Panel 3: Applying Quality Framework to Ambulatory Virtual Visit Use Cases

July 12, 2023

ID10124

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00:00So we're going to resume now with
00:02the second-half of our symposium.
00:04This panel entitled Applying Quality
00:07Frameworks to Ambulatory Virtual
00:09Visit Use will be the first of two
00:11panels that will conclude the session.
00:14And we chose to divide this work
00:17into two different use cases.
00:19The first, which I think is
00:20the one that got the MO,
00:21has garnered the most popularity.
00:24And the most visibility during the pandemic,
00:25which is the use of virtual video visits
00:28or I I assume the panel may also touch on
00:32audio only interactive virtual visits.
00:33That's really the entity that exploded
00:36during COVID and that was new to
00:38so many patients and practitioners.
00:40But we also have asynchronous use cases.
00:44They've been around a lot longer.
00:45They've gotten a lot less I think publicity,
00:48but we need to think about the quality
00:51framework as it applies to those.
00:53Interactive digital exchanges,
00:54which might be quite different and
00:57might really challenge our notion
00:59of what a visit is.
01:01And so I think it's it's going to
01:03be really exciting to split those
01:04into two different groups.
01:05So next slide please.
01:07I'm delighted to introduce the
01:09moderator for this session,
01:11Doctor John Scott,
01:12a medical director at the University of
01:14Washington's, a digital health program,
01:16professor of allergy and infectious diseases,
01:19a very good friend and colleague who
01:21has been a really wonderful sound.
01:23Board for me as we've struggled with and
01:25grappled with issues like the digital
01:27divide and how we should measure quality,
01:30how we work together collaboratively.
01:31And he's just been such a wonderful partner
01:34in all this and so generous in sharing
01:36the the work that that they have done
01:39and the solutions that they've come up with.
01:41So John,
01:42I'll turn it over to you.
01:43Great.
01:43Thanks Lee and and welcome everybody.
01:45I'm glad you all can join.
01:47I think what I would like to do is
01:49start off with the introductions
01:50of my fellow panelists.
01:53And then we'll go into objectives and
01:55we have each some slides we prepared.
01:57But we really wanted to spend
01:59at least half the time of this
02:01hour just taking questions.
02:03So feel free to put those
02:05questions in the Q&amp;A and
02:08if we get a bunch, we'll we'll answer
02:10some of them just in the Q&amp;A function.
02:12Otherwise we'll let's announce
02:15those through the Q&amp;A session
02:17and and talk about those.
02:19So what I want to do is turn it over
02:21to Albert for a brief introduction of
02:23himself and then we'll go to Christine.
02:25Albert, do you just want to
02:26do a brief introduction?
02:30Thanks, John. Good afternoon, everyone.
02:33I'm Albert Chan.
02:34I'm a family physician and Chief
02:36of Digital health, Etcetera Health,
02:38also adjunct clinical professor at the
02:41Stanford Center for Biomedical Informatics.
02:43And my pathway to virtual care
02:46actually came quite securely.
02:48Let's say it's the power and benefit of a
02:51negative randomized clinical trial actually.
02:53So during my fellowship at Stanford,
02:56I was working on a really great
02:58system for hypertension directed at
03:00physicians and multi center trial,
03:03great product, great use case and
03:08essentially a negative trial.
03:09And it was at that point in my life I
03:12realized that it had to be something better
03:15at least in my mind and so I turned to.
03:18To essentially patient centered decision
03:19support the idea that we can empower
03:22patients with these tools and and the
03:24power of virtual care to empower them.
03:26And so that's that's why I actually was
03:29then and got involved with a the early
03:32at work at Center Health to launch Epic's
03:35first my chart instance in the country.
03:37And what we saw there,
03:40we continue to see there is actually
03:42over 50% of the interactions are in
03:44need virtual maybe not be a camera.
03:47And so you're here for Panel 4,
03:48but really these virtual interactions,
03:50including asynchronous communication.
03:51So I'm happy to share our experiences, etc.
03:54And thanks, John,
03:55for having me on the panel.
03:57Yeah, thanks very much, Albert.
03:59And next, I want to introduce Dr.
04:01Christine Peoples. Dr. Peoples,
04:02you want to give a brief background? Sure,
04:05sure, sure. Good afternoon, everybody.
04:07My name is Christine Peoples.
04:09I'm a rheumatologist at the University
04:11of Pittsburgh Medical Center.
04:13So I'm coming to you today from
04:14the great city of Pittsburgh.
04:16I've been providing care in rural and
04:19underserved areas of Pennsylvania going
04:22on the past eight years in rheumatology.
04:24And I'm the director of the Tele
04:27rheumatology program here at UPMC.
04:28And so I will be chatting
04:30more about that today,
04:31obviously in a setting of quality framework.
04:35Great. Thanks Doctor Peoples,
04:36if we can go to the next slide please.
04:39So we have 3 objectives for the next hour.
04:41The 1st is we're going to talk
04:43about metrics and share what we're
04:45using at each of our institutions.
04:47And hopefully you can.
04:49We're going to see some
04:51consensus around what is,
04:52what are some of the good metrics to define
04:55quality in synchronous virtual visits.
04:58The next we'll talk about
05:00logistics of how do you get going,
05:02because I know a lot of you are
05:04joining today and you don't have a Qi.
05:08Framework yet or Qi program for telehealth
05:11and and we're hoping to share Okay.
05:13Well this is where you
05:14start and these are the,
05:15the things you need to have in
05:17place to get a program going.
05:19And very important along with
05:21getting started is hopefully we can
05:23share some of the mistakes we made,
05:25some of the barriers that we've
05:27encountered and you can avoid
05:29repeating those mistakes so that
05:30you can really hit the ground
05:33running with your own Qi program.
05:35So if we can go to the next slide,
05:36I'm going to share a little bit about
05:38what we're doing here in Seattle.
05:39And just to kind of rewind
05:42to February of 2020.
05:44We had the very first identified case
05:47of COVID just about 10 miles north
05:50of Seattle in mid January of 2020,
05:53seems like a long time ago.
05:54And then towards the end of
05:56February we had the first death
05:58that just across the lake from us
06:01at a nursing home and we are very.
06:03Quickly overwhelmed with with the
06:05highest numbers we've had in the
06:08whole pandemic were in March of 2020.
06:10So we had to very quickly pivot to
06:14telehealth and and fortunately had
06:16a good foundation to build upon.
06:19We had we did already have a Qi program.
06:22It was very much in its knees
06:24and beginnings but we at least
06:27had some some foundations begin.
06:29We went from around 200.
06:31Telemedicine visits in February
06:32to a peak of 33,000 in May and
06:35like many of others on the call,
06:38we've kind of sold out around 15 to
06:4020% of our total inventory visits.
06:41So right around 20,000 visits a month
06:45still and now 18 months into the pandemic.
06:49So what I want to talk about is the
06:52four pillars that we have instituted
06:56for our Qi program at UW Medicine.
07:00And this is something that we started
07:02pivoting to in the summer of 2020.
07:04We knew that we kind of built
07:07this plane as it was you know in
07:09the air and we we knew that there
07:12were probably some holes.
07:13So we so we were very fortunate to
07:16have a leader and our Chief Medical
07:19Officer who comes from a Qi background
07:21and he was very supportive of this.
07:23But the first pillar of that
07:26program was event reporting.
07:27So like a many places we have
07:30an anonymous reporting tool at
07:31every computer at U dot Medicine.
07:33So anyone who has a log
07:35in can report a safety event and
07:38this was initially started for
07:40like things like Ron's wrong site,
07:42surgery or pharmacy air.
07:43But we pivoted to digital health
07:46because it could really happen anywhere
07:48in the health system and so we see
07:52these events on a weekly basis.
07:54And can flag them and then we do a
07:57root cause analysis but it really
07:59helps us to identify problems
08:01before they they really explode.
08:04The second thing we have are
08:07surveys and complaints.
08:08So you know it's good to hear
08:10what the patient experience is.
08:12We use the press gaining survey and one
08:16of the the key questions there is would you.
08:20Recommends telemedicine,
08:21so the willingness to recommend
08:23and we actually compare that to
08:25other parts of our organization.
08:27This is a top line bit of data
08:32that is reported to leadership and
08:34you know we're being graded on
08:36on how we're doing in that area.
08:38So very motivated to respond to
08:42patients feedback on that and one
08:44thing I will say is that the the kinds
08:47of things that patients are saying.
08:49Has changed.
08:50So initially there was a lot of
08:53complaints around technology,
08:55like I don't know how to use Zoom,
08:56you know, I don't know how to,
08:58you know, unmute myself,
09:00all those kind of things that's become
09:02a less and less of an issue and now
09:05they're more of kind of the same
09:07complaints that we get in person.
09:08So the most common complaint
09:10today is the doctor was late.
09:12So we're working with our our colleagues.
09:16To just tell them, hey, you know,
09:19Doctor Scott's running a little bit late,
09:21might be 1015 minutes.
09:22If you want to, you know,
09:23go get that flashlight or that thermometer
09:25to make sure it's a great visit,
09:27then please go do that now.
09:28But you know,
09:29don't don't feel like you're
09:31in the wrong place.
09:33And then the the third pillar in
09:36our Qi framework is peer review.
09:38So this is just random peer review that
09:42my colleague and I do every month.
09:45So we do 30 each.
09:47So we're in around 500.
09:49We've done so far and we are
09:53taking prespecified questions.
09:55So about a three or four page survey
09:58and we just evaluate it and we,
10:00we started with the National
10:03Quality Forum guidelines here.
10:05And so if there's like 1 document I would
10:08steer folks to it would be this 20.
10:10I think it was 2017 when this came out
10:12and that's a great place to start we.
10:15We found that the the principles
10:17were pretty general,
10:18but then you can kind of build
10:20from those generals to to more
10:22specific kind of questions.
10:23And in in particular there's a,
10:25there are a couple of questions
10:26I I found really valuable and
10:28that one of those questions is,
10:30was this appropriate for telemedicine
10:33And #2 was this visit safe?
10:36And so we, you know, we say yes,
10:37no and if there's a yes, we say why.
10:39And so we report out to our
10:41leadership.
10:42When when I meet with legislators,
10:44I I'm very proud to say that no,
10:46over 99% of the time we can say
10:48it's appropriate and it was safe.
10:50And if people want specifics,
10:52we can kind of illustrate the the few
10:55examples where it wasn't appropriate
10:58and other things that we do or
11:00we look at was consent obtained.
11:02So in our state there's not
11:04a mandatory written consent,
11:06but it is strongly advised in our training.
11:09Which is which is mandatory in our
11:11state that it is obtained and we
11:13usually just do it verbally and
11:15so there is a a dot phrase that
11:18we've created in Epic you know
11:20that the documents that you got
11:22consent and where you are and where
11:23the patient is and if there's
11:25anyone else assisting in the exam.
11:27So we we do our survey and and ask did
11:30they did they get consent and document it.
11:33There are other things about billing like
11:35using the right GT or are no modifier.
11:39And then a couple other things
11:42around prescribing of medications.
11:44So we knew that there are a
11:46couple of highrisk categories like
11:48prescribing of controlled substances.
11:50So we, we look into that.
11:51And then as an infectious disease doc,
11:53I'm always concerned about
11:55overprescribing of antimicrobial.
11:57So we have a particular question about that
12:00and whether it was appropriate or not.
12:02And then finally we have
12:05specialized Qi projects and so.
12:07The two projects we're looking at
12:09this year are trying to improve access
12:12to our Spanish speaking patients.
12:14We found that that even with the making
12:17our technology a little bit easier that
12:20our Spanish speaking patients have
12:22really lagged behind other populations.
12:24And So what with some things we've
12:27done is we've created videos and
12:30they have have translated them
12:32into our top 6 languages.
12:35So we're hoping that's going
12:36to kind of move the needle.
12:37And then the other one is looking at
12:40responsible scribing of of antimicrobials.
12:43So I wanted to also talk about some
12:45of the the infrastructure that was
12:48necessary to launch our program and
12:51the first thing I want to talk about
12:53is this governance and reporting.
12:55So as I mentioned we've had a
13:00a group of other.
13:03Folks in in the University of Washington
13:06who report Qi metrics and it's
13:08kind of a grab bag of other folks.
13:11So it's like our GME office and research
13:14because most of our Qi is done in
13:16the department or the institution,
13:18the hospital level.
13:19And so I already I had built in a way
13:24to report any kind of Qi concerns and
13:27that meets quarterly then that that
13:30group is consist of risk management.
13:33Administration and as I said,
13:36the folks in research and GME,
13:39well, we are also able to hire an
13:42associate medical director at 50% FTE
13:45and her major charge is around QY.
13:49So she's been leading that work.
13:51And in addition,
13:51we have a 50% FTE who's doing
13:53the program manager.
13:54So kind of collecting the data
13:56and you know sending all those
13:59those patient charts to us.
14:03So let's go to the next slide.
14:05I want to, I want to share
14:07some of our from our outcomes.
14:09So one of our high level metrics is that
14:12what we call a failed telemedicine visit.
14:15And what you can see is on the far right
14:18there is that when we started in in 2020,
14:21it was almost one out of 10
14:23visits we couldn't connect.
14:25You know the the video didn't work
14:27or you know the link wasn't working.
14:29And that has declined down to right
14:32around 3 1/2% which was actually our
14:34goal when we started back in 2020.
14:36And it kind of varies across our
14:40our institutions within UW Medicine.
14:41So Hall Health is our student Health
14:44Center with a lot more tech savvy folks.
14:46So it started out pretty low
14:48and it's almost almost 0% now.
14:50Harborview where I work is
14:52our public hospital,
14:54about half of my patients don't don't
14:56speak English as a as a first language.
14:58And so that was a particular challenge
15:00in it and not surprisingly had some of
15:02the highest failure rates the beginning.
15:04But even at Harborview we've made
15:06a great progress and we're sitting
15:09around 5% in our more of our community
15:11hospitals have had a a similar
15:13trend in our University Hospital
15:15also has made progress.
15:18So then the other thing we look at
15:20is some of the DEI metrics we looked
15:22at use of telemedicine by race,
15:24ethnicity and language.
15:25And I think very similar to
15:28what other folks have reported,
15:30you know,
15:31proportionally speaking in 2020
15:33there were more people who are white
15:36race who had commercial insurance.
15:39We're college educated,
15:40we're urban,
15:41you know looking in urban areas and
15:43we've started to see that start to level
15:46up now so that our African American
15:48patients are patients who have Medicaid.
15:51And folks who don't live immediately
15:54in Seattle are now able to join
15:56telemedicine approximately the same
15:58rate as they would as in person.
16:00The big difference was I said earlier
16:01was our Spanish speaking patients.
16:03So we're that's why we're identifying
16:05them as a target area in the next year.
16:08So we also have some metrics around
16:11willingness to recommend and this
16:12is where like a Net Promoter
16:14score can be useful.
16:15I think it's kind of an industry standard.
16:18And I know other folks
16:20are using that as well.
16:22As I mentioned before,
16:23I want to make sure that consent
16:25is obtained and documented and then
16:28that the physical exams performed.
16:30This is one of my pet peeves and
16:32when I do chart reviews that I'd
16:34say about you can see in the little
16:36graph here is about 1/3 of the time
16:38there is absolutely no physical exam,
16:40so they say there's a telemedicine visit.
16:42Therefore I did not do a physical exam.
16:45And there's quite a bit of information
16:48that you can do that you can gain
16:51from from just a video visit.
16:53You know, first of all,
16:54the mental health exam was just
16:56basically the observation,
16:57you know, that their speech,
16:58their their mood, things like that.
17:02I I work in the liver clinic so I can,
17:04you know, have them pull their eyes down,
17:06you know, are they jaundiced?
17:07Do they have a flap,
17:10Have them stand up and.
17:12Pull up their shirts so I can
17:13see if they have ascites,
17:14have them self selfexam.
17:16So I actually can get quite a bit
17:19of information and a lot of the
17:21specialty societies have guidelines
17:23now on how to do an exam specific to
17:27that area and I think doctor peoples
17:29will get into that a little bit more.
17:31And then the last one is I mentioned
17:33safety and appropriateness of
17:35the visit for telemedicine.
17:37So just to end with a little bit of advice,
17:40if you're launching AQI program
17:42for telemedicine,
17:42first of all make sure you
17:44have proper resources.
17:45That means time and and so time of faculty
17:50and support stuff and and also money.
17:53You might need you know a little
17:55bit of money for special projects,
17:57getting data,
17:58upgrading your your equipment whatnot
18:01and and this kind of is obvious but
18:03make sure you focus on the patient.
18:05And also the provider for education,
18:07I think there's a question in our
18:09in our first session around maybe
18:12our less tech savvy providers.
18:14And so it's a real push to make our
18:17technology as simple as possible
18:20and make sure that they have
18:21support when you launch,
18:23but also ongoing support if if there's,
18:26you know maybe something
18:27new that's happened with an
18:29upgrade update to Epic or Zoom.
18:31And then my last point is to make
18:34friends in IT finance and your patient
18:36scheduling center because they're all
18:38going to be part of that whole experience.
18:41And so with that,
18:42I think I'm going to move it on to our
18:45next presenter and that's Doctor Peoples.
18:47Christine,
18:47you want to take
18:48it away? Yeah, thanks. Thanks, John.
18:49I just want to say before I start,
18:52I really enjoyed all the discussions and
18:54I hope that what I'm going to talk about
18:57kind of with the care I provide that.
18:59I kind of give kind of an added and a
19:01different angle than what I do every day
19:04and kind of in the guise of quality.
19:07So I wanna kind of start a little bit
19:09with kind of the framework and kind
19:11of how our program is structured in
19:14order to set the groundwork for for
19:16talking about some quality issues.
19:18So rheumatology, care to telehealth center,
19:21why? So there's been an increasing demand
19:24for patients and healthcare systems
19:26for access to academic specialists,
19:28including rheumatologists through
19:30telemedicine modalities.
19:32And I think we all know that agree with that.
19:34That's been the mantra for years,
19:36even before COVID and workforce
19:38estimates predict a shortage of about
19:412500 rheumatologists by the year 2025,
19:43which is actually not that far off.
19:46And in recent American College
19:48of Rheumatology,
19:49workforce analysis really highlighted the
19:51lack of rheumatology care in rural areas.
19:54And so the need for access through
19:57telemedicine is really greater than ever.
19:59And it really accelerated into the
20:02spotlight with the COVID-19 pandemic,
20:04which continues as we all know.
20:06So our program at UPMC was started back in
20:112012 and has continued to grow each year.
20:14And currently I provide rheumatology
20:16care to three different rural and
20:19underserved locations in Pennsylvania.
20:21We estimate that about 40 to 50% of all
20:25new patient referrals that I see would
20:27simply just not see a rheumatologist if
20:30they had to travel three to four hours.
20:32Sometimes to Pittsburgh is just not
20:34something that patients are going to do.
20:36And I provide care for both new
20:39patients and follow up visits and
20:41I'm fortunate to be able to work with
20:43at all three locations a trained,
20:45experienced RN that serves as the
20:49telepresenter my hands since I
20:51can't be physically there.
20:53Next slide please.
20:57So kind of going through
20:59the how in the workflow,
21:00I think really leads itself to talking
21:03about different ways that we can
21:05improve quality care at each step.
21:07So patients or referring providers are
21:09able to contact a central scheduling office,
21:13but I highlight the local telehealth
21:15center because they really are the best
21:17at really getting the patients scheduled
21:19appropriately and they can also be
21:21scheduled through our office in Pittsburgh.
21:24Patients are told that it is a
21:26telemedicine visit and this really
21:28applies obviously to new patients.
21:30We try very hard and we have
21:32from the beginning to let them
21:34know what to expect at the visit.
21:35We let them know this.
21:37We have this information on our website
21:39and we also encourage them to check
21:41with their insurance plan to see
21:43if there's coverage for this visit.
21:45This was much more of an issue with
21:47the beginnings of our program and
21:49this has improved with the COVID-19
21:51pandemic and I think some of these.
21:52Lessening of restrictions will continue.
21:55The local telehealth center plays
21:57a very big role in confirming,
21:59confirming the visits,
22:00explaining what's going to go on during
22:03the visit and really to confirm the
22:06previsit new patient paperwork for
22:08those patients that are new referrals.
22:10And I put in there in parentheses
22:12gown versus exam outfit.
22:14So when I first started providing
22:16care like this,
22:17we started to notice that several
22:19patients would communicate
22:20through feedback and surveys.
22:22That they really did not want to
22:24wear an exam for new appointments.
22:27And I think nobody really likes
22:29to period as a patient,
22:31whether it's a traditional in person
22:33visit or a telemedicine visit.
22:35But they really mention this especially
22:36because the camera was right there.
22:38And so we kind of came up with the,
22:40the nursing staff that I work
22:42with kind of an exam outfit that
22:44we recommend patients to wear.
22:46And we find that patients are much
22:48more comfortable wearing appropriate
22:50clothes where we can examine
22:52the joints with minimal kind of
22:54shuffling around then the gown.
22:56And so these are kind of pearls that
22:58we've kind of looked at over time to
23:00kind of improve the patient experience.
23:02Follow up visits are able to be scheduled
23:04right there at the local telehealth center,
23:06but can also be scheduled through our
23:09central scheduling modality in our office.
23:12And we've really developed a large
23:14referral base in the community.
23:16And I often talk with on the phone,
23:18you know,
23:19local providers about different things,
23:21certainly with the start of the
23:23COVID-19 pandemic and watching
23:25cases in those rural areas,
23:27which are obviously less than here in
23:29Allegheny County where Pittsburgh is.
23:31But I've certainly,
23:32you know,
23:32started to do more visits that were audio
23:36only and certainly home video visits.
23:38And so with those,
23:40it's a little bit easier for me,
23:42especially the home video visits to kind of.
23:45Tell patients to remember what they,
23:47what went on,
23:47when they saw me at the telehealth
23:50center. And so during visits,
23:51especially new patients and I'll
23:53use the example of patients with
23:55rheumatoid arthritis, You know,
23:57I explain what goes into the joint exam,
23:58what we're looking for,
23:59what we're doing and constantly educating
24:02the patient and also the telepresenting RN.
24:05And so when they're at home and
24:06having a visit or even on the phone,
24:08they have knowledge of kind of
24:10the things I want to know in
24:13terms of physical exam markers.
24:14Of things.
24:15And so I think that's also been mentioned
24:17you know earlier today about some of
24:19that and that's very important to do.
24:21We again kind of go through the
24:24workflow and kind of what's going
24:25to go on on our website in terms of
24:28physical exam training and experience.
24:30This is probably one of the most often
24:32kind of comments and questions that I get.
24:34So all of the telepresenting
24:36R N's that I work with,
24:38I personally trained in the
24:40exam in person and they also.
24:44When we kind of kind of on board
24:47new staff members and new R
24:48N's as well as time goes on,
24:50we also have a video on the Muscosalt
24:53exam that they view and we're going
24:55to kind of start to develop our own
24:58standardized telepresenter training video.
25:00And I also want to point out that as
25:03time goes on and as I provide care,
25:06I certainly point out pathology to the
25:09telepresenting R N's that I work with.
25:11And experience that they've
25:13had so far over the years,
25:14it's very helpful and I find that
25:17patients don't mind that and and it
25:18really makes for a good visit to kind
25:20of point out some of these things.
25:22Certainly I can't do procedures
25:24and we've addressed that.
25:26Fortunately my colleagues and orthopedics
25:29at all three locations where I see
25:32patients are able to efficiently and in
25:34with pretty good urgency can perform
25:37a joint arthrocentesis if need be.
25:39For those patients,
25:40because that is one thing that I
25:43obviously cannot do and we haven't
25:44gone to the point of training to tell
25:47the presenter to do these procedures.
25:49So I do rely on my colleagues
25:51for that next slide.
25:55So since I started providing care like this,
25:59I've always kind of thought about
26:01quality improvement concepts
26:03as I think about our workflow.
26:05And so patients that that have visits
26:07with me at the telehealth centers,
26:10we always get consent for this
26:12type of care that's built in to
26:14the framework for every visit.
26:16We discussed the HIPAA compliant platform.
26:19We talked about the technology
26:21that's secure and I can't emphasize
26:23the previsit preparation,
26:25how important that is,
26:26letting the patients know what type
26:29of visit this is, what to expect.
26:31What will go on each piece we really
26:34let patients know what to expect.
26:36And then for certain diseases
26:38that I see in manage over time,
26:40we talk about various disease activity
26:43measures and they're starting to
26:45be a shift towards more of those
26:47components that are relatable and and
26:49and received from the patient versus
26:51relying on those disease activity
26:53measures that the laboratory test is
26:56required or something else and I use
26:58the example of rheumatoid arthritis.
27:00So patients that I follow
27:02for rheumatoid arthritis,
27:03they fill out a rapid 3,
27:05which is one of the disease
27:07activity measures available in the
27:09setting of rheumatoid arthritis.
27:11After they fill that out,
27:12that scan into our electronic medical
27:15record and I review that with patient
27:17during the visit and we talk about that.
27:20We talk about what that means,
27:21what are the things could influence it.
27:23And so you can do some of these things,
27:26you know again previsit
27:27preparation very important.
27:29And we constantly solicit patient feedback,
27:32look at surveys to see what
27:34patients comment upon.
27:35We also really want to broaden some
27:38of this to really include learners.
27:40And so we have developed to tell a
27:43rheumatology elective for our second
27:45year rheumatology fellows to have
27:47exposure because the care I provide
27:49in rural settings is not going away
27:52what regardless of what happens.
27:55With the pandemic or you know other
27:56things that they could go on in
27:58infectious disease world in the future.
28:00And so really kind of getting learners
28:02involved is very important and I
28:03think that that also lends itself to
28:05developing a lot of metrics to kind of
28:08standardize and prove physical exams.
28:10We also kind of you know offer patients
28:13a traditional in person visit and
28:14this comes up a lot for those patients
28:16that are going to be involved in our
28:18various research studies and clinical trials.
28:21At the University of
28:22Pittsburgh Medical Center,
28:23we're fortunate to have specialized
28:24centers like a lot of us are in terms of
28:27myositis and Scleroderma and some things.
28:29So we're able to get those patients
28:31there and there's certain diagnostic
28:33testing that can't be done that's a
28:35little bit too specified that I can't do,
28:37you know, locally for them.
28:39And so it's much easier for me
28:40to talk with them about that,
28:42make a plan for that,
28:43help them with scheduling in this
28:46instance and then really thinking about.
28:48Pushing this model out to
28:49multispecialty care and I think
28:51that's been touched on earlier today as well.
28:53You know, the rheumatologist,
28:55the pulmonologist, the dermatologist,
28:56Can we all kind of have these
28:58virtual care clinics at telehealth
29:00centers or even potentially visits
29:02while the patients at home?
29:03And then constantly looking at
29:05outcomes research, you know,
29:06looking at what happens with these
29:08patients when they're diagnosed,
29:09How do they do on a chronic longterm basis,
29:11kind of what happens with time?
29:14And then now that we have a
29:15lot of these choices and a lot
29:17of us have mentioned this too,
29:19all these different visit types,
29:20all these different ways to
29:22provide care and monitoring.
29:23How do we triage those?
29:25How do we do those things for
29:27new patients and decide what
29:28type of visit is best for them?
29:29How do we do that for follow up patients?
29:32And kind of thinking about
29:33the staff that's required,
29:34kind of the time commitment that's
29:36required to really sort out what what's
29:39the best visit type for each patient.
29:41So next slide.
29:44So kind of the future and it's
29:46really kind of now we have options,
29:49you know, but how do we navigate them?
29:51How do we do what's best?
29:52Yes, we can provide virtual care
29:54in many different ways now,
29:55but how do you make sure that
29:57that's really the the correct care?
29:58And I kind of gets back to the mantra,
30:01the right care for the right patient,
30:03the right time and the best way.
30:05And I think that really underlies all of
30:07what we do and everyone around the world
30:10really when we provide virtual care.
30:12Again, really kind of integrating learners,
30:14developing fellowship training for
30:16whether medical students, residents,
30:18fellows about providing care this way can
30:22we have visits with two rheumatologists,
30:24one more generalized like I practice
30:26and then one of my colleagues,
30:28you know at our myositis center and the
30:30patient and a common goal and again as I
30:33mentioned multispecialty telemedicine visits,
30:35so virtual care clinics with a rheumatologist
30:38and a dermatologist for example.
30:40And then can we get to the point where
30:42we may need to do standardized procedure
30:45training for the telemedicine presenter,
30:47Would that help with that kind of
30:49looking at kind of the the number
30:51of arthrocentesis that needs done,
30:53you know,
30:54is that something that we should integrate
30:57with the telemedicine presenter skill set?
31:00Can be used different ways of innovation.
31:01So I put down glove examples.
31:04So there are different kind
31:05of technologies where you can
31:07actually palpate joints remotely.
31:09You know,
31:10is this something that should be used?
31:11Would this improve the exam?
31:13Would this improve the patient experience?
31:15We don't know.
31:16We have to consider it.
31:17And then linking a lot of this with
31:19artificial intelligence, you know,
31:20a lot of the care we deliver,
31:22can it be linked? Is it just as good?
31:24Do patients still appreciate it,
31:25things like that?
31:27And then really broadening
31:29to pediatric rheumatology,
31:31really kind of thinking about quality
31:33metrics for rheumatology care there
31:34since there's even less pediatric
31:36rheumatologists than adults in this country.
31:38And then always the underlying
31:40theme is additional study is
31:42needed especially in the field of
31:44of telemedicine and rheumatology,
31:45you know outcomes research,
31:47randomized control trials reviews
31:49to really make sure that we know,
31:51we know we can provide care this way.
31:53Does it work, do patients like it,
31:54what we do better,
31:55how can we improve things.
31:57And again that's through the whole
31:58framework today for quality,
32:00you know kind of you know we this is
32:02here to say this isn't going away.
32:03There was a need for this before
32:05the pandemic.
32:06But how can we kind of juggle all
32:08of these different issues.
32:09So at the end of the day we get the
32:11patients that care that they need
32:13and they're satisfied and they feel
32:14comfortable with what's going on.
32:16So I will kind of end there.
32:18I think it's my last slide and
32:20kind of leave time for additional
32:22discussion and hopefully
32:23like I said this was helpful framework
32:25in a little bit different way of
32:27conducting visits and how I provide care.
32:30Great. Thanks Doctor Peoples and just
32:32a reminder if you have questions for.
32:35For Doctor Peoples or myself,
32:37please put them in the Q&amp;A.
32:38And with that, we're going to
32:41go to our last presentation.
32:42That's Doctor Chan from Sutter.
32:44Doctor Chan, you would take it away.
32:46Thanks, John. So kind of giving you
32:50a foreshadowing of what I'm going
32:51to talk about a little bit today,
32:52which is I wanted to take a very different
32:55look at quality and partly because I can't,
32:57cannot steal John Scott's medical director.
32:59So that's, that's one reason or
33:01Christine for that matter, but.
33:03It's actually harkening back to what I
33:06said earlier about that that faithful
33:08randomized trial that didn't work and
33:10really trying to think of the patients.
33:11And so I want to talk about some of the
33:14ways we're actually looking at the signals
33:16from patients to try to assess quality.
33:19Just to give you a little more
33:21background about that, our health,
33:23we are 24 hospital system in Northern
33:25California and we had the opportunity
33:27like others to see a really rapid
33:30increase in in virtual care.
33:32Let me give you some sense of the numbers.
33:34In 2019 we were doing very
33:37little telemedicine visits.
33:38We were doing about a total
33:417400 for the entire year.
33:44In 2020 we did 1.1 million and
33:48that that big change happened of
33:50course because of COVID we had,
33:52we had prior to and I'll say there's
33:55two periods BC before coronavirus and
33:57A/C after coronavirus, right, so BC.
33:59We had this plan,
34:01we had this plan to say okay,
34:02let's get our 5000 doctors,
34:05just clinicians up and running,
34:07let's take two years to do it,
34:09let's and that's a really aggressive plan.
34:11That's really aggressive, right.
34:13That's that's our hope. COVID happens.
34:16And actually I had my own visit
34:17to touch with this.
34:18I had a patient come in in February,
34:21kind of like John in February.
34:22This patient come in directly
34:24from the San Francisco airport,
34:26literally directly from the airport.
34:28With a couple who had traveled from
34:30you guys to Asia and they came to my
34:34clinic and the nursing staff said,
34:36hey, you're going to gown up now.
34:37And I'm like, what?
34:38And then so I walked in with the, you know,
34:41the, the face shield, the goggles,
34:44the the, the gown and so forth.
34:48And I thought,
34:48this is going to be completely nuts,
34:50Completely nuts.
34:51We have to do something different.
34:53So.
34:55As a result of that experience and others,
34:56we essentially put together a a
34:59new telemedicine plan, 4 weeks,
35:015000 clinicians and a scale up.
35:04What was interesting as as I mentioned,
35:06we're really large organization,
35:07so we had and this and the governor
35:10actually ordered the lockdown.
35:11So we had lots of constraints,
35:14constraints like how do we get
35:16video capability.
35:17All these doctors in fact we thought we
35:19were going to have two years to do it.
35:20So we didn't have cameras installed
35:22at every workstation for example.
35:24We just didn't.
35:25And then we had these workers who
35:27were actually signed to home.
35:29So how are we going to do this?
35:30So we took a strategy of using tablets
35:33and since we provisioned 5000 tablets
35:36centrally in a in a big garage
35:40type structure, I've been it was rather
35:42fortunate we had over 200 team members, most
35:45of whom I've never met before in my life.
35:47Actually come together and work through
35:49this really aggressive plan and it
35:51was amazing thing to see people.
35:53We had these huddle calls every
35:54morning at 7:00 o'clock in the morning.
35:56We'd get together, we'd work through our
35:59task list and you know, very quickly.
36:01So run through these things each
36:03and every day and slowly but surely
36:05we got throughout 5000 clinicians
36:07and then we and as you can see here
36:10on the right was what happened.
36:12Here's here's one of these
36:14interesting outcomes.
36:16In dark green is essentially the highest
36:18volumes and light greener some activity
36:21throughout the state of California.
36:22I'll point out we are only
36:24based in Northern California.
36:26So it makes sense to the dark green
36:28episodes where in cases where we
36:30were geographically collocated,
36:32but we saw patients all around
36:34the state of California.
36:35I presume it's because many of our
36:37patients sought to move elsewhere
36:38in the face of the pandemic and
36:41spread all across the state,
36:42but we we saw this pretty
36:45interesting phenomena.
36:46The other thing I would in terms of
36:48quality is to say what what environmental
36:49impact do we have on our community.
36:51And we actually did some calculations
36:53and said we think we saved about 11.5
36:56million miles of patients commuting
36:58from their homes to the clinics,
37:00saved about $1.5 million in gas expenses
37:03and 4000 metric tons and CO2 emissions.
37:06So really trying to quantify this,
37:08you know if you will,
37:09the quality change we saw here.
37:11Next slide.
37:16Next order businesses to say is this
37:19relevant, is this comparable to in person
37:22care and I I really didn't know right,
37:24I didn't really, really didn't
37:26know what this is going to yield.
37:27So we've been tracking this is a dashboard
37:29and this is very dynamic and so we
37:31will we try to look for our common,
37:34you know is this a real trend or is
37:35this common cause variation right.
37:37So but we are tracking this quarterly and.
37:40Essentially we look at as John
37:42Starr indicated earlier,
37:44Net Promoter score.
37:45So we're looking at how do patients
37:47rate these interactions as compared
37:49to in office care.
37:51Another alternative is
37:52so-called walking care,
37:53which is our retail nurse APC
37:56clinic and then real time urgent
37:58care and you can see here that this
38:00various or so it doesn't seem to
38:02be related necessarily to modality
38:04whether it be video or in person.
38:07It really relates to the overall
38:08experience and I'm proud to say
38:10we've had a very good experience
38:11where essentially our video
38:13visit experience has been on par
38:15with our in person experience
38:19on the rights. Another graph,
38:20one of the things we've actually
38:23very been very attentive to is
38:25building a building out a patient
38:27service center that services the
38:29digital health needs of our patients.
38:32So this is, this is a.
38:34Service offering,
38:35that's a one 800 number and and it's
38:38purely dedicated to engaging our
38:40patients with all the help that they
38:42need to engage with the digital service.
38:44So for example,
38:45if they need access to password resets,
38:47we have a service that
38:49essentially 12 hours a day,
38:50five days a week offers
38:51that service the same desk.
38:53It was interesting because as we
38:55launched these these video visits,
38:57we noticed a very interesting phenomenon.
38:59We said, hey.
39:00It turns out this is one of the,
39:02this is the only digital dedicated patient
39:06facing service available etcetera health.
39:09So they can call their doctor,
39:10right,
39:11They call their doctor and try to
39:12get help or they call this dedicated
39:14professionals and they figure this
39:15out very quickly that they can call
39:17these folks and we figured out very
39:19quickly we need to train these folks
39:20to better service the needs of our patients,
39:22how do they get into the mobile
39:24app to be able to connect.
39:25Video,
39:26how do they handle when the video
39:28cuts out or the audio cuts out,
39:30these sorts of things.
39:31So we actually did really very quickly
39:33in addition to training the clinicians
39:36to to deliver video of virtual care,
39:38we actually had to train these this,
39:40this team and one of our quality measures
39:42is to look at the the various traffic
39:45if you will that comes into the center.
39:47So you can see here in this
39:49graph there's sort of four bars.
39:50That shows essentially calls.
39:53So I should step back and say one
39:56other thing we we wanted to sort
39:58of to to match or to model our our,
40:01our idea.
40:02We're an Omni channel organization, right.
40:04So we offer calls,
40:05we offer in person,
40:07we offer asynchronous messaging,
40:09we offer video,
40:10We thought we ought to offer support
40:12and those veins as well so patients can
40:15either call the number send messages.
40:17And we've actually instituted an
40:19online chat a la Amazon to borrow
40:21something from John's neck of the
40:23woods where patients could actually.
40:25And we had, we had,
40:26we had envisioned this in the
40:27concept of you're in a,
40:28you're in a in a like let's say a
40:31tech workspace and you have cubes and
40:32you don't want to say I have a rash out loud,
40:34but that's how we envisioned
40:37the service being deployed.
40:38And but obviously people are working
40:40from home now but that's how this works.
40:42It's an online chat featured
40:44like they're in like into Amazon
40:46and you can chat with somebody.
40:48And by the way one of the things
40:49we found is people start using
40:50other languages with this.
40:51So it turns out our our well you
40:55know go figure and turns out we're
40:58in based in Utah where we happen
40:59to have lots of folks who
41:00have lots of language skills.
41:02So our our I should explain our clinical
41:04services are in California but our.
41:06Patient service center is
41:07actually based in Utah.
41:09So and and you can see one of these
41:13we've been tracking is what percentage
41:15of our total contacts are due to
41:17virtual care and to video visits,
41:19excuse me and did we see a change in that.
41:22So as we sort of you can sort of see
41:24the curve that's the the green line
41:27once you started figuring out some
41:28of the Q core challenges that left
41:31that equated to some opportunity.
41:33So for example if we saw lots
41:35of hardware troubles we.
41:36I use that to identify where the the key
41:39bugs are and fix them and see what happens.
41:41And so that's how we've been tracking
41:43this data because because the other
41:45thing we noticed with with doctors and
41:48and I'll pick up my my colleagues as
41:50doctors not our other clinic clinicians,
41:52they very often say you know we
41:54have this catastrophic problem.
41:55It always breaks that's what they always
41:57say it always breaks and every single
41:59my video visits fail and then you look
42:01at the data it doesn't and John's smiley.
42:04And it turns out that's not true,
42:05right.
42:05I mean so they tend to be unreliable
42:08historians for our clinicians on the call,
42:11right.
42:11So we actually turn to the
42:13patients and say hey how many,
42:14you know,
42:15how many virtual you know video
42:16visit calls are we getting from our
42:19patients And we use that as a as
42:20a marker of saying as it getting
42:22better or worse or the same.
42:24And you can see here as we've tweaked
42:26things it's definitely gotten better.
42:27Next slide.
42:31Some other surrogate measures of what
42:34I'll call quality or or experience
42:36on the left is percent of the
42:39video visits of of overall visits,
42:41So percent of visits that were done
42:43by video versus the total overall.
42:45And what you'll see here as you've seen the
42:48sort of the pattern of the slopes here,
42:50like many organizations,
42:50we saw a very High Peak at the beginning
42:53of the pandemic and then a gradual
42:55plateauing or dropping of the overall number.
42:57One of the things I point out to my team.
43:01Thank. Thanks Lee.
43:02For sure one of the things I'll point out
43:04for my team is the following observation.
43:06You know we had up to four upwards of
43:0840 or 50% actually I think Max was
43:1140% overall of our care being done
43:14via video visit and some especially
43:16is like behavioral health.
43:18We we continue to see it like
43:19over upwards or over 90%.
43:21So we were seeing these sort of
43:23patterns and then but overall we
43:25have seen this this shift towards
43:27coming back more in person.
43:29And we've we've flat out about 10 to
43:3115% that's what we're looking at today.
43:33And so my team was kind of lamenting
43:35this fact.
43:35I said wait guys remember what
43:37I told you 2019, we did 7400,
43:39we're now doing 10 to 15% of our
43:42overall visit volume this way.
43:44It's we've really changed the landscape,
43:46we've really changed the the the
43:49experience of what patients can expect
43:51and see. So, so we're looking at this.
43:55And one of the things we wanted
43:56to use this metric to to,
43:58to check is if we start seeing dips,
44:02because we did see some dips,
44:03it's not clear this part of the graph.
44:07Yeah,
44:07some of the darkest green in the
44:09map in San Diego maybe, Yeah.
44:12But one of the things we we wanted
44:14to track as sort of a surrogate
44:16measure was are doctors starting
44:17to pull away from virtual, right.
44:19If there were more technical
44:21barriers with the will,
44:23we see the volume drop and you
44:24can see every foot of plateaued,
44:25which is interesting.
44:28On the right hand side is another thing.
44:30As we all know, we have all,
44:31we all have life things besides medicine.
44:33At least, you know,
44:34I like to say we we hopefully do.
44:36And so one of the things we tried
44:38to empower is remember when I said
44:41we actually didn't we we we didn't
44:43put in cameras in every exam room.
44:44We actually,
44:45we gave every doctor to every
44:47clinician a tablet.
44:48And then we,
44:49we started noticing this
44:50interesting experiment.
44:51One of the things we asked for
44:53them to do is if they were going
44:54to do a video visit from home,
44:56please put in this little marker,
44:57this little code so we can track
44:59you and track that to see what
45:00what volumes we were seeing.
45:01And this is how we were asked.
45:03We were able to ascertain that upwards of
45:0525% of our video business rush
45:07should be done in in the homes of
45:10our clinicians by the clinicians,
45:11so which is fascinating.
45:13And I started asking them why
45:15and they said, well look,
45:16I have to pick up my kids, right?
45:18You know, I still got to
45:19do my Epic in Baskets.
45:21Sorry all due respect to my friends at Epic,
45:26this has given me tremendous flexibility.
45:30And so the and so we're and
45:32these volumes are are persisting.
45:33We have seen that people are some
45:35of our colleagues are really
45:36changing the way they practice.
45:38They can imagine having a day or half a day
45:41a week that's truly dedicated to virtual.
45:43And they can figure out how to schedule
45:45that out and how to segment that out again,
45:47to be to be more accommodative with
45:50their personal leads in addition
45:51to their professional leads.
45:53And in fact, I think what I found it too
45:55is this allows me some flexibility in my day.
45:58So if there's a patient who wants to
46:01be seen at night and it happens to fit
46:03after put the kids to bed, why not, right?
46:05Why not do that?
46:06I'm not saying it's an expectation
46:07that we all should have or share,
46:08but it gives you that flexibility,
46:10that option.
46:11And that's something we we we
46:13couldn't have had if we had actually
46:15put in cameras in every exam row
46:17throughout the system.
46:18Next slide
46:22and this is again back to
46:24the point about patients,
46:25my final slide as we lead into discussion,
46:28one of the things we wanted to
46:30do is have a very robust sort
46:32overseer of this patient experience
46:35instead of these episodic data, so.
46:39This coincided with an effort by our system
46:41to to develop patient and family advisors.
46:45And so I thought to myself, okay,
46:46why don't we try to recruit E patient family
46:50advisors specifically for digital health.
46:52These guys can these patients,
46:54these patient volunteers
46:56can help us track issues,
46:57they can help us walk through
47:00upcoming new features.
47:01They can be our our golden testers when
47:03we go live with new functionality.
47:05So as we we I don't know I think
47:08many of us have experienced this
47:10where we go live with the feature.
47:12It works pretty well on on the Sunday that
47:13we first launched cuz Saturday night.
47:15When it gets implemented Sunday
47:16night works OK Monday night works OK.
47:18Tuesday the blankets the fan because
47:20we actually we ramped up the number
47:22of people using it and we saw
47:24this this thing happen.
47:25So one of the things these the
47:27EPF A's for digital health do is
47:29they give us early signal, right.
47:31It's sort of like early post
47:32marketing surveillance.
47:33They actually we asked them to go ahead
47:35and start testing as patients with
47:37their own workflows not the ones we dream of.
47:40And they actually help us you know with
47:41their own workflows and their own needs.
47:43They punch holes in our build and
47:45help us capture things we didn't
47:47capture pretesting or you know in our,
47:49in our, in our purchase.
47:52Anyway,
47:52I hope that was useful and adjunctive.
47:54And so I'm headed back over to John.
47:57Great. Thanks, Albert.
47:58So I'm going to kick things
48:01off with the first question.
48:02And just reminder for our attendees,
48:04if you want to type any
48:05question in the Q&amp;A box,
48:07so we'll pick it up.
48:08And so I want to kick us off with the,
48:10the last objective,
48:12which was to to name a barrier that
48:15you encountered in setting up your Qi
48:17program and how you overcame that.
48:21So maybe if I can start with Doctor
48:23Peoples or Doctor Chan and then I'll
48:25chime in with my own experience.
48:28Sure, sure. Great question John.
48:30And I think you know in the field
48:32of rheumatology, I'll kind of use
48:34rheumatoid arthritis as an example.
48:36When we start looking at some quality
48:38improvement measures in the care
48:40of rheumatoid arthritis patients,
48:41a lot of focus is on measuring
48:44disease activity.
48:44You know we know we need to
48:47diagnose rheumatoid arthritis early.
48:48We need to get patients on appropriate
48:51disease modifying treatments.
48:52We need to treat the target
48:54which is low disease activity.
48:56And so while we have choices six 7-8
49:01different disease activity metrics,
49:03when we look at the disease activity
49:06measures that involve components of
49:08the physical exam at the beginning
49:10we start to get tripped up because
49:12you know that really has relied on in
49:14studies and and and and things like that on.
49:17The physician or medical provider
49:20laying the hands of the patient
49:22and feeling if the joint is swollen
49:24and then assessing tenderness.
49:25And so when we thought about that,
49:28well, I'm not obviously putting my
49:30hands on that patient's joints.
49:32You know, telepresenting RN is doing that.
49:36And so can we use that?
49:38Is that the same?
49:39Is that the same type of thing?
49:40Do we need to look at that differently?
49:43And then kind of extrapolating
49:44that to home video visits with
49:46patients doing their own exam,
49:47I think this came up earlier today
49:49with rheumatoid arthritis and
49:50patients doing their own exam,
49:52especially those that are in
49:53registries and research studies.
49:55So when we look at studies of patients
49:57kind of doing their own exam for
49:59rheumatoid arthritis disease activity,
50:01you know,
50:01they can certainly tell us a lot
50:03about what they can do at home
50:04and what they can't do.
50:05But looking at kind of tender and
50:07swollen joints ends up, you know,
50:09being an issue.
50:10And so you know patients and
50:12and physicians and providers,
50:13the assessment of joint tenderness is,
50:15is is pretty consistent,
50:16it's the joint swelling that tends
50:19to be a little bit less you know you
50:21know congruent with with both the
50:23provider physician and the patient.
50:24And so when we look at the quality,
50:27when you look at how patients with
50:29rheumatoid arthritis do when they get
50:31their care at our telehealth center,
50:32I mean look at those metrics,
50:34which metrics should you use,
50:35what's the best one and can we
50:37kind of take the step?
50:39With some of the physical exam components,
50:41you know can we still use those and
50:43look at those similarly or should
50:45they be looked at differently
50:46when we look at those outcomes.
50:48And so I think that's you know
50:50for chronic disease management in
50:52patients that I see with underlying
50:54systemic rheumatic diseases over
50:55time this keeps this always comes up.
50:57Because we don't really have you know,
51:00you know a blood test and patients
51:01go and get it and then that's the end
51:02of the story for disease activity.
51:04We just don't operate in that framework.
51:06And so with rheumatology it's hard
51:08to tease out some
51:09of these issues especially when you're
51:11providing virtual care versus kind of
51:14patient joint exam, RN joint exam,
51:16you know PCP or other provider joint exam,
51:18you know things like that.
51:19What can we take into account to kind of
51:21drive what metrics we look at for quality.
51:24Right. Thanks. Thanks Christine.
51:27Albert, one barrier that you you
51:29had how'd you go for comment?
51:31Sure. Thanks John.
51:31I I think I have a pet peeve to share
51:34with everyone which is why is it that we,
51:37I think all of us clinicians can figure
51:39out what are the things we want to measure,
51:41but each institution and we're we use
51:43many of us use the same EMR, right.
51:45EHR, why are we always having
51:47to individually as individual
51:48organizations have to figure out
51:50how to actually quantify these data?
51:53Like why do we have to go figure
51:54out our own queries and figure
51:55and do the mappings and all that
51:56stuff to figure this out?
51:57This seems to me be to be crazy.
51:59And one of the things I've been
52:01saying to our partners is can we
52:03as we launch a new tool can we
52:05anticipate the measures we should have.
52:06And you guys you deliver those
52:08reports to us in anticipation like
52:09upfront please because that would
52:11that would actually help us measure
52:13from and then had the experience.
52:16That's a great point Albert
52:18about just just getting data and.
52:20To the extent that you can make the
52:23data like automatic you know doing
52:25hand extractions and hand counts
52:26that can can really get tedious.
52:28So I think that's a really great point.
52:31I'll share something from from Seattle
52:34and that's around reporting so and
52:36kind of being very clear what kind of
52:38events come to telehealth and which
52:40come to the clinical department.
52:42So I'll share what we've done
52:45around Telestroke so.
52:46You know if if there's a safety
52:48event where someone got TPA when
52:50and they shouldn't have.
52:51I I'm not a neurologist I can't say
52:54that that was a bad event or not and
52:57it has nothing to do with telehealth.
52:58So that you know that's a very obvious
53:00example but sometimes teasing out
53:02how much of this was telehealth,
53:04how much of this was actually the
53:06clinical care you you need to be
53:08very specific and make sure that
53:10you know the that the issue doesn't
53:12get dropped it doesn't fall between
53:15the the cracks there so.
53:16So that that's really helpful.
53:18I wanted to come back to Dr.
53:19Peoples and and one thing that
53:21struck me John,
53:23just sorry before you leave that topic,
53:24I just wanted to, I just wanted to answer
53:26that question you posed and flag another
53:29issue which is the challenge of aggregating.
53:33So our solutions reporting system that
53:36we use for reporting any adverse events
53:39or quality gaps doesn't allow us to.
53:43You know, say oh this happened in
53:45a telehealth context if that's
53:47not the substance of the report,
53:49so let's just say that there was a,
53:51you know, adverse prescribing behavior.
53:54I I prescribed the wrong antibiotic.
53:57We would see that as an antibiotic
53:58problem unless they said this happened
54:00during a telehealth visit and there
54:02was some check box, we could say oh
54:04let's aggregate those all together.
54:06Is there a pattern,
54:07so this concept of the taxonomy and being
54:10able to aggregate based on modality type.
54:13We we can do that if we
54:16link them to the encounter,
54:17the actual encounter,
54:18and then figure out whether it was
54:20a telemedicine encounter or not.
54:21But I think we need a better framework
54:24for that so that we can all pull
54:26the same denominators if we want
54:28to run reports across institutions
54:29to try to compare rates of of,
54:31you know, adverse effects.
54:34Yeah, very good point. And and Lee,
54:36we actually had this issue because when
54:39we went live in 2020, we had two Emr's.
54:42Our inpatient was Cerner and our
54:44outpatient was epic. So and it was,
54:45it was it was like just driving us crazy.
54:48So we finally went to 1 EMR and
54:49that's made it a lot easier.
54:51But yeah, garbage in,
54:53garbage out if the data is not good,
54:55great point.
54:56I I wanted to turn to this topic
54:59of the digital divide.
55:00We've talked about this and a
55:02couple other panels and really
55:04interested from the the panelists.
55:06How are you interacting with folks
55:09at your organization around digital,
55:11the digital divide,
55:12Is this part of your your job in Qi
55:17with telemedicine or you know that you
55:21have a separate group and and how do you,
55:22how do you work together And and
55:24maybe I can start with you Lee,
55:25because I know you've done some great
55:26work at Mass General and if you could
55:28share what you guys are doing there?
55:30Yeah, we we we embraced this early
55:32on in part because I was quite
55:35interested in this phenomenon and and
55:37also because we had actually at our
55:40peak around 62% of all visits after
55:42six weeks we're we're being done
55:44virtual and we saw right away as did
55:47others and the UCSF report early on
55:49in the Catalyst that older patients,
55:51patients who didn't speak English
55:53or limited digital literacy were
55:55were the most vulnerable.
55:57So we did a couple things.
55:58One, we were fortunate that in Massachusetts
56:00we got reimbursement for audio only.
56:02So we were able to massively convert
56:05those things into audio only visits,
56:08have them as structured visits with
56:10Med rack and you know documentation
56:11of the plan and all that.
56:13And so that was really important
56:15lifeline for us.
56:16But we've also as you know John cuz you've.
56:20On this grant with us,
56:21we submitted a grant to our self
56:23insured risk management foundation
56:25and we have a grant actually to try to
56:27study with digital discovery agents
56:30why patients are having trouble.
56:32I mean we have a lot of assumptions
56:33and I think there's a big risk of
56:35implicit bias here about what exactly is
56:37the underlying nature of the digital divide.
56:40I suspect it's very heterogeneous.
56:42I suspect we'll need a multi pronged
56:44intervention language alone.
56:45Not enough.
56:46Videos that explain the thing you know,
56:49unique to every operating system and device,
56:51helpful,
56:51but probably not enough.
56:53Some of this will be due to poverty
56:55and things we can't overcome.
56:56And what we're focused on now is also
56:59trying to understand in a way that is UN
57:02that is not going to lead to any form of.
57:06Inappropriate ascertainment or
57:07application Can we identify through
57:10the EHR patients who are likely
57:13to struggle with a virtual visit
57:15and either see them in person or
57:17direct them to a more intensive?
57:19Training and experience center
57:21to teach them how to be able to
57:24conduct a virtual visit.
57:25And in the future,
57:26we're going to try to collect information
57:28about our patients communication
57:30capabilities as part of their profiles.
57:33So we'll be able to know if you're
57:35equipped for telemedicine or not
57:36when we think about scheduling.
57:38So those are just some of the
57:39things that we're grappling with.
57:41Great. Thanks, Lee, Christine or Albert,
57:43I think we've got about two minutes left.
57:47So one of the things that's happened
57:48with with our virtual care,
57:50you know, virtual care experiences,
57:51it made us pull data.
57:53We, I saw the same article you did Lee,
57:56about the UCSF experience and I said,
57:58oh, let me look. So let's,
58:00let's take a look under the covers.
58:01And I said, Oh my gosh,
58:03our Spanish speaking patients are so
58:05much lower both in in our my chart
58:07adoption and therefore subsequently
58:08the use of our virtual care platform.
58:11And I thought, OK,
58:12so one of the things that I can
58:13do with this is let us look.
58:15And I systematically look from end
58:17to end from the enrollment parts,
58:19the educational parts, the FA Q's,
58:21even toward downstream support
58:22of our patients via that center.
58:25Utah, what parts were in,
58:27in multiple languages including Spanish,
58:29turns out not very many.
58:31So one of the things that's
58:32happened is we've actually take it,
58:33take a systematic look at all our pages,
58:35all our even our contracts with
58:36experience to do the online
58:38enrollment automatically,
58:39automatically and turn those in to
58:41be Spanish, be Spanish capable.
58:43So they actually hopefully lead
58:45to some of the infrastructure last
58:47mile solutions and get us the
58:49patients to equal access that
58:51that's our current approach.
58:55And Christine?
58:58My kind of what we end up doing is,
59:00is not very sophisticated,
59:01but we really kind of implore and and try
59:04to help family members out with patients.
59:06And so for patients I see in rural areas,
59:08there's a Wi-Fi issue,
59:11there's a device issue,
59:13there's often a hearing issue and things.
59:16And so if family members come to visit,
59:18which is pretty common,
59:19I mean we that often happens
59:21because people are pretty local
59:22and they don't have to travel far.
59:24You know, I asked them, you know,
59:25can you help if we need to do you know
59:27a video at home to kind of check in on
59:30things you know and so patients will often,
59:32you know, kind of their,
59:33you know, daughter, son,
59:35granddaughter sometimes, you know,
59:36we'll get them a device and
59:37and then help them set it up.
59:39And they kind of I kind of it's really
59:41kind of preparation for the visit.
59:42I kind of say you know get an
59:45expensive you know device stand,
59:47you know go in the kitchen with
59:48the table or dining room table and
59:50you know just be there, you know,
59:51for the visit.
59:52It's actually very helpful and then.
59:54The family member is often involved
59:56in their care anyway,
59:57so it's a helpful kind of visit
59:59and so I try to think you know,
01:00:01outside the box in terms of getting
01:00:03them the access that they need because.
01:00:05You know,
01:00:06right now I'm not in a position to fix
01:00:08the broadband issues or the device issues.
01:00:10But and then I will also say that a
01:00:13lot of patients that I care for or
01:00:15in nursing homes or assisted living
01:00:17facilities and they've been very good
01:00:19about getting devices for those residents.
01:00:21And so we again,
01:00:22you know,
01:00:23previsit preparation,
01:00:24get the visit scheduled,
01:00:26make sure there's staff there to help
01:00:27them and the devices there and we
01:00:29don't we kind of work around the Wi-Fi.
01:00:31Issue and then you know for kind of
01:00:33in between visits and emails and
01:00:35things a lot of patients of mine
01:00:37they go to their local library and
01:00:38and log on which is obviously not
01:00:40great for a visit but certainly we
01:00:41can do you know emailing that way.
01:00:43And so just trying to think about
01:00:45what's available until we kind
01:00:47of have a statewide and really
01:00:48nationwide and international kind of
01:00:50improvement in a lot of these things.
01:00:53Great. Thanks so much.
01:00:54So I want to thank my
01:00:56fellow panelists for their.
01:00:58Have really insightful comments
01:00:59and ideals they've shared and
01:01:01I want to turn it back over to
01:01:03Lee for our next presentation.