Panel 1: General Principles of Quality Measurement for Virtual Care

July 12, 2023

Information

Panelists: Judd Hollander, MD (moderator), Daniel Albert, MD, Susan Edgman-Levitan, PA, Emily Hayden, MD

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