Clinical Case Study: Telehealth for Hypertension

The virtual session provides an overview of techniques for managing hypertension via telehealth and remote patient monitoring. Speakers also present telehealth hypertension case studies.

Speakers

• Kate Kirley, MD, MS, director, chronic disease prevention, AMA
• Debra McGrath, MSN, FNP, director of health information technology, Health Federation of Philadelphia
• Ritu Thamman, MD, FASE, FACC, assistant clinical professor of medicine, University of Pittsburgh School of Medicine

Host

• Bernadette Lim, project manager of digital health strategy, AMA

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Lim: Alright. Good morning everyone and thank you for joining us. Today's Telehealth Immersion Program session is focused on using telehealth for hypertension and we have an incredible lineup for today in terms of an agenda. We have Dr. Kate Kirley, who will give an overview of the AMA’s MAP initiative and then following Dr. Kirley's presentation, we have two clinical case presenters joining us today.

Our first is Debra McGrath from the Health Federation of Philadelphia, who will share her experiences using remote patient monitoring. I'm sorry―we'll share her experiences implementing an SMB program across a network of health centers. And our second case study presenter is Dr. Ritu Thamman, and she's joining us from the University of Pittsburgh School of Medicine, who will share her experiences using remote patient monitoring for postpartum hypertension.

This presentation will be recorded and shared out with all participants following today's presentation, along with the slides. And throughout the duration of today's event we welcome any questions you might have down in the chat. After each clinical case study presentation we’ll reserve time to answer those questions live.

And it is my absolute pleasure to introduce our first speaker today, Dr. Kate Kirley. Dr. Kirley is the director of chronic disease prevention in the improving health outcomes group at the American Medical Association. She serves as a clinical lead on AMA’s chronic disease prevention initiatives and leads efforts to advance chronic disease prevention via utilization of digital health solutions and improving medical education. Prior to joining the AMA, Dr. Kirley was a practicing family physician and health services researcher at North Shore University Health System, as well as a clinical assistant professor in the department of family medicine at the University of Chicago. And with that, Dr. Kirley, I'll turn it over to you.

Dr. Kirley: Thank you so much, Bernadette. We can go ahead and advance to the next slide. And we have a disclaimer, and there’s me, and go ahead and move it along. Let's do a little level setting about why thinking about virtual hypertension care is so important, both pre-pandemic as well as if we consider what we have seen and what is happening currently in the ongoing COVID-19 pandemic. So I suspect you all are very familiar with slides like this one. We know that high blood pressure is extremely common among adults. Prevalence increases with age, as you can see here, but it's something that I suspect you are all dealing with in your practices and your organizations all of the time, so it's very common.

But unfortunately, despite the fact that as a country we were making progress in improving blood pressure control rates over the course of about 15 years, if we look at from 1999 to about 2014 as a country, we saw improvements in blood pressure control rates. But now what we are seeing is actually a downturn in that trend. So despite the fact that we are taking care of patients with hypertension all of the time, we are losing ground in terms of controlling blood pressure across the country. And while we are seeing this change or this decline in blood pressure control rates, we are also seeing deaths due to cardiovascular disease on the rise at the same time periods. So as a doctor who focuses on prevention primarily now, this is of course very concerning to me. And I suspect it's also very frustrating to those of you who are caring for these patients and doing what you can to prevent cardiovascular disease.  

And then to make matters even more complicated, COVID hit. Now this, I think, is a really interesting graphic. It's from a piece that was published relatively early on in the pandemic, so about 15 months ago. And this was sort of back when we were talking about a little more about waves of the pandemic. And what they're showing in this graphic was something that we were all really thinking about and worried about at the time and are still worried about was this idea that we were very focused early on dealing with this kind of first wave of acute COVID morbidity and mortality. But in the meantime, we were starting to see patients with other conditions defer their care. We were seeing deferred or delayed interventions for cardiovascular disease. And they were predicting at the time about 15 months ago that we would continue to see impacts from that as well as impacts that were related to interrupted outpatient care for cardiovascular disease and preventive care.

So this was sort of a prediction back earlier in the pandemic, and we're seeing much of this sort of pan out now. We know that there has been decreased utilization of services related to cardiovascular disease and cardiovascular disease prevention. We know that people have delayed how long they wait to seek care from the time that they may experience symptom onset until they actually seek care from a clinician. What we don't really know yet, but what we are expecting to see, is that this is probably going to negatively impact health outcomes for many people. And so that's something that we're sort of waiting to see―how these longer-term health outcomes are impacted by some of this avoidance of care or this inability to access care during the pandemic.  

And already we're measuring this where we're seeing changes in health care utilization. This slide here, I suspect, is something that you all have been experiencing firsthand. So this study looked at primary care visits, office-based visits, and they compare the number of visits in Q2 of 2020 to the number of visits in Q2 of 2018 and 2019. And what they saw was that there was a substantial decrease in office-based visits in 2020. So office-based primary care visits were basically cut in half. And specifically on the topic of blood pressure they saw that blood pressure assessment or blood pressure measurement was occurring at about 70% of those office visits.

Meanwhile, as you all know and the whole reason we're talking today, telemedicine visits dramatically increased. So telemedicine visits went up 35% in 2020 compared to 2018 and 2019, specifically Q2. But what they also saw was that blood pressure assessment was occurring at less than 10% of those and telemedicine visits. And blood pressure assessment, it's absolutely crucial to blood pressure care, right? And so in a lot of these cases we're seeing that patients are accessing care less. They're doing so more via telemedicine, but also we're seeing less blood pressure measurement, blood pressure assessment occurring. And so to a certain extent we're flying blind a little bit when it comes to blood pressure care.

So what can we do? How can we change the tide, turn the tide?

So at AMA and in my unit where I work, we have a structured quality improvement program called the AMA MAP program that we run with health care organizations and physician practices of all shapes and sizes. This is a free program. It's evidence based. We've demonstrated that it improves blood pressure control within an organization. And it's based on what we call the MAP framework. And I think even though we developed the MAP framework years ago, really focused on in-office blood pressure care, it applies very well to virtual hypertension care. So I'll just quickly outline what that framework is.

The “M" piece of MAP is about measuring accurately, so making sure that we have accurate and actionable data to diagnose high blood pressure and to assess blood pressure control. “A” is about acting rapidly, which is initiating or intensifying evidence-based treatment and really avoiding therapeutic inertia, which is a big issue with our hypertension care, oftentimes.

And then “P” is about partnering with patients and really supporting them and engaging patients in self-monitoring of their condition, self-managing their condition and really improving their adherence to treatment. And while all pieces of the MAP framework are important for improving blood pressure care, I think what we're seeing as we start to implement more virtual hypertension care is that we really struggle with that “M” piece, that blood pressure measurement piece. That's the tricky part sometimes to figure out how to do that virtually, get good quality measurements virtually. So I'm going to focus really my piece talking a little bit more about that. I know Deb later on is going to talk about that a lot as well.

So we do have guidelines that tell us that out-of-office blood pressure measurements are something that we should be using. They are better correlated to cardiovascular risk than in-office blood pressure measurements. And so there are multiple guidelines, including what I'm showing here, the ACC/AHA guideline about high blood pressure, that tell us that we should be getting out-of-office blood pressure measurements both to confirm a diagnosis of high blood pressure as well as to help guide our titration of blood pressure lowering medications. However, we want to make sure that we're not just telling patients to go home and measure their blood pressure. It's really important that information comes back to us and that we use it to inform counseling of our patients. So we only see out-of-office blood pressure measurement really improving blood pressure control if we pair that with telehealth counseling or other clinical interventions or in-office counseling with our patients. So it's really important that we sort of have that connection with our patients as we advise them to go measure their blood pressure outside of our office.

So how are we doing in terms of whether patients are actually using out-of-office blood pressure measurements, particularly what we call self-measured blood pressure? So this was before the pandemic, but this particular study looked at patients who have hypertension and they were asked whether a health care professional is recommending that their blood pressure be checked outside of the office. And they said that 70% of them have said yes, my doctor has told me to check my blood pressure outside of the office, and then 60% of them said yes, I actually checked my blood pressure outside of the office. The most common way that people check their blood pressure outside of our office is at home, home blood pressure measurement. So 85% of people who check outside of the office do so at home. But I think this is really interesting. Only 7% said that they shared their blood pressure readings with their health care professional via email or internet. So our patients are out there measuring their blood pressure pretty commonly, but they're oftentimes not sharing that information back with us. And so that's one of the really important pieces of virtual hypertension care―making sure that we get good blood pressure measurements at home and that information actually comes back to us.

OK, so let's talk about some strategies for really optimal management of high blood pressure using SMBP or self-measured blood pressure monitoring. So I would say if I had to boil it down as simply as possible, there's three critical considerations for a self-measured blood pressure to be effective. One, you want to make sure that your patient is using a blood pressure measurement device that has been validated for clinical accuracy. Two, you want your patients receiving guideline-directed education and instructions. And then three, you need to think through how you're going to access and use that self-measured blood pressure data.

So regarding the validation piece, it may surprise you to learn that many of the blood pressure measurement devices or the home blood pressure devices out on the market actually have not undergone a transparent validation for clinical accuracy. It's not part of the FDA 510(k) clearance process. So what AMA has done is put together the U.S. blood pressure validated device listing. It's the only listing of this type in the United States. There are others in other countries. And the way this works is that we convened a group of experts to determine what are the criteria for validation for clinical accuracy. So they defined what those criteria are. Blood pressure device manufacturers then submit their validation evidence to an independent group that is outside of the AMA, and this group verifies whether or not specific devices have met the validation criteria set forth by the experts. And then if the device meets the validation criteria for clinical accuracy the device gets listed on this online listing.

So when we talk to doctors about doing self-measured blood pressure we always recommend that you review the devices that are listed on validatebp.org and that you point your patients towards those validated devices.

So two is about giving patients guidelines-driven education. It's very important that your patients prepare themselves properly and position themselves properly when they take home measurements so that they can get accurate readings. You also want them to be following an appropriate measurement protocol, which we would say is taking two measurements in the morning and two measurements in the evening, ideally for a week. But three days is OK.

And so there are a number of resources out there to really support your care teams and being able to educate people, educate patients. And you do want to make sure that a member of the clinical team does spend time actually educating patients about how to do home blood pressure measurements. And not that you're simply telling people, go measure your blood pressure at home, you want to make sure they know how to do so properly. At the end of my section, I have a link to a whole pile of resources that you can use for this. And on this slide, which everyone should be receiving, there are also two links to two different patient training videos that you can direct patients towards which will help them understand how they should measure their blood pressure at home.

And then the third piece, I think Deb is going to talk about this a fair amount too, is really thinking about how you're going to access and use that self-measured blood pressure data. So there are sort of various steps along the way here, starting with thinking through how are the patients actually going to capture their S&P data at home? This could be measurements being stored within the device itself and the device memory. The measurements sometimes can be digitally transmitted to a mobile app that the patient can then review on their own, and they can simply write down their measurements on a paper log. The results then need to be shared back to the care team so this could be done through some sort of verbal report like a phone call. Sometimes results or measurements can be transmitted to a web-based portal or a dashboard that the care team or the clinician can view. It could be as simple as the patient bringing their device or showing their device over a video visit and actually showing you the measurements. Or they could be sending you their measurements through some sort of secure email or patient portal or messaging system.

Then when you get their blood pressure measurements back, remember we said we want patients taking two in the morning, two in the evening, ideally for a week. Three days is OK. The way you interpret those blood pressure measurements is you want to average all of the systolic measurements and average all of the diastolic measurements. That average is what you want to be using for clinical decision making. There are some tools out there that can help make that average piece a little bit quicker and easier. And then it's up to the care team to interpret the results. And then, of course, really important to document what your plan is and really work with your patient on determining that plan and making sure your patient knows what the treatment plan is from there based off of their self-measured blood pressure measurements.

Just want to flag a couple of things for people quickly. First of all, there are CPT® codes available that support self-measured blood pressure measurement. There is a code that covers the education piece. It's a one-time code and then there is a code that can be used monthly that really covers the interpretation of the measurements―the care planning and the sort of documentation of treatment and the communication of the treatment plan to the patient. So there are CPT® codes out there that support self-measured blood pressure.

And then the other question that we get a lot is, wait, don't I have to report in-office blood pressure measurements for my quality measurement reporting? Generally speaking these days, really as of last year, the quality measures that most of you are likely to be using, oftentimes they are based off of one version or other of the HEDIS measure for blood pressure control. Those can now include blood pressure measurements that are taken outside of the clinician's office. They may have a couple of caveats depending on which measure you're using, but the most recent version of HEDIS home blood pressure measurements can be used. It takes whatever the most recent documented measurement is, and if the clinician decides that the best measurement to use there is a home blood pressure measurement or even an average of home blood pressure measurements like I was talking about, if that is documented in the EHR, that's what's used to calculate the measure. So whole measurements can be used for quality measure reporting.  

So I said a lot in a short period of time. If you want to go back and remember some of what I said, the two things I recommend you check out are the AHA and AMA joint policy statement about self-measured blood pressure. It covers the evidence base behind what I was just talking about and a lot of the clinical stuff to what I was just talking about.

But then probably the best place to find sort of really, how do you do this, and all of the resources I was talking about is on the link at the bottom of this slide, which is the AMA 7-step SMBP quick guide. It talks through really everything I just talked about in a little more detail and does point you towards those references or those resources that you can use in your clinics and with your patients.  

So that wraps up my portion, and I am going to hand it off to Miss Deb McGrath. First I'm going to go ahead and introduce her a little bit more formally. So Debra McGrath is director of health information technology at the Health Federation of Philadelphia. She's a nurse practitioner and a health IT professional. Miss McGrath joined the Health Federation in 2012 as a consultant and became a full-time employee in 2017. She has extensive experience helping groups, including folks with successful health IT implementation and optimization projects. In addition, she has broad expertise in assisting medical practices in creating a governance structure for the administration of IT that ensures a reliable medical record containing accurate and complete patient data.

She earned a bachelor's degree in nursing from West Chester University, a master's degree in perinatal nursing from the University of Pennsylvania, attended Wilmington University to earn a post master's family nurse practitioners certificate and has completed doctoral coursework in the College of Information and Technology at Drexel University. She has helped many practices create a foundation for the ongoing development of the system that supports the work of the practice for many years and is able to add a unique perspective from both the clinical and information technology points of view. And I can speak from experience that she knows what she is talking about. So Deb, I'm going to hand it over to you.

McGrath: Well, thank you so much for that introduction. I hope I can live up to it.

So I just wanted to give out a little bit of a context of the work that we do at the Health Federation. Among many programs we have a health center control network that supports the work of about 25 health centers across the State of Pennsylvania, and these are federally qualified health centers. So primarily they have a mix of payer, but mostly Medicaid patients. Somewhere around 500,000 patients are served. And I think that number changes, obviously changes a lot, but we are currently supporting about 12 health centers of varying size to implement self-monitor blood pressure programs in a variety of the projects that we have.

What I'm really going to focus on today from a data perspective is a three-year project that or it's actually a four-year project and we’re finishing up the third year of a project really focused in southeastern Pennsylvania, really looking at following a group of patients for a while around hypertension. I just want to let you know that we support multiple EHRs. This is only three of the EHRs that folks in our network use. But these are largely the ones that we've used in this particular project. We do have a fair number of groups using NextGen as well and a smattering of Energy, one Epic user and one MEDENT user. So we're learning the ways of EHRs in this work as well.

So I kind of want to paint a picture today of the journey that we've been on for the last―it's really probably more than a year. Because we initially supported getting blood pressure cuffs to the health centers where patients didn't have access through their insurance and that was really more focused on getting a blood pressure cuff in the hands of the patient. Last year, in June, we saw our blood pressure control rates really beginning to drop in this cohort. And what is I think important to focus on is the gray line on this graph, this run chart in front of you, because that represents the number of patients who had a medical visit, and that includes a telehealth visit, that did not have a blood pressure reading in the measurement. And that was really an alarming discovery for us last year, and at that point we decided that we really needed to pay attention to that. And that meant probably shifting our focus to more of an SMBP program rather than just getting cuffs into the hands of the patient. So a lot of what Dr. Kirley talked about earlier― that concept of your patient needs to be educated and understand what their role is in this process―that became really clear to us. Now you can see that number of missing blood pressures is starting to drop off, which is great in this case. That downhill piece on this particular run chart is a good thing because we A, are getting more patients into the office again and B, we are also more focused on gathering those home blood pressures.

So the next slide is just our aha moment. We needed to step it up on implementing self-monitor blood pressure programs. And that's when we sort of took a people, processes, technology approach to this. So I'm going to spend a fair amount of time on this slide. But then towards the end of my presentation I'm going to show you some of the tools that we use and I want to make it clear that we're happy to share the tools that we've compiled. I feel like it's really important to get these things out there and used by others to get more feedback on how they're working.

So when we had that aha moment, one of the things that we really thought about was we need to get self-reporting blood pressure cuffs into the hands of patients and care teams. But we also needed to stand up programs at each of these sites that were interested. And we had four sites that were part of our Million Hearts project and that was a great place to start. We had a little bit of funding that we could share. We also had groups that were accustomed to hearing about self-monitor blood pressure and were on board with it. And they were willing to allow us to use this funding in such a way that it would get blood pressure cuffs to them. And we did a little bit of math and figured out that we could cover about 10% of their uncontrolled patients with the funding that we had to get blood pressure cuffs out there.

What I didn't realize when we started out on this journey is how hard this was going to be. It seems simple, seems like a great aha moment, but it really does require thinking about the people, the processes and the technology. So we needed leadership and sponsorship at the highest level to be able to identify people that would be clinical champions. That went pretty easily. Then we needed to get the providers on board and we needed to think about staffing for patient enrollment, patient monitoring and then some support around prescribing. So I will tell you that in one of the programs, one of the health centers that was involved in this program, we've had some well, had several really interesting ways of getting the program launched and activated.

So the people―that clinical champion, we needed enrollment specialists who could engage and activate patients, right? We need an activated care team and we need activated patients, so the patients have to be engaged in this. Then we needed care management and nursing staff to monitor patient progress and communicate with the prescribers. And we did have some clinical pharmacists involved. One of the groups actually has two staff clinical pharmacists. And in that case they are the people who are performing a medication therapy management visit with the patient. So they're going over all their medications and they're enrolling them in the self-monitor blood pressure program.

So in that case we really had it―the enrollment and the pharmacy support and the prescribers consolidated into one role and function within the organization. In others, that has been diffused throughout the care team. And in some cases we have community health workers in the enrollment specialist role. In some cases we have specially trained medical assistance. In others, we have two other people who have been specially trained actually to activate the program. So it's been pretty challenging to get these things staffed because it does require a fair amount of time with the patient at the point of activation or enrollment to help them to really be able to share those blood pressures back.  

I just want to say one more thing about the people involved. Getting buy-in from the prescribers, or the providers that are actually prescribing antihypertensive medication and other therapies is an important step in all of this, and we addressed it somewhat through training and education. That has been and is provided in an ongoing way just to get folks to really talk about what their concerns are. There's a lot of concern over “I'm not going to be looking at these blood pressures every day, every hour … what if the patient has an out-of-range blood pressure, for example?” We've been able to help people understand that a patient has an out-of-range blood pressure anyway, and now at least we know about it and we do have a plan for addressing it.

And I'll tell a story about one particular patient that we've encountered who has had an out-of-range blood pressure all along, but we are seeing progress towards the goal. We're not there yet, but the patient's engaged, the provider staff is engaged and they're staying in touch with this patient. And we are seeing them start to make some progress and we can begin to understand why they're not making progress, right? Is it because they're not taking their medication as prescribed? Are there side effects to this medication that makes them not want to take it? Is there a cost factor? Is there just an access factor? So we've been able to address those things and despite the fact that patient’s still running a kind of an alarming range of blood pressure, again, at least we know about it.

So I'm going to show you our project plan that we use, and I have a tendency to kind of go to this sort of key decision language. And what I mean by that is that if you plan, if you take the time to plan and you list out all of the areas that you're going to have to make decisions and start to make those decisions, it's a lot easier to start delegating the components of a self-monitor blood pressure program to members of the team, and it's much easier to understand when you can actually pull the trigger and start enrolling patients.

And so we really take a fair amount of time, and I'm going to go through those key decisions in a second. But I think it's very important to be thinking about what do you need in place, what is the infrastructure of people, processes and technology that you need in place at that starting point? And then workflow again, workflow around enrolling patients. We've developed a checklist for enrolling patients that folks can use. It's based on pulling together what we've learned, what's out there in the literature, and it really does help with that process. We've worked on workflows around the care team communicating. I think it's overwhelming to providers to think that all of these vital signs are coming in. And oh my goodness, what do I do with them? And that's where the care team comes into play, and there should be somebody who is specially trained to surveil them to reach out to Mary McGillicuddy when she's taking her blood pressure every five minutes. And you know, you don't need to be doing that, Mary, and John, who hasn't taken his blood pressure in three days or never did take a blood pressure. So there needs to be outreach staff and sort of monitoring of that work being done.

And then unfortunately, the EHRs and I'll talk about this a little bit more in the technology. There needs to be, in some cases, manual data entered into the EHRs. Who's going to do that? How is it going to get in there? What's it going to look like? How is it going to be presented to the end user?

And then we're very fortunate that across all of the health centers that we're supporting at the moment, we have a population health management tool in place and we're able to do tracking. We're able to move patients into registries. We're able to look at patients―that group of patients where we could focus and get some good results, so that has been extremely helpful.

I talked about the training and education. And then the other thing that we've learned in all of this is addressing digital literacy. And that's on the part of the patient, but also on the part of the staff. We're asking staff to help a patient take their mobile phone, download some sort of app to it. And oh, by the way, there isn't enough room on the phone for one more app. And no, I'm not giving up Words With Friends. So what do we do now?

So these are some of the real world things that happen. How do we address some of those concerns about now we're putting real technology that's sort of, you know, extremely important to the patient's health and well-being in the hands of the patient, in the hands of the care team staff. And how do we make sure that they have what they need to feel confident and comfortable and like real participants in this project?

And then sort of metrics from the beginning, what's going to constitute success? What data do we need? How will it be collected? How will it be documented? How will we report out on it? And in our case, much of that is building out capability and functionality within the health management system, but also making sure that patients are getting entered into that registry. That's not an automatic process. It does require some manual work, but we put those processes in place.

So here are the key decisions. Need to identify the patients who are going to be in the program. What makes them eligible for this program? Is that a referral from a prescriber or provider? Is that self-referred in? Are we just going to look at a list of patients who could qualify and go from there? Where does that live? Addressing some of the operational details like what are we going to use and to Dr. Kirley's point, needs to be a validated cuff. I feel very strongly as a provider myself, although I haven’t practiced at the bedside in a while, but from my perspective we have to be able to unequivocally say to the folks on our team, they can rely on those blood pressure readings, and here's what we are doing to make sure that they're reliable. So we've only worked with validated cuffs and use the validate list extensively.

Are you going to use a loaner program or are you going to give the cuff to the patient? COVID made everybody a little bit crazy about not sharing cuffs and having to sanitize them in between. But some of our health centers now are leaning more toward a loaner program. Who's going to staff it? That's a big if, you know, and having that staff and what are the roles that they're going to play? In some of our materials, and this has been really helpful through the National Association of Community Health Centers SMBP program work of laying out all of the roles and responsibilities rather of staff. Not that you need a person in each one of those roles, but understanding what you're going to need.

So how were those blood pressure measurements going to be reported to the prescribers? What customizations need to be made in the EHRs? What customizations and configurations need to be set up in the population health management system? What report customizations might need to be made and what training is needed? So having a template and we've developed a work plan which again, I'm happy to share with anybody. Not that it's the end all and be all, but it might be a great place to start if you're trying to put a program like this in place. It lists out all of these key decisions and basically asks you to respond to them as a team.

So, the technology. I'm going to share with you here some of the on-the-ground things that we have run into. We have run into not enough space on the phone, absolutely running into that. We have run into no network capability for patients to use their device in a health center waiting room or office. So we've had to deploy hotspots. We've had to walk patients through downloading that app before they got into the office, which can be super challenging, especially if they can't get on in an a/v visit with you on some sort of a screen share so that you can really walk them through what they're seeing on their screen.

We think it's really important to have a clinical portal that allows for you to see the monitoring of patients enrolled in the program in one place. The EHRs typically are not set up for that. EHRs work on a―they're very patient centric. They're not population centric. So it becomes a one-by-one-by-one scenario often. And we think that clinical portal is extremely important. When you're selecting the cuffs, you need to know if it can support an extra large cuff. We have run into lots of issues around pretty high BMIs in this group and needing to have extra large cuffs.

Are you going to use Bluetooth connectivity or are you going to use … an LTE really stands for wireless mobile connectivity. What kind of cuff are you going to use for that? And it really should be validated.

So what kind of patient engagement tools are you going to use? Are you going to text with the patient? We recommend that. It's been our experience that texting is very effective for this group of patients. Are you going to text reminders to them if you're not seeing their blood pressures coming in? Some systems out there actually allow you to set that up on an automatic cadence, which can be helpful. Although what we have also found is that personal touch, that somebody out there who's looking for your blood pressure, who is going to connect with you, personally makes a big difference in patients submitting their blood pressure readings. It really makes a difference.

Are you going to use some kind of inventory management tool if you are going to have a loaner program? And I think that depending upon how long you expect this to be a part of your service offerings, the investments that you're going to make today may make it much more scalable going forward.

And then mobile devices and connectivity for patients who don't have smartphones. We're working with a particular vendor right now who does offer that out and offers it out through the Emergency Broadband Benefit program that's part of the most recent COVID funding through the FCC. And that comes at no cost to the patient and no cost to the practice and can be billed directly. Actually, the vendor does the billing directly and they get reimbursed by the feds. So there are opportunities for patients who just don't have a smartphone or any kind of tablet device that you can use for this.

And I think this takes me to the point, and I neglected to really pay attention to my time, which is a common problem that I have. So I don't know if somebody can help me with time.

Lim: Yeah, go for it, Deb.

McGrath: OK, so I am going to share my screen here. And what you should be seeing is―let me move these out of the way―is our smartsheet. This is the project plan that we put in place. So here are the key decisions that I just talked through listed out here, and sort of asking you to answer those questions. We then get into the key staffing area. So here are the keys―can you guys see this OK? These are all sorts of roles and functions that people play in an SMBP program, and it can look overwhelming when you look at the number of functionalities. But again, these can be consolidated. One individual can fulfill multiple functions.

We then have some suggested curriculum for training, and at the Health Federation we have provided some of this also with our partners at the AMA. You guys have been extremely helpful in this and it's been very effective. We've use the podcasts extensively and the providers really like the podcasts because it's something they can do asynchronously. It seems to resonate with them. It hits just what you need to know and it's very manageable.

We then kind of talk about the patient identification piece and then we get into implementation. Like here we are now, we're ready to roll this out. And then we sort of develop a protocol for monitoring those patients and kind of reporting back. So in many of our groups now we're at the point of either they're right on the cusp of enrollment or they're actively enrolling patients. And we're at the point now where we're getting feedback―the numbers of patients who are enrolled and how they are doing. And in one case, for example, we had 14 patients enrolled, seven were reporting their blood pressure readings and all seven of them reached a blood pressure of less than 140 over 90 in a two-month time frame. So that's very encouraging, and it definitely keeps that group going. And then we're down to the end. These are the evaluations that we're trying to look at, and one of the things that we're really trying to get to is the number of encounters that result in intensification of therapy. It's really hard to get to that information with the way EHRs work, but at any rate it is extremely helpful to understand how we're narrowing that number.

We're getting to a place where patients are reaching control much more quickly and staying there, at least right now. I mean, we're only a few months I would say into really good enrollment numbers so it's hard to say, but early early indications are that it will. It will be OK.

So I wanted to show you the clinical portal that we have chosen to use for most of them, and it's not necessarily saying this is the only one out there, but I want to show you that simply to express or to demonstrate how this can be super useful. And I have no financial ties to this group or anything like that, but they have been good partners and I did want to give you a chance to see what they have out there.

So what you're looking at is my view as a provider in the organization. I can edit the columns fields here through this area, I can decide what I'm seeing or not seeing. So if I got rid of date of birth, it would go away. I do want to take one step back on this technology. The patient downloads the app, the patient can sense at the point of downloading this app that their blood pressures are going to be shared. They're made aware that this portal is not monitored 24/7; they are instructed that if they're not feeling well or if they're having issues to seek emergency care. That disclosure happens at the point that they download this app and then we're able to see the individual patients. We can go into an individual patient and this is what's presented to me from in there. Now, I'm in a demo database so this is all demo data, and it looks like our developers are healthy because I think these are probably their blood pressure that they're submitting. But at any rate you're able to get right into that patient area. You are also able to decide what vital sign fields you're looking at. This particular app covers glucose monitoring as well as pulse oximetry readings, weight, blood pressure, et cetera, so you're able to make those determinations yourself.

You can see the BP alerts and I can actually filter on alerts. So I can see all of those patients who are running high here. I can also go to a practice overview area and I can see everybody who is running greater than 160 systolic and that would give me a patient list. So this is helpful so that the team can monitor. And then from there I help to distill it down for the prescribers.

I just want to briefly show you this―this is Sano Health, the company I was talking about. They are an EBB service provider, if you're interested. This is another organization that we've worked with in the past that does allow for inventory management of any kind of DME. You can create a barcode for anything that's in your organization. And again, I'm not endorsing this as much as I just want folks to be thinking about what's out there to help manage these programs and think about the technology that could be used.

So I think I'll stop there, and if there are any questions that I can answer.

Lim: Thanks so much, Deb. If anyone has any questions, please go ahead and type it down in the chat. The first question that we have is just general around technology and how to respond to questions or patient questions around just what happens if the technology potentially fails, right? And there certainly could be something that goes wrong. You had mentioned disclaimers―anything else you would recommend around just communication to patients on this particular note?

McGrath: Well, this is not ambulatory blood pressure monitoring, right? These patients are taking their blood pressure twice in the morning, twice in the evening, and it goes directly to this clinical hurdle. As long as their Bluetooth stays connected, and that is challenging. So I think what I would say to patients is if we're not seeing your blood pressure readings in there, we're going to reach out to you. This is why it's important for you to consent. It is why it's helpful for you to allow us to see those blood pressure readings. I think it's a matter of having that relationship with the patient, which is why I talk about having clinical staff available to monitor and reach out to patients individually. I know there's automated processes around text messaging. The Sphygmo portal does allow us to message right within the portal to the patient's mobile phone so that can be an ongoing communication tool. The thing that I like about the Sano Health device or any device like that is that it's unlimited voice and unlimited text so the patient can have a telehealth device. So you're not up against what minutes they have left for using their phone for text or voice. So I hope that is helpful and answers some of the question, but it is a concern that providers have for sure.

Lim: Yeah, and I would just add to just to answer one question, I think you had mentioned that recognizing that if they're not feeling well to make sure that they're coming in, too. So not just solely relying on the technology, but just being mindful of that.

McGrath: Exactly.

Lim: Alright. I'm not seeing any other questions. I had a few for you, but this is pretty comprehensive, really appreciated you sharing lots of good questions to prompt, right? Like your project plan, and we can share a version of that post as well. Thank you for taking us into just your portal. That was really helpful.

I wonder, too, Deb, maybe you can just talk a little bit about just that selection process of determining how you determined to work with that vendor.

McGrath: That's a really good question. I think that we initially started out using a clinical portal that was associated with one blood pressure cuff manufacturer. And when we started to use that portal we ran into some issues. For example, when a patient was through the process and already controlled, we had no way of stopping those values coming into the portal, so it became noise―like this patient's already controlled. We don't really need to be seeing their blood pressure values anymore, and it was really dependent on the patient to stop sending, which was really challenging. And in this case, one of the key things about this particular portal is it's on our end so we can take action and we can block those submissions and then we can restart them at any point along the way, if needed. So that was one area.

The other area was the way it was presented. As you saw, I could see the whole practice. I could see everybody enrolled in one place and I got information about them. In the other portal we had to click into each patient to actually see their blood pressure readings. This gave us a real dashboard of what we needed to focus on. It was an interesting journey as well because the developers of this were interested in hearing feedback and making some changes. So one of the things that happened is the app that the patient downloads. It's also called Sphygmo―which is a very difficult name for everybody to understand, I have to say, makes sense to us medical providers, not so much to a patient―but at any rate the consents were written at a college level literacy level. We needed that literacy level brought to closer to a middle school level, which they did on our behalf. So I think that they have been willing to work with us and take feedback, and that's been part of the journey. So I hope that helps answer the question.  

Lim: Thank you, Deb, for your presentation. Dr. Kirley, I'll turn it over to you to introduce Dr. Thamman, and please feel free as again throughout the duration to either type in the chat or use the reactions to raise your hand if you'd like to ask your question live. Alright, I'll turn it over to you.

Dr. Kirley: Thanks, Bernadette. Alright. Dr. Ritu Thamman is an assistant clinical professor of medicine at the University of Pittsburgh School of Medicine. She is a fellow of the American College of Cardiology and of the American Society of Echocardiography, and she serves on the board of directors of the American Society of Echocardiography. Her research focuses on cardiovascular disease in women, mitral valve prolapse, mitral annular disjunction and innovative implementation tools for cardiovascular disease.

She is the chair of the echocardiography Twitter journal club, a formal journal, a formal journal club on Twitter for which she has developed the CME for the American Society of Echocardiography, and she is the chair of the Women in Echo Task Force at the ACE. She is the co-founder of hashtag telemed, now a prominent telemedicine discussion on Twitter, which teaches a myriad of telemedicine topics with CME. And she serves on the ACC heartbeat health workgroup, developing a telemedicine solution for cardiologists from the ACC, and is the co-chair of the ACC/CTA standards for telemedicine workgroup with Google Health, Samsung and Apple.

Dr. Thamman is participating in multiple national and international society guidelines and position statements. She is a member of the writing committee for the 2021 American College of Cardiology, disparities of care guidelines and the ASC's burnout prevention guidelines. She is a member of the ACC women in cardiology leadership council and started the PA chapter of women in cardiology. Dr. Thamman is the social media editor for Circulation, Cardiovascular Quality and Outcomes and the Journal of the American Society of Echocardiography. Her writing and interpretation of scientific articles has led to her being a top national and international social media figure for advocacy and education for cardiologists. So I will turn it over to you, Dr. Thamman.

Dr. Thamman: Thank you so much for that wonderful introduction, and thank you to you, Dr. Kirley and to Shirley [Debra] for amazing presentations that really have set the stage for me now to talk more specifically about a program that was started here in Pittsburgh.  

So we developed a postpartum hypertension program, and specifically it was chosen because we have a audience that is captive. These are women who are admitted to the hospital having their babies; they cannot go anywhere. So it's very easy then to take a captive audience and try to convince them to enroll in a study. And as you all know, postpartum hypertension is a leading factor for worse cardiovascular outcomes in women, and it is something that is gaining much more national awareness as something to ask all women when they come in to see you for any kind of assessment, particularly any cardiovascular assessment.

So in this captive group, we had started with one nurse practitioner who was able to recruit from this target audience. So it was easy to start enrolling because we had an excellent person that was able to recruit. And so all of the eligible women who were admitted having their babies and were hypertensive after they delivered, about half of them agreed to be enrolled. So it's not perfect, but it's better than a towing cost. We had a call center. That was how we were able to manage these patients and monitor their blood pressure for six weeks. And when we first started this program, which went through a million hiccups because of the problem interoperability and also because we needed obviously to get funding, which we got funding from a company, Vivify, to supply the digital know-how and also help in getting us digital kits that we would then mail to and we had to pay for that to be sent to the patients. Now that was started years ago and subsequently, now we're hoping that the insurance companies will start to pay for the blood pressure cuff. Right now it's not standard. Patients still have to pay out-of-pocket, and that can be a limiting factor. But in our case, we had it funded and we were able to show that by controlling blood pressure, about a third of the patients that were enrolled avoided going to the emergency room.

And that is a key point that patients need to know and also obviously the insurance and the physicians, because ultimately those patients and people who are trying to implement such a program are looking at the bottom line, which is how much money am I going to be able to save when you're trying to convince your admin to go for such a program?

In addition, for this particular subset of patients, there was a decline in readmissions, which again, we were able to show, and some of the patients had their blood pressure well enough controlled that they didn't have to come in for their one-week postpartum visit. So then again, that not only provided patients with increased, you know, you have a newborn and a lot of those patients are not coming in for their appointments, it's overwhelming. So that was a huge win for us in terms of those patients.  

So by enrolling this group of patients we were qualitatively able to show that those patients then followed up―a much better percentage 90% versus the national benchmark of 50%. And of course everyone's got their eye on the neatest programs and trying to gain the stars that will lead to your institution getting more money. And right now that is being revised and revisited and we're hoping that will be a major incentive for patients, for organizations to get on board in such a program. Because obviously there is a cost factor up front in hiring a nurse and also having that nurse take the phone calls and then having buy-in from your physicians who are going to be the back-up.

And if the nurse calls and says, “Mrs. Mary Jones has a blood pressure of 180 over 100―I've gone through the protocol,” which we wrote out very succinctly and purposefully and gave a lot of autonomy to the nurses, just like you would like as your intern would if you're a resident taking care of patients. And we were able to really streamline that process. But those patients that didn't meet those criteria then had back-up to talk to a physician. And so you have to have buy-in because it was a 24/7 physician on call all the time. And we would do it one week at a time. And sometimes you get no calls, sometimes you're very busy. But the experience overall was met by the patients with very high satisfaction. And many of the patients almost 30% than enrolled, were able to transition just their care to PCP, and that was a slightly higher number. A lot of these patients, they have their baby and then they're off and you never see them until they re-present 10 years later with heart failure or an arrhythmia or AFib, or some other cardiovascular complication, or sometimes in the Black population they present with a stroke.

And so trying to avoid that is such a key part I think of our U.S. guideline impetus and the AMA has done tremendous work. I know the NHLBI has a huge implementation arm again trying to do just like what we all are talking about here.

So some of the things that are not generally considered when we're starting this program or evaluating these types of remote patient monitoring programs is, there's a cost savings. The patient doesn't have to travel. Pittsburgh weather is terrible and there's always some problem in the winter. And you need to know that if the staff and then everyone involved in the patient is engaged you're going to have better outcomes. That's been shown universally. And it also pertains to these postpartum hypertensive patients as well.

This is a financial model. I don't want to get into the weeds here but when you are trying to present to admins who control your budget, you're going to have to say we used a model based on some kind of economist giving some feedback that says, “we have this potential to reduce costs.” Everyone wants to hear that. As clinicians, we don't always think in terms of, “I want to save money.” We're worried about outcomes. But clearly both of them are linked because if there is a financial incentive that the organization can use then you are going to have better outcomes because your patients are going to get enrolled. So it's a win-win situation for both sides and we have to acknowledge as clinicians that we cannot ignore that and we have to keep it front and center.

So this pilot was successful and then COVID hit. And then COVID opened up a whole other huge set of problems of which Dr. Kirley so nicely explained in terms of reduction in visits for hypertension and overwhelming need for telehealth visits for hypertension. In fact, that was the number one reason that telehealth visits were occurring, according to data that was published at the end of last year, showing when we were really in the height of COVID in this country that was the main reason people were coming in and having a telehealth visit with their physicians.  

So some of the things that obviously are very important is you have to be able to sell this program to your organization. And then figure out how are you going to have a call center structure, because you're going to need a nurse on call who understands and is able to follow an algorithm that you would provide, but you also perhaps can use a pharmacist. I must say that I presented some of this data to the American Organization of Hospital Pharmacists and they're very keen also to get involved with these types of implementation programs, especially if we're going to be going to a population health model where there's going to be just a global payment. And I think that’s very soon in the next five years.

And then the other part, like I mentioned, is getting your providers, your doctors, to be able to take back-up calls if their patient is hypertensive. What advice do you have to be able to give that advice in real time? And you have to be able to do that 24/7. And so this program, now that we're sort of in the third wave of COVID here in Pittsburgh, it's a very small one, at least at the time that I'm speaking not to know how it's going to end this year, but we have a very high vaccination rate. And so we're trying to now get money to do this for all hypertensive patients. But again, the caveat being that this program was successful because we had a very limited target audience, a captive audience, if you will. And now we're going into half the population has hypertension, whether known or unknown, and so we're trying now desperately to figure out how to implement on a larger scale.

So some of the data, this is a little bit older―pre-COVID―just to alert everyone to the problem that it's almost one in five deliveries that are coming in with this problem of postpartum hypertension. That's significant considering the population of women giving birth. And that's just here, but that's also other places. And we have shown that there is potential for cost savings. And I think that is the message that you would always have to convey. And these numbers are going to be very―they're not sticky numbers. They are going to be variable depending on where you are and which economic factors you're using in your modeling. And so everyone's going to have a different number. But the bottom line is there will be cost savings. And when you're trying to bargain with insurance companies you need to be able to say that.

So this is one of my favorite quotes, which is really apropos here in the world of telemedicine. “The only problem with communication is the assumption it occurred,” by one of my favorite writers, George Bernard Shaw. This is universally a problem for all humankind and all of us in health care know that this is true. And to that end, when we're talking about telemedicine, we need to be really alert to what sort of problems we're going to run into when we're doing remote patient monitoring. The number one is obviously difficulty connecting, and the way we've come around that is you have to anticipate and try to prevent this problem. Right now we have someone call the day before. Make sure if we're using an app-based device that the patient has the app and they're able to download it. If they're not, they don't have the connectivity, we try very much to help them. Now, of course, all sorts of things that have popped up. This is techie friends. It's like phone a friend and you can just call and say, can you FaceTime me and help me? Because not everyone has a grandson or grandchild close by that will be digitally savvy and able to help, say, an older person. But if we can anticipate that that's going to be an issue, then that's number one. In the future we look to be giving out cards for connectivity. We always ask patients, what is their speed if they know it? Are they connected? Just like we give parking passes in real life and patients come in to the clinic, now we have to offer data cards because I'm going to get into this in a second.

So again, this is just the general preparing. This is more universal in terms of if you're seeing a patient video, but we're talking, a lot of this is asynchronously done.

Remote patient monitoring. So then we ask what is the speed and because the speed of your connection is going to interfere with how valid, sometimes if you're evaluating fine motor tasks and it's been shown, so you really do need to know this and digital health equity is really a necessity now. It is not fair. Health care should be. There's always debate, but most of us clinicians are thinking this should be a right. If you're born, then you should have a right to good health, you know, be healthy. And this is a great article for any of you. Written by my friend Dr. Rodriguez from the BI, and I'm really outlining how important this is, and one of the ways we're doing this is by offering digital cards, data cards so patients can get this if they don't have funds or the means. In the future what we're also debating is whether libraries that are free for books, et cetera, would also have free iPads or phones, something that is digitally connected that patients can then go and check out like or are they going to be opening up those sort of kiosks around town just like we used to have in the old days, like telephone booths. Now we're going to have little telemedicine kiosks. They could be within stores like Target and Walmart, places that our patients are frequently going to, but then also should be devoid of necessarily a business connotation so public agencies like the libraries or even schools. So that's being debated.

So there is a difference between if we're talking about video use, am I actually able to see the patient or do I have to go back to telephone? And this is hotly debated right now because of the issue of whether this is going to be paid for or not. It's not decided. There's always rumors, but we don't know for sure. There was a great article that a fellow cardiologist wrote about a patient. Sometimes just like Shirley [Debra] said, they want to know that we care. And even if you can't see them on video because you lost the connection or it was too poor, the fact that you're on the phone with them is so important because it shows you care. So you're still trying and you can still help them. But there is a huge disparity and you can see, obviously by age and by race of the use, whether they're going to be using telephone. You know, you can see that the Hispanics and the Blacks, and if they're not native English speakers, they're the ones that are really going to be using the telephone. More so here again, there's this disparity of care. You have to be aware of that and understand that.  

So again, with the non-English speaking, we have much lower use, so you have to see which patient population you're talking about. A lot of the newer companies, my friend who owns Cloudbreak Health, they have translation built into the system. So if you are trying to speak to someone, I mean, a lot of us have used Google Translate in the hospital and I've had Russian patients, other types. It's not great, but if you actually have translation services built in, this is not standard of care, but there are more and more companies that are building that in. And I think that's something we're going to see pretty soon as being fairly standard.

And then of course the topic of health literacy, which has come up in all the former talks because it is the only way that we're going to be communicating effectively. A wonderful study out of Yale by Erica Spatz looked at hiring community health workers in this group of patients who had low digital literacy, and it was fantastic. It was really helpful for controlling hypertension. However, those community health workers were paid for by her study, and the problem is, once your study is over, then what―you lose those health workers. And so that's another thing that anyone who's negotiating with insurance companies has to say, “You know, when we're looking at a population health model, we need these kind of services sort of built in.” Even if you say, OK, we're supposed to be saving money, yes, we are, but we need these kind of services. And of course, the more they get automated, the easier it's going to be in terms of lowering the costs. But we absolutely have to be clear, because many times the language that we're speaking, even if it's English in this technology field, can be very misleading, even amongst physicians. I could be talking digital literacy, and it means something to me and somebody else who may not be as familiar may say, “I'm not really sure, does it mean that I can turn on the device?” Or is it really, you know, what level? And are we really assessing our patients? When you hand them a device or an app like they're not graded, you don't give them a quiz and say, OK, you passed and therefore you're OK to use this. But it may come to that. So look out for those pop quizzes for your patients.

And of course, I wrote this paper with my husband, Andrew Watson, at the beginning of the pandemic with Robert Wah, who was the AMA president a while back, and this was just at the start of this pandemic on remote patient monitoring. And some of the issues that we raised are still very relevant today because remote patient monitoring in this manner of controlling blood pressure asynchronously is the future. It is now and it's also the future, much more so than video visits because it's all the time in between the asynchronous times that we're able to control it. And if the patients need those extra touch points in between seeing a clinician or any clinical provider, that's the only way that we can engage them. We know from the data that 50% of patients either don't know they're hypertensive, so they're not measuring in the U.S., they present with some morbid cardiovascular complication, or if they have a diagnosis, 50% of them are not taking their medications for a multitude of reasons. But the real value of this remote patient monitoring is going to be in increasing the adherence. It's already been shown in patients, certainly diabetics and some populations of hypertensive patients that if you are giving text messaging that is very targeted and very specific, you are able to improve outcomes measured as, say, a drop in your systolic blood pressure or adherence to your medication. So this is really the now and the most important thing I see in telemedicine that will improve patient outcomes the most.

OK, thank you so much. I am happy to take any questions.

Lim: Thank you, Dr. Thamman. I'll give everyone just a minute now. If you've got a question feel free to use the reaction and raise your hand if you'd like to ask it live if you'd prefer us to ask it. You can also type it in the chat so I'll just give everyone a minute.

Dr. Kirley: Bernadette, maybe while people are putting questions in I was just going to reflect for a moment, especially on the last comment that you were making, Dr. Thamman, about the future of a lot of care, including hypertension care, really relying on data from patients that is generated outside of our offices. I mean the reality is with blood pressure that should have always been the case. These blood pressures that we take in our offices, they're problematic for a lot of reasons. Patients experience the alerting response in the white coat effect, where their blood pressure tends to be more elevated in the office. Doctors do the worst thing. We do this thing where our medical assistants take the blood pressure and we go, “I don't know about that―I'm going to repeat that,” and then we take it ourselves and we decide that's the one that we're going to use. And that's probably even worse. While what we talked about today, I think, does sound like a lot of work. I mean, it is admittedly a lot of work to get a good remote patient monitoring program or self-measure blood pressure program in place. I think we sort of owe it to our patients to figure out how to do this well. And it will take time because their measurements outside of the office are a much better picture of what's really happening with their blood pressure.

Dr. Thamman: And I think as we go on, I mean, COVID certainly accelerated all of this for all of us in the States and around the world. I'm just hoping that we have seen sort of a drop in telemedicine use. If you look at the newer numbers coming out, I'm really hoping that when they decide the budgets, et cetera coming up, that they will still include payment for these kinds of things that you described in your slides. I think that's really important. Even if we get paid once in 30 days for an asynchronous remote patient monitoring, that's something. And I think that as more people have it streamlined, for example, at the ACC level, we've partnered with Heartbeat Health and we have an app and it's fantastic, it's free, and it's secure and we're working on getting all of that data published from the people who are already using it now, both private and academic organizations. The easier we can make the process, how wonderfully, Shirley [Debra], you shared all of your processes. The implementation is where we all struggle. If we had an unlimited bank account, we could just do this. But all of us have limited resources and we're trying―when we're doing pilot studies, there's so much of our own personal time invested. I would have to drive to the call center to check in to make sure that I didn't lose somebody there, a nurse didn't drop out of the program or they were happy. I had my daughter baking cookies. I mean whatever we could do to keep people engaged when it was really just trying to get it off the ground. So much of it is just your own personal determination and ground work. So yeah, you have to be determined to get this done.

Kim: Alright, we either have a quiet group today or your presentations are incredibly thorough. If there's any other questions that come up please feel free to send them our way and I will make sure that they get to Dr. Thamman and Deb and Dr. Kirley afterwards.

Laura, if you wouldn't mind just pulling up the slides, I've got a couple last slides here to wrap up. If you are joining us for the first time, we do have a web page that you can see our complete program. It's www.ama-assn.org/telehealth-immersion. On that website you'll see all of the upcoming events, including the next session, which will focus around how to incorporate learners into the telehealth encounter. We'll also have all of the recordings from the sessions we've had to date, as well as additional resources. This is our contact information. If you have any questions about the program, if you're interested in collaborating, if you're in the association or society, please do not hesitate to contact us directly.

And with that we thank you all for joining. Have a wonderful weekend. You'll receive an email from us probably around next week with the resources, the recordings. And there also will be a brief survey that we will ask you just take a minute to fill out. It'll be for questions. We really appreciate your feedback. It'll help us determine future programming. So thank you so much and thank you so much to our presenters. Have a wonderful weekend.

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Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.