Panel 2: Developing a Framework for Virtual Care Quality

July 12, 2023

Information

Panelists: Bart Demaerschalk, MD (moderator), Zarrina Bobokalonova, RN, Jordan Coffey, Jason Goldwater, Kristin Rising, MD

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00:00Thank you all of the members of panel one.
00:03That was a terrific introduction to
00:05the topic and I think raised a lot
00:08of issues that Panel 2 will now start
00:10to address in the form of a framework
00:13for actual virtual care quality.
00:15So if I can have the next slide, please,
00:17I'm delighted to introduce panel two
00:20and my good friend Bart Demarshak,
00:23who is going to talk to us about this topic
00:27and and lead his distinguished panel of.
00:30Of. Of. Of panelists. Excuse me.
00:33So for those of you who don't know Bart,
00:35he is professor of Neurology and medical
00:37director of research Quality and outcomes
00:39in the Center for Digital Health at the
00:42Mayo Clinic College of Medicine and Science.
00:44A long time telehealth pioneer and
00:48early telestroke adopter who has
00:50moved kind of up the value chain to.
00:53Lead and develop programs for
00:57telemedicine virtual care across the
00:59care continuum and has had a lot of
01:03experience thinking about the ways
01:05that we measure quality overall.
01:07And in fact,
01:08we worked together on a a quality
01:09measurement statement for the
01:11American Heart Association and the
01:13American Telemedicine Association.
01:14So we're delighted to have Bart join us
01:17and lead his panel through this conversation.
01:20And Bart,
01:20I'll turn it over to you.
01:23Thank you very much Lee.
01:24Are you able to hear me? Perfect.
01:29Well, good day to all of you.
01:32We're we're we're very excited
01:35at the number of participants in
01:38this symposium and I'm delighted
01:40to be working with a tremendous
01:43colleagues on this panel.
01:47The stage is being set.
01:50With the first panel discussion regarding
01:52the general principles of quality
01:54measurement for virtual care and the
01:56responsibility that we have for panel
01:59two is to share with you a number of
02:04examples of frameworks for virtual care,
02:07quality assessments and presentations
02:10that have been developed and adopted by
02:14a number of healthcare organizations,
02:17first and foremost, Secondly.
02:19We're going to have a a panel discussion
02:23regarding what we have observed and
02:26recognized as some of the most common
02:29similarities between these frameworks,
02:32some of the differences between the
02:35frameworks and then what we have
02:37believed is probably the most rich and
02:40interesting part of the discussion is,
02:43is for each of us to reflect
02:45on and share with you.
02:47What have been the greatest complexities,
02:51the gaps, the missteps?
02:54What what? What?
02:56What have we observed regarding the
02:59vulnerabilities of these frameworks?
03:02Which Which of the elements of the
03:04frameworks have been most rigorous?
03:05Which have been most vulnerable?
03:07What have we changed over time?
03:11I'll make a just a few opening additional
03:14remarks each of our panelists.
03:17Will have approximately 10 minutes
03:19to take and share with you a few
03:22slides that are representative of this
03:26topic And that should leave ample
03:29time for us to address objectives
03:31#2 and three in a discussion mode.
03:34And like in the first panel,
03:37please to all of you participants,
03:39don't hesitate to pose questions
03:42in the Q&amp;A and myself and.
03:46Our our symposium facilitators
03:49will ensure that we've viewed those
03:52and and we take an opportunity
03:55to answer them as as we go.
03:57I'll make,
03:58I'll make introductions of all the
04:00panelists at the start and then
04:02we'll invite one after the other
04:04to to to share their slide set.
04:08Jason Goldwater is a senior researcher.
04:12Scientists at Index Analytics
04:14and I've had the opportunity,
04:16along with these panelists to to
04:17meet and discuss with Jason this
04:19topic now for a number of weeks
04:21leading up to the symposium.
04:22He has a bachelor's and master's
04:24degree in Emerson and a master's
04:26in public administration,
04:28and he has 24 years of health
04:31information technology experience,
04:33and he's a master at helping people
04:37understand the intersection.
04:39Of data, technology and healthcare.
04:41So I do.
04:43Ideally suited for a topic on
04:46quality and virtual care.
04:48Jordan Coffey is a close friend,
04:52a colleague,
04:53and a partner of mine at Mayo Clinic
04:55College of Medicine and Science.
04:57He's the director of Digital
04:59Health Practice Enablement Unit
05:00for Research Quality and Outcomes,
05:02and we partner in that endeavor.
05:04He has a bachelor's degree in chemistry
05:07and MB a a master's of health.
05:09Care administration and 15 years
05:12of research experience the majority
05:15of those now in in exclusively
05:17in digital healthcare.
05:20Zarina Baba Clenova is the executive
05:23director for Ambulatory Quality
05:25and Population Health at Stanford,
05:28and she has a bachelor's degree in
05:30International Economics of a Masters
05:31of Arts and Jurisprudence and a
05:34bachelor's and masters in Nursing.
05:36She has influenced Stanford's.
05:38First step in enterprisewide
05:40adoption and approach to quality
05:43Improvement for Population Health
05:46Goals and Kristen Rising.
05:48Doctor Rising is an associate professor
05:51and Director of Acute Care Transition
05:54in the Department of Emergency Medicine.
05:56She was one of the founding directors
05:58of Jefferson Center for Connected Care,
06:00her medical degree from the University
06:02of California in San Francisco,
06:03and her emergency medicine
06:05training at Boston Medical Center.
06:07And Masters of Science and Health
06:10Policy Research at University
06:12of Pennsylvania like like all of
06:15the panelists in panel one we've
06:17had a lot of fun with this topic.
06:20In fact the the the discussion has
06:23been lively leading up to this
06:26symposium and and again like like
06:29you've heard from panel one we
06:32appreciate input questions and and.
06:34From the from the participants
06:37so so let's begin.
06:38Jason can I invite you to
06:41to share your slides.
06:43Be happy to
06:44and thank you very much to everybody.
06:46It's great to be online.
06:49I apologize for the void
06:51that is my picture on video.
06:54I do not look like this normally but for
06:57some reason Zoom just hates me today so.
07:00My picture is not going to be on.
07:03But there are those that
07:04know what I look like.
07:05So just envisioned in your mind
07:07and it's still the same me. Jason.
07:10Sometimes quality is just invisible. Yes.
07:12Though you're very sweet.
07:14Doctor strong. Thank you.
07:16And I really do want to thank doctor
07:19Demarchek for that wonderful introduction.
07:21I you make me sound 10 times more
07:23impressive than I actually am,
07:25as Kristen and Judd will attest to.
07:28So what I want to do today is really
07:30sort of talk about the measurement
07:33framework that the National Quality Forum
07:36developed to help catalyze the creation
07:39of measurement specific to telehealth.
07:42I worked for the National
07:44Quality Forum starting in 2015,
07:46all the way up to the end of 2018,
07:49and while I was there,
07:51one of the projects that I had the great
07:55honor of leading was this framework.
07:57That would provide a platform to
08:00develop measures around telehealth.
08:02The National Quality Forum cannot
08:04develop quality measures because it
08:07is an arbiter that determine what
08:09measures should be endorsed based upon
08:11a very select and very strict criteria.
08:14And then those endorsed measures are
08:16usually the ones that you see in value
08:18based programs across the country.
08:19But what the National Quality Forum can
08:23do is create a framework that provides a.
08:27Platform that gives domains of area
08:30and areas of which measurement is
08:32needed and provides guidelines on how
08:35those measures should be developed.
08:38So we formed a committee of 20 highly
08:41sought after highly knowledgeable
08:44experts on telehealth,
08:46some of which I'm sure on this call,
08:48and we have the great joy of Judd Hollander
08:50being one of the chairs of that group.
08:52And from that then we decided that we would.
08:56Work through the process of framework
08:59development and start with elements and
09:02then move down into the categories of
09:04which telemalth measurement was needed.
09:07So the way a framework works is
09:10that you have a conceptual model.
09:13What are the important areas of telehealth?
09:16If we're going to measure what are
09:18the things that we want to measure?
09:20We then move into domains.
09:23Which are a grouping of high
09:26level ideas and concepts.
09:27So like access to care or cost of telehealth,
09:32That is a idea, it's a concept.
09:34And then from that then what domain
09:37subdomains do we need to have under those?
09:40So you have access to care as a
09:43large domain and under that it's
09:45access to care for a patient,
09:48providers being able to deliver access
09:50to care through telehealth and so forth.
09:53So it's a more finite set of
09:55categories under a specific domain.
09:58And then from that then you start
10:00developing concepts for measures.
10:01And it's important to understand
10:03that we're talking about concepts,
10:05not measures themselves.
10:06We're not talking about a formal measure
10:09with the numerator and and a denominator.
10:12What we're talking about is a concept
10:15around access for patient travel.
10:18Or the overall experience of care for
10:20a patient when they are in a telehealth
10:23encounter or the effectiveness
10:25from a technical standpoint of
10:27the telehealth platform.
10:28That's a concept for a measure.
10:30And then from those concepts you
10:33think how could we measure this?
10:35What information do we need to get
10:38that would allow us to build a
10:40measure that aligns with this concept
10:43which subsequently aligns with a sub
10:45domain and a domain. Next slide.
10:51So the telehealth measurement framework,
10:54you know, we had a wonderful,
10:56wonderful committee.
10:57I mean, really people that were
11:00leaders in this area that had
11:02obviously been doing this for a very,
11:03very long time and clearly understood some
11:06of the most prevalent issues around LL.
11:10And so when we talked about this,
11:12we're like what domains
11:13do we need to start with?
11:15And it was fairly unanimous that
11:17the four areas that became really
11:20critical were access to care on
11:23the financial impact and the cost,
11:25the overall experience and then
11:27the effectiveness of telehealth.
11:29And then underneath that,
11:30we got a little bit more granular by
11:33talking about access to care for a patient,
11:35for a family,
11:36for a care team or access to the
11:39appropriate information during
11:40a telehealth encounter for both
11:42the patient and the provider.
11:45We talked about the financial
11:46impact and cost for the patient,
11:48for the family, for the care team,
11:50for the health system,
11:51for the payer and then overall for society.
11:55And having just recently completed
11:57a a large national cost benefit
12:00study on telehealth during COVID,
12:03I can tell you there are absolutely
12:05societal and costs that have
12:08to be considered.
12:09Then there is the experience,
12:10which is the overall experience of the
12:13telehealth encounter for the patient.
12:14For the family,
12:15for the care team and for the community.
12:18And from an effectiveness standpoint,
12:20looking at 4 very distinct categories,
12:23the system effectiveness,
12:25clinical effectiveness,
12:26operational effectiveness
12:27and technical effectiveness.
12:30Those all were deemed by the
12:31committee to be the most critical
12:34and important areas of telehealth
12:36in which measures were needed.
12:38Next slide.
12:42So how do we then take that pathway
12:45that we developed with the domains and
12:47the subdomains and narrow that down to
12:50facilitate the development of measures?
12:52So we asked the committee,
12:54let's get even more granular,
12:56let's get more finite.
12:57What are the real critical areas that
13:01relate to these domains and subdomains
13:04in which measures would be beneficial,
13:07would advance telehealth
13:09and would show the utility?
13:11And the committee said,
13:12these are the six things that we
13:15really should be focusing on.
13:16Telehealth and care coordination,
13:18the empowerment of the patient and the
13:21provider during the telehealth encounter.
13:24What added value does a
13:27telehealth service provide?
13:28Does the telehealth service
13:30provide actionable information?
13:32And this was viewed as very critical and
13:34that is during the course of an encounter.
13:37Does the provider receive enough
13:39information to know what to do next?
13:42Do they have enough that they can be?
13:44They can act on timeliness.
13:47Do you provide care in a timely manner?
13:50So not care three days after an incident,
13:53but care very shortly
13:54after an incident occurs?
13:56And then finally patient travel?
13:57This has always been thought of as one
14:00of the advantages of telehealth in that.
14:02You don't have to get into a car
14:04or take public transportation
14:05to get to a provider facility.
14:08You can use telehealth to
14:09make that connection.
14:10And again the cost benefit study
14:12that we just I just completed with
14:15my wife really shows how critical
14:17travel is as a way of as an area
14:21of telehealth that really should
14:22be measured and that a lot of the
14:25individuals that we looked at lived
14:26in areas of which there was no
14:28provider within a close proximity.
14:30Sometimes 75 to 150 miles away one way.
14:35And given the seriousness of their condition,
14:38care was needed immediately,
14:39so it had to be timely.
14:41Otherwise there might have been
14:44exacerbations of that condition itself.
14:46So I really think even though this
14:49was created in 2016 and right 2021,
14:52all of these areas are still incredibly
14:55valid and I think even more meaningful.
14:59As we head into in 2021,
15:03next slide.
15:05So how do we leverage this framework
15:08for acceptance Now mind you we
15:10created this prior to COVID,
15:11so this has changed a little bit in
15:14that COVID really showed what the
15:16value and utility of telehealth can be.
15:19You know the if you incorporate
15:22telehealth as we have seen it really
15:25does integrate with that triple aim.
15:28It's patient focused.
15:29Because it allows the patient to
15:31have an active conversation or
15:33dialogue with their provider,
15:34it provides quality and that
15:36it's timely access to care.
15:38There are numerous modalities
15:39as everyone has now seen.
15:41It's not just video,
15:43it is also remote monitoring.
15:45It is store and forward.
15:46There are mobile devices and we saw the
15:49addition of audio only telehealth services.
15:53It's comprehensive care.
15:54In that the patient can continually
15:57engage in a dialogue and through
15:59several encounters with a provider,
16:01and you can also have a
16:04tear team coordinate with
16:05a patient virtually.
16:07It does lead to quality improvement
16:09and not so much as a comparison
16:12between telehealth and in person care.
16:15I know Judd and I have been talking
16:18about this as long as I can remember,
16:20but and I think COVID made this
16:22abundantly clear, it's not.
16:24Correct. I think to just look
16:26at telehealth versus in person,
16:28it really is important to look at telehealth
16:30versus not getting any care at all.
16:32And had telehealth not been
16:34available during COVID,
16:36you're talking about millions of people
16:38not having access to needed care.
16:41And then you can see what the
16:43results are because again,
16:44engaging and continue with conversation,
16:47dialogue and encounters for the
16:50provider allows measurable results.
16:52So by developing these measures,
16:53delineate in the framework,
16:55the telehealth focus will turn
16:57to what telehealth can provide,
16:59what its impact on quality is,
17:00how it improves health for populations,
17:03how it reduces costs.
17:04And we did see in our study that
17:06there are significant cost savings for
17:09Medicare and Medicaid through telehealth,
17:11especially the more you use it or it
17:15can keep cost of budget neutral and
17:17what its limitations may also be.
17:20Next slide.
17:24And that is it for me. Thank you so much.
17:27Great, thank you so much Jason.
17:30I'm so excited to follow Jason in
17:32the work that the heated with the
17:34national quality form as you'll see
17:36is as we share a little bit about
17:37Mayo Clinic's recent experience,
17:39there will be a lot of similarities
17:41in the concepts that he outlined.
17:42We we definitely borrowed on the experience,
17:45the knowledge, the recommendations
17:46of the national quality form as we
17:49started to think about you know what.
17:50What does value and quality look
17:52like for telehealth services at
17:54at Mayo Clinic for the patients
17:56and the care teams that we serve?
17:58So really quickly I want to recognize
18:00that we we acknowledge today's
18:02conversation is is focused around quality,
18:05but we also recognize that there's
18:07often a continuum and a bit of a
18:09conflation between the concepts
18:11of of quality and and value.
18:13And really part of this stems from
18:15you know what we think is a lack
18:17of a common and generally accepted
18:18definition of value with organization.
18:20Patients, you know,
18:21having a natural tendency to focus on
18:24features rather than understanding
18:26that the true reason why they're users,
18:28albeit patients care teams turn to
18:32telehealth as a enabling approach.
18:35So you'll have to indulge us because
18:37a lot of today's conversation within
18:39our side is going to acknowledge
18:41the term value of which quality
18:43is an intrinsic part.
18:46So really, at its core,
18:48we feel in organizations,
18:49products or services really have
18:51no intrinsic value themselves.
18:53Instead,
18:54it's the context that determines how
18:57users form these perceptions of value.
19:00At Mayo Clinic,
19:01we really wanted to ground
19:02our value definition.
19:03Or the understandings of a potential
19:06levers to pull in order to enact impact
19:09for our users to be based on best
19:12practice and to be iterative and and
19:14based on continuous learning as well.
19:17So with that in mind,
19:18you know we we conducted environmental
19:20scan to inform the development
19:22of of our framework to identify
19:25existing measures and measure
19:27concepts related to telehealth and
19:29really try to inform them based on.
19:32Concepts and frameworks like this one
19:34that that has been so vitally important
19:36that's offered up by the American
19:38Medical Association stringing together,
19:40you know the the different domains and
19:44subdomains of of value with some of
19:47the important environmental concepts
19:49which also impact those value value
19:51dimensions to create an overall value stream.
19:54Next slide please.
19:55Again,
19:55like you heard our our first
19:58panelists touch on really telehealth
20:00in itself does not represent a
20:02different type of healthcare,
20:04rather a different modality of
20:06healthcare delivery and that was
20:08so well articulated among our our
20:10first panelists and so we'd be
20:12remiss if we didn't reflect on.
20:14You know some of the frameworks
20:15and core concepts of value,
20:16value and quality that have helped
20:18to frame up the conversation
20:20for healthcare in general.
20:22So we tried to ground again our
20:24our frame and our concepts in in
20:27some of the standards like those
20:29from the the quadruple aim.
20:32Next slide please.
20:35So using these concepts we as as kind
20:38of a basis we were able to construct
20:41a framework with four domains and
20:43it was validating when we became
20:46familiar with the national quality
20:48forums work as we actually had come to
20:51these four domains before uncovering
20:53their their recommendations and
20:55frameworks based on on other works
20:59around customer engagement and digital
21:01customer engagement in general.
21:03And so we we use these.
21:05To really organize and conceptualize
21:08our value leverages a lot of the same
21:11concepts as as Jason talked about
21:14from the National Quality Forum.
21:16Really we we tried to approach first
21:19with the concept of a framework or
21:21conceptional model around which to
21:23organize our idea and really to provide
21:26high level guidance and direction.
21:28On measurement priorities and and
21:30to organize the the potential impact
21:32that they'll have on healthcare
21:34delivery and outcomes within those.
21:37Then we focus down into domains,
21:39in this case, recognizing 4 domains,
21:41which represent the high level ideas
21:44and concepts that describe the
21:46measurement framework and help ensure
21:48that we're tracking performance against
21:50key priorities as we support the
21:52organizational goals within each of those.
21:55And you'll see this a little bit further.
21:57Is you know organizing this down
21:59into subdomains so that we can,
22:01you know better crystallize the categories
22:04and and groupings around these concepts.
22:06And then finally as as Jason just described,
22:09really getting down to those measured
22:12concepts which you know include that
22:14that description of the measure,
22:15not necessarily that numerator and
22:17denominator as he noted that we work
22:19through that and the application
22:20of this framework,
22:21but really making sure that we have some
22:24congruence around the concepts themselves.
22:26We really feel that this four domain
22:29model provides the a really great
22:31combination of utility and simplicity,
22:33well you know allowing a degree
22:36of of core accuracy.
22:39Again this builds on the themes that
22:41were established the the existing
22:43framework from the AM A I HI from
22:45National Quality Forum and other
22:47best practices from the the broader
22:50consumer space.
22:51I encourage people to look at works
22:54like that from Forester research around
22:57consumer value and value propositions.
23:00Really, we identified 4 dimensions.
23:02I'll go into those in a little
23:04bit more depth in a further slide.
23:06The economic dimension really or domain
23:09really representing financial costs,
23:12but also moderating those costs by
23:14effectiveness and safety of of the
23:17models or the programs that are deployed.
23:20The experiential domain describing
23:22the overall experience of either
23:25receiving or delivering care through
23:28these telehealth modalities.
23:30The functional domain describing
23:32the effectiveness and impacting the
23:34clinical operating environment in which
23:37we deploy our different telehealth
23:39services and then of course equity
23:42or access to clinical services.
23:44Again,
23:45we'll describe in a little bit more detail.
23:49You can go ahead to the next slide.
23:51So digging into these domains a bit more,
23:53and I recognize that this this ends up being
23:56a little bit of an eye chart for some.
23:58Hopefully you'll be able to to
24:01explore these in the recording or
24:03in in subsequent distributions.
24:05But again within the first domain
24:07representing that financial impact or cost,
24:10which again includes clinical
24:12efficacy and outcomes,
24:13we look at the financial
24:14and operational reach,
24:15which among others includes
24:17things like revenue generated from
24:20professional technicals fees taking
24:21into account the overall cost of care
24:24for the public and private payers.
24:26Organizational cost savings or neutrality,
24:29ability to reach patients or provide
24:32greater patient management capacity
24:34and things like operational impact that
24:37results in efficient use of resources.
24:39Within clinical outcomes,
24:41quality and safety,
24:43really the ability to impact things
24:45like avoidable readmissions and
24:47and emergency department visits.
24:49The ability to affect difference in
24:52morbidity to your mortality for our
24:54patients there to reduce medical
24:56errors or adverse events within the
24:59second domain representing experience
25:01including that of care teams,
25:03patients and caregivers for patients
25:06and family.
25:07The likelihood to recommend or thinking
25:08of things like Net Promoter scores,
25:10the effect on patient self management
25:13or shared decision making.
25:14In other words,
25:16concepts of patient self efficacy and
25:19activation from the clinician experience,
25:21considering overall satisfaction as well
25:23as comfort with telehealth and procedures,
25:25quality of communications with patients,
25:27and satisfaction with the
25:30overall delivery method.
25:31Within the third domain representing
25:33impact the system, clinical,
25:35operational or technical aspects,
25:38thinking of complexity,
25:39interesting to see this,
25:41we we think about this as a critical
25:44counterbalance measure considering
25:45some of the challenges introduced
25:47potentially by the technology itself
25:50for the ability of integrating
25:52that technology into an effective
25:54clinical workflow.
25:55The availability,
25:55the timeliness of of receipts
25:58of healthcare services,
25:59the ability to impact things like
26:02reduce cancellation or patient
26:03family caregiver time and travel
26:05And and Jason acknowledged that
26:08as well within clinical process.
26:09The the ability to impact things like
26:12practice patterns and in in order
26:15being able to measure and impact the
26:18appropriateness of services and.
26:20The ability to help patients to gain
26:24greater compliance with care regimens,
26:25care plans and discharge instructions,
26:28and the ability to achieve
26:31diagnostic accuracy with these
26:33different modalities and approaches.
26:36And then finally within the 4th domain,
26:38focusing on equity or the access to care,
26:41access to healthcare services for
26:42those living in in traditionally
26:44underserved communities whether
26:46that be rural or urban communities,
26:48access to those based on the appropriate
26:52specialists and and needs of the patient.
26:56So really we see this framework as an
26:58incredibly important way to understand
27:00you know which levers to pull.
27:02First of all,
27:03what is the intent objectively of
27:05the different telehealth services
27:08without layering on bias within
27:11that and thinking about as as we had
27:14consider overall clinical challenges
27:16and overall organizational strategy,
27:18how we might combine the use of
27:21different telehealth services.
27:23To affect the needs of our
27:25practice and affect that strategy.
27:27And you'll hear a little bit
27:28more from my colleague Laura
27:30Kristofferson this afternoon about,
27:31you know, how we've tactically
27:33applied some of these concepts
27:35within remote patient monitoring,
27:37one of our telehealth modalities.
27:44Thank you very much.
27:46Go ahead. Go ahead, Serena.
27:49All right. Thank you, Jordan, for that.
27:51I think it's interesting how
27:52we're going through this,
27:53this session with really starting with the
27:56overall framework and QF and what they've
27:59provided from a conceptual standpoint.
28:01I think my talk today will be a little
28:03bit kind of geared towards how do we
28:05take that framework and the conceptual
28:07design into an operational model that
28:09we've tried to implement at Stanford.
28:11And I want to share some of our
28:14earlier learnings in hopes that
28:16other organizations as they continue
28:18to deliver telehealth quality,
28:20quality in a way that makes sense for the
28:23patients and provides the appropriate
28:25value for all of our population.
28:27So there is no one technology that
28:29we've seen in the last 100 years
28:31that has been implemented as fast as
28:34telehealth visits have been implemented.
28:36During the era of COVID,
28:38when we all of a sudden looked at
28:40our footprint and the visits that
28:42were occurring at Stanford Healthcare
28:43were realized, Oh my gosh,
28:45we have over 70% overnight use
28:48of telehealth visits.
28:49So how can we really make sure that we're
28:52providing safe and appropriate quality
28:54care in the modality of telehealth?
28:57Without compromising our ability
28:59to provide access to the various
29:01populations that we're serving.
29:03So with that said if we go to the
29:05next slide I a group at task force
29:07was brought together at Stanford
29:09called ambulatory transformation
29:10Task Force whose task was we need
29:12to look at how do we chat,
29:14how do we manage the challenges of COVID.
29:16And at the same time create subcommittees
29:18that will really work on creating
29:20the framework not just for quality
29:22but for our patient experience,
29:24our access to care and how those.
29:27Specific instances can reflect
29:29into the various modalities that
29:31telehealth can provide.
29:33So with that said,
29:34the charge of the Subcommittee on
29:36Quality was really around creating the
29:38framework and operational model that
29:40can be applied across not just Stanford
29:42Healthcare to the adult footprint,
29:44but they could be easily applicable
29:46across both of our community clinics as
29:49well as our Pediatrics pediatric sites.
29:51With that said,
29:52we also struggled with the idea of
29:54how do we create a framework and at
29:57least some cross cutting measures
29:59that could be applicable across
30:01a 200 subspecialty and specialty
30:03clinics across the board And give
30:06them at least an opportunity to
30:08start asking themselves the question
30:10of how do I measure quality in
30:12my telehealth visits compared to.
30:14In person or phone visits,
30:16are we providing the same level
30:18of care that we normally offer
30:20and and we're known for.
30:21So with that said,
30:22as we go to the next slide,
30:23we took the some of the NQF framework
30:27that was already predeveloped and
30:29applied it slightly in a different
30:32way to Stanford specifically.
30:33So I'm not going to spend a whole
30:35lot of time on this slide given that
30:37you've heard already from Jordan and
30:39Jason a little bit around the domains,
30:41the measures and how that framework really.
30:44Allows the flexibility for the various
30:47different organizations to create an
30:50operational model that is applicable
30:52to your instance of care delivery.
30:54So with that said,
30:56the next slide that I wanted to go to
30:58is really our way of discarding them
31:01to take that model and translate it
31:03into a domain and the framework itself,
31:06we actually took a slightly
31:08different approach and did
31:10incorporate somewhat like the value.
31:12The equation as well as the
31:14quality into this framework.
31:15So Jordan was pointing out the fact
31:17that it's very challenging to separate
31:19between quality and value whereas value is
31:22encompassing of both patient experience,
31:25provider experience that
31:26the cost and the quality.
31:28So we try to do a similar and I
31:30think design with our domains.
31:33So as you can see,
31:33we really wanted to focus
31:36on six different domains,
31:37but prioritize four of them as
31:39mandatory in year one implementation
31:41within Stanford Healthcare,
31:43the domains one through 4
31:45around the clinical quality,
31:46safety and harm,
31:48resource use and social equity are
31:50things that we really feel strongly.
31:53Given the fact that our video visit
31:55volume is continuing to stay at a
31:57very high rate around 35 to 40%,
31:59so those were a must for us but we
32:02didn't want to then at the same time
32:04inhibit the each individual's entity
32:06and the need for innovation and a
32:10different type of thinking with.
32:12Mandated metrics that may not be
32:14as well applicable to the various
32:17subspecialties.
32:17So with that said,
32:18we wanted to allow room for both
32:20innovation and market differentiation
32:21within each one of the areas.
32:23For example,
32:24neurosurgery can start thinking
32:26about Telestroke,
32:27while that may not be applicable to
32:29all other areas of the organization.
32:31So with that said,
32:32the next slide really starts then
32:35getting into the specific measures
32:36as we started to think about each
32:39specific domain and what question
32:40are we trying to solve for.
32:42So the first one is really around
32:44safety and harm avoidance.
32:45So the question we were asking
32:47ourselves is how can we ensure
32:49that telehealth or virtual care
32:52facilitates providing highest
32:53level of quality for our patients?
32:55So the metric and we brought together
32:57a group of 30 plus stakeholders,
32:59both researchers, academicians,
33:01clinicians as well as administrators
33:04who've been very well worst in
33:07creating measurement design into
33:09coming up with these measures.
33:11So the measure that we've developed
33:13as a crosscutting is really looking
33:15at a D visit rate within seven
33:17days after three different types
33:19of modalities and you will see
33:21that as a theme as we go along
33:23other crosscutting measures.
33:24So we're looking at.
33:26Comparison of EV visit
33:27rate after phone visits,
33:29after video visits and after in
33:31person visits Truly see it's
33:33very challenging to say what is
33:35the quality when you don't have
33:37a a benchmarking opportunity or
33:38really a comparison for you to
33:41develop your insights.
33:43So this would allow us to then look at.
33:46What has been the quality
33:47to date in these other
33:49modalities and how can we
33:50use that as a comparison?
33:51While National Quality Forum
33:53and other organizations,
33:54they continue to develop benchmarking
33:55capability in some of these measurements.
33:58So that was our measure,
33:59one appropriate use criteria.
34:00We really wanted to focus
34:02around resource use.
34:03Are we using the telehealth visits?
34:06In the appropriate way,
34:08given that some specialties
34:09were creating video visits as
34:11a entry into their specialty,
34:13while others may consider that as a
34:15as the only point at for deciding
34:18between a video visit or in person visit.
34:21So in primary care we looked at,
34:23do we generate a repeat visit
34:26after the first?
34:28And visit may be in person or
34:30telehealth or phone visit as a way
34:32of looking are we then creating
34:34double number of visits for these
34:36patients or not utilizing the
34:37different modalities appropriately
34:39for specialty offices,
34:40we kind of extended that time
34:42frame given that access to
34:44specialists can be very challenging.
34:45So we want the signals from
34:47our data to be meaningful.
34:48So in specialty arena we broaden
34:51that scope into up to 14 days to
34:53really allow the subspecialties to
34:55be able to look at their own data.
34:57The next two are domains,
35:00if we can go to the next slide is
35:02really now focusing around clinical quality.
35:04This is the one where we spent a lot
35:06of time in trying to figure out.
35:09So how do we then?
35:10Make sure that the clinical
35:12quality that's delivered in a
35:14telehealth visit in comparison to
35:16other modalities is appropriate.
35:18We've heard feedback from our
35:19orthopath saying I scheduled
35:21the video visit with my patient,
35:22but they're trying to hold the phone
35:24in one hand and show them the the
35:27wrist or the knee that's hurting.
35:28And can I really assess that knee and
35:31and make sure that I'm providing the
35:34appropriate diagnosis for this patient.
35:36Are we then ordering a lot more
35:38imaging studies because we
35:39don't feel confident in the.
35:40In the our ability to diagnose our
35:42patients in a telehealth visit in
35:44comparison to an in person visit.
35:47So this one is actually a both
35:50patient and provider level embedded
35:52survey that asks the patients in a
35:55video visit or and in person visit.
35:57Around could this visit been done
36:00in the telehealth modality instead
36:02of an in person?
36:03Do you feel like you're connecting
36:05with your provider and getting the
36:06quality of care you would have
36:08expected from your provider While
36:09the same question is then asked
36:11to the clinician?
36:12Are you getting the level
36:14of quality that you are?
36:15Are you providing the level of quality
36:17that you normally provide in an in
36:19person visit and could this visit
36:21been done in the telehealth visit?
36:22This data will really be powerful for
36:25us as we continue to think about how do.
36:27Segmentations into different
36:29modalities of of visits and then
36:31how does that then reflect on both
36:34the clinical quality we provide.
36:36But then downstream around how
36:37are we able to create
36:39stickiness with our patients and ensure that
36:41we're providing great patient experience,
36:43but also can create the opportunity
36:46to engage with them at A at a more.
36:49Relationship based level,
36:50the last but not the least is really our
36:53mandatory domain has been around social
36:55equity all of the three measures that I
36:57kind of described in the previous slides.
36:59We've actually built social equity filters
37:02for every single one of them to really
37:04start measuring in the various different
37:06clinics both Pioneer Care and specialty.
37:08Are we seeing a difference between?
37:10The equity that we're providing to our
37:13patients in comparison to phone or or video
37:15visits because it's all really a comparison,
37:17right for our patients were 65 and over.
37:20You could imagine that ability to use
37:23telehealth or various technology as a
37:25modality can be very different by zip code
37:28or where the patients live given that some.
37:31That are around Palo Alto region where
37:34there's a very high level of educated
37:37elderly that may not be a problem,
37:39but as we start getting into more
37:41of the community based areas,
37:43do we start seeing a.
37:45And equity and and how we see and
37:47provide care for these patients.
37:49So I think the last but not the least
37:51slide is we've actually gone all the
37:54way down to creating the framework,
37:56operationalizing and building in a dashboard.
37:59So our dashboard now looks at the
38:01three domains that I highlighted.
38:02The 4th domain is coming given that we
38:05are just starting to collect our patient,
38:07our provider and patient.
38:09Survey data for the clinical quality domain,
38:11but the three domains are already
38:13available and we've deployed a model
38:15where we require all of the entities
38:17within Stanford to adopt at least one
38:20metric that aligns with their current
38:22processes to really start measuring.
38:24Is there a signal that we can
38:27see and then I think from.
38:29Just an example perspective,
38:30the first learning that we
38:32saw after the data was live,
38:33we noticed one of our primary care
38:35clinics had a three times higher rate of
38:38Ed utilization after a telehealth visit.
38:40What is that?
38:41What does that really mean?
38:42Are we starting to see that we are
38:46inappropriately triaging patients
38:47between video visit and telehealth visit?
38:51How do we see those signals and
38:52how do we start then creating the
38:54the measurement system as well as?
38:57The improvement methodology needed
38:59to start creating a better patient
39:01experience for our populations at large.
39:04So with that said,
39:05I'll stop here and then hand it
39:07off to my next colleague.
39:11Thanks, Arena. Go ahead, Kristen.
39:15Great. Thanks. And I also see there's
39:17some weird animation in this slide.
39:18So I think you could click Karen until
39:20we see the rest of it. Yeah, great.
39:22So I think this connects in very nicely
39:26to where is Arena left off talking about
39:28social equity and thinking about a really
39:31important piece that I think kind of
39:33to date when most people think about
39:35telehealth quality or how do we measure
39:36telehealth or where is it incorporating,
39:38it really kind of is getting left out right.
39:41We talked about how does the
39:42visit go when it happens and what
39:43happens after and everything,
39:44but all of those frameworks
39:46are rather irrelevant if we.
39:48Can't really get patients on equitably
39:50and really be thinking across
39:51different patient groups because also
39:53we might think that older patients
39:54have some of the challenges, right.
39:56But I think there are other populations
39:58that are going to be defined by some
39:59things that maybe we capture and measure
40:01in our health systems and some we don't,
40:03but that are going to limit the ability for
40:05us to truly have equitable access or an
40:08actual use really I'll say the use part.
40:10And so I and my team have spent a
40:12lot of time in our doing increasing
40:14work thinking about this concept that
40:15really is the broader 1 here that
40:17I talk about of digital readiness,
40:19thinking about kind of what is the,
40:21what feeds the kind of existing
40:22and potentially growing if we're
40:24not thoughtful about addressing it,
40:25digital divide.
40:26And you know,
40:28most of what's been talked about or
40:29looked at to date really sits within
40:31that digital literacy piece that
40:32I've laid out the thinking about do
40:34people have the access to a device
40:36and just do people know generally
40:37how to use their device and yet.
40:39As I think is probably logical to
40:41most people on here and certainly
40:43as we experienced at Jefferson,
40:44very clearly kind of you know a few
40:47months into the pandemic when we when
40:49I had gotten just under $1,000,000
40:51from the Federal Communications
40:53Commission to get devices for a
40:55bunch of the patients to use.
40:56There are many steps between handing
40:58someone a device and getting them
41:00miraculously on to telehealth and some
41:02of it is that knowledge piece in the
41:04digital literacy kind of component.
41:06But it's increasingly clear that
41:08there are much more important kind of
41:10fundamental challenges that some people
41:12face that limit their digital readiness.
41:13And so I'm kind of, you know,
41:15proposing and focusing that we
41:16really need to think about and
41:18think about then down the line,
41:19how do we measure these other
41:20bits And some of it we know.
41:22So one of the things is trust.
41:23And trust is there are different
41:25parts of even that to break apart,
41:27right.
41:27Some people may have challenges with
41:29trusting that it's safe to put their
41:31information in and to trust using
41:32their device for a telephone visit.
41:34We spend so much time telling people.
41:36Who don't use technology much, right?
41:37Like, watch out for scams,
41:39don't put your personal information anywhere.
41:41And then suddenly we, you know,
41:43the health system gives them
41:44a device that probably seems
41:45even weird in general, right?
41:46That like, why are you giving me
41:48an iPad and suddenly we say put all
41:49of your information in here and
41:50like have a visit with your doctor.
41:51So there may be trust issues
41:53around that kind of security piece.
41:55And then there are certainly trust
41:57issues with certain populations
41:59about can my doctor really provide
42:00adequate care via telehealth?
42:02And this certainly links into earlier
42:04conversations we were having about.
42:05Physical exam and how much can be done
42:07there and can enough be done right?
42:08But the patients question this as
42:10well and probably some get more
42:12reassurance and some get less depending
42:14how experienced the providers are.
42:16On the other end of things,
42:18there are also issues that we've been
42:19hearing about though and talking with
42:21populations about kind of acceptability
42:22and relevance to life as well.
42:24People saying I've gotten
42:26healthcare my whole life in person.
42:27We've been doing this for generations,
42:29like why would I start getting
42:31it via telehealth?
42:32And not understanding that those
42:33very groups that might be hesitant
42:34to use this and everything you know
42:36are the ones where actually maybe
42:38there is the most relevance in life.
42:39Because we go back to Lee's comment,
42:41right,
42:41I'm kind of the everything the
42:43patients go through to see us that
42:45really undocumented and lost patient
42:47opportunity costs into seeking
42:48care in person.
42:50You think of a single parent with
42:52kids working a couple jobs trying
42:54to get in person and you know.
42:57Helping them to see the relevance
42:58where they can kind of fit in
43:00a visit in between things,
43:01you know has immense value.
43:02And so this digital readiness I
43:03lay out is something that I think
43:04is really important to think about
43:06and that we need a measurement
43:07framework to be thinking about this.
43:08Karen, you can go to the next slide.
43:12And so I, you know, in looking a little bit,
43:14again, as I said,
43:15most of what's been looked at today is
43:16really looking more around digital literacy.
43:18So there are some measures that people use.
43:20There's a digital literacy,
43:22digital health literacy instrument,
43:24which again is looking much more at
43:26the functional operational skills of,
43:28you know, can you use a device and
43:31can you get information on it.
43:33But not quite to that point of
43:35understanding and kind of,
43:36you know,
43:37being able to really kind of
43:39fit telehealth into one's life.
43:41Next slide,
43:43another one that probably is one
43:45of the more commonly ones talked
43:46about and used as an E health
43:48literacy assessment toolkit.
43:49Again though,
43:50just these are examples of
43:51the measures that exist.
43:53They measure some of maybe what's important,
43:55but are missing some key domains as well.
43:59Next slide.
44:01And so I kind of I put this more out
44:03not as a framework we're using,
44:05but as a measure that we've been kind
44:07of thinking about and doing some early
44:08work into and our work and development.
44:10But it's kind of a digital readiness measure,
44:12something that we could be using and
44:14that I think should be using to be
44:17measuring across the domains which some
44:19of which I lay out here and others
44:20of which I haven't identified yet.
44:22But to really be able to understand what
44:25are all of those elements that feed
44:27into digital readiness and then how can
44:29we develop interventions to really be.
44:31Addressing them so that we can get people
44:33on equitably and while we acknowledge right,
44:36telehealth is never going to be the
44:38right thing for everyone every time.
44:40I think with this work we can at
44:43least work to ensure that everybody
44:45has a legitimate choice to say,
44:47is telehealth the right thing
44:48for me today or not,
44:50Can understand how to use it and
44:51can understand what it could do for
44:53them so that people can be making
44:54some better decisions about,
44:55you know,
44:56when and how they fit telehealth into life.
45:02And I think that's the end of my
45:03slides there in the end of us,
45:04so happy to turn over to
45:06questions fantastic Kristen
45:10to the participants that continue to
45:13send us your questions in the chat
45:16function and myself and the members
45:18will will answer them either live in
45:21our in our in our panel discussion
45:24or or through the chat function.
45:26But to start us off we've you know,
45:30we've heard.
45:31We've heard now a number of frameworks
45:36presented regarding the the multi domain
45:41assessments of quality and virtual care.
45:44I I I have found and and and the.
45:46The panelists in this group have found it
45:50quite reassuring that there are although
45:53these were in largely independently
45:56developed that there are tremendous.
45:58Overlap and similarities but they're
46:01definitely some differences Let let's
46:03start with that if I could just open it
46:06up to to the paddle members who would
46:08like to who would like to discuss what
46:11what what you've observed with regard
46:13to perhaps let's start with with the
46:16most striking similarities between
46:17the between the frameworks presented.
46:24I can start this is Jason so
46:27I I mean I think.
46:30There, there are two things
46:31that immediately come to mind.
46:32I think conceptually we were all really
46:36thinking along the same lines as rather
46:39than getting into high degrees of
46:43specificity with being prescriptive
46:45in what needed to be measured,
46:47we were thinking much more conceptually.
46:49And I think that's really
46:52important to understand because.
46:54I've been around quality
46:56measurement long enough,
46:56as I'm sure everybody on this call has been,
46:58that when you get overly
47:00prescriptive about it,
47:01it measures tend to not work because
47:04they're they're not taking into
47:06account I think some of the nuances
47:09or the variations in practice.
47:12And they're really just sort of focused
47:14on a very singular event and measuring
47:17that event at that time and I think.
47:20Telehealth provides a whole new,
47:22different output outlook,
47:24which is you know,
47:26the various patients are going to
47:27be using telehealth for various
47:29reasons and they're not all going to
47:31be just around a single encounter.
47:33It may be far more comprehensive than that.
47:35And the reason why they are using
47:38telehealth is also going to be very
47:40different. It may not just simply be.
47:43They can't travel to a provider.
47:47It may be because they can't take
47:49work off because they don't get
47:52any sort of compensated paid time
47:54off to go see a provider.
47:56It may be that they are uncomfortable
47:58being in front of a provider and
48:01more comfortable being in front
48:02of a computer screen.
48:04And I would somewhat jokingly say that
48:06probably applies to 98% of teenagers
48:08and adolescents everywhere because
48:11they communicate via their devices,
48:13not necessarily in person.
48:15So I think that conceptually
48:17when we start looking at what
48:19these overarching concepts are,
48:21that's really the best foundation
48:23of which to build measures from.
48:24Because you're taking like an overall
48:27concept of access and you're really
48:29trying to understand what access means
48:31in the concept of a telehealth encounter.
48:34And that I think provides a measure
48:36that is much more comprehensive
48:38and much more accurate and really
48:40assessing the impact and overall
48:42quality of that encounter.
48:44Because it's really building
48:46from this high level concept into
48:49a very specific detailed one,
48:51and I'm talking a lot with my hands,
48:53which is unfortunate that none
48:54of you can actually see me.
48:56The second part is that I really
49:00appreciate my fellow colleagues and
49:04panelists for aligning I think these
49:06frameworks into the overall AAA,
49:08which I think we were all doing.
49:09You know, it's.
49:11And what thoughts on the triple AM can vary,
49:14but what it really does get to
49:16is you know what's the value,
49:17what's the impact and what's the what
49:19the where the quality outcomes going to be.
49:21And and that's really what that's supposed
49:24to be focused on value impact cost.
49:26And and I think that because
49:29of that it really shows,
49:31I think that when we start really
49:34getting into these measures
49:35that we're really going to show
49:38how telehealth can align.
49:39With normal with care delivery
49:41and and I think that's
49:42another thing I heard people on the
49:44first panel say and I heard all of
49:46us echo which is and and Jordan said
49:48this as well as anybody could say
49:50I usually always make this joke as
49:52Judd knows that that people think
49:54telehealth is this magical mystical
49:56form of healthcare like a Unicorn
49:58which it's not there's no such
50:01thing as a Unicorn so this is just
50:03regular healthcare delivery and.
50:04I think when we show how measures
50:07align with the triple lane,
50:09we're really making that case a lot
50:12stronger that it's it's just a it's
50:15just healthcare delivered through
50:16another media and and the sooner we
50:19get people to understand that the
50:21longer it's going to be around and
50:23the more accepted it's going to be.
50:25I think a lot of people have started
50:27to see that because of COVID,
50:29but I think that it's sustainability over
50:32time is really going to be aligned to.
50:35People accepting it as a form of
50:37care and not as some form of of
50:41care that is beyond their level of
50:43comprehension and the way to do that
50:45is really evidence based practice
50:47and measures that align with the
50:50triple-A really goes a long way.
50:53Thank you very much, Jason.
50:59In the frameworks presented there,
51:01there were there were certainly
51:03some differences that came out.
51:06Some of the differences that we noticed
51:07not not all the frameworks have have
51:10had a domain or included domain focused
51:13on social equity and not all the
51:17frameworks have had a domain that is
51:21focused on innovation and marketing.
51:23Do any of the panelists want to
51:25speak a little bit more detail about
51:27maybe some of these these concepts
51:30and and implications of?
51:32Of their presence or absence for
51:35that healthcare organization.
51:43This is Jordan. I can definitely
51:44start and I'll look to
51:45some of my other panelists
51:46to jump in as well. And Dr.
51:48Schwam had shared some
51:51insights as well noting that.
51:54You know, value is often a little
51:56bit different than quality in
51:57in terms of the fact that it it
51:59often doesn't take into account
52:01some of the financial components.
52:03And I think that's that's
52:04a really great point.
52:05And and was one of the things
52:08that we wrestled with as we were
52:10starting to think about how do
52:12we create an objective framework
52:14around which to think about our
52:16approach to different telehealth
52:17services and modalities really
52:20recognizing that value or quality.
52:24Is largely subjective.
52:28It's relative to a individual's perspectives,
52:32right?
52:33And so we really wanted to try to
52:35create a framework that depicted A
52:38telehealth service independent of
52:40anyone's individual preferences on those,
52:43those individual dimensions.
52:44And we really felt remiss if we
52:47didn't include some of those those
52:49cost factors within that because
52:51we often recognizes that that's it.
52:53A big driver of a lot of,
52:55a lot of conversations,
52:57especially if we're thinking
52:58of a value or quality from the
53:01perspective of our payers or our
53:03employers that we partner with,
53:06but also very much from the perspective
53:09of our patients for which cost,
53:12healthcare costs overall are a big,
53:16a big factor.
53:17And a big consideration as they
53:19think about not only different
53:21types of services but different
53:22modalities through which those
53:24services are delivered.
53:26You know Bart, let me just make a
53:29quick comment which is you know,
53:31I find again it's another one of
53:32those apples to apples comparisons.
53:34Nobody questions me about the value
53:36of a follow up visit in my clinic for
53:39a patient who I saw in the hospital.
53:42No one says what is the value of a
53:43neurology visit is should that be paid for,
53:45does that need a prior authorization?
53:47Should I, you know,
53:48should I limit that to a specific
53:50network different than the network
53:52of providers I would normally issue.
53:55But with virtual care we're often asked
53:57to just what is the value of that visit.
54:00And I think it's a it's a very difficult
54:02question to answer really along the
54:04lines that that Jordan has mentioned,
54:06but I can say for certain that.
54:09Telehealth activities,
54:10virtual care activities are always
54:13viewed through the lens at at my
54:15organization of how will this?
54:17What is the financial impact of
54:20shifting care to this modality?
54:23I need to see that along with the
54:26quality implications so that I can
54:28understand whether or not I can
54:31continue to afford this massive shift.
54:34Because if you think about it.
54:36Any one of our health systems,
54:37if you told them you were going to
54:39take 20% of their volume and drop
54:41its revenue by a fixed portion
54:44or eliminated entirely,
54:46that would be a nonstarter,
54:47right, that you,
54:48you'd have to have a very compelling business
54:50plan for why you were going to do that.
54:52And so I I think that it's unfortunate that
54:55it's inextricably woven into the finances.
54:58But on the other hand,
54:59maybe again the false dichotomy of quality
55:03versus cost here is something that we.
55:06Are always thinking about on the
55:07in person brick and mortar side.
55:08We just don't talk about it in
55:10the same sentence.
55:11So maybe it's in fact a step forward.
55:13Yeah I I think you're rightly I think
55:16you're right it it's not it's not so
55:19much that it's not so much that our
55:22leadership across healthcare organizations
55:24have dismissed or or or let go of
55:29the of the cost aspect of a of a more
55:32traditional healthcare model but but.
55:34But when, but when cost is relatively stable
55:39or understood or fluctuates only by a little
55:43degree in any incremental period of time,
55:46it's as though there's an
55:49enhanced focus on the quality.
55:51In this instance,
55:52as you've as you've highlighted,
55:54we are in an era with a dynamic shift
55:58in incremental cost associated with.
56:02With reengineering, retooling,
56:04redeveloping our operations and
56:07systems to accommodate all of our
56:10digital healthcare modalities and
56:12transactions for our providers and
56:15patients and and and hence therefore
56:18an an intense scrutiny today.
56:21And on on on quality which is the
56:23focus of this forum but but in in
56:26addition to that to that incremental
56:28cost with and the health economics
56:31of course viewed through a number
56:34of different perspectives.
56:35But in our healthcare organizations
56:37the the fundamental perspective is,
56:39is that of that healthcare organization.
56:42I totally,
56:42totally agree.
56:50I wanted to add a little bit.
56:51I think that health insurance is right
56:54and and really that the national trends
56:57around is telehealth visits here to stay.
57:00I think we all agree yes.
57:03But to your point the amount of
57:05how much that reimbursement will
57:07really drive the the success of of
57:11telehealth visits in in the long term.
57:13I think some of the the challenges
57:15we face in in probably in all
57:18of our organizations is around.
57:19How do we actually even understand
57:23the value that is provided both
57:25from the operational efficiencies?
57:27Are we using the same number
57:29of MA's in in video visits?
57:31Because at least at the beginning the
57:33assumptions were you don't need anybody,
57:34you don't need space,
57:35you just need to be in a room
57:37and just provide this visit.
57:38But we quickly saw a huge decrease
57:40in the way we were providing care
57:42to our populations where all of the
57:45preventative screening rates across the
57:46board and the nation dropped significantly.
57:49Why?
57:49Because we didn't know how to
57:52collect that information or how
57:53to continue to drive patients to
57:56engage with preventative screening
57:58and cancer screening rates.
58:00I don't know if many of you looked
58:02at the heaters rates that were
58:04reported this 2-3 months ago.
58:06The benchmarks got released and every
58:09single benchmark on he just measures dropped.
58:12To the level above before 2017,
58:15which tells me that it wasn't
58:17just the impact of COVID,
58:19but it was also the impact of COVID
58:21plus the fact that we aren't able
58:23to see our patients Facetoface
58:25visits where we can order labs,
58:27make sure that they go and get their
58:29A1C checked at the same time and and
58:31their blood pressure is checked.
58:32So how do we start creating the
58:35the processes to be able to collect
58:38this information?
58:39Asynchronously outside of the
58:42visits we saw a huge dropping off
58:44hypertension controlling rates
58:45right and and we're like Oh my God,
58:47we're not collecting information
58:49on patients blood pressure.
58:52So we need to start thinking about
58:55what other modalities do we develop
58:57as well as patient reported vitals
58:59and our use of technology in patients
59:02home that will continue to give
59:04us the insights.
59:05Necessary to provide the level
59:07of quality that we are used to
59:09giving an in person visit.
59:10So I think we have a lot more room to grow,
59:14but at least it's a start.
59:17I just want to make one quick comment
59:19about what Serena just said about the
59:21heatest measures because this came
59:22up as well in our own organization
59:25and and and across the United States.
59:27You know this issue is a big one
59:29and and hypertension control.
59:30In particular, I'm what I don't
59:33know yet is whether the denominator
59:36shifted and not just the numerator.
59:38Because if the measures are calculated
59:41based on the proportion of reported
59:44blood pressures and which of those
59:46are under or over the target,
59:49then patients checking their own blood
59:51pressures at home that are recorded
59:53in the text of our notes that meet
59:56the criteria are not getting counted.
59:58And so it may be that the loss
01:00:01of control is less than we fear,
01:00:03but it's certainly going to be
01:00:05greater than we would hope,
01:00:06You know that that the, the,
01:00:08the losses of control is going
01:00:09to be worse than we hope,
01:00:11but maybe not as bad as it looks in
01:00:12those denominators and numerators
01:00:14that we're seeing from heaters.
01:00:15I don't know yet how those measures
01:00:18are being calculated and if they
01:00:19take this into account,
01:00:21but it is a terrific driver for why we
01:00:24need to get even just very primitive.
01:00:27Remote monitoring capability to write
01:00:29back those values to our electronic
01:00:31health records so they can be
01:00:33counted in these national measures.
01:00:37Thank you Lee.
01:00:41If I if I could ask the
01:00:42panelists the following.
01:00:46Clearly in these multi domain
01:00:49models there are components of
01:00:53the quality framework where?
01:00:56Data is accessible, it's being collected,
01:01:01it's easily extractable,
01:01:03measured, presented.
01:01:04But for other parts of the multi
01:01:07domain models that's not the case.
01:01:10The data may either be a non existent
01:01:12or only recently tracked or hard
01:01:16to extract what what what have,
01:01:19what have you
01:01:23in these instances? What?
01:01:25What's our recommendations you
01:01:27might make with regard to the
01:01:30differences between the easily the
01:01:32the the components of the framework
01:01:34where data is easy to identify and
01:01:37components of the framework where
01:01:40the data is not easy to identify?
01:01:43Tips, suggestions, recommendations.
01:01:52I can try to take a stab at it
01:01:54but I think as we develop the the
01:01:57framework but then more along the
01:02:00lines of how do we then create
01:02:03operationalization of those frameworks
01:02:05and insights into the various areas.
01:02:08The we have to be very careful around
01:02:13balancing the the need for a lot
01:02:15of of data and and measurement as.
01:02:18And well as providing the
01:02:21flexibility for individual units,
01:02:23may it be a specific specialty
01:02:25or specialty in being creative
01:02:26and how they consider the various
01:02:29modalities and and the type of quality
01:02:32that those modalities provide.
01:02:33I think that at least in our
01:02:36instance at Stanford,
01:02:37we've tried to give a lot of flexibility
01:02:40to that even though that wasn't.
01:02:43May be shown in some of the
01:02:45slides that we shared.
01:02:46Our year two goals have already
01:02:48been kind of in at play where we're
01:02:51going to look then at individual
01:02:53units both quality as well as
01:02:55operational units to start thinking
01:02:57about what quality means in their
01:02:59specific area of expertise.
01:03:01And and for an ortho pod and may be
01:03:03very different than a neurologist
01:03:05or a primary care provider to start
01:03:07thinking about creating measurement
01:03:09system that allow them to be able.
01:03:11To stack up the the different
01:03:13modalities of care that they're
01:03:15providing and measure quality in
01:03:17those various different modalities.
01:03:19And I think that will give us that the
01:03:22the necessary endpoints to to start
01:03:25thinking outside of the framework
01:03:27that has been so far established.
01:03:29And I and I hope that as the NQF
01:03:32and other national bodies to start
01:03:34thinking about those as well as.
01:03:36Specialty societies that can be woven
01:03:39into the measurement systems that
01:03:41they have developed as well too.
01:03:43And I think from some of the
01:03:45ones that I've seen already,
01:03:47we are seeing CMS and others
01:03:50are incorporating.
01:03:51That helps visits into the
01:03:53denominator of many metrics that
01:03:54they're starting the measurement on.
01:03:56It's just a matter of how do we
01:03:58start dissecting that information to
01:04:00give us more insights into where do
01:04:02we need to then focus our energy.
01:04:03Because at the end of the day,
01:04:05the goal of quality measurement is
01:04:07really then identify where we may
01:04:09have potential issues and then how
01:04:10do we start creating performance
01:04:12improvement projects around those
01:04:14to address those issues on hand.
01:04:19I'll, I'll build
01:04:20on that a tiny bit. I don't have his his
01:04:23comprehensive of responses as Arena does.
01:04:27But you know it's the old challenge, right.
01:04:28What gets measured gets changed and the
01:04:31extension of that is what gets measured
01:04:33is oftentimes what are those things
01:04:36where the data are are easily accessible.
01:04:38So that that creates potential gaps
01:04:41and a potential overemphasis. On, on.
01:04:45Those factors that are easily quantifiable.
01:04:48So one of the things that I appreciate
01:04:51about and QF and other frameworks and
01:04:53and the frameworks you've seen today
01:04:55is I do think they they acknowledge A
01:04:57balanced approach which includes both
01:05:00quantitative and qualitative factors.
01:05:02So the the approach we've taken,
01:05:04we've chosen to take in the interim is
01:05:06to at least acknowledge that one thing
01:05:09I didn't get a chance to touch on in our
01:05:11framework is we tried to label the term is.
01:05:16Eloquent,
01:05:16but hard benefits versus soft benefits.
01:05:18Acknowledging the fact right
01:05:19at the face of that framework,
01:05:21what are things that tend to lend
01:05:23themselves to being more easily quantified?
01:05:25And what are things that are likely
01:05:28more qualitative or need proxy
01:05:30measures in order to speak to?
01:05:32So at least we can try to
01:05:34provide a full picture.
01:05:35So we give.
01:05:36Different telehealth products and programs,
01:05:38the opportunity to acknowledge for themselves
01:05:41what value dimensions they intend to impact.
01:05:43We can share that up,
01:05:45make that visible,
01:05:46but then fully acknowledge that there's
01:05:48only certain ones of these that
01:05:49we're going to be able to directly
01:05:51quantify at least in the time being.
01:05:55That's it's an excellent discussion,
01:05:57isn't it? That's, that's another,
01:05:59that's another topic in question,
01:06:01which is the the distinction between.
01:06:04Quantitative measures
01:06:06and qualitative measures,
01:06:08how any framework intends to balance
01:06:12those and is there an opportunity
01:06:16for waiting of of of various quality
01:06:19measures and and if and if waiting
01:06:22is incorporated into the framework,
01:06:24how, how, how do you,
01:06:27how do you introduce fairly or
01:06:28equitably a a waiting scheme?
01:06:30And then ultimately is there an
01:06:34opportunity for a composite quality,
01:06:37composite quality measure that
01:06:39that is that that depicts the,
01:06:42the overall assessment of of of
01:06:45quality for any particular digital
01:06:48healthcare modality thoughts on any
01:06:52of those concepts Jordan and others.
01:06:56I mean I completely agree with
01:06:57you Jordan, I think that.
01:06:59The recognition of we measure things
01:07:01that we measure often because
01:07:02they're the things we can measure.
01:07:04And you know resisting doing that
01:07:07and continuing to have really kind of
01:07:10thoughtful you know dialogue as larger
01:07:12groups to think about really what
01:07:14are the core things that in our deal
01:07:17world we would measure or could measure.
01:07:19And you know figuring out building in the
01:07:21systems when possible to do that we don't,
01:07:23you know the last thing we want is
01:07:25more and more and more surveys for
01:07:27patients and others but figuring out.
01:07:29How that can be built in the system to get
01:07:31to as close to that ideal point as we can.
01:07:33And I think it is some of the
01:07:34things we've talked about right.
01:07:35But and this is the world has shifted
01:07:37much more towards certainly patients
01:07:39and stakeholders being involved much
01:07:41more in identifying those concepts,
01:07:42right.
01:07:42And I think here as much as anywhere
01:07:44it's important to have that engagement
01:07:46and sometimes at least we can get
01:07:48the qualitative engagement from
01:07:49them to ultimately inform hopefully
01:07:51more of a quantitative end.
01:07:55But I think being open
01:07:56to the incorporation of.
01:07:58Things, you know and consideration of what
01:08:00are patient opportunity costs around care.
01:08:02When we talk around cost and we always say,
01:08:04right, like the cost dialogue is always
01:08:05like here's all the cost and like,
01:08:07oh, and there's a bunch of stuff for
01:08:08patients we don't really know too.
01:08:09But like we could quantify some of that
01:08:11stuff, maybe it's valuable, maybe not.
01:08:12We should at least have dialogues around
01:08:15the other aspects of care that you know,
01:08:17we haven't typically thought
01:08:18to measure to date and.
01:08:20Think about a different system and you know,
01:08:22I'm will in the end of the day hopefully,
01:08:24you know, build digital rights assessment
01:08:26into Jefferson's landscape at least.
01:08:28And you know,
01:08:29but those concepts of where and how
01:08:30could we build some stuff in and what
01:08:32do we ultimately want to measure,
01:08:34I think is an important place to,
01:08:35you know,
01:08:36sit in these next years for some time.
01:08:41I also like, I do like the fact across
01:08:43our panels and like the frames that like
01:08:45and I think this point has been made,
01:08:47but that as much as we can think
01:08:50about these assessments not being.
01:08:52In person or telehealth, right.
01:08:54And a lot of these,
01:08:54the measures and the approaches we're
01:08:56taking is just for care, right.
01:08:57And looking at that visit,
01:08:59regardless of whether the visit happened
01:09:00telehealth or in person or not.
01:09:02And starting to think of it as a
01:09:03kind of wraparound system instead
01:09:04of kind of always separating out.
01:09:06Because I think dichotomizing that
01:09:08doesn't help with patients or reluctant
01:09:10providers or whoever it is to pick
01:09:11it up to sometimes realize, right.
01:09:13Sometimes you need telehealth,
01:09:14sometimes you in person,
01:09:15we kind of fluidly move and it's all
01:09:17part of care and as much as we can look
01:09:20at the impact of every single care visit on.
01:09:22Patients and outcomes and such
01:09:24and have measures and approaches
01:09:25that kind of apply across that.
01:09:26I think it doesn't benefit to,
01:09:29you know,
01:09:29to everyone in the end.
01:09:32Thanks, Kristen.
01:09:33One last question for the panelists.
01:09:35And and that's around maintaining
01:09:38objectivity and reducing bias.
01:09:40If you're like myself,
01:09:43I've observed that the advocates
01:09:46and proponents of virtual care
01:09:48modalities often presents.
01:09:51An outstanding quality of their of
01:09:55their digital health transaction.
01:09:58Rarely, rarely is rarely is the quality poor.
01:10:03But as we stand back from this as
01:10:05panelists and and participants
01:10:06and members of the symposium,
01:10:08obviously we want to build frameworks that
01:10:11allow for the most objective and unbiased.
01:10:15Assessment of quality as possible.
01:10:17What of each of you encountered
01:10:19in your own organization and and
01:10:21thoughts around ensuring that
01:10:23we maintain the highest degree
01:10:25of objectivity as possible.
01:10:29You know, I'm Bart,
01:10:30I will just say I think we only
01:10:32have a minute or two left on this.
01:10:34I do want to try to balance some
01:10:37of the comments that Kristen and
01:10:39others made about wanting to keep
01:10:41these flexible enough so that.
01:10:43You know, each institution can measure
01:10:45quality in a way that's meaningful to them.
01:10:47But I do think we need to figure out how
01:10:49to come up with some consensus measures
01:10:51that we would all agree to capture,
01:10:53some of which are readily
01:10:54comparable to in person,
01:10:56some of which are unique to virtual.
01:10:58So I imagine a three-part
01:11:00agenda for quality measurement.
01:11:01One is a core set that is true
01:11:04across all care modalities and
01:11:06that we can use the exposure of
01:11:09interest being the modality.
01:11:11And see if there's variation.
01:11:12A second would be those that are common
01:11:15for virtual care and that we all agree to,
01:11:19to assess much like we when we
01:11:21do clinical registries,
01:11:22we come to agreement on certain
01:11:24standard quality measures.
01:11:25And then the third set that are kind
01:11:27of homegrown best practice what works
01:11:29for me and those become candidates
01:11:32for consensus adoption through the,
01:11:34you know,
01:11:35a network of of participating facilities
01:11:37as experience with them accumulates.
01:11:41Well, well, well, sadly,
01:11:42I want to thank each of the panelists
01:11:46for excellent presentations and a
01:11:48robust discussion regarding the
01:11:50Q&amp;A and and and the similarities,
01:11:53differences and complexities of
01:11:54the development of the framework.
01:11:56And on behalf of all of our panelists,
01:12:00we hope that we've put our colleagues
01:12:02in panel three and four in a
01:12:05good position to begin to apply
01:12:07those frameworks to individual.
01:12:09Virtual care use cases.
01:12:11Thank you very much.