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

Transcript

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