,
15:33we wanted to learn more about what
15:35types of content were needed or
15:37wanted by the practice and as we
15:39look to develop our curricula.
15:40We wanted to know how to structure the
15:43content such as aligning by telehealth
15:45competencies versus specific solutions.
15:48So video telemedicine or video visits
15:51would be an example of a specific solution.
15:55Additionally,
15:55we recommend gauging interest in
15:59structuring the content by roles.
16:01And gathering information to help you
16:04determine whether to take a broad or
16:06a more focused approach to develop
16:08education to either tailor it to the
16:10specialty practice and solutions,
16:12or whether to develop generalized
16:14education that can be broadly applied.
16:17So for curriculum design,
16:19we recommend gathering information
16:21about what types of curriculum
16:23would be useful for various topics.
16:25For example,
16:26does the practice report that
16:28asynchronous learning?
16:29Such as a video or a module would
16:32be better for them?
16:33Or are they really looking for
16:36things like observed simulations,
16:38Simulations that they can participate in,
16:40or experiential learning as being
16:43most effective or more easily
16:45adopted in their practices?
16:48And then for curriculum implementation,
16:50we were interested to get practice
16:52feedback on preferences for
16:54implementation with an eye towards
16:56selecting an approach that would really
16:58drive the adoption and utilization
16:59of telemedicine in our practice.
17:01So for our needs of assessment,
17:03we were specifically interested in
17:05feedback about a super user train,
17:07the trainer model and taking a
17:10required versus voluntary approach
17:12to telehealth education adoption.
17:15And then finally,
17:16we wanted to know from our practices
17:18what metrics they wanted related
17:20to their consumption of telehealth
17:22education and go to the next slide.
17:30So in addition, we offer several
17:33recommendations for content design,
17:35implementation and assessment
17:36of telehealth education.
17:38In developing our telehealth program,
17:41we really took an agile approach or I
17:44guess you could say where did you go
17:45approach to developing the content.
17:47And we did this so that we could
17:50quickly respond to the education
17:52needs within our practice.
17:54We did learn a lot along the way,
17:56and as such we are offering our
17:59best practices based on some
18:00of those lessons learned for
18:02curriculum content and design,
18:04implementation and assessment.
18:06So for curriculum, content
18:08and design, we recommend considering
18:10the domain and the user role
18:13when developing the curriculum.
18:15So for example, best practices
18:18for communicating with patients
18:20asynchronously via secure message
18:22might vary depending on which care
18:24team member is communicating with the
18:26patient and then how also how that care
18:29team has structured their workflows
18:31for who's managing secure messaging.
18:34So that's just a a good example of how the
18:38way that the care team is approaching the.
18:41The telemedicine can can drive
18:44the way you structure education.
18:46Other considerations include
18:47considering the format and where
18:49the learner will use the education.
18:51I'm considering how their needs varied
18:54depending on their prior experience,
18:57whether they're very experienced
18:59or they're a novice,
19:00the context,
19:01and then how the complexity of the topic
19:03might lend itself to specific formats.
19:07So for implementation we recommend
19:10ensuring buy in from the key
19:13stakeholders and leadership groups,
19:14specifically focusing on those who have the
19:16most to gain from using that education.
19:18As a start,
19:19we've had a lot of success by working
19:22collaboratively with our early adopters.
19:24These groups are really the most excited to
19:27implement telehealth and they can really Dr.
19:29adoption in our practices.
19:32Particularly with using education,
19:34they can also be a really rich source
19:36of feedback to infer to inform our
19:39early versions or prototypes of
19:41education that we can then refine
19:43before we disseminate to a larger
19:45group for the entire practice.
19:48Role models can also be leveraged
19:49to encourage others to implement
19:51the education into their training
19:53programs as well as using testimonials
19:55from those role role models.
19:58And then we really recommend emphasizing
20:00the what's in it for me to drive
20:03the adoption of the telehealth
20:05education during implementation.
20:07Finally,
20:08we recommend setting goals
20:09even if they're modest.
20:11It doesn't have to be
20:14intense analytics, just some some
20:17goals and analytics that you can use
20:20to drive and measure adoption along
20:23with gathering regular feedback.
20:26Whether that's qualitative or quantitative,
20:28but just using that feedback to improve
20:31the education program over time.
20:33So just to summarize,
20:35these best practices are really
20:37based on our experience to date.
20:40We are learning a lot as we
20:42develop and implement telehealth
20:43education into our practice,
20:45so we're happy to share some
20:47of those lessons learned,
20:48sometimes painfully right.
20:50So I look forward to hearing from you
20:52all when we get to the question and
20:55answer about what your best practices
20:57have been and also just hearing kind of
21:00where you're at in regards to telehealth,
21:02education and the challenges
21:04that you're facing,
21:05especially post post COVID or mid COVID,
21:09however you look at it.
21:10Thank you.
21:15Okay. Hello everybody.
21:16Thanks for including me in
21:19this amazing symposium.
21:21I'm learning every minute
21:23and thoroughly enjoying it.
21:24Before I get on to this slide,
21:26I will make a few definitions. So.
21:28So when we think about computer science,
21:30the computer is central and the
21:33peripherals are all the devices
21:35that hook into the computer.
21:37So in the case of.
21:38Telemedicine,
21:39the peripherals are the medical
21:40device and each one has its own
21:43story in terms of its evolution,
21:44its innovation, its conceptualization,
21:46its role in medicine and enhancements
21:50that are coming down the road.
21:52So peripherals are are very
21:54important to the practice,
21:56but in addition to being important,
21:57they're the linkage to our study of
22:00innovation and they can provide a very,
22:03very rich curriculum in in that area.
22:06And I do want to address that a little bit.
22:09In this talk,
22:11my own personal involvement in
22:13telemedicine dates back 50 years to
22:161967 and back then I was employed
22:19in a dual track as a pathology
22:22resident as well as an NIH funded
22:25laboratory director with a special
22:27interest in medical imaging and
22:31because of my involvement in.
22:35Medical imaging.
22:35I was drawn into the preliminary testing
22:37of television microscopy equipment.
22:40We would call that telepathology Today.
22:42That could be used for sending video
22:44images of blood smears from the
22:47Logan International Airport to to
22:50the Massachusetts General Hospital
22:53Telediagnostic Clinic 2.7 miles away
22:56for stat readouts by pathologist.
22:59And at that time,
23:00the research question focused
23:01on the need for color TV.
23:03In telemedicine and interestingly it
23:06was decided not necessary and showing
23:09that not necessary for teledermatology.
23:13I wonder about that,
23:15but because of the my preclinical
23:19and pre implementation studies,
23:23I was given the honor of signing
23:25out the first telemedicine case.
23:28Telemedicine microscopy case coming
23:30from the Logan Airport the next
23:33year in 1968 and shortly thereafter
23:35was informed that I had become the
23:38first resident to actually sign out
23:40a telemedicine case and that made
23:43history have been involved really ever since.
23:46Now one of the faculty members in
23:49the program was Doctor John Knowles
23:51and he was the general director of
23:53the Massachusetts General Hospital.
23:56And he was a brilliant educator who
23:59was totally immersed in medical
24:01student and resident education.
24:03And you'll see in a moment why
24:05that was important.
24:06Just historically, he was also interested.
24:09Interesting because he became general
24:12director of the MGH at age 35,
24:15and 10 years later, at age 45,
24:18he came, became president of
24:20the Rockefeller Foundation,
24:21but always remained very,
24:24very interested in telemedicine.
24:26Now and he was also one of my mentors
24:29and and and helped promote my career.
24:32Now he teamed up with a a a famous
24:35medical student a brilliant medical
24:37student at Harvard Medical School
24:39who was in his fourth year and
24:41and it already published almost
24:43I think 8 or 10 books and but so
24:46the star of the show was the six
24:48foot 9 inch tower of a man
24:50the HMS senior student
24:53named Michael Crichton.
24:55And of course, Michael Crichton
24:56went on to become a famous author
24:59of Jurassic Park and about 30 other
25:01novels and the famous movie director.
25:05But they put their heads together
25:07to define with the optimal,
25:10with the optimal core aspirational
25:14core competencies would be for medical
25:17students rotating through telemedicine.
25:19And they decided one thing
25:21would be the patient encounter,
25:22which has been the major
25:24subject of today's discussion.
25:26But they also thought it was very important
25:29and cultivating and understanding of
25:31the process of medical innovation.
25:33And I was just delighted that in panel #3,
25:38Julian Jenkins brought up innovation and
25:40that was going to get up and applaud.
25:43So anyhow,
25:45Crichton rotated through the
25:48pioneering program.
25:50A couple of months before he graduated,
25:52it was the same time that he was
25:54finishing up Andromeda Strain,
25:55so graduation he was publishing
25:58those two books Now.
26:00The half million dollars he made was
26:02for the rights to Andromeda Strain,
26:04but nevertheless his book on entitled
26:08Nonfiction book entitled 5 Patients.
26:10The patient examined included a very
26:13informative chapter on telemedicine
26:16and his work up on telemedicine.
26:18And his insights into how
26:20telemedicine would be leveled into
26:23the general study of innovation.
26:25So in that chapter,
26:28Crichton meticulously records his mentor's
26:31work up of an actual telemedicine case, Mrs.
26:35Sylvia Thompson.
26:35And when he was sitting over at the
26:38side of the room rapidly taking notes,
26:40anytime you would see Michael Crichton,
26:42he was always rapidly taking
26:44notes or walking down the hall.
26:46At 69 inches,
26:47she had just flown from Los
26:50Angeles to Boston,
26:51had walked to the New Logan
26:54Airport Walk in Clinic,
26:55had some chest pain,
26:57intermittent chest pain which
26:58emerged while they were flying over
27:01Ohio and was worked up remotely
27:03over television by a doctor over
27:05on the mayor's general campus.
27:06Doctor's name was Raymond Murphy.
27:09She turned out to have pneumonia.
27:12Crichton describes her reaction
27:14to her telemedicine.
27:15Experience in a highly quotable way,
27:18she said.
27:18Quote, my goodness,
27:19it was just like the real thing, UN quote.
27:21And she never heard of telemedicine
27:23when she walked into the room.
27:25So this set the tone for probably
27:2780 or 85% of future patients
27:30reactions to telemedicine.
27:31Not everybody loves it,
27:33but generally it works very, very well.
27:36But Crichton,
27:37being Crichton,
27:38goes much much further and with
27:41the help of John Knowles.
27:42Set up appointments to talk to the
27:45leading gurus at Harvard Medical
27:47School of the Massachusetts General
27:49Hospital and at MIT about the
27:52futures of future of technology and
27:54what were really the hot topics,
27:57and the Crichton describes those
28:00with remarkable foresight.
28:01The technology is being pioneered
28:03in Boston at that time,
28:05and at that time they had what was
28:08becoming a medical informatics unit,
28:11a very famous one.
28:13And and so he studied the things
28:15that would become highly relevant
28:17to medical practice And now in
28:19hindsight we can see how they turned
28:22out 50 years later.
28:24And what he looked at in particular
28:26were such thing as a I algorithm
28:29driven patient interview systems
28:31and he also looked at the power of
28:34networking of electronic health record
28:36systems And of course those are the
28:38things that are about to already have
28:41revolutionized the practice of medicine.
28:43So it showed that you know,
28:46everything that you would could
28:48teach about innovation today will not
28:50be outmoded in the next few years.
28:52And a lesson learned was a
28:56modern telemedicine rotation.
28:57Clinical rotation does benefit
28:59from instructions on processes
29:01of medical innovation,
29:03and telehealth devices per se
29:06become the tools for teaching
29:08medical students about innovation.
29:11Innovation, next slide please.
29:17OK. So these are some of the
29:20telemedicine medical devices
29:21that are 21st century physicians,
29:23black bag if you will,
29:24the telemedicine kit.
29:26And so telemedicine devices
29:29are the equivalent to socalled
29:31professionals peripherals, I'm sorry,
29:34as defined in computer science.
29:38Finally, I would like to make a point.
29:43About innovation,
29:44that I think is critically important,
29:47and some of the more senior
29:49faculty members who have been on
29:51university committees over the
29:53years can really relate to this.
29:55This really involves telemedicine
29:57and telehealth in a major
29:59way and a very urgent need.
30:02There is an urgent need for
30:04medical schools to take a stake.
30:07Claim a stake in the area of
30:10healthcare innovation, Education,
30:11telehealth gives us the golden
30:14opportunity to make that claim.
30:17As several speakers have mentioned,
30:19today, medical schools are
30:21late in coming to the table.
30:24Now I tell that to people and our faculty,
30:26and they just can't get that straight.
30:28They say, well, that just can't be the case.
30:29We're always at the lead.
30:30No, you're not at the University of Arizona,
30:33our nursing school,
30:34and our school of public health.
30:36Have offered very popular courses
30:39on telemedicine for over a decade
30:42and in some cases have laid claim
30:45to that as their area their their
30:48their area in in education.
30:51So I think that the universities,
30:54the way that universities work once
30:56a college or a department to claim
30:59declares ownership of an education
31:02franchise it tends to be in their.
31:05Education portfolio for perpetuity
31:07and the subject matter for innovation
31:11should be part of medical schools.
31:14And I think that they will.
31:16We can leverage studies of medical
31:18devices as an example of medical
31:22device innovations that can become
31:25a centerpiece of our curriculum.
31:27Okay. Thanks.
31:28Next slide, I think there's one more slide.
31:34OK, this is and my final slide.
31:37This is the point I would like to make.
31:39You know we're now post Flexner Centennial
31:43and what we're seeing is a mass migration
31:48of medical science coursework for medical
31:51schools and to undergraduate colleges
31:54and currently the University of Arizona
31:57is putting a new curriculum in place.
32:00Which is called BS in Medicine,
32:02not medical science, BS in Medicine.
32:05And this is a collaborative
32:06effort of our College of Medicine,
32:07Nursing, Pharmacy,
32:08Public Health and our College of Law.
32:12And it takes, it's,
32:14it's it's basically cloning what's
32:16happened in our College of Business
32:18where our Bachelor of Science in
32:21Business is our number one freshman
32:23major and the number 2 freshman major is.
32:27Bachelor of Science and Public Health
32:30and the third one now is going to be
32:33Bachelor of Science and Medicine.
32:34And I would predict that within 10 years,
32:36all preclinical medical science will
32:38have migrated into the college level.
32:41And this is the way,
32:42one of the ways that we're going
32:44to deal with core curriculum
32:46for interprofessional education.
32:48And now there's a major,
32:49major move to bring medical science
32:52curriculum into K12 schools in
32:55order to deal with.
32:56The issue of health literacy,
32:59now as this massive migration takes place,
33:02that's the time when we have to be very,
33:04very focused on grabbing the parts of the
33:07curriculum that could be within our domain.
33:11And I would argue telehealth gives
33:14us tremendous leverage in that area.
33:16We're currently putting together a report
33:19that's showing in a sketch to the right,
33:23and it's called Flexner 3.0.
33:26And Threxner 3.0 describes Flexnerian
33:29science moving first into graduate schools.
33:32That's Flexner 2.0,
33:34and then into college is Flexner 3.0.
33:37And the name of the report
33:39will be Reinvention of Medical
33:41Education in the United States.
33:43And hopefully it'll become a book as well.
33:46And we've got 11 out of the 20 chapters
33:48pretty pretty close to being finished
33:50and and this, this, this could be.
33:52We think it's going to be important.
33:54We'll see how it turns out.
33:56If you want to read more about it,
33:57just Google Flexor 3.0.
33:59A whole bunch of papers come up,
34:01but we think it's very important
34:03and we think it is a trend.
34:05And once again,
34:06I would urge people who are in the
34:09telemedicine telehealth arena to realize
34:11that they are actually center stage,
34:13whether they know it or not.
34:15And this is a real opportunity
34:17for medical schools to expand
34:19their educational franchise.
34:21Thank you.
34:25Thank you, Ron for that segue.
34:28The transitions nicely into a little
34:30bit of a discussion about the devices
34:32that are currently on the market and
34:34opportunities for integrating this type
34:37of devices and mobile health and apps
34:40into the virtual care delivery model.
34:42Seeing that you know,
34:43we think about M health and remote
34:45patient monitoring and virtual care
34:48delivery as sort of separate entities,
34:50but really in an ideal world they
34:52would be able to be integrated.
34:55Down the line.
34:56So one of the things that is important
34:58to think about going back to panel two,
35:01is the general competencies in
35:04performing histories and physical exams.
35:07You know,
35:08can you do a history and a physical
35:10exam and build completely if you don't
35:12have basic things such as vital signs,
35:14which are called that because they're vital.
35:17And so there are a number of
35:20devices including Fitbits,
35:21Apple Watches, pulse oximeters.
35:23Digital thermometers,
35:25which have been around for a while,
35:27and even digital blood pressure cuffs
35:29that can be used to ascertain this.
35:31But before I talk about
35:33each individual thing,
35:34I think one of the important things
35:36to talk about is what if a patient
35:38doesn't have these things or that
35:41idea of sort of the digital divide.
35:43If a patient can't afford it,
35:45or just doesn't have a CVS or a
35:47Walgreens nearby to access one of
35:48those things to objectively tell you
35:50their information from their home?
35:52So one of the tools that has been
35:54talked about is called the Roth score,
35:56which is actually not a device,
35:58It's a clinical measurement and
36:01it's particularly relevant in the
36:02age of COVID where oxygenation and
36:04dyspnea is important to ascertain.
36:06So it's used to assess a patient's
36:09ability to count and it uses their
36:12counting times to risk stratify
36:13their dyspnea and the severity of it
36:16as it correlates with their level
36:18of hypoxia and it has been shown to
36:20correlate with their dyspnea severity.
36:23And it works by having the patient
36:24count from 1 to 30 in a single breath,
36:27and as rapidly as possible.
36:29And the primary result of that Roth
36:31score is the duration of time they
36:32are able to count and the highest
36:34number they're able to reach.
36:36A maximal counting number less than 10,
36:38or a count time of less than 7
36:41seconds identifies patients with a
36:42room air pulse ox of less than 95%
36:45with a sensitivity of 91% and 83%,
36:48respectively.
36:48And if they can only count to
36:517 seconds or less,
36:53or their count time is less than 5 seconds,
36:56that can identify patients with the
36:58room air pulse ox of less than 90%
37:00with a sensitivity of 87% and 82% each.
37:03So this is a tool that not too
37:07many clinicians sort of anecdotally
37:10that are aware of and so.
37:13It would be ideal if these types of
37:15devices were measuring objective
37:17numbers to ascertain hypoxia were
37:19actually available and as ubiquitous
37:21as something like ATV remote control
37:23or cable box or a
37:25fire extinguisher that could be
37:27found in the average American home.
37:29And that'll segue nicely into the next
37:32panel about access equity and sort of
37:35the influence that we as physicians can
37:38have with policymakers and pairs to.
37:40Invest in this kind of technology
37:42as part of something that can be
37:45used in virtual care delivery.
37:46So for ascertaining things like heart rates,
37:50the Fitbit can provide that
37:52and the Apple Watch E KG,
37:54the Series 5 pictured here can
37:57also ascertain 3 lead EKG's.
37:58There are other devices on the market
38:01that can ascertain up to six lead
38:02EKG's with wireless remote technology.
38:06One of the benefits that could be
38:08seen here using evaluation for cardiac
38:10patients and routine follow up or if
38:13they're having an urgent care concern
38:15like they're feeling palpitations,
38:17you might be able to say you know this
38:19looks like sinus tachycardia or SVT.
38:20Maybe we could try some bagel maneuvers
38:23at home before sending you in,
38:25especially if the patient is in a
38:27high risk COVID area or is afraid
38:29of going in which tends to be much
38:31of the collateral damage that we're
38:32seeing during COVID where patients are
38:34having symptoms or they're concerned.
38:35But they're really afraid to go
38:37in because of COVID,
38:38and so they end up having adverse
38:40events from things that are not
38:42taken care of because of their fear.
38:46Other things such as the Pulse ox
38:48are pretty routinely available
38:49at most pharmacies,
38:50although during COVID periods
38:51much of that has sold out,
38:52including on things like Amazon.
38:55And then we also have the digital
38:58scales that can be synced to
39:00Bluetooth technology with.
39:02Apps and iPhones and can also be
39:04synced with electronic medical
39:06records so that a patient might
39:08tell you what their weight is,
39:09but might that might differ significantly
39:11than what is actually recorded and
39:14so it keeps people honest as well.
39:16Next slide.
39:22So these are more advanced devices that
39:25can be used to ascertain different
39:27aspects of the physical exam that
39:30might be subspecialist specific.
39:32So the butterfly IQ pictured in the
39:35bottom left is a remote ultrasound
39:37that can be used with an iPhone.
39:39Typically the applications for this might
39:41be used in the setting of paramedicine,
39:43where a patient might be able to be
39:46evaluated remotely with a paramedic
39:48who's been trained in how to apply
39:51the the device to the patient's
39:53chest or whichever body part they're
39:55looking to ultrasound.
39:57It can also be used for
39:59things like assessing.
40:00Remote fetal activity for pregnant
40:02mothers who are concerned,
40:04or if someone has abdominal pain,
40:05it's an easy way to assess the patient's
40:08gallbladder or kidneys if they're
40:11having back pain or urinary symptoms.
40:14Above that is the Eco Duo
40:18EKG and Digital stethoscope,
40:20which enables remote auscultation and
40:23can also be done while visualizing
40:25A realtime E kg.
40:27The devices to the right in green
40:32are sort of neurospecific devices
40:34that can be used.
40:36The Impatica biosensor was developed
40:38by Roslyn Picard at the MIT Media
40:40Lab and that can be used for
40:42evaluating and detecting elevated
40:44sympathetic nervous system activity
40:46and prodrimal seizure activity,
40:48and can prevent unnecessary
40:50deaths from unwitnessed seizures,
40:52especially in kids.
40:55The device in the top right
40:58is the Affectiva wearable
41:00biosensor from the MIT Media Lab,
41:02which I had done some research on
41:05during medical school with doctor
41:07Ed Boyer and we use that to detect.
41:11We use signal processing from that
41:13sensor to detect patients craving
41:15and actual use of cocaine and
41:17opioids and it used a combination
41:19of looking at patients heart rates.
41:21Their electrodermal activity and their
41:23peripheral body temperatures and
41:25how that might vary with times that
41:27they're experiencing craving and use.
41:29And it was very distinguishable from
41:31other types of elevated sympathetic
41:33nervous system activity,
41:34including if they were riding
41:35a roller coaster or going for a
41:37run and the signals were.
41:39Used to identify and and In many
41:42ways the goal was to try to prevent
41:44the relapse by triggering a signal
41:47to their support network in a,
41:49a or things like that to encourage
41:51the patient to seek alternative
41:53avenues to meet their cravings
41:58in the middle. In the blue on top
42:00we've got the neuro ophthalmology
42:01tools from the Volk ion view,
42:03which is something that can be used to look.
42:06Through the iPhone using a Fundus camera.
42:09And then there's also below the title care
42:12devices that can be used and are linked
42:15with on demand virtual care subscriptions.
42:18These are things that can be used
42:20to do throat exams and ear and eye
42:23exams and are good ways to sort of
42:28evaluate remotely orifices that might
42:30not be so easily evaluated otherwise.
42:33And then there's also not featured here
42:35something called the Mid, Mid Tygo,
42:37which is a subscription service where
42:40they provide these types of tools to be
42:42used in the home and they included in
42:44something that they call their life pack.
42:46And the idea is that it links them
42:49with a telehealth service and a
42:51physician access and tools that they
42:53can use remotely so that if they
42:55don't have access to them otherwise,
42:57they're provided with the
42:59toolkits from Mid Tygo.
43:01So one thing to think about just in
43:04going back to the sort of vital sign
43:07ascertainment one of the institutions
43:09that's been using these types of
43:11devices is Ochner Health in Louisiana.
43:13And they have,
43:14they represent a unique case
43:16study where they offer sort of
43:17prescribable devices and apps that
43:19are vetted by their doctors there.
43:21And they offer it in conjunction with
43:23what they use or partner with a retail
43:25O bar and it functions like an Apple
43:27Genius Bar providing tech devices
43:29and apps and training and teaching.
43:31At their various clinical sites
43:32and one of the programs they've
43:34used it for is with hypertension.
43:37So patients enrolled in their
43:39digital hypertension program,
43:40they need to have access to a smartphone
43:42and then the patient will pick up a
43:45wireless blood pressure cuff either
43:46at the O bar or via mail fulfillment.
43:48And then they take their
43:50blood pressure routinely.
43:51And then the readings are
43:53automatically integrated with the EHR.
43:56And this way the patient's care
43:57teams are able to see their data
43:59remotely and they can see it.
44:01As it changes over time and
44:03intervene when necessary.
44:04They published some of their outcomes from
44:07this study and they found that at 90 days,
44:1071% of patients in the hypertension
44:12digital medicine cohort achieved
44:14target blood pressure control,
44:15whereas only 31% of patients getting usual
44:18care achieved their blood pressure control.
44:21So there is some data to support
44:24efficacy and using this digital
44:26evaluation technique with devices.
44:29Thank you,
44:29Kelly. So we are going to move on
44:33with the with looking at our time.
44:35We want to make sure that we give time for
44:39our panelists to answer some questions.
44:42So as far as Neil,
44:45I wanted to ask you how you know
44:48you have some great simulations.
44:50I think these are perfect
44:52for physicians on you know,
44:53just basic simple techniques
44:56for website manner.
44:57How do you evaluate the effectiveness of
45:00these simulation models when teaching?
45:04That's an excellent question.
45:06So right now, we're doing it mostly
45:09based on feedback from our participants,
45:13all of the sessions that go
45:15into special specialty areas.
45:17So we've done this training
45:19with dermatologists,
45:20we've done it with psychiatrists.
45:21We have faculty members from their
45:23department actually join us for
45:25the simulations and the debriefs to
45:27give their personalized perspective.
45:29And we've actually modified the course
45:31over the course of the last two years.
45:34Based on all that feedback to the point
45:36where it is right now and tailored
45:38it specifically to to specialists,
45:40I think one of the things that we're
45:42going to be looking at is really do
45:44these simulations and do what do
45:46the improvements that we see in the
45:48simulations correlate to actual care.
45:49And I don't think we have an
45:52answer for that yet.
45:53I think that's something that
45:54we need to look into and really
45:56figure out how to evaluate.
45:58It could be a checklist kind
45:59of evaluation where.
46:00You know,
46:01we have tapes of these learners
46:04and so we can definitely utilize
46:06checklists and and do it that way.
46:08But until that checklist is,
46:10we have a validated checklist
46:11which I think was referred to by
46:13Doctor Joshi in the previous panel,
46:15it's hard to see whether or not you
46:17actually have that translation of skill.
46:19So I think that's the future.
46:20That's where we have to go with this
46:21and I think it's going to be very
46:23important as we continue to train people.
46:26Thank you, Neil. Laura,
46:27can you speak more on the differences
46:29for new versus established patients,
46:32particularly as trust me,
46:34I've already been developed for
46:36the established patients during
46:39prior in person encounters.
46:44Sorry, I have to hit on mute. Not being
46:46very technical today,
46:49I have to say that I don't think
46:51that we have gotten to that level of
46:54granularity with our telehealth education.
46:56I think, I think that there you'd
46:59probably want to take it on a case
47:02by case basis depending on how
47:04you've structured your curriculum
47:07and delivery as to whether you
47:11would actually need to distinguish
47:13between established versus new.
47:16But we have not taken that approach.
47:17We've taken more of a.
47:20A standard approach where we're
47:24emphasizing empathetic communication
47:25versus like distinguishing how how
47:28the communication may be different
47:30between established versus new patient.
47:34And you had also sparked the spoke on the
47:37role of of having Tele telehealth champions.
47:40We've developed at Indiana University
47:43a telehealth panel of champions from
47:46I think 20 to 30 different departments
47:49and it's it's intriguing how how you
47:52know their uptake or acceptance of the
47:56importance of the role of telehealth in
47:59their own department really affects how
48:01they communicate to their other providers.
48:05And the the effective
48:06dissemination of information.
48:07So how do you think you best engage
48:11champions, virtual champions,
48:16I I mean
48:17I guess we've just adopted kind
48:19of a we with our champions.
48:22I guess we just adopt A.
48:25Approach where we're just developing
48:27a close relationship with them and
48:29as we're developing the education
48:31and looking to implement it,
48:34we're just working.
48:35We're just giving them more support
48:37and time and interacting with them
48:39to make sure that they're successful
48:41and getting the education implemented
48:44and that we're responsive to their
48:46feedback and to make changes or
48:49or pivots based on on their input.
48:53And Ron, you had spoken on medical
48:56schools and that includes ours here in
49:00Indiana University being late to the game
49:03As far as advancements in innovation,
49:06how do we get our medical schools to
49:08see the importance of advancing in
49:10the innovations, particularly around
49:12peripheral devices in telemedicine
49:161 message is that there's there's
49:18just tons of money out there.
49:20For Pacori grants and NIH grants
49:23and in that book that I mentioned,
49:25we just published a chapter
49:26on the 1st 10 years of Pacori,
49:29you know 3rd 88 telehealth grants
49:31designated as such worth $381,000,000.
49:33And
49:36NIH has come to us and they and they've
49:38said for the projects we were doing,
49:40we'll multiply it by 5:00.
49:42So the amount of money that's going certainly
49:46into innovation grants, Ind grants.
49:49Or DNI grants you know in in NIH
49:52is over $1.5 billion this year.
49:54It's more than stem cell research.
49:57So the opportunities 11 way is to find
49:59faculty members who are interested
50:01in doing that and can make that
50:02central to what their agenda is And
50:05those individuals will certainly
50:06be aware of where that innovation
50:09interface is and and and often are
50:11interested in teaching about it.
50:13So I I think that's that that's one Ave.
50:16that's very interesting very appealing.
50:19And I'll give the mic back over to Lee.
50:22I know we are out of time.
50:25You did a wonderful job.
50:26In fact you left me two minutes
50:28to to make my own summary comment.
50:30So that was also terrific set
50:33of examples of really trying
50:35to think about this work from
50:36a variety of different lenses.
50:38One thing that struck me as I listened
50:40to really the wide-ranging scope of
50:42the presentations in this section
50:45was when we talked about evaluation.
50:48Or feedback.
50:49It's very different when we
50:52give feedback about social and
50:54emotional qualities like empathy,
50:56Then when we give, you know,
50:58feedback on execution of a of a procedure,
51:01you know,
51:01the proper execution of a procedure where
51:04there may be more easily quantified
51:06metrics and where individuals may
51:08have a different sense of a personal.
51:11Emotional injury.
51:12When you give them feedback
51:13about their performance,
51:15you know when I tell you you
51:16didn't tie that suture, right?
51:17I can learn to tie that suture better
51:19when you tell me that I didn't
51:21relate to that patient very well.
51:23It it can sometimes be perceived
51:24as a sort of personal attack
51:26or an emotional attack.
51:27And so it is a wide-ranging set of skills
51:30that we're talking about delivering.
51:32And I think it also reminds us that
51:36our profession has been one based
51:38on the concept of apprenticeship.
51:40Right.
51:41Most of our models of didactic
51:43learning are you come,
51:45you stay with me for several years,
51:47You watch what I do, You learn by my elbow.
51:50And when I think you're ready,
51:52I give you your diploma.
51:54And you can go hang your shingle
51:55up and open your shoe store or,
51:57you know, your, your forge,
51:59your blacksmithy forge next to mine or,
52:01you know, in the next town, right.
52:02It's a very much an apprenticeship model.
52:04And we're really talking about,
52:06in a lot of ways, shifting that.
52:08To more of a measurement and
52:10outcome based assessments of
52:13competency that that vary, right.
52:15So somebody may be ready in a year,
52:17someone else might not
52:18be ready for five years.
52:19Actually,
52:19it's interesting.
52:20I have colleagues in Germany and
52:22in Germany the residency program
52:23lasts as long as the chair of the
52:26department thinks it takes you to get ready.
52:28So some may graduate early and some
52:30may graduate several years later.
52:32They they don't have a fixed length
52:34of time and so it's an interesting.
52:37MA is a very different model,
52:38but I do think that it raises some
52:40really interesting questions well.