Panel 5: Keeping the Patient in the Center: The Impact of Virtual Care on Patient Experience

July 19, 2023

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00:00We've we've we've come to the top
00:02of the hour and if I could have the
00:05next slide from Karen and we're
00:07really now in the home stretch where
00:09we're going to devote the remainder
00:11of the time to really thinking about
00:13putting the patient in the center
00:14and and what is the impact of virtual
00:17care on the patient experience.
00:18And if you go to the next slide for me,
00:21the the main objectives for this
00:22session are really going to be #1,
00:24measuring patient experiences
00:25and thinking about how we do that
00:28differently for a virtual encounter.
00:31Thinking about HealthEquity and whether
00:33virtual care is our best friend or our
00:36worst enemy when it comes to HealthEquity.
00:38And then lastly,
00:40key strategies to ensure that
00:41patient access and quality in virtual
00:44care endure during a pandemic.
00:45And if I can have the next slide,
00:47I believe that's the speakers great.
00:50So I'll be moderating this session and
00:52it's my my great pleasure to welcome
00:54several people who I work closely with.
00:56Susan Edgeman, Levitan,
00:57I've known for many, many years.
00:59She's the executive director of
01:00the Stokel Center for Primary Care
01:02Innovation at Mass General Hospital,
01:04named after one of our founders really,
01:06in the field of primary care,
01:08John Stokel, who was,
01:09I would say,
01:10a master of of of bedside empathy.
01:13She lectures in the Department of
01:15Medicine at the MGH and also works
01:18as an associate in health policy
01:20at the medical school.
01:22She's done an enormous amount
01:23of work thinking about.
01:25Engagement of patients thinking
01:27about systems measurements such as
01:29the H CAP scores worked with the
01:32Institute for Healthcare Improvement
01:33and the Lucian Leap Institute,
01:35so she really is an expert in
01:38this area of thinking about how we
01:41conceive of the patient experience.
01:44She'll be followed by Christian Dankers.
01:46Dr. Dankers is a colleague of mine.
01:50We both share a love of philosophy,
01:51which we studied in college.
01:54And that he has,
01:55he and I have worked together very
01:56closely through his work in the
01:58Center for Quality and Safety and
02:00now as the Associate Chief Quality
02:01Officer where he and I have been
02:03thinking together about the equity
02:05issues and also how to build a
02:07quality framework for measuring
02:09quality and virtual care.
02:11And then lastly,
02:12we'll be fortunate to have a
02:14suite of 10 Mcgrory talk.
02:16With us,
02:17she's the Administrative Director
02:18at the Mongon Institute of Health
02:20Policy at here in Boston and also
02:22the Director of the Disparity
02:24Solutions Center as well as adjunct
02:26faculty at Northeastern.
02:28And I've worked closely with the
02:30Sweda on a variety of projects
02:32aimed at making sure that medical
02:35interpretation services are readily
02:37available to our patients and really
02:39thinking about patient centered
02:40ways to ensure that our patients
02:42who work in isolation during COVID.
02:44Would have the opportunity to still
02:47be in touch with family members.
02:49So a suite of focuses on a lot
02:51of issues that deal with social
02:53determinants of health and racial and
02:55ethnic disparities in healthcare.
02:57And she's also worked closely with the
02:59Massachusetts Public Health Association
03:01and really brings an incredible experience
03:05of hands on understanding in this area.
03:08And then lastly,
03:09our final panelist is Andrea Barandi, Kitz,
03:12who I met only again through this process,
03:14who's an extraordinary patient advocate.
03:18She comes to us from her work at Leahy
03:21Hospital and she is always reminding
03:23us on this panel work as we've done so
03:27far to keep that patient perspective in
03:30mind and has brought so many important
03:34perspectives and ideas to light for us.
03:37She works. As a patient outreach and
03:39research specialist at the Leahy Medical
03:42Center in lung cancer screening,
03:44where she also works with research.
03:47She's an associate editor for the Journal
03:49of the American College of Radiology.
03:51And I could go on and on
03:53about her accomplishments,
03:54but I'll let her tell you a little
03:56bit more about herself when we
03:57get to the panel presentation.
03:59So let me with that being said,
04:00now turn the microphone over to Susan,
04:03who is going to walk us through her talk.
04:05Thank you, Susan.
04:07Thank you, Lee. And I just have to say,
04:10I am unbelievably grateful that I was
04:12invited to be part of this symposium
04:15because it's been astounding in
04:17terms of all the information and the
04:20innovative ideas that have been shared.
04:22I probably won't sleep for a week.
04:25So today I'm going to be sharing with you
04:28a little bit about what we've learned in
04:31our health system in Boston about our
04:34patients experiences with telehealth.
04:36Before I get into the data,
04:38I also want to make sure that everyone
04:41knows that the CAPS Consortium and
04:43CAPS is an acronym that stands for
04:46Consumers Assessments of Healthcare
04:48Providers and Systems.
04:50Is rapidly developing a telehealth
04:53survey that will be available
04:56for use in early October.
04:58CAPS is the national consortium.
05:00We've been working since 1995 to develop
05:03all of the national standardized surveys,
05:07many of which are mandated by CMS
05:10and other national organizations.
05:12The telehealth survey was on
05:14the fast track because ARC,
05:16which is our funder.
05:18Was very interested in being able
05:20to evaluate patients experiences
05:22with telehealth and it was also on
05:25a fast track because NCQA uses the
05:28CAPS health plan survey and they
05:30were very interested in using this
05:33new telehealth instrument in their
05:35health plan survey that is required
05:38by all health plans in the United
05:40States in order to get accreditation.
05:43So sometime next spring we're going
05:45to have a huge amount of comparative.
05:48Data from health plan members about
05:51their experiences with telehealth.
05:53And we've designed the survey so that
05:56we ask the same questions about a
05:58person's experience with an in person visit,
06:02a virtual visit,
06:02or a telephone visit so that we can
06:05compare which of these seems to be
06:07working the best and where do we need
06:09to focus our improvement efforts.
06:12So I wanted to make sure people
06:14know about that.
06:15And then I'd like to move to what
06:16we're doing in our own health system,
06:20excuse me, to gather
06:22feedback from our patients.
06:24So we recently began working with
06:27the new patient experience vendor
06:29and decided that it was paramount
06:31that we collect information
06:33about telehealth visits given
06:35everything that happened with COVID.
06:38With the way that we collect data
06:40with our new vendor is that we
06:42survey everyone who's had a visit.
06:44They are surveyed within one
06:46to three days after the visit,
06:48and we surveyed them initially by
06:50requesting that they respond by e-mail
06:52and if they don't respond by e-mail,
06:54then they get a telephone
06:56call where we query them using
06:58interactive voice recognition.
07:00So to date this state is about 10 days old.
07:05We reached out to 50,000 patients in our
07:08system that it had a telehealth visit
07:11and we got responses from about 17,000.
07:13We also allowed them to add comments
07:16and we got about 9000 comments.
07:19So about half of the people that
07:22responded added comments to the survey.
07:24As part of the evaluation that
07:27we asked them about,
07:29we asked them to rate their experience
07:31on a scale of zero to 10 and that
07:35allows us to calculate what we call
07:37a Net Promoter score where we take.
07:40Number of patients that gave us A9 or
07:43A10 and then we subtract the number
07:45of patients that gave us anything
07:47below a six because when anything
07:48below a six we know they have not had
07:51a good experience and that correlates
07:53with them indicating there were a
07:55lot more negative responses to the.
07:57Survey items than there were
08:00positive responses and we're getting
08:02about an 88.3 net provider score.
08:05We are Net Promoter Score which
08:08is quite good.
08:09The vendor that we use their
08:11telehealth average is about 84%.
08:13So let's go to the next slide.
08:19So the other thing I also want to tell
08:21you a little bit about what we're asking
08:24them about because we also decided that.
08:26We have a core set of items that we ask
08:28everybody who's had an ambulatory visit.
08:31We wanted to keep that core set.
08:33So again, we could look at any differences
08:36that we might see between telehealth
08:38visits and face to face visits.
08:40And then we also added some questions about
08:42the technical aspects of a telehealth visit.
08:45So. We asked them about the connection,
08:48you know, was it easy to connect V
08:51virtually or through a phone call?
08:53And we also asked them if they
08:55needed interpreters.
08:56Was it easy to get interpreters
08:58for the visit?
08:59In general,
09:00and then the other thing I want to
09:03mention is that when the vendor
09:05gets the comments back,
09:06they run the comments through a
09:09natural language processing system
09:11and they have a whole set of words
09:13that if anything shows up when they
09:15do that NLP evaluation that looks
09:17like there may have been a problem.
09:19Something that may even be an adverse event.
09:22If there was something really critically
09:24bad that happened in the visit.
09:25We get what they call a service alert.
09:28Some of the service alerts really show
09:30up because a person will say I love
09:32my doctor to death and that triggers
09:34the NLP to say this may be a problem.
09:37But in general,
09:38the service alerts are pretty accurate that
09:40something didn't go quite as it should,
09:43or that we may need to get in
09:45touch with them,
09:45or even sometimes even report
09:48it as as an incident.
09:50And interestingly enough,
09:52only 1% of the telehealth visits
09:55triggered a service alert,
09:57which is quite good.
09:59We're seeing in general about a
10:021 to 3% service alert for other
10:04settings in our delivery system
10:06and in some of in then if you look
10:08at it by practice or by service,
10:10sometimes we see as high a number
10:12as a 5% service alert that we're
10:17receiving 91% of the patients
10:19expressed positive sentiment.
10:21And they were especially positive
10:24about their providers,
10:26about the information and
10:27education they received,
10:28the courtesy and respect they felt
10:30they got from their providers and the
10:33professional skills as part of the visit.
10:35So to just a little bit more in in general,
10:38we asked them about did they
10:40feel like the clinician treated
10:42them with courtesy and respect,
10:44were were there clinical issues explained
10:46to them in a way they could understand?
10:49Do they feel like they were involved
10:51enough in the in giving input about
10:54whatever was being discussed in the visit?
10:56We also asked them about whether they
10:58got access to care in a timely fashion.
11:01Did they have to wait and what was
11:04their experience with the office staff?
11:05And I already discussed the technical issues,
11:09so I want to go to the next
11:11slide because we have pages and
11:14pages and pages of comments.
11:17That I went through to gather some
11:19of the ones that I thought were most
11:21illustrative of the common types of
11:24positive and negative comments we got.
11:26So I'm not going to read all these verbatim.
11:29But I think some of the most important
11:31themes that came up over and over
11:33again were how much people appreciated
11:35not having to travel to a visit,
11:37not having to deal with Boston parking,
11:39not having to deal with Boston traffic
11:42or many of our patients because we're
11:45a coronary academic Medical Center,
11:47often travel from other states
11:49or even from around the world.
11:51And they were able to access the care they
11:54needed without any of that aggravation.
11:56They also love being able to see their
11:59own doctors and see them especially
12:01during COVID where isolation has
12:03been such a challenging issue.
12:06I think the other thing that I am
12:08really thrilled about that I think is
12:10one of the side effects of telehealth
12:12that we need to study more and really
12:15enhance is the fact that this really
12:18requires our patients to step up.
12:20It requires them to be much more engaged.
12:23They may have to collect data that
12:25normally they may have forgotten
12:26about or they didn't pull together
12:28before Facetoface visit.
12:29They have to pull their medications together
12:32so they can show them to the doctor.
12:34And I think that's incredibly valuable.
12:37The other thing we're hearing from
12:38our patients in a positive way,
12:40and we're actually hearing this
12:41from our clinicians as well,
12:43is when you're doing a virtual visit,
12:45no one's getting interrupted.
12:46The doctor,
12:47the no one's knocking on the doctor's door,
12:50no one is interrupting the patient.
12:53And they very much like that.
12:56And they also very much appreciated
12:58the fact that they felt safe and
13:00they didn't have to come in for
13:02care in person at a time when many,
13:04many people were afraid to even
13:07leave their homes.
13:08So let's go to the next slide.
13:11And then we heard about some
13:13of the negative things.
13:14People were concerned about why,
13:16you know,
13:17how important is the physical exam?
13:19We know that they're probably less important
13:21than many of our patients think they are,
13:23but nevertheless,
13:24we have to do a lot of education about that.
13:27People were concerned about not
13:29being able to get lab work done
13:31or vaccines that they needed.
13:33We also had some issues with
13:36how the technical sides of the
13:39telehealth visits were managed.
13:41People maybe got some sort of
13:42e-mail about when to call in,
13:44but they may have missed it.
13:46Some people that were on a zoom
13:48call that then failed and they had
13:50to call in and sometimes the call
13:52in didn't work or they didn't even
13:53know what number to call back.
13:56They also didn't necessarily know
13:59about if appointments got changed and
14:01that actually came up quite a bit,
14:03which is was a little bit surprising.
14:06And then the last the last quote
14:09I I saw
14:10that kind of touched my heart because
14:13this came from a teenager in one
14:16of our pediatric practices where
14:18the person said please no more,
14:19no more virtual visits.
14:21But just not the same as
14:23seeing the doctor in person.
14:25I do not live in a virtual
14:27world and I am not a robot,
14:29and I wanted to share that
14:31with you because I was.
14:32I was really moved by that,
14:35coming from someone who was
14:37clearly an adolescent.
14:38So before I go to the last slide,
14:40which I assembled upon quite
14:42late last night and felt like
14:43I had to share it with you,
14:45I also want to mention that.
14:47One of the things that we do is
14:49part of the work we do to improve
14:52the patient's experience of care
14:53and our health system is we take
14:55as much advantage as possible of
14:58partnering with patients to help
15:00us redesign or design new services.
15:04It's invaluable and I am convinced
15:07that when we don't do that,
15:09we are always going to be
15:11challenged and we'll probably
15:13never get whatever the service is,
15:15whatever the process of care
15:16is that we're trying to.
15:17Designed that will never get it right.
15:19And I think we have a golden
15:22opportunity here to partner with
15:23patients and families to really
15:26think about how we can design
15:28this new form of care in a way
15:30that meets everyone's needs.
15:33So let's go to the last slide.
15:36This came from an adult.
15:38After listening to the virtual virtual visit,
15:41my wife wanted to be a patient.
15:43So with that I'm going to stop and
15:46we're going to hear from Christian
15:48and from Asweta and Andrea,
15:50Well, thank you Susan.
15:52That was just fantastic.
15:53And I think you know we really have
15:56to keep these issues in mind and
15:58know that one size doesn't fit all
16:01and and some patients feel blessed.
16:03With the virtual visit and others
16:04as you said, feel like a robot.
16:06So thank you so much.
16:08And Christian,
16:08we're excited to hear from you.
16:13Great, thanks very much.
16:15And I think Susan Lee know that one
16:17of my favorite aspects of of virtual
16:20interactions as you can where you know.
16:22Shirt and tie on top and and and
16:25shorts and Crocs on the bottom.
16:27Theoretically, theoretically.
16:28Although Christian, I will
16:29tell you your camera is not on,
16:30so we have no idea what you're wearing.
16:32That's probably for the best.
16:36So thanks very much for the for the chance
16:39to to be here and and hear this wonderful
16:43rich discussion and it's been really
16:46inspiring to hear the talk, all the work.
16:50To try to help learners and everyone
16:54really be more effective practitioners
16:57virtually and to talk just about some of
17:00the the the broader promises of telehealth.
17:03But we've also heard a little bit
17:05about some of the potential pitfalls
17:07and I think in particular what are the
17:09speakers mentioned the digital divide
17:11and access to telehealth technology
17:13and I think it's important to to.
17:17To acknowledge a little bit the difference
17:20between the virtual the video telehealth
17:22visits and the phone telehealth visits,
17:27videos associated with higher patients,
17:30understanding and satisfaction as
17:31several studies have have showed
17:33and probably many of us on the
17:35phone or on the the symposium here
17:38have either participated in virtual
17:41visits as a a patient or provider.
17:44Perhaps video and phone and you can
17:46see the difference in that experience.
17:49So it's important for us,
17:50I I think as we think about our
17:52own telehealth programs and as we
17:54interface with learners and help them
17:56to understand the promises and the
17:59pitfalls of telehealth that we think
18:01about who's at risk of being left behind.
18:04You're really who who does not have
18:07access to to to video services that
18:10took to participate in video telehealth.
18:13There's actually a great article
18:14that that some of you may have
18:17seen in the New England Journal,
18:18Catalyst from UCSF talking about
18:23addressing equity in telemedicine
18:25for chronic disease management.
18:27It's got actually a great sort of
18:28framing of this issue in general and I
18:30encourage all you to just seek that out.
18:34But you know, so in thinking about you,
18:38who's really at risk of being left behind?
18:41There are a couple couple data points.
18:44I think you're helpful.
18:45So older adults,
18:46so among Americans,
18:47over
18:496518% of The Who are 18% of the
18:52population and hence the most likely
18:55to need chronic disease management.
18:57Only about 55 to 60% of these patients own
19:02a smartphone or have home broadband access.
19:05And of the 73% of this population
19:08that uses the Internet.
19:11Only around 60% were able to send an e-mail,
19:14fill out a form, find a website that
19:17presents some pretty significant
19:18barriers to setting up a virtual visit,
19:21which, you know,
19:23fortunately for us in our system,
19:25Lee is really working to make this seamless.
19:28But is is still.
19:30It's still complicated for those
19:32who may not be as familiar with and
19:36comfortable with digital technologies.
19:39Another at risk population
19:40low income patients.
19:42One in eight Americans showed to have
19:46lower rates of smartphone ownership 71%,
19:49a home broadband access close to 60%,
19:54Internet use 82% and basic
19:57digital literacy 53%.
20:00And then there are other
20:02vulnerable populations,
20:02just limited digital literacy or
20:05access in general rural residents.
20:07Racial ethnic minorities talked
20:09about older adults,
20:11limited English proficiency.
20:13So the result is that almost one in
20:17four Americans may not have the skills
20:20or the access or the devices to engage
20:25in these virtual visits for video visits,
20:30which creates a real problem.
20:32So.
20:34These are the patients that
20:35are are at greatest risk.
20:36So what do we see as we look at
20:40actual rates of of of access
20:42if we can go to the next slide,
20:47so a couple studies that I think show
20:51that patients who are theoretically
20:54at risk based on access actually are
20:57utilizing telehealth at lower rates.
21:00So one study was from Mount Sinai
21:03in in New York at the beginning of
21:06the COVID crisis and they looked at
21:08around 75,000 patient encounters.
21:10This was really around COVID care
21:13and was again earlier in the in
21:16the pandemic between March and May.
21:19And they looked at what were the
21:21odds ratios for use of office visits
21:24versus use of telehealth visits
21:27for different populations.
21:29So to look at age patients who were 18 to 30,
21:34the odds ratio of that group relative
21:37to older patients using an office
21:40visit versus telehealth was .75.
21:42So what that means is the the 18 to
21:4730 year old patients were much less
21:49likely to need or use an office visit
21:52relative to those older patients looking
21:55at a slightly different way black
21:57patients compared to white patients.
21:59The office to to to telehealth
22:01odds ratio was 1.4,
22:03so white patients much more likely.
22:07Sorry,
22:07black patients much more likely
22:09to use an office visit,
22:10less likely to use telehealth
22:13than white patients.
22:14Similar pattern for Hispanic
22:16patients compared to white patients
22:18that odds ratio was 1.16 and for
22:21Spanish speaking patients compared
22:23to English speaking patients.
22:25Was the 1.19.
22:26So in all of these groups,
22:29the more vulnerable groups were
22:31more likely to use office visit,
22:33less likely to use telehealth,
22:38another data set from UCSF primary care.
22:44So in a two week period before and after.
22:49Sort of the rapid ramp up of telehealth
22:52around the the COVID lockdowns they
22:55looked at for different types of
22:58patients what was what was the percent
23:01of overall primary care visits for that
23:04particular group before and after the
23:07switch to predominantly telehealth.
23:09So they went from video visits being 3%.
23:14To 80% of their total weekly visit.
23:17So basically kind of think it,
23:19think of it as very little telehealth
23:22to mostly telehealth visits.
23:24So what happened to the to the to
23:26the percent of visits for each
23:29of these populations.
23:30So patients over 65 years old was 41%
23:37of that practices visits before COVID.
23:4235% when they went predominantly
23:44to telehealth,
23:44a big drop in the percentage of of
23:47of older patients who were who were
23:50getting care before and after that
23:53COVID switch you looked at nonenglish
23:57versus English patients 14% to 7%,
24:01so 50% drop and for patients with Medicare.
24:06Went from 4043% of that practices
24:10overall visits before COVID to 22%
24:14of the visits after they switched to
24:18telehealth and Medicaid was 17% to 10%.
24:22So this this data seems to bear out.
24:27To bear out the fact that you know these
24:29these at risk groups are really getting
24:32less care or getting different types
24:34of Care now that we are really more
24:37predominantly using telehealth and this
24:39is also what we're seeing in our system.
24:42So unfortunately we we we have this data
24:44but haven't shared it internally yet.
24:46So I get show the slides directly but just
24:49as an example we're also have looked at.
24:53Our our telehealth visits both phone
24:57and video and looking at what is the
25:00percent of video telehealth visits
25:02versus phone in different communities.
25:05And what we've seen is in some of
25:09our more affluent communities we're
25:12seeing basically a 50% of of of
25:16visits of telehealth visits are video.
25:21Versus in our lower communities or lower
25:24socioeconomic communities is about 10%.
25:27So huge disparities in use of video
25:30visits for telehealth in our local Boston
25:33community and we're seeing the same
25:36patterns you know looking at by race,
25:38ethnicity and language that that
25:40are represented in the data here.
25:43So, so I.
25:45We could heat up some of the real
25:49challenges that we face in trying
25:51to provide access to telehealth
25:54for a more vulnerable patients,
25:56and important to make learners aware
25:59of some of these vulnerabilities.
26:02And now I'll turn it over to a sweeta who,
26:04as usual,
26:05is the person who has to then
26:07solve these problems.
26:14Hi, everyone. Thanks for that question.
26:19And and it's it's kind of interesting
26:21to look at that UCSF data because I
26:23have seen some preliminary data by
26:25practice and I think the numbers are even
26:27higher for drop offs of virtual visits,
26:30I mean higher meaning lower rates
26:32of of patients getting it.
26:34And so I I also wonder what the
26:37UCSF practice is doing that?
26:39You know there is some difference,
26:40but it's not as high as as we've
26:43seen in our system.
26:44And what I have here up on our slide
26:47is just a reminder that you know,
26:49a lot of our patients have
26:52challenges with health literacy,
26:54but also digital literacy and then language.
26:58And So what we have built during the
27:00time of COVID is really a resource
27:02that's publicly available on our
27:04Disparity Solutions Center website.
27:07That both internal folks and
27:08external folks can use to really
27:11get at some of the educational
27:13material that's necessary to help
27:15patients access virtual visits.
27:17And that's sort of a mix of
27:19materials in in different languages,
27:23but also videos that we have used
27:25to try and get patients engaged in,
27:28in doing virtual visits as well as
27:32push out the information about COVID.
27:35If you can move to the next slide.
27:40And this is a study that was led
27:42by Doctor Karen Donlon and Dr.
27:45Estevan Barreto here at Mass General,
27:47where we actually were looking at
27:49transitions and care for patients.
27:51And we had a survey done.
27:53It was a telephone and mail survey
27:56and this is actually the actual
27:58survey was on transitions of care.
28:00But we actually added some
28:03questions around technology use.
28:05And for you data nerds out there,
28:08this is the end was 224 patients that we
28:11interviewed either by phone or by paper.
28:14We had a 60% response rate,
28:16which is fairly high and then we had
28:197 languages total in the survey.
28:21And I think the take away here is
28:24the question was in the last year,
28:26did you use Patient Gateway or patient
28:29portal or my chart and the red means no.
28:32And I think there is this false
28:35assumption sometimes that like patients
28:36who aren't using these portals are
28:39patients who maybe don't speak English,
28:40but as you can see,
28:42patients who self identify as black
28:44or African American and who are
28:46likely probably English speaking.
28:48They also said 61% of those patients said no,
28:51I've not used it in the last year.
28:53And then definitely when you look at
28:55patients for limited English proficiency
28:57or LEP, you see this is a huge,
28:59huge number and the Latino patients.
29:01So I think the take away of this
29:04survey is that patient gateway,
29:06patient portals are our entryway into
29:09a secure virtual visit definitely
29:11in our system and so.
29:14We are leaving people behind
29:15when we are moving towards this,
29:17especially in the current climate
29:19and this is important for us to
29:21remember and it's important for us
29:22to remember as providers and I I know
29:24everybody's alluded to it previously.
29:26So maybe if you can move to the next slide.
29:31And really one of the takeaways in some
29:34in doing this work is the default is to
29:37build a system for an English speaking
29:39patient and I will amend that to say an
29:41English speaking patient with a smartphone.
29:44And perhaps some of that is because
29:46that's our world, right, But that's
29:49not necessarily the patient's world.
29:51And so we build this system for
29:53that patient and then we should have
29:55retroactively realized, oh wait,
29:57we're missing some patients and we have
29:59to make adjustments or workarounds
30:01or or or add in different pieces.
30:03And one of the biggest thing is really can
30:07the virtual platform integrate interpreters.
30:09This is a third party that's
30:11going to join your visit.
30:13And as one of the members of of team
30:17of at least team reminded me is
30:19the more secure you make a virtual
30:21visit because there are a lot of
30:23concerns about security, right?
30:25Both from our organization but also
30:27provider and and patient perspective.
30:29The more complex your system is,
30:32so it'll make it harder for a patient
30:34to join the virtual visit when
30:36you try to increase the security.
30:39So, and this came up because a lot of our
30:41patients in the community Health Center are,
30:43and I have it on my phone as well,
30:45we use, oh God.
30:46Now of course I forgot the name
30:48of the app WhatsApp, you know,
30:50to communicate with our families.
30:52And so one of the questions from
30:53providers was why can't we just
30:54use WhatsApp to do these calls?
30:56Well,
30:56because it's really in not a secure platform,
31:00but it's easily accessible to patients.
31:02So that's sort of the,
31:03the tension that we run here.
31:06And then when we think about the most
31:08secure virtual visit in our system,
31:09it really requires my chart enrollment
31:11and you just saw the data that we
31:13had from surveying our patients.
31:16And as Christian also alluded is there's
31:19a difference in using a desktop versus
31:21a smartphone versus just a phone call
31:25in the quality of your of your visit.
31:30But also to remember that for many of our
31:33patients who don't have all the resources,
31:35we've heard from them,
31:36that one virtual visit will wipe out
31:39their entire data plan for the month.
31:41And I have a teenager and I very
31:44much resisted switching to the the
31:46unlimited plan for a really long time.
31:48And then I realized that I was actually
31:50probably saving money by doing it.
31:52But not everybody has that luxury.
31:54So we have to kind of be mindful of that.
31:56And the patient may not understand
31:58that their data will be wiped
32:00out and then who's going to.
32:01You know,
32:02supplement that.
32:02So those are the things that we
32:04have to think about.
32:05And then the third party edition,
32:07as Christian said,
32:07may mean it's a phone visit,
32:09It may not be good quality,
32:11the platform may not support it.
32:13There's all sorts of reasons and
32:15we've heard from interpreters
32:16that phone business aren't as great
32:18as being able to see the patient
32:20in order to do the interpreter.
32:22The other thing is we have the system where
32:24the reimbursement rates of video visits
32:26might be different versus a phone visit.
32:28It just depends on on what
32:30kind of visit it is.
32:31And so I think for the OP patients,
32:34there's a flat rate, but this is also
32:36something that the providers know.
32:38And so we just want to make sure that
32:41we don't set up a system where we favor
32:44visits that patients with language
32:46or technology or literacy barriers
32:48or broadband barriers can't access.
32:51And we really have to be mindful of not
32:53developing sort of structural racism in
32:55our system where we take care of 1 pair,
32:57one group of patients because they can
33:00access this virtual visit and the other
33:02thing that's come up is really patients
33:04are concerned about immigration and ICE.
33:07And not wanting to download these apps
33:09that they don't really understand on
33:12their phone and also being afraid of
33:13what we will do with their information.
33:16And so as a healthcare organization,
33:17as a provider,
33:18you have to be able to reassure
33:21your patients about the privacy,
33:23but understand that,
33:24you know,
33:25there have been instances where ICE
33:27has has picked up patients from a
33:30healthcare organization and those stories.
33:33While they might not be in our backyard,
33:35they do circulate in the immigrant community.
33:37And so those have more impact and more
33:40weight with a patient than just us saying,
33:43oh don't worry,
33:44we won't report you to ICE or immigration.
33:47We won't share that information.
33:48And I think legally,
33:50if there's a court document,
33:51we actually have to share that information.
33:54I and I had looked into that.
33:56And lastly,
33:57I just wanted to address the social
33:59determinants of health of when
34:01there is no technology at home.
34:02Home to do the virtual visit also as
34:05a healthcare system or as a provider,
34:06giving a patient a tablet for example.
34:09Does that fulfill the need?
34:11And we are currently doing a small
34:13feasibility pilot of distributing
34:15these Amazon Fire tablets to
34:17patients that have been donated and
34:20we were finding out that while yes,
34:22it may address some of the issues.
34:25We actually called 53 patients to
34:27find out if they have Wi-Fi at home
34:30that could participate in a pilot
34:32and 19% said they had no Wi-Fi,
34:34but they were interested in
34:37participating still.
34:38And then 13% said actually
34:4013% we couldn't reach, right,
34:42because the number wasn't correct
34:44that we had in our system.
34:46And so you know.
34:47I think we have to think about that
34:50when we sort of roll out these,
34:52these these pilots about addressing
34:54sort of the the technology piece that
34:56even if we give something to the patient,
34:59it doesn't necessarily solve the
35:01issue and you need somebody who
35:03can work remotely with a patient
35:05to help them download zoom,
35:08download patient gateway.
35:09Download e-mail, show them how to use it,
35:13like how will you do that.
35:14So I think these are sort of the nuances
35:16and then we haven't talked about the
35:19big piece which is broadband access and
35:21and so I will just end with like the
35:23things that we have been working on in
35:26the virtual visits are not unlike what
35:28schools are currently facing and trying
35:31to provide a school and education to
35:33patients and having to address like.
35:36Families not having the laptops,
35:38not having broadband,
35:39you know that the lack of sort of
35:42interactivity of having a remote school.
35:45So I I I've thought about that as
35:47I was getting ready for school.
35:48Like, God, this feels so familiar.
35:51So I'll turn it back over to Lee
35:55and the next speaker, I believe.
35:58Yeah. So thank you so much.
36:00As sweet, you know,
36:01I I said at the very beginning of the talk,
36:03I feel like the equity challenge is it's
36:06like fighting the hydra in Greek mythology.
36:09Every time you think you've found a solution,
36:112 new problems crop up.
36:13And it really speaks to the concept that to
36:16overcome these barriers in access to care,
36:19you can't just eradicate 1 barrier,
36:22you have to eradicate all the barriers
36:24because if you don't plow the road,
36:26like all the way from start to finish.
36:28It doesn't matter that like the
36:29end of your driveway is plowed if
36:31the top of your driveway isn't,
36:33you still can't get your car out.
36:34And it it really,
36:35it keeps us honest and it it it addresses
36:37that issue I mentioned at the beginning,
36:40which is sort of don't look,
36:41don't tell in the in the face of
36:44poverty there are many challenges with
36:46delivering good quality healthcare.
36:48And so the deeper we look the more we
36:50will find that needs fixing and the more
36:53innovative we will have to be in order
36:55to do it in a sustainable manner so.
36:57We're really grateful to your team
37:00and Christian's team and Susan's team
37:02for keeping us honest and not patting
37:05ourselves on the back too much that,
37:06hey, we did a million virtual visits.
37:09Well, we did,
37:10but there was a group of patients
37:12we totally left out in the cold and
37:13we have to work tirelessly until we
37:16have solutions for those as well.
37:18I do want to open it up for questions
37:21now and I'd love to hear from Andrea,
37:23one of our patient
37:25stakeholder representatives.
37:26You know your reflections on the
37:28the comments both from this panel
37:29and from earlier in the day.
37:31Andre,
37:31are you there?
37:34You'll need to unmute. There you are.
37:39So first of all, you know,
37:41thank you to all the presenters.
37:42It was a lot of great information.
37:47I would just say that there is a
37:49lot of focus on telehealth now.
37:51But the most critical thing here
37:53and especially that had as has
37:56been pointed out through COVID-19
37:58and health disparities is we can't
38:00continue going the way we are.
38:03What Asweto was talking about,
38:05we have to do that right now.
38:07If we just continue rolling this
38:09stuff out and keeping rolling on,
38:10we're never going to address
38:12the the disparities piece.
38:13So if we take anything at all away
38:16from today with all this great work and
38:18we're serving a lot of patients very well.
38:21We're leaving a lot of them behind.
38:23And until we actually have a solution and
38:28have that we're not doing the system justice,
38:32we're actually increasing health,
38:35health and equity.
38:37And you know, believe me,
38:38I'm a strong advocate of telehealth.
38:40I have been for a long time and I
38:42think it improves access to care.
38:45But at this point,
38:46we cannot move forward until we
38:48address the health disparities peace.
38:50And you know, it's interesting,
38:51I want to reflect on that for a
38:53moment because prior to COVID,
38:55Telehealth is a sort of boutique
38:57offering that created a convenient
38:59access point for for a group of
39:01patients who were really interested,
39:03the early adopters.
39:04But but the folks who we're talking about
39:07now, they still had the luxury in quotes,
39:10the option of coming in person,
39:12they could come in person on the bus.
39:14They have insurance coverage.
39:15They many of them have, you know,
39:17coverage for medication.
39:18So we had a channel for delivering care.
39:21When COVID locked everybody out of the
39:24health system, telehealth was amazing.
39:26And restoring access,
39:27it's like it was a power outage and suddenly
39:30we lit up houses all over with power.
39:32But guess who got left out of the grid?
39:34Those, like, they always,
39:36yeah, they always get left out.
39:38So guys, you know.
39:39How do we have to do it?
39:41We have to do community outreach.
39:42We have to do education.
39:44We have to actually go out and
39:46maybe use health coaching,
39:48I mean health coaching
39:49and use health coaches,
39:51Train community health workers to be health
39:53coaches and really go out to community,
39:55provide the tools they need
39:57and the education to help.
39:59Really bring bring telehealth
40:00and bring access to this group.
40:02We can't just.
40:03Trying to do little pilot projects
40:05and study on the side guys.
40:07I mean, if we do that,
40:08we're going to continue where
40:10we are and our next symposium
40:11that we're going to have,
40:12we're going to be talking
40:14about the same thing.
40:15And maybe they'll be a little
40:16research study here or there,
40:17someone who did something good.
40:19But we're not going to change
40:21the system unless we actually
40:22take it seriously stop and and
40:24and make that the first priority.
40:26Yeah, I think what you're really highlighting
40:29is this concept of user experience.
40:31And the reality is and as we alluded to it,
40:34it's a pretty terrible user
40:35experience right now, right?
40:36You got to download the secure app,
40:38download the zoom, configure your camera,
40:41can connect to the Wi-Fi like it's 18 steps.
40:44And we've accommodated
40:45to it because we had to,
40:47but it is not a great user experience.
40:49So part of what we're doing,
40:51at least in our health system is looking
40:54for alternative video vendors where we
40:56can have a much simpler browser based,
40:58one click solution.
40:59So that patient, if they have a
41:02device and they have a connection,
41:04that's a big if.
41:04But if they have it,
41:06it's 1 push and they're connected.
41:08And so we're, we're gonna work,
41:09we're working more towards that.
41:11Susan,
41:11I know you had your mic
41:12unmuted there for a minute.
41:13Just one real quick thing.
41:15So I think it was Julian that was
41:17talking about the innovation piece.
41:21So that's the thing we need to do.
41:23We need to find an easy solution.
41:25I mean, almost everybody has a television.
41:27Why can't we do it via some
41:28kind of television access?
41:31So we need an easy button.
41:33Susan, you need to unmute though.
41:35Susan, you're still muted. There you go.
41:39I guess my question,
41:40and it's related to what Andrea was
41:42just talking about and also the issues
41:44that the Sweden Christian have raised.
41:46I know that they're national
41:48patient advocacy groups.
41:50That are working with technology
41:52groups about how do we expand
41:54broadband access and all sorts of
41:56things that I personally think if
41:58we're thinking about getting you know,
42:01dealing with structural racism,
42:03our academic medical centers is
42:05anchor institutions and communities
42:07could also play a role in that.
42:10What's happening on that front?
42:12So there there is actually a lot
42:14of conversation about broadband
42:16and and equitable distribution of
42:18broadband and in some communities
42:20thinking about free free broadband
42:22really because without the pipe
42:25the devices is is useless. I think
42:28the country of Estonia has free
42:31broadband for everyone. It can be done.
42:35So I we're not going to solve it here today.
42:37But I agree with you Susan,
42:38advocacy is also a really important
42:40component of this and there is.
42:42You know, right now CMS has a proposed
42:44rule that's going to change how
42:46these services are paid for after
42:48the public health emergency expires.
42:50And so I would encourage all of you
42:52across the country to make sure that your
42:55government affairs team is aware of this.
42:57There are telehealth provisions in there.
42:58Make sure that your voice is heard and
43:01that you emphasize the importance of
43:03of equity in access as part of that.
43:06Well, it is 459.
43:07I promised we would start on time
43:09and end on time. I want to thank.
43:11All of the panelists for what was
43:13really an extraordinary symposium,
43:14I'm so delighted we recorded it.
43:16It's going to be live on our
43:18website probably in a week or so.
43:20Thank you all the attendees who
43:23bore with us for five hours.
43:25That's an unprecedented event.
43:27I actually,
43:28I think Christian was on the whole
43:30time that's it's really takes,
43:32takes stamina.
43:33To to to do 5 hours on Zoom,
43:36but thank you so much.
43:37I'm so indebted to all of you and
43:40the goal will be to publish some
43:43written summary digest recommendations
43:45from this work that we did today.
43:48So please be on the lookout for e-mail
43:52communication from Karen and we'll
43:54figure out how to think about drafting
43:56various sessions for this work.
43:59So thank you all of you and
44:01have a wonderful day.