Panel 1: General Principles of Quality Measurement for Virtual Care
July 12, 2023Information
Panelists: Judd Hollander, MD (moderator), Daniel Albert, MD, Susan Edgman-Levitan, PA, Emily Hayden, MD
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- 00:00So I'm delighted for this session.
- 00:03I'm going to introduce the moderator
- 00:04and then I'm going to have the moderator
- 00:06introduce the other panel members.
- 00:08So I'm really delighted.
- 00:09Thank you so much. Doctor.
- 00:10Judd Hollander is with us.
- 00:12Judd is the senior vice president
- 00:14for Healthcare delivery innovation.
- 00:15He's also associate Dean for strategic
- 00:17health initiatives and a professor of
- 00:20emergency medicine at Thomas Jefferson.
- 00:22I think Judd has really been one of the
- 00:24kind of four horsemen, so to speak,
- 00:26you know, pioneers in this area,
- 00:28has really built out an extraordinary
- 00:30program at Thomas Jefferson and has,
- 00:32I think, really understood and grappled
- 00:35with many of the fundamental and pragmatic
- 00:39aspects of getting virtual care.
- 00:42Instantiated with an organization
- 00:43becoming part of the strategic framework
- 00:46and the strategic value proposition.
- 00:48And I'm really interested and excited
- 00:49to hear him lead this session.
- 00:51So let me turn it over to you,
- 00:52Judd, and thank you again so much
- 00:53for chairing the session.
- 00:55Well Lee, thank you for inviting me.
- 00:56Thank all the participants for
- 00:58coming to listen to what we have to
- 01:00say and and and the only thing I'm
- 01:02going to add for my background is I,
- 01:04I'm at Jefferson and for those of
- 01:05you who follow healthcare mergers,
- 01:07when I went to Jefferson in 2014,
- 01:10we were a small little three hospital
- 01:12system in Philadelphia and and we are
- 01:15now an 18 hospital system announced a
- 01:18huge deal with general Catalyst in the
- 01:21innovation space in the last couple of days.
- 01:24And actually became a
- 01:26payer provider this week.
- 01:27So one of the great things about
- 01:29working on the Steve Glasgow at
- 01:30Jefferson is you wake up every day
- 01:32and you are a bigger health system.
- 01:34But it's given me the experience
- 01:36of beginning a telemedicine program
- 01:38at a three hospital system.
- 01:39And then as we merge slash acquired
- 01:42with other health systems,
- 01:43I am now on my 6th implementation
- 01:46in health systems which is a
- 01:48distinctly unusual position to be in.
- 01:50And and if you could name something
- 01:52you could do wrong,
- 01:53we have pretty much found it over
- 01:55the last seven or eight years,
- 01:56but we're moving forward.
- 01:59So and Lee,
- 01:59I want to thank you too for pairing
- 02:01me with great panelists and I would
- 02:03ask all the panelists to put their,
- 02:06you know, video on.
- 02:08And before I begin with them
- 02:10introducing themselves,
- 02:11I do want to say that we had a prep
- 02:14call for this and and we never made
- 02:16it past the first question because
- 02:18we had such interactive discussions.
- 02:20That we decided we have about
- 02:23six or seven slides,
- 02:25but we have given each other permission
- 02:27to make this very conversational or
- 02:29as The New Yorker would describe it,
- 02:31We can just interrupt the hell
- 02:33out of each other and and have
- 02:34a little fun with this.
- 02:35So I will follow the slide order
- 02:37and we'll just do introductions.
- 02:39And then circle back to each
- 02:41of the speakers that that will
- 02:43speak for a little bit before we
- 02:46pepper them with questions.
- 02:47And and we invite you to throw stuff in
- 02:49the Q&A as well that we could insert.
- 02:53We'll give each speaker a total
- 02:55of about 15 minutes to say what
- 02:57they wanted to say to deal with
- 02:58the questions that come in.
- 03:00And and then we'll have a little bit of
- 03:02wrap up if there's any time at the end.
- 03:04So Dan,
- 03:04please say a couple words about yourself.
- 03:08First of all, thank you Judd,
- 03:10and thank you, Lee,
- 03:11for inviting me to participate in this.
- 03:13Very, very interesting.
- 03:15I'm very excited about this,
- 03:17having done telemedicine for quite a while.
- 03:21I'll get into that in a little bit.
- 03:23I'm a professor of medicine
- 03:25and Pediatrics at the Geisel
- 03:27School of Medicine at Dartmouth.
- 03:29I'm Vice Chair of for Faculty and Academic
- 03:31Affairs in the Department of Medicine.
- 03:34I was a Robert Wood Johnson Clinical Scholar
- 03:36at the University of North Carolina.
- 03:38And when I first got into health
- 03:40services research and now I participate
- 03:44with the Dartmouth Institute for
- 03:46Health Policy and Clinical Practice,
- 03:48mainly in the telemedicine space.
- 03:51All
- 03:52right, Thanks, Dan. Susan,
- 03:54Hi. I'm Susan Edgman Levitan,
- 03:56and I'm the director of the
- 03:59Stokel Center for Primary Care
- 04:01Innovation at Mass General.
- 04:04I also cochaired the Mass General
- 04:07Brigham Patient Experience Leaders
- 04:09Committee and I'm one of the four
- 04:12PI's on the national ARC funded CAPS
- 04:14consortium to develop standardized
- 04:16patient Experience of Care surveys. All
- 04:20right, thanks, Susan. Emily.
- 04:23Thanks, Chad, and thanks, Lee.
- 04:24And for this whole panel,
- 04:25it's been, as Judd said,
- 04:26it was amazing to put us together
- 04:28and a lot of insights here.
- 04:29So I'm Emily Hayden.
- 04:30I am the Director of Telehealth for
- 04:32the Department of Emergency Medicine
- 04:34at Massachusetts General Hospital.
- 04:36My outside is the antidote for the ER chef.
- 04:39So I'll pretend I'm a
- 04:41newscaster here outside.
- 04:42So I also have been in the
- 04:45Tele space since 2016, 2017.
- 04:47I've led our specialty of emergency medicine.
- 04:51On some of the aspects of telehealth,
- 04:53such as creating a research agenda
- 04:56for the specialty and telehealth.
- 04:58And I also am on the Telehealth
- 04:59Advisory Board for advisory committee
- 05:02for the AA MC which created the
- 05:04competencies for telehealth and
- 05:06hopefully building up a high quality
- 05:09cadre of physicians from the UME
- 05:12undergraduate medical education all
- 05:13the way up to the faculty level.
- 05:16So thank you.
- 05:17Great. Thanks, Emily. Welcome.
- 05:18Welcome to everybody.
- 05:19Can I have the next slide please?
- 05:23So this is what we hope to
- 05:25accomplish in the first panel.
- 05:27We we really want to talk about
- 05:29principles of quality measurement.
- 05:31We don't want to talk about
- 05:34quality frameworks that exist,
- 05:35but but of course somehow we will,
- 05:37we will drift and we'll try and
- 05:39come back because the next session
- 05:41is really on the frameworks.
- 05:42So we want to differentiate and
- 05:45define quality as it relates to
- 05:47telehealth versus in person visits.
- 05:49And and we will actually discuss quite a bit,
- 05:52is it different, is it the same,
- 05:53what's different, what's the same?
- 05:56We, we want to talk about measuring
- 05:59unique problems related to understanding
- 06:01the success of telehealth on
- 06:03patient and provider experiences.
- 06:06We we think a lot about the patients.
- 06:08But the patient's having a good
- 06:09experience is driven by the providers.
- 06:11So you'll hear quite a bit about that.
- 06:13And finally,
- 06:14we really want to evaluate quality
- 06:16and telemedicine as a means to
- 06:18a care continuum of patients.
- 06:20And I won't explain what that
- 06:22means because the next hour is
- 06:24going to discuss what that means.
- 06:25Can we have the next slide,
- 06:27please,
- 06:30upside, Did we skip one?
- 06:34No, Okay. So I think Susan, you are
- 06:36up first, if I have this right. Yes,
- 06:38you do. So can we go to the next slide?
- 06:44So I'm going to give a quick overview
- 06:46of a little bit about what we've learned
- 06:48about how patients view telemedicine,
- 06:50some of the challenges and how
- 06:53we're measuring telemedicine
- 06:54through the eyes of the patient.
- 06:57So we have been measuring
- 06:59our telehealth visits.
- 07:01Since July of 2020,
- 07:03in most of the organizations that
- 07:06comprise the Mass General Brigham
- 07:09Health System at this point in time,
- 07:12we have over 1.5 million survey responses.
- 07:16Obviously, they're not all about telehealth.
- 07:20But we have been measuring them in
- 07:22all of our ambulatory care settings,
- 07:24and we do the measurement in a way
- 07:27that we ask the same items regardless
- 07:29of whether it was a telehealth
- 07:31visit or a face to face visit,
- 07:34which allows us to compare how how much
- 07:37people are enjoying one or the other.
- 07:41And consistently,
- 07:42our scores on our telehealth
- 07:44visits are a little bit higher
- 07:46than our face to face visits.
- 07:48We also collect thousands of
- 07:51comments that I review frequently.
- 07:54The positives that we see in the
- 07:56comments are that people love the
- 07:58fact they don't have to travel.
- 08:00Many of these,
- 08:01I'm sure you are all well aware of,
- 08:03they don't have to park some
- 08:05of our organizations.
- 08:05It's very challenging to park and
- 08:07they don't have to sort their
- 08:09way through a very complicated,
- 08:11large institution.
- 08:12They don't have to wait for
- 08:15rides to get home.
- 08:17And they don't have any interactions
- 08:19with some of the very challenging
- 08:21COVID requirements that are necessary
- 08:24right now to get into our organizations
- 08:27to even get into a practice.
- 08:29They also talk a lot about how much they
- 08:32like having the undivided attention
- 08:34from their clinicians during the visit.
- 08:37They don't have to interact with the
- 08:40cast have been her once they check in.
- 08:42They're not meeting with lots
- 08:44of different people,
- 08:45many of whom they don't really
- 08:47understand what their roles are,
- 08:48and they very much enjoy the longer
- 08:51time with their doctors that their
- 08:53nurse practitioners and PA's.
- 08:55They also really like being able
- 08:58to include family members,
- 08:59and I think during COVID this
- 09:02was especially important.
- 09:04When people were having to have difficult,
- 09:06serious illness conversations and
- 09:08they couldn't be with their children,
- 09:11and their children were maybe
- 09:13nowhere near Boston and they were
- 09:16able to bring them in to have a lot
- 09:19of these conversations that were
- 09:21incredibly powerful and helpful.
- 09:23And they also can show their
- 09:25clinicians around their home.
- 09:26They can take them and show them
- 09:28the medicine cabinet.
- 09:29Various things that may be obstacles
- 09:31that would be very difficult to
- 09:33explain if they were in the office.
- 09:35The negatives that we have and we
- 09:37spent a lot of time talking about
- 09:39this at last year's symposium,
- 09:41and I think it's one of the huge
- 09:44challenges in general for telehealth
- 09:46is trying to provide the same quality
- 09:49of care to people that are very
- 09:51challenged with no Internet access.
- 09:53They work in environments where
- 09:55they have no privacy,
- 09:56or they're live in home
- 09:58environments where they have no
- 09:59privacy. For a confidential visit,
- 10:02they need interpreters,
- 10:03and being able to connect our
- 10:06interpreters is sometimes a
- 10:07bit challenging during a visit.
- 10:09And the other thing that we see
- 10:11comments about a lot is we've very much
- 10:14trained our patients that a visit is
- 10:16not a real visit if someone doesn't
- 10:18listen to their heart and lungs.
- 10:20Our clinicians know that's
- 10:22not necessarily true,
- 10:24but our patients don't really know that.
- 10:26So let's keep going to the next slide.
- 10:30Susan, I promised to interrupt,
- 10:32so I'll, I'll throw the first volley
- 10:34out at you if you can go back a slide.
- 10:36Although it's not the area of my expertise,
- 10:39I have heard from our Chief Experience
- 10:41Officer that H CAP scores have plummeted
- 10:44during times of COVID across the country,
- 10:47in a large part related to lack of visitors
- 10:50in the inpatient setting and other things.
- 10:53And I wonder if you could speak to the
- 10:56initial patient experience metrics early
- 10:59on in COVID when people had no choice and
- 11:03then later on in COVID where people could.
- 11:06Come back to the office or later.
- 11:08Have you seen a difference both
- 11:10in the ambulatory office visits
- 11:12and in the telehealth visits?
- 11:15We No, we have not.
- 11:16I mean, what we've seen is a drop
- 11:19in the the the number of telehealth
- 11:21visits compared to a year ago,
- 11:24a year and a half ago.
- 11:25But we have not seen a big drop in
- 11:28people satisfaction with them and
- 11:30what they're telling us about their
- 11:32experiences with communication, etc.
- 11:34You know some of the access
- 11:36issues they had early on,
- 11:38they still have and actually we have
- 11:40not seen the drop in our H Gap scores.
- 11:42And I think nationally I don't think
- 11:45that's been a common pattern because
- 11:47if anything what we have found is
- 11:50that our patients were so incredibly
- 11:52grateful to even be able to get
- 11:55there that our patient experience
- 11:58they just stayed pretty static
- 12:00across the the last year and a half.
- 12:03So, so a follow up question to that,
- 12:05because I think what I heard you
- 12:07say is telehealth experience scores
- 12:09beat in person experience scores
- 12:11and they stayed beating them,
- 12:13but yet telehealth as a percent
- 12:17of visits fell off.
- 12:19So, So what do you think explains
- 12:21that if the patient experience
- 12:23is better but the patients have
- 12:25resorted to what they would consider
- 12:28maybe a less good experience?
- 12:30I think I mean and when
- 12:32I say they're different,
- 12:33they're not dramatically more positive,
- 12:35but they are more positive.
- 12:37And I think in some respects what
- 12:40has changed that is that our
- 12:42system has really been encouraging
- 12:44patients to come in for face to
- 12:47face visits whenever it's possible.
- 12:49We've also changed some of
- 12:51our policies about,
- 12:52and I'm most familiar with primary care,
- 12:55but where people can actually we
- 12:57were it was fine for people to be
- 13:00at home doing telehealth visits.
- 13:02I think there's been a lot of encouragement,
- 13:06if you will, of our clinicians
- 13:08to come back into the office.
- 13:10So that they can do face to face and
- 13:13telehealth visits given that more people
- 13:15are coming in for telehealth visits.
- 13:17And I also think a lot of people had
- 13:20postponed care that are now coming
- 13:22back in for in person visits where they
- 13:25really do need to be seen in person.
- 13:28Thank you.
- 13:30Should I go on?
- 13:33Please do. Someone else will
- 13:34interrupt shortly, but until okay.
- 13:37So some of the opportunities that
- 13:40we see and it's something that we're
- 13:42really trying to think about how we can
- 13:45learn much more about this is how do we
- 13:47figure out how to match the visit mode.
- 13:50To the problem that the patient is
- 13:52having so that we can be sure to
- 13:55enhance their safety and outcomes,
- 13:56when is it okay to do safely do a
- 13:59telehealth visit versus when do
- 14:01we really need someone to come in?
- 14:04And one example of this is that a
- 14:06lot of our patients like the longer
- 14:08time that they get for their annual
- 14:11physical exam done via telehealth,
- 14:13but they really get concerned because
- 14:15they're not having an annual physical.
- 14:17And they worry about that even if they're
- 14:20perfectly healthy and asymptomatic.
- 14:22And so figuring out how do we match again
- 14:25the mode of the visit to the problem
- 14:27that people are having and what they're
- 14:30comfortable with and where necessary,
- 14:32how do we begin to reeducate
- 14:34patients about what is safe with
- 14:37telehealth versus face to face.
- 14:39And again I I already mentioned that
- 14:41the need to address misconceptions
- 14:43about the physical exam.
- 14:45Another thing that we are talking about,
- 14:48and I know I think that Francis Fulham,
- 14:51who's speaking later today,
- 14:53is also going to say something about this,
- 14:55is how could we provide equipment or
- 14:58tools for people at home that would make
- 15:01it much easier for them to get chronic
- 15:05disease management virtually with scales,
- 15:08blood pressure cuffs,
- 15:09glucometers,
- 15:10various screening tests that can be done
- 15:13at home to avoid their need to come in.
- 15:15Because many of the patients with
- 15:18chronic conditions are the ones who
- 15:20have the most challenges getting into
- 15:22our hospitals and to our practices.
- 15:25So that's something that we're
- 15:26also thinking about.
- 15:28So I'm not an internist,
- 15:29although I trained an internal medicine
- 15:31and boarded an internal medicine,
- 15:33but I don't practice internal medicine.
- 15:35I'm curious what parts of the physical exam.
- 15:40Is there evidence they make a
- 15:42difference in health and Wellness
- 15:44and and how many of them could be
- 15:47accomplished by a blood pressure cuff?
- 15:48Like I can easily believe that finding
- 15:51out you have hypertension is a really
- 15:53good thing to find out and most people
- 15:56figure it out when they're asymptomatic.
- 15:58But if you know or you know anybody
- 16:02knows where are the areas it's
- 16:04proven that that it's going to make
- 16:06patients healthier and well for long.
- 16:09And and then within that,
- 16:10are there areas that we could do with
- 16:14remote devices or wearables or yet,
- 16:17you know, easier ways for patients?
- 16:19Yeah, I'm a family medicine PA,
- 16:22so I'm not just making this up,
- 16:24but there is a lot of debate about
- 16:28the value of the physical exam and
- 16:31an annual physical exam visit.
- 16:34Some doctors are huge proponents
- 16:36because it gives them an opportunity
- 16:38to spend more time with patients.
- 16:40But you know, and some some physicians
- 16:43and other providers think that doing that
- 16:45annual physical exam is really critical.
- 16:48Others don't.
- 16:48There's been a debate about
- 16:50the need for this for a while.
- 16:52I think that the other things
- 16:54that we can do remotely,
- 16:56I know in an organization that
- 16:58I used to run called the Picker
- 17:00Institute where we were always
- 17:03looking for really effective
- 17:05patient centered interventions,
- 17:07we were featuring oncologist
- 17:10from cancer centers.
- 17:13Who were taking care of adults and
- 17:15children remotely because they have
- 17:17so many people that come in to see
- 17:19them from all over the world using
- 17:21all sorts of remote devices to do
- 17:24everything from listen to someone's cough,
- 17:26look in their ears,
- 17:28look in their throats etcetera.
- 17:30And this was in the early 90s and we don't,
- 17:33I don't see a lot of that right now,
- 17:36but I think that a lot of
- 17:38those tools and resources.
- 17:40Have been around and could be brought
- 17:42back into play to do the kinds of
- 17:45things that I think our patients are
- 17:47wondering if we can offer to them,
- 17:53should I keep going okay.
- 17:56So I also just want to mention a
- 17:59little bit about what the CAPS
- 18:02consortium has done because.
- 18:03Back in the spring of 2020,
- 18:06we began to work on developing A telehealth
- 18:10visit survey that would be incorporated
- 18:13into the Clinician Group CAP survey,
- 18:15which is the most commonly used ambulatory
- 18:19survey in the CAP suite of surveys.
- 18:22And again, this was designed so that you
- 18:25could compare a telephone visit with a
- 18:28virtual video visit with a Facetoface visit.
- 18:31This has been piloted across the
- 18:34VA and we're also talking with
- 18:36other sites about piloting in.
- 18:38And if anyone's interested,
- 18:40please let me know.
- 18:42And it's been challenging and it's been
- 18:45challenging in ways that we thought
- 18:47were I think naively would be easier.
- 18:51But I think it highlights some of
- 18:53the work that we need to do around
- 18:55the language we use with telehealth,
- 18:56telemedicine, televisits, etcetera.
- 18:58So we did extensive cognitive testing
- 19:02with the public to figure out how
- 19:04do we make sure that when we are
- 19:07asking somebody about a phone visit
- 19:09that they are understanding that
- 19:11that is a telehealth phone visit and
- 19:14it's a virtual visit where they're
- 19:17seeing someone on camera etcetera.
- 19:20And in the VA pilot, which was quite large,
- 19:23what we saw is when they went
- 19:26in and looked at the responses.
- 19:28The responses about type of visit
- 19:31did not necessarily agree with
- 19:33what the record said about how the
- 19:35visit was delivered.
- 19:37And at first we thought,
- 19:38well,
- 19:38maybe this is a data issue with
- 19:40how you're recording your visits,
- 19:42but it actually wasn't.
- 19:43And So what that said to us is that we
- 19:46need to do a lot more work to understand,
- 19:49you know,
- 19:50if someone is asked about a phone visit,
- 19:53are they thinking that's like a
- 19:54phone call with the triage nurse?
- 19:57Or is that a real phone visit?
- 19:59And that's just one example.
- 20:00So that's more work that we're
- 20:02planning to do so that we can
- 20:04try to get the questions right,
- 20:06so that we can trust that the data is
- 20:08credible when we get survey results back.
- 20:12So, so Susan, there's a couple questions
- 20:13in the chat and there's one from
- 20:15John Taylor which at which asks is it
- 20:18worth distinguishing obtaining vital
- 20:19signs which could be wrapped into RPM
- 20:22buckets from a physical exam. Which,
- 20:26yeah. Yeah. And I yes, totally.
- 20:29And that's something that I think
- 20:31we can easily prepare people to do
- 20:34at home with blood pressure cuffs,
- 20:37pulse oximeters, that sort of thing.
- 20:40And then on the physical exam thing,
- 20:42Peter Grunwald asked how to comment
- 20:44in a question, which amounts to.
- 20:46Who's the problem here?
- 20:48Is it the patients expecting the physical
- 20:50exam or the physicians and advanced
- 20:52practice providers expecting to do one?
- 20:56I think it's a little of both,
- 20:57but it's the one comment that I see
- 21:01most often in our primary care comments
- 21:04about questions that people have about
- 21:07the efficacy of a telehealth visit
- 21:09when it's done for an annual physical.
- 21:15But I think it's on both sides.
- 21:17I would do from my experience
- 21:21any more questions.
- 21:23Now I guess I'm going to throw
- 21:24to Dan the same question, right,
- 21:26because Dan has a specialty that if he,
- 21:28if he he's not on video now,
- 21:29so maybe is he back. OK.
- 21:32So Dan, you know you have a
- 21:34specialty that a lot of people
- 21:35would say need hands on.
- 21:37How do you feel about the physical
- 21:38exam and do you agree with Susan
- 21:40or or do you think there are some
- 21:42specialties where you just can never
- 21:44do anything without a physical exam?
- 21:47Well, I I think I have a lot of different
- 21:53opinions about all those different
- 21:56questions because they're so important.
- 21:59You know, in some cases the fiscal exam can
- 22:03be essentially abbreviated to to vital signs,
- 22:06and I even have some patience.
- 22:08That have voluntarily and on their own
- 22:11taking their vital signs and giving to
- 22:13me during a telemedicine appointment.
- 22:16So I'm very pleased when that happens and
- 22:19some things are are of course impossible
- 22:22to to elucidate without a physical exam
- 22:26even even very sophisticated workaround.
- 22:30So we do some workarounds right,
- 22:32you know we'll take a chest X-ray instead
- 22:35of listening to people etcetera, etcetera.
- 22:38But even even the most sophisticated
- 22:41tests like MRI's and ultrasounds
- 22:43sometimes can't give us the same
- 22:47information as a physical exam.
- 22:49And so the, you know, the,
- 22:51the key question is who,
- 22:53who needs a physical exam and who doesn't.
- 22:55And you know, I think that that's in a very,
- 22:58very difficult and individual you know,
- 23:00case scenario and you know the
- 23:04question is can we do use.
- 23:08Can we use virtual visits to sort out
- 23:11who needs an in person evaluation?
- 23:14Because I think that's one of its functions,
- 23:17one of the functions are.
- 23:19You know we're we're having a virtual
- 23:22conversation with the patient,
- 23:23they talk to us about their Musco skeletal
- 23:27complaints and then we make a decision.
- 23:29The decision is you know do you need to
- 23:32be seen in it as an in person evaluation
- 23:35or do you or we okay continuing this?
- 23:38Sometimes I can work around like
- 23:40fibromyalgia tender points.
- 23:41What a great example, right?
- 23:43You can't duplicate that with anything,
- 23:46right?
- 23:46You can't work around it in any
- 23:49way shape or form.
- 23:50But you know if the well this
- 23:53is children but but adults too.
- 23:55If there's a significant other or
- 23:57someone else in the room you can teach
- 24:00them to to push on their trapezii
- 24:02and make make the patients worm.
- 24:05And you know that works great.
- 24:07So there are.
- 24:08These sort of you know,
- 24:10pseudo physical exam if you will,
- 24:13things that we can do,
- 24:16but we have to be very inventive,
- 24:18you know this is.
- 24:20And evolving technology,
- 24:21it's brand new and we're trying to be
- 24:26the sophisticated providers that you
- 24:28know we we went to school to to train to be.
- 24:33So yeah, that's just a long
- 24:35winded answer to your question,
- 24:36Judge.
- 24:37Let me just jump in for one second
- 24:39and comment that I think it's
- 24:41important that we not get caught in
- 24:43this trap of of dichotomizing. Right.
- 24:45It's not purely virtual or purely in
- 24:47person because quite frankly, most of us,
- 24:50by the time we see the patient,
- 24:52someone else has actually done
- 24:53components of the physical exam,
- 24:55gathered the vitals, whatever,
- 24:56walked the patient to our office.
- 24:59And so that would be like saying
- 25:00all of that must be done by
- 25:02the physician or not at all.
- 25:03I think what we need to recognize is
- 25:05there are elements of every single
- 25:07visit that can be done virtually.
- 25:09And there are some elements that
- 25:11can't be done virtually or can only
- 25:13be done in a screening in a manner
- 25:16as Daniel was was alluding to.
- 25:18And from a patient perspective,
- 25:20it still might be better to have as
- 25:23many of those components virtualized
- 25:25as possible and then come in for
- 25:27a 15 minute visit where you have
- 25:29all the background data,
- 25:30you just need to push and
- 25:32pull on the muscles.
- 25:33And then you can already have
- 25:35ordered some tests which you now
- 25:37review and the patient's value.
- 25:39Per minute spent with you in
- 25:41person is is maximized.
- 25:42So I think it's a it's a great conversation.
- 25:45It will clearly require that we have
- 25:47a new taxonomy for how we think
- 25:49about the quote UN quote visit into
- 25:50more of a quote UN quote experience.
- 25:53And I think just before going back to Susan,
- 25:56this is one of the points,
- 25:57it was the last element on the slide
- 25:59when we talked about objectives.
- 26:01What we tend to talk about this as
- 26:03a dichotomous visit and it it's not
- 26:05patient care is not about a visit,
- 26:07patient care is about the whole journey.
- 26:10And and either taking a patient
- 26:11who's sick and getting them back to
- 26:13their baseline so they're closer to
- 26:14well or taking a well patient and
- 26:16preventing them from getting sick.
- 26:18And I think, you know,
- 26:19I know what's on Susan's slide.
- 26:20So I know one of the conversation
- 26:22topics is how do you actually measure
- 26:25the patient's experience when it's,
- 26:27you know, you know, a little of column A,
- 26:28a little of column B and a little
- 26:30of column C.
- 26:31And so I'll turn it back to Sue's
- 26:32and to head us in that direction.
- 26:34Yeah,
- 26:3511 quick, I I agree with everything
- 26:37that we and Doctor Albert just said
- 26:40and I I really do think that we
- 26:43need to really take our blinders
- 26:45off and relook at how we're mixing
- 26:48and matching everything in Sweden.
- 26:50The country has a countrywide
- 26:53registry for people with rheumatoid
- 26:55arthritis and to the vast extent
- 26:58most of those patients with RA.
- 27:01Do all their joint exams at home
- 27:03enter the data into the registry
- 27:05before they ever come into a visit.
- 27:08And one of the things they love about
- 27:10that is that they have so much more time
- 27:13because if they did all of that in the visit,
- 27:16there'd be no visit left.
- 27:17So I think there are lots of
- 27:19examples that we could look to,
- 27:21but I want to finish my little piece with
- 27:24the story if you go to the next slide.
- 27:26The cartoon is an example of what
- 27:29many patients are glad to be chat of,
- 27:31as we say in the South,
- 27:33and I think that the story I
- 27:36want to share is.
- 27:37We had at our Patient Experience
- 27:40Summit at M GB this past summer.
- 27:44We had patients talking about what it was
- 27:47like to get ambulatory care during COVID,
- 27:50what they liked,
- 27:51what they didn't like,
- 27:52what they really want us to keep around.
- 27:54And one of the patients was
- 27:56a mother of four children.
- 27:58She was pregnant with her 5th.
- 28:01She had a congenital disorder that two
- 28:04of her children were affected by and she
- 28:07was pregnant and her youngest child,
- 28:10who was at the time a little over
- 28:13a year old they have been told
- 28:15would never walk during COVID.
- 28:18This child got PT twice a week
- 28:21virtually and was walking and the
- 28:24story she told was so incredibly
- 28:27moving because because of her own.
- 28:30Difficulty.
- 28:31She herself is in a wheelchair
- 28:33With all these children,
- 28:35bringing this young child in for
- 28:37physical therapy twice a week would
- 28:40have been completely impossible.
- 28:42And because it was virtual,
- 28:44all of the the youngest child
- 28:46siblings got to play along and
- 28:49participate in the PT to really
- 28:51encourage her make it a fun thing.
- 28:54And she was walking and this.
- 28:57Mother has zero interest unless
- 28:59she absolutely has to and
- 29:02going to the doctor's office.
- 29:04So that was just one really
- 29:06powerful example that we heard.
- 29:08And the final thing I want to say is
- 29:11that I'm also part of a national group
- 29:13called the Patient Experience Policy Forum,
- 29:16that is a group that brings
- 29:18together Chief experience officers.
- 29:21And patient and family advisors
- 29:23from organizations all around the
- 29:25country to advocate for policies
- 29:27that we think are very important.
- 29:30And one of the subcommittees
- 29:32of that organization is,
- 29:34is all made-up of patients and patient
- 29:37partners and they have written a
- 29:39whole paper about the importance of
- 29:42telehealth and how important maintaining
- 29:45reimbursement and continuing telehealth is.
- 29:47Especially for people
- 29:49with complex conditions,
- 29:50older patients,
- 29:51people who live alone and parents of children
- 29:54with complex medical problems.
- 29:56So I'm going to stop there. Thank you.
- 29:58The great story to end on.
- 30:00I think we skipped Dan.
- 30:02I think I messed up the order.
- 30:03So let's go back to Dan,
- 30:04slide and turn it over to Dan.
- 30:07Thanks, Judd. Actually,
- 30:08I'm very happy that Susan went first,
- 30:11because, you know, many of the issues
- 30:14that she dealt with are the overwhelmingly
- 30:17most important issues, and that is.
- 30:19You know how does it how does it
- 30:22work for the patient you know and
- 30:24you know what what works for us is,
- 30:26is is not important as much as it you know
- 30:30in terms of its you know the logistics of it.
- 30:33It is important in terms of you know the
- 30:36accomplishments of a of medical care
- 30:38but it but in terms of the logistics.
- 30:41You know, we can we can be pushed,
- 30:43put in one room, exam room, one another.
- 30:45We can do it from home,
- 30:47we can do it from, you know, wherever.
- 30:50But I wanted to talk a little bit
- 30:53about about the sort of I want to make
- 30:59a capsule history of telemedicine,
- 31:01at least from my experience.
- 31:03I started in 2011.
- 31:05Yeah, there was a large rheumatology
- 31:08practice at Southern Vermont Medical
- 31:11Center and the and the provider left
- 31:15with 1000 active patients and nowhere
- 31:19to get care because that's Bennington,
- 31:22Vt That's a little out of the,
- 31:24you know, mainstream, right.
- 31:27So I was elected,
- 31:29put that in quotes to go down
- 31:32there once every two weeks.
- 31:33To take care of patients and
- 31:36the other alternate weeks,
- 31:38I did it by telemedicine.
- 31:40It took us six months for me to
- 31:42get a Vermont license.
- 31:43These days really did exist,
- 31:46and it took six months for the
- 31:48hospital to nail down a contract,
- 31:51our hospital with their hospital.
- 31:53And then we started doing it and we
- 31:56tried to figure out who was appropriate
- 31:58for telemedicine and who wasn't,
- 32:01you know, just like we do now.
- 32:03So that was,
- 32:05that was the essence of this hybrid program,
- 32:09which is still an issue today.
- 32:13But what has happened over the
- 32:16last 10 years is, you know,
- 32:18earth shaking, you know mainly.
- 32:21Propelled by COVID with all the changes
- 32:25that everybody in this audience is aware of,
- 32:28you know,
- 32:29with changes in regulation and
- 32:31coverage and so on so forth.
- 32:32And now we're in a different view
- 32:35of telemedicine.
- 32:36And I think that telemedicine even
- 32:38today is evolving almost on a daily basis.
- 32:42I mean, I had an encounter just a
- 32:45day or two ago with the patient in person.
- 32:49But there were two other significant
- 32:51others and we had two different iPhones,
- 32:54you know,
- 32:55one with one significant other and the
- 32:57other with the other significant other.
- 32:59And what do you call that?
- 33:01What do you call that?
- 33:02Is it a virtual appointment or
- 33:03is it an in person appointment?
- 33:06I don't know what to call it,
- 33:07but I'm but I'm just saying that this is a,
- 33:10this is an evolving technology
- 33:13and we are going to have to be
- 33:17extremely flexible in how we use it.
- 33:19In the future we'll probably have
- 33:22you know hybrid clinics where
- 33:24we're doing telemedicine on one
- 33:26encounter not in another.
- 33:28Patients are going to call us up,
- 33:31you know the morning of the appointment
- 33:33and say I can't make it, my XY&Z happened,
- 33:36can we make this a telemedicine
- 33:38appointment and we're going to be able
- 33:40to do that and we're we're doing it now.
- 33:43I will say to to Judd's point that I've.
- 33:47I I have some flexibility in how I schedule.
- 33:51So over the, you know, the last year
- 33:55or so I've been 2/3 telemedicine,
- 33:571/3 in person and more recently based
- 34:02on wait times, I've had to switch it
- 34:06to 2/3 in person and 1/3 telemedicine.
- 34:09Now why is that?
- 34:11I think it I think it's largely
- 34:15have it not not really.
- 34:17Content derived.
- 34:19I think people want to see me in person
- 34:24because that's the way it always has been.
- 34:27I would make an analogy of telemedicine
- 34:31and in person to what happened when
- 34:34telephones were introduced to to the
- 34:40world in a context where every three
- 34:46appointment wasn't. House call.
- 34:48So now the people who were who were
- 34:51blessed with having telephones could
- 34:54basically circumvent the necessity
- 34:56for a house call by simply getting
- 34:59the information over the phone
- 35:01and doing what the doctor said.
- 35:04And I think that that's sort of an analogy.
- 35:07It's a little bit distant,
- 35:09but in any case, many of the
- 35:12features of it are still relevant,
- 35:15that is many patients.
- 35:17Don't have interact Internet access.
- 35:20Many patients are not particularly
- 35:24particularly a
- 35:28Internet savvy user.
- 35:31So there's a lot of problems in in
- 35:38getting telemedicine to various
- 35:43subsegments of our population.
- 35:46That is some people who are
- 35:49in very rural locations,
- 35:51some people who are simply not not
- 35:57savvy with the Internet and so on.
- 36:00So, so I think that that's that's
- 36:04a a big problem that will have
- 36:06to work very hard to overcome.
- 36:08But telemedicine is clearly
- 36:09here to say as Judd said.
- 36:12And we're going to have to work out
- 36:15techniques that are appropriate to
- 36:19deal with disadvantaged populations,
- 36:22but also populations where the lack of a
- 36:27physical exam will make a big difference.
- 36:30In our studies from rheumatology,
- 36:33we think about 20% of our
- 36:36encounters require a physical exam
- 36:39for a meaningful diagnosis. But
- 36:45but that's after screening patients for
- 36:48those who are appropriate for a telemedicine
- 36:52appointment and those that aren't.
- 36:55So, for example of people
- 36:57who are hard of hearing.
- 36:59And people who are not particularly
- 37:05verbal are more difficult
- 37:08than the telemedicine space.
- 37:10People who need interpreters.
- 37:13We can do it,
- 37:14but it's difficult and we do do it.
- 37:17And sometimes we have a three-way
- 37:21virtual visit because art,
- 37:24our translators are.
- 37:29Basically available only
- 37:31by virtual appointment.
- 37:32So it's a IT.
- 37:34It gets to be a a pretty
- 37:36sophisticated of arrangement,
- 37:39but in the end you know the the the need
- 37:43to have an appropriate understanding
- 37:46of what's wrong with the patient,
- 37:49an appropriate approach to managing
- 37:52that problem and an appropriate.
- 37:57Feeling of comfort that in
- 38:01the on the patient side is
- 38:04what we're all aiming toward.
- 38:06So I'm very excited about this
- 38:09conference and and I hope that
- 38:12we can come down with some
- 38:16tangible frameworks. So I'll turn it
- 38:18back over to you, Judge. So I got a
- 38:22couple questions for you Dan and
- 38:24and so I'll begin with one which
- 38:28is my observation, physicians,
- 38:30clinicians rather over test, right.
- 38:33I think there's nobody on this session or
- 38:36any session that wouldn't say some amount
- 38:40of testing is unnecessary and so one of
- 38:43my observations as an emergency physician.
- 38:46Is that it's harder to test on telemedicine.
- 38:50So for things like the
- 38:52Choosing Wisely campaign,
- 38:53which look to doing less tests
- 38:56and subpopulations of patients,
- 38:58we actually compared compliance with
- 39:00the Choosing Wisely recommendations for
- 39:03antibiotics and potential sinusitis
- 39:05and found that the same clinicians.
- 39:08Did better when they work telemedicine
- 39:10than they did in the ER or urgent Care
- 39:13now now we don't honestly know why.
- 39:15We think it's because after a
- 39:17patient waits five hours in the ER,
- 39:18they're not going home without their
- 39:20antibiotics and after they wait 5
- 39:22minutes for a telemedicine visit,
- 39:24they just aren't going to fight about it.
- 39:27Taking head CT's as an example,
- 39:30we all know that we over utilize head CT's
- 39:33for patients with a traumatic headaches.
- 39:36I've never ordered.
- 39:36Well, that's not never.
- 39:38I seldom order a head CT on a patient
- 39:40I see with a headache on telemedicine.
- 39:43I have found better ways to assess
- 39:45it and I don't do the test.
- 39:47But in an ER with a six hour wait,
- 39:50the patient wants 100% reassurance
- 39:52and they end up talking their way
- 39:55into a head CT And I wonder what,
- 39:57Dan, whether your experience is
- 39:59the same or different,
- 40:00you know,
- 40:00and we'll throw the same question Emily,
- 40:02who also practices in the urgent Care World.
- 40:04To to see what her experience is
- 40:07it is it Oh my God I'm hog tied I
- 40:09need to send them for an in person
- 40:12evaluation or or is the perception
- 40:14maybe we actually do better because
- 40:16we don't order unnecessary tests.
- 40:19Well I think that's very
- 40:21it's very insightful the.
- 40:24I think it it could go to it goes two ways.
- 40:26Sometimes when we need a physical
- 40:29examination and it's not possible
- 40:31we do a work around and do some
- 40:34imaging sometimes and and I I credit
- 40:38the virtual environment for this.
- 40:42Our communication with patients is infinitely
- 40:45better through through virtual media.
- 40:47So for example I'll I'll see a patient.
- 40:52And I and if they were seen in person,
- 40:58they might have to wait a month,
- 41:00two months, three months for a
- 41:02follow up in the virtual space.
- 41:04I use a lot of messaging.
- 41:06So I I'll, I'll ask the patient to
- 41:09message me as frequently as daily
- 41:12or even twice daily about symptoms.
- 41:15And by that means I avoid testing.
- 41:19And you know, I think that.
- 41:21That that I'm not alone in this.
- 41:24I think very many people utilize this
- 41:28technique unless they're in baskets
- 41:31are are just overwhelming and that
- 41:36allows us to avoid unnecessary testing.
- 41:39So it goes both ways I think
- 41:44Emily yeah. And I think on a little bit of a
- 41:47different tangent on this one with.
- 41:49The idea of if you're doing
- 41:51virtual care and you all of a
- 41:52sudden are trying to figure out,
- 41:53do you need to do some type of
- 41:55testing or imaging, Not only is it,
- 41:58do you need to do this or not?
- 41:59Do you need to try to be inventive
- 42:01or innovative with your physical
- 42:02exam to really make a decision?
- 42:03Do they need to come in,
- 42:04Do we need to send resources
- 42:06to them or vice versa?
- 42:07But I think it also it changes our
- 42:09paradigm in our minds when we're doing
- 42:11this that it's no longer your inperson
- 42:13clinic and what you have available
- 42:15down the hall for imaging or for labs.
- 42:18You are now looking at potentially the whole
- 42:20catchment area of your healthcare system.
- 42:22So that patient may not live
- 42:24next to your hospital to come
- 42:25right in to get that head CT,
- 42:27that chest, X-ray,
- 42:28that COVID swab or whichever.
- 42:29But now you you this virtual care allows
- 42:31you not only because of you're on the
- 42:33screen and the patient can stay at home,
- 42:35but you can go ahead and start
- 42:36helping that patient out even more.
- 42:37To be like you can go and get your swab,
- 42:40your chest X-ray,
- 42:41your ultrasound for your DVT and a place
- 42:44that's closer to and convenient to.
- 42:46So.
- 42:46I think it also it changes that
- 42:48paradigm and makes it harder sometimes
- 42:50or maybe easier to measure some
- 42:52of the quality when this is now
- 42:54expanding outside of the actual
- 42:55footprint of what has been developed
- 42:57over decades of the inperson care.
- 42:59So I think from the urgent care
- 43:01perspective is is sometimes.
- 43:03Trying to think about that and trying
- 43:04to think about quality of care
- 43:06and patient experience by trying
- 43:07to get them to that right spot.
- 43:08And it may not be coming into
- 43:10your actual hospital there,
- 43:12but maybe another one in your system.
- 43:13So
- 43:14Emily, that leads to a great point.
- 43:16A couple of years ago when we were
- 43:18looking at our marketing campaign,
- 43:20Steve Klasko, who's our CEO was,
- 43:22you know, super, super brilliant guy,
- 43:23but very insightful.
- 43:25He's like. Right now,
- 43:26we don't need to differentiate ourselves.
- 43:28We're the only people doing telemedicine.
- 43:30We don't need to advertise it much,
- 43:31you know, we need to make sure people
- 43:33have brand recognition, he says.
- 43:34But imagine four or five years
- 43:36from now when everybody's doing it,
- 43:38then what's going to be
- 43:39our differentiating point?
- 43:41Well, we are at that point in time
- 43:43now where pre COVID, you know,
- 43:45maybe there was 1 institution in the city
- 43:48that had a robust telemedicine program,
- 43:50but you know, at the tail end of COVID.
- 43:52Now what makes MGH or Dartmouth?
- 43:56But Jefferson,
- 43:56better than the place around the corner
- 43:59and I think you just illustrated it.
- 44:02It's about convenience and 24/7
- 44:05access and care coordination.
- 44:07So we do two things that have
- 44:09been a little bit discussed.
- 44:10We do what we call the virtual
- 44:12emergency department,
- 44:13which COVID testing is the
- 44:14easiest way to conceptualize it.
- 44:16You call, you need a COVID test.
- 44:17We set it up for you.
- 44:18We circle back with the results and
- 44:20close the loop and and from the time
- 44:22of your phone call to your test results
- 44:24is under 24 hours like we develop.
- 44:26Develop the system because we were going
- 44:28to be the best place in the region to do it.
- 44:30But it became not about telemedicine,
- 44:32it became about how do we leverage
- 44:36telemedicine for outstanding care
- 44:37coordination and and we will even
- 44:40do that for some ultrasound studies
- 44:42like DVT's or head CT studies or
- 44:45mild trauma send people for the
- 44:48outpatient testing.
- 44:48And you know what people say,
- 44:50well, how do you do that?
- 44:51Not in the ER, They need it right away.
- 44:53But you and I know because we work in Ers,
- 44:55that's eight hours in the waiting room,
- 44:56They get nothing right away.
- 44:58If they could call telemedicine,
- 45:00they're not going right into
- 45:01a room in the ER, right.
- 45:02So if we could close the loop in six
- 45:05or eight hours as an outpatient,
- 45:07they will get their care faster and better.
- 45:09And I think since this is a quality session,
- 45:12we, we need to be sure we're talking about,
- 45:15you know, I, I've heard the term recently,
- 45:16a bunch clicks and mortar,
- 45:18right.
- 45:18How do you take the clicks and send
- 45:20them to the right bricks and mortar
- 45:22building and maybe get a click
- 45:24back to them to to close the loop?
- 45:26And and to Dan's point about,
- 45:28you know, you got two iPhones in
- 45:30the room with families.
- 45:31You know,
- 45:32we've talked about,
- 45:32we call it virtual rounds or
- 45:34family engagement.
- 45:35We don't count that as a telemedicine
- 45:37call in our telemedicine numbers,
- 45:39but the patients count that as a
- 45:42telemedicine call because to Susan's point,
- 45:44wow,
- 45:46definitely.
- 45:50All right. Thanks. Great insights.
- 45:52We'll turn it over to Emily. I
- 45:54just wanted to to add that you know our
- 45:56patients average 2 hours away from our
- 45:59Medical Center because this is New England
- 46:01and and in the winter it's frequently
- 46:04impossible for them to get to us.
- 46:06So we do a lot of.
- 46:09You know, our virtual care at local
- 46:13small hospitals that can facilitate
- 46:16the testing that Judd talked about.
- 46:20So it's, you know,
- 46:21it's a it it it it does,
- 46:23it does vastly extend our reach and
- 46:28it's all to the patient's benefit.
- 46:31Sorry to interrupt.
- 46:33No, please do. We need more interruptions.
- 46:35That's the goal, Emily, to you. All
- 46:37right, Let's see if we can get five
- 46:39interruptions during this slide.
- 46:39So, so, yeah, so we've already
- 46:41touched upon a little bit of this,
- 46:43but I think it's back to when we're thinking
- 46:45through this afternoon into this evening.
- 46:47About telehealth and quality measurements,
- 46:49I think we also need to recognize,
- 46:51and this is something that the other
- 46:53panelists have already mentioned too,
- 46:54but things are changing.
- 46:56This is this moving target.
- 46:57And so some of the things to keep in
- 46:59mind when we're creating quality metrics
- 47:01or measuring quality is that idea the
- 47:04COVID has changed how we work and when
- 47:07I say that specifically to this side.
- 47:09Are specific to this slide is that I've
- 47:12seen a trend we had COVID all of a
- 47:14sudden basically forced many providers to
- 47:16switch from in person care to virtual care.
- 47:19You know there was that steep ramp up and
- 47:20we're seeing a lot of things out there.
- 47:22McKinsey reports,
- 47:22other reports about how there's
- 47:24less claims now for telehealthcare
- 47:26and there's more in person care.
- 47:28And so while that may be happening that
- 47:30you can sort of see from the data that way.
- 47:32What I've been seeing when I talked
- 47:34to others around the country is that.
- 47:36You know,
- 47:36providers got a taste and patients
- 47:38definitely got a taste of telehealth.
- 47:40And now I feel like they're almost
- 47:42like being that cook that's riffing
- 47:43in the kitchen.
- 47:44You know,
- 47:44there's a dash of telehealth we can put here,
- 47:46whether it be remote patient monitoring
- 47:48or maybe a an extra video visit or
- 47:51something else that happens there.
- 47:52And then someone else in another
- 47:54program says,
- 47:54well,
- 47:54let me take 2 tablespoons of another part
- 47:56of telehealth and put it into my program.
- 47:58Which I think is great.
- 47:59It's basically it's almost
- 48:00like this awakening again.
- 48:02We had sort of this like summer
- 48:03with like the the sun beating
- 48:05down with all this telehealth.
- 48:06We went into the fall,
- 48:07then all of a sudden,
- 48:08you know,
- 48:08it became a little bit more dormant,
- 48:10maybe not completely winter.
- 48:11But now we're starting to see like
- 48:13these small little saplings grow
- 48:15of different parts of telehealth,
- 48:17which makes it hard to sometimes
- 48:19measure quality of telehealth.
- 48:20And this is something that Lee had
- 48:21mentioned when he came on earlier too about,
- 48:23you know,
- 48:23it's not just telehealth or in person.
- 48:26So when you start trying to figure out.
- 48:27Quality metrics,
- 48:28How are you going to be capturing those
- 48:30different little pieces of telehealth there?
- 48:32It's not that I don't want those
- 48:34different pieces of telehealth there,
- 48:35it's just something that confounds
- 48:36the picture, makes it more complex.
- 48:38The other piece here is that
- 48:40telehealth is still relatively new.
- 48:41So yes,
- 48:42there are specialties that have
- 48:43had telehealth for decades now.
- 48:45We have Telestroke that has done
- 48:46a lot and has a lot of robust
- 48:48quality measures there,
- 48:50but there is also quite a bit of
- 48:52telehealth that's much newer on the scene.
- 48:54And so if there's a program
- 48:55that's newer on the scene and
- 48:56you're trying to measure quality,
- 48:58what are you measuring?
- 48:59Are you measuring the actual program?
- 49:01Are you measuring how
- 49:02well it was implemented?
- 49:03If there might have been a high
- 49:05staff turnover rate?
- 49:05Are you actually measuring that
- 49:07issue there with maybe some of the
- 49:09human resources and not the actual
- 49:11care that's being provided from
- 49:12the clinician to the patient, so.
- 49:14While we need to have quality
- 49:15measures for these new programs too,
- 49:17we need to take the outcomes we're
- 49:20measuring back to food and algae
- 49:22with a grain of salt because there
- 49:25is inherently there are some other
- 49:27confounding factors when we're measuring
- 49:29something that's being implemented
- 49:31and just keep an eye on time.
- 49:32I we already talked about some of this,
- 49:33the telehealth may not be
- 49:34a discrete program that.
- 49:36You could have a telehealth program,
- 49:37but we also need to figure out
- 49:39how to measure how telehealth,
- 49:40the tool of telehealth,
- 49:42the application of that is impacting care.
- 49:45So I wanted to make sure there was
- 49:49time for more discussion and I
- 49:50didn't get the five interruptions.
- 49:51So if there's other interruptions
- 49:52people want,
- 49:53here's
- 49:53an interruption. There we go.
- 49:55I think that I think that's a very,
- 49:56very important point and that is that.
- 49:59You know, you can be as sophisticated
- 50:01a provider as you possibly can be,
- 50:04but if the mechanics of
- 50:06the interaction don't work,
- 50:07you're you're just, you know, toast.
- 50:11And you know,
- 50:13for every telemedicine session I have,
- 50:16I would say a good quarter of them.
- 50:19For one reason or another,
- 50:21the interface doesn't work and that can be.
- 50:25You know, you know,
- 50:27I'm sure everybody's experienced,
- 50:29these patients in cars trying to
- 50:33get Wi-Fi because they're in the
- 50:36Walmart parking lot and, you know,
- 50:39not having that be successful.
- 50:42To just you know random zoom
- 50:45issues and and other stuff.
- 50:47So you know we have to be you know
- 50:51as providers were were very flexible
- 50:54we switched it to a telephone
- 50:56inter inter you know encounter.
- 51:00But from a telemedicine standpoint
- 51:04discriminating between mechanical
- 51:06problems and provider problems are
- 51:10probably going to be insightful.
- 51:12In in terms of teaching people
- 51:14how to do this,
- 51:15because there are different set of
- 51:19skills to debugging the interface
- 51:22between you and the patient in terms of
- 51:26the the Internet connection and so on,
- 51:28which we all get good at and the other
- 51:31things that we have to be good at.
- 51:34And that is eliciting all the symptoms
- 51:36and you know sometimes signs that
- 51:39point us in the right direction.
- 51:43I think the other issue here
- 51:46that we also that will evolve,
- 51:48but we have whole teams of people
- 51:51that are involved in these visits,
- 51:53scheduling them, preparing for them etcetera.
- 51:57And one of the areas that I also see
- 51:59a fair number of comments from our
- 52:02patients where they're not happy is
- 52:05when their visit was actually virtual.
- 52:07But that wasn't clearly explained
- 52:09to them and they show up in person
- 52:13and there's massive confusion and
- 52:15they didn't want to come in and now
- 52:18they're there and can they even be
- 52:20seen because sometimes they're whoever
- 52:22they're planning to see is at home.
- 52:25So it's, you know,
- 52:26there's some some of these operational
- 52:28workflow issues are also things that I
- 52:30think we're going to need to sort out,
- 52:32but I know we will over time.
- 52:36Just to that point, you know,
- 52:38sometimes I've had to reverse virtual
- 52:43meetings so the patient shows up because
- 52:46they were confused and I'm home.
- 52:49And so we give them an iPad in the
- 52:51exam room and I'm home, you know,
- 52:54so we've done it that way too. Yeah,
- 52:56I don't think we're doing that yet,
- 52:58but Lee would would know actually.
- 53:01Yeah, we have a version of that
- 53:03where we have patients who are doing
- 53:05multidisciplinary care at the Cancer Center.
- 53:07So they'll come in the room,
- 53:08they'll be one provider in the room,
- 53:112 providers located remotely
- 53:12and the patient in the room.
- 53:14Because the patient's also
- 53:15getting chemo that day,
- 53:16but they still get the opportunity
- 53:18to visit with multiple providers.
- 53:20The other point I was going to make,
- 53:21and it's teeing off of what Emily said,
- 53:23is like apples to apples.
- 53:25And I think we just don't do that routinely.
- 53:28So a nice analogy for this would be we we,
- 53:32we have satisfaction surveys
- 53:33where we're constantly asking,
- 53:35you know, could you connect,
- 53:36was the connection of good quality,
- 53:38could you hear the doctor,
- 53:39Could you see the doctor?
- 53:41I have yet to see a survey that says,
- 53:42did you have trouble getting
- 53:44on the Mass Turnpike?
- 53:45Did you find the exit to the hospital?
- 53:46OK, could you find the parking lot?
- 53:49Did you find the elevator?
- 53:50You know, how was the waiting room?
- 53:52Because we just put that burden on
- 53:54the patient and we say everything
- 53:56that happens until you hit the front
- 53:58door of my office is your problem.
- 54:00And what happens in the office is my problem.
- 54:02So I think we that's why we have to
- 54:04think a little bit more broadly so
- 54:07that as we redesign the experiences.
- 54:09We're really thinking about
- 54:10the the true patient journey,
- 54:12the physical as well as the emotional
- 54:14journey so that patients spend the
- 54:17most amount of time with us as a
- 54:20proportion of the journey as possible.
- 54:22So late to to that point, I, I,
- 54:25I I think that's such an outstanding point.
- 54:27I will share my wife's story twice at
- 54:29a health system I'm very familiar with.
- 54:32She showed up,
- 54:33got caught in a little traffic,
- 54:34went into a parking lot,
- 54:36there were no parking spots.
- 54:38Circled around left,
- 54:39went to another parking lot, found a spot,
- 54:42got to the appointment 17 minutes late.
- 54:44We apparently have the most ridiculous,
- 54:47most least patient centered
- 54:48rule known to mankind that if
- 54:50you're more than 15 minutes late,
- 54:52your appointment is cancelled.
- 54:53So in an inperson appointment,
- 54:55my wife, who waited months to see
- 54:57her rheumatologist and happened to
- 54:59this one day actually be having a
- 55:01flare during a routine appointment,
- 55:03got sent home only to be seen.
- 55:05She was actually shocked that she got
- 55:07a phone call from the COO apologizing,
- 55:10but that didn't actually get
- 55:11her better care yet.
- 55:12You know, we we you're you're 100% right.
- 55:15But if the technology fails,
- 55:17you hear about it, I hear about it.
- 55:19We get texted all day.
- 55:20We know about it right away.
- 55:22Can I just jump in for a second?
- 55:23Is there any time because Lee,
- 55:26I think I think what you just
- 55:29mentioned is a little bit of a
- 55:32complicated issue because you know,
- 55:33we've done research for decades
- 55:36about how patients define quality
- 55:38of care and in contrast to what we
- 55:41often think the amenities never ever
- 55:44get mentioned like parking, food.
- 55:46Wayfinding, even though we see
- 55:49some of that in in comments,
- 55:52but with the telehealth visits,
- 55:54the connectivity is actually quite critical
- 55:57to the clinical experience of care.
- 56:00And I think that when somebody's
- 56:03scheduled for a virtual visit,
- 56:05they're really looking forward
- 56:07to seeing the doctor and they
- 56:08don't want to be on the phone.
- 56:10So they get upset when the technical side.
- 56:14Doesn't work.
- 56:14And that I think has a different
- 56:17impact on the clinical care
- 56:19than the parking or the traffic
- 56:21on Mass Pike or whatever.
- 56:23So Susan, let me let me turn it around
- 56:25because my intention was not to say
- 56:27we shouldn't pay attention to that.
- 56:28It was to say that we should
- 56:30be paying attention to.
- 56:31What are the what we see is almost a
- 56:34victimless crime of what our patients
- 56:36go through Just to get to us. I'll make.
- 56:39I'll just share very briefly an anecdote.
- 56:40I ask my patients all the time
- 56:42you know how was this did this
- 56:44visit meet your needs and you know
- 56:45do you miss coming in person.
- 56:47And I've I've had several patients
- 56:48say to me paraphrasing them.
- 56:50Basically Doctor Schwaman,
- 56:52I love meeting with you.
- 56:53It's great to see you in person
- 56:54but I have to be honest.
- 56:56You know as wonderful as it is
- 56:57it's is it really worth the four
- 56:59hours I have to take out of my day.
- 57:02To get to and from the visit and the
- 57:04waiting room and all that stuff.
- 57:05Whereas in person visit my time with
- 57:08you is less than 25 or 20% of my total
- 57:11time I spend is was spent with you,
- 57:13with a virtual visit it's 90%.
- 57:15I think that's what we should be
- 57:18remembering when we overvalue what it
- 57:21means to see the patient in person.
- 57:22For us it's easy,
- 57:23we're sitting in our office and
- 57:24people March in and March out.
- 57:25But for our patients it's it's
- 57:27quite a journey especially for
- 57:29those with mobility challenges.
- 57:30So I think that.
- 57:31I think that we need to embrace the
- 57:34journey for our in person patient
- 57:36experiences equally so that we can
- 57:39then judge the true value of where
- 57:41virtual is is meeting our patients needs.
- 57:43Yeah,
- 57:43no, I completely agree with that.
- 57:46All right, let's go to the next slide.
- 57:48I have a wrap up slide and you can
- 57:50see that I am far from a genius.
- 57:52Because the title says what you have just
- 57:55heard, which is what we spent a lot of
- 57:57time discussing when we had our prep call,
- 57:59but you didn't hear all of this today.
- 58:01So I really expected to blow through
- 58:03this slide in about 30 seconds.
- 58:04So I'll take two or three minutes
- 58:06because we're running out.
- 58:07Anyway, we spent a bit,
- 58:09Susan really addressed, you know,
- 58:11what is the term, is it telemedicine?
- 58:12Is it telehealth?
- 58:13And, and we all feel we've
- 58:15all discussed these,
- 58:17It's just a form of care delivery,
- 58:19which is what causes the problem.
- 58:21Sometimes you get it via telehealth,
- 58:23sometimes you get it via your
- 58:25Apple Watch or remote device,
- 58:26sometimes you get it in person,
- 58:28sometimes you don't get it.
- 58:30Which leads us because remember,
- 58:31this is a quality symposium.
- 58:33We've had broad ranging discussion,
- 58:35all of which is quality,
- 58:36but we haven't used that word
- 58:38as much as maybe we should have.
- 58:40Quality is quality regardless
- 58:42of how it's delivered.
- 58:43So we need to look at what is
- 58:46the integrated quality model
- 58:47for the care delivery system,
- 58:50not as it visit by visit
- 58:52and then quality isn't,
- 58:54this is really goes to the robust
- 58:56discussion that Lee just opened
- 58:58up and and Susan commented on
- 58:59that quality's measured based on
- 59:01the signs and symptoms and the
- 59:03disease entity and the outcomes.
- 59:05So quality isn't different in telemedicine
- 59:08for a neurostroke patient than it
- 59:10is in person for a stroke patient.
- 59:13It's the same outcomes.
- 59:14You want to reperfuse the patient and get
- 59:17them walking and being functional again.
- 59:19And it's really important we
- 59:20don't spend too much time focused
- 59:23on the technical quality.
- 59:25That being said,
- 59:26I have a different analogy here than Lee's
- 59:28if the building collapses when you're in it.
- 59:31It's pretty much a bad quality day,
- 59:33right?
- 59:34And and if the technology doesn't
- 59:36work it's also bad quality.
- 59:38So we we need to take these things
- 59:41into account but we not to need
- 59:43to be unduly or disproportionately
- 59:45focused on it which is like a great
- 59:47point from the last discussion
- 59:48and and then we have spent a bit
- 59:51of time talking about the clicks
- 59:52and mortar hybrid approach.
- 59:54And it's really total care
- 59:56rather than episodic care.
- 59:58And and as we go through the rest of
- 01:00:01today talking about quality programs,
- 01:00:04we need to keep the framework and
- 01:00:06the discussion that we've had in the
- 01:00:09last hour in mind that sometimes
- 01:00:11we shoot ourselves in the foot
- 01:00:13as advocates for telemedicine
- 01:00:15and virtual care because we make
- 01:00:18it something different.
- 01:00:19And we now have to just make
- 01:00:21it something that is,
- 01:00:22it's just part of healthcare,
- 01:00:24it's not unique or different,
- 01:00:26the health and the disease,
- 01:00:28that's what we're responding to.
- 01:00:31And we should have similar metrics
- 01:00:33for health and disease outcomes as we
- 01:00:36do whether there's quality or not.
- 01:00:38But I I do, I think I still have
- 01:00:39a couple minutes left and there
- 01:00:41was some questions in the Q&A
- 01:00:43that got addressed in writing.
- 01:00:45But are are worthy of discussions,
- 01:00:47so I'll throw them to my colleagues
- 01:00:49on the panel from I'm going
- 01:00:50to put to your last name.
- 01:00:52I'm sorry Indira, Indira Padu Bidri.
- 01:00:57What are your thoughts on how
- 01:00:59telemedicine should impact the continuity
- 01:01:01of care if a patient's physician is
- 01:01:03not telemedicine capable or savvy
- 01:01:10at my primary care panel is Susan,
- 01:01:12Why don't you take that?
- 01:01:15I don't actually know. I mean,
- 01:01:17I think one thing I will say is that
- 01:01:21another thing that we see in our
- 01:01:24comments from our primary care patients
- 01:01:25is when I look at the comments,
- 01:01:28if they get flagged,
- 01:01:29if they have negative language in them
- 01:01:32and if it's about a telemedicine visit,
- 01:01:34it's often about.
- 01:01:35The clinician's competence with
- 01:01:38just doing telemedicine and it's
- 01:01:40often something as simple as
- 01:01:42just where they put the camera.
- 01:01:44You know, they may have two screens
- 01:01:46and they're looking at Epic on
- 01:01:48one and the patient on the other,
- 01:01:50but the patient thinks they're online
- 01:01:52shopping because they're not looking at them.
- 01:01:55You know, I mean there's literally,
- 01:01:56I've seen comments like that.
- 01:01:58So I think that there are,
- 01:02:00I think we need to be able to
- 01:02:02provide coaching and training.
- 01:02:03This is a new mechanism.
- 01:02:06Of delivery that people need help with.
- 01:02:08They weren't just born knowing how to
- 01:02:10do this and I think it's very important.
- 01:02:13Yeah we've I know last year at least
- 01:02:15session you know spend time on this but.
- 01:02:18But I think one of the ways that I look
- 01:02:20at it it's like the day you go up on Epic.
- 01:02:22And I don't mean that as an epic joke
- 01:02:24like when it when I showed up at Jefferson
- 01:02:26my first day we weren't on Epic and
- 01:02:28I sat down next to someone in the ER
- 01:02:31my extensive training on the EMR was.
- 01:02:34How do you do orders, you know?
- 01:02:35And as I went through my day,
- 01:02:36I figured it out, but,
- 01:02:38and you can't do that in telemedicine.
- 01:02:40It's like going up on Epic.
- 01:02:41The person to your left and the person to
- 01:02:43your right has never used the thing before,
- 01:02:45so you got to go through a boatload of
- 01:02:47training to figure out how to do it.
- 01:02:49Our early career,
- 01:02:50mid career and late career season veterans,
- 01:02:53they know how to take care of a patient.
- 01:02:54They don't know the right way
- 01:02:56to do it via telemedicine.
- 01:02:57So, So we really need robust
- 01:02:59training programs, which you know,
- 01:03:00many of our shops have now.
- 01:03:02That session last year was one of the,
- 01:03:05I think, the best parts of the
- 01:03:08symposium on the training.
- 01:03:11Yeah. And I think, you know,
- 01:03:11the AA MC took a lot of that learning
- 01:03:13and and took it and ran with it.
- 01:03:15Now, you know, really developing some nice,
- 01:03:17you know, content related to it.
- 01:03:20All right, let me see.
- 01:03:21Other questions we haven't gotten to.
- 01:03:24There was some physical exam questions.
- 01:03:26Oh, there was one question
- 01:03:27early on saying what is the
- 01:03:29appropriate percentage of overall.
- 01:03:31Visits that should be done via telemedicine,
- 01:03:33which is a question that we all get asked.
- 01:03:37And and so Emily,
- 01:03:38let's throw this to you first.
- 01:03:41I think I'm going to cop out in a
- 01:03:42way to say that back to the piece
- 01:03:44where it's not just a virtual visit
- 01:03:45versus not that it's going to be
- 01:03:47integrated much more into the care.
- 01:03:48There's going to be much more hybrid care.
- 01:03:50But I do think that the in person visits
- 01:03:55are going to become more and more scarce.
- 01:03:59And I think there's going to be
- 01:04:00more and more either guidelines
- 01:04:03or I'll say guidelines of which
- 01:04:06patients are going to be scheduled
- 01:04:07for in person is already happy now.
- 01:04:09But I think that there's going to be a
- 01:04:11switch to much more pushing for virtual.
- 01:04:14And so it's it's,
- 01:04:15it's going to be interesting.
- 01:04:16And so I don't want to put a number on it,
- 01:04:18but I do know the trend is
- 01:04:19going to go that way.
- 01:04:20And for the last word of the
- 01:04:22day from Dan, do you care to
- 01:04:24add anything to that comment?
- 01:04:27Yeah. Well, I would just say that the
- 01:04:30economics for telehealth are so strong.
- 01:04:33It saves so much money for the patient
- 01:04:37and it and not surprisingly it saves a
- 01:04:40lot of money for the institution because.
- 01:04:44You can have less space devoted
- 01:04:47to in person clinical space,
- 01:04:49you can have less support staff etcetera.
- 01:04:53So I think in the end,
- 01:04:54I don't think we've achieved this now,
- 01:04:57but soon there's going to be more and
- 01:05:01more of a sort of push from institutions,
- 01:05:05from provider organizations and also from.
- 01:05:10Insurance companies to do more telemedicine,
- 01:05:12what the right amount is,
- 01:05:14I have no idea. All
- 01:05:16right, thank you all for a great discussion.
- 01:05:17Thank you for the participants for great Q&A.
- 01:05:20And Lee, I will turn it back to you
- 01:05:22to head us into the rest of the day.