Clinical Case Study: Telehealth for Primary Care

This interactive session discusses techniques for delivering primary care via telehealth and remote patient monitoring. Speakers also address telehealth primary care trends and opportunities.

Speakers

• Diane George, DO, chief medical officer, Henry Ford Medical Group Primary Care
• Matthew Sakumoto, MD, primary care physician, Sutter Health
• Steven Waldren, MD, vice president and chief medical informatics officer, American Academy of Family Physicians

Host

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

Explore the AMA STEPS Forward® Innovation Academy on-demand library of webinars on physician burnout, digital health, private practice, BHI and more.

Lim: Alright, it is the top of the hour so we will go ahead and get started. Good morning, everyone, and thank you for joining today's Telehealth Immersion Program session focused on telehealth for primary care. Before getting started, we have just a couple of housekeeping items. This session is a peer-to-peer event and we highly encourage virtual engagement. You can start off by introducing yourself in the chat. If you'd like to type your name, role, the organization you're working with and any questions that you might have or anything that you might be interested in learning about today specifically we'd love to hear about that.

After each case study presentation we reserve time for a live Q&A. If you have a question, please feel free to use the Raise Hand function at the bottom of your screen and we will invite you to ask your question live during these designated times. Since today's session is a Zoom meeting we ask for your help in minimizing any disruption by keeping yourself on mute during the presentation and when you are not speaking. And lastly this presentation will be recorded and made available on our program web page following today's event.

And without further ado, it is my privilege to introduce our first speaker, Dr. Waldren. Dr. Steven Waldren is the vice president and chief medical informatics officer at the American Academy of Family Physicians. He is a nationally recognized expert in health information technology and has over 15 years of experience. Prior to joining AAFP, Dr. Waldren was a National Library of Medicine medical informatics postdoctoral fellow at the University of Missouri Columbia, at which time Dr. Waldren earned a master's degree in medical informatics. Dr. Waldren is also a residency trained family physician, and besides his role at AAFP he participates in many national health care informatics initiatives, such as being on the board of Logica Health, co-chair of Da Vinci Clinical Advisory Council and past commissioner on the federal Medicaid Payment and Access Commission. And with that, Dr. Waldren I will turn it over to you.

Dr. Waldren: Great, thank you very much. It's a pleasure to be here today and chat with everybody. I'll talk about this as kind of a view from family medicine, just because that's the data that I have. But I think it's pretty representative across all the primary care. So the data that I have actually is two surveys that we did, one in May of 2020 and a follow up in September of 2020. We just completed another survey that just finished about a week ago. So I looked at that and made sure there wasn't anything that would invalidate any of those prior survey data that I have, but I won't really talk about that particular survey.

Those surveys that we had in May and September had about 200―a little over 200 in each of those surveys. See if I can get the next slide to go. One thing that I think is really important to understand is that primary care provided what I call kind of a high-g maneuver back at the start of the pandemic. You know, you think about a high-g maneuver in an aircraft―it puts on a lot of stress on the technology, also puts a lot of stress on the pilot. And I think that was very true of the early days of the pandemic back in even as late as May in the pandemic. In primary care and family medicine at least, we had about 15% of our members that were doing telehealth prior to the pandemic. But at that time in May another 81% had added some type of virtual visits to their office. So well above 90%―around 94% and our September numbers put that at 97%. So I think the vast majority of primary care adopted the technology to try to support the needs of their patients.

And I think there were a lot of trends that we saw during this transition, a lot of utilization of audio-only for a lot of issues, from the technology adoption, from broadband issues, from patient acceptance of being able to figure out how to do it well. But I think even as late as September found that there's still a significant high value of providing kind of audio-only telehealth visits to patients. So definitely from our perspective they will continue to promote and advocate for the payment of audio-only as a valid utilization methodology in primary care.

One anecdotal piece that I will say, though. I've talked with a couple of our docs that have done the audio-only and one of the concerns they have is that with the video visit you can still do your nonverbals just like you do in in-person visits to kind of keep patients on time and to let them understand that you have a limited amount of time that you can spend with a patient. Those are not able to be done in audio-only. So we talked to our other docs saying that those audio-only seem to last a little bit longer than the video visit sometimes, so just keep that in mind. I'm sure you're experiencing that as well in your practice.

We did see a high level of satisfaction―they said that they were either moderately or highly satisfied with it. It was about 80% that said that they were satisfied with the technology and with the adoption of the telehealth in their practice. And if you think back in May of the challenges that we all had in trying to get this new technology into practices and still seeing that high level of satisfaction was really remarkable for me when I looked at the data. And we saw that very similar type of data with a larger number now highly satisfied with the technology, the telemedicine in their practice.

So I think there's also this strong desire to continue leveraging telehealth post-pandemic. So about 76% of our members in those surveys said they wanted to continue to deliver telehealth in the post-pandemic. So I think with the increase in desire on the patient side and the satisfaction on the physician side and the payments starting to happen, I think we'll continue to see a significant continuation of telehealth in primary care. But I think there are two challenges. One is this significant utilization of consumer tools to provide the video visits. And with the pandemic of course there's the relaxation of enforcement of HIPAA. So while I think a lot of our docs use technology that were more consumer focused that were highly secure, they didn't have the level of the business associate agreement. And so they could not be HIPAA-compliant utilization. So now they're trying to contemplate, well what should I use? And we had I would say almost over a quarter of our docs using some type of consumer technology, and they'll have to make that transition post-pandemic when those relaxations of HIPAA are discontinued.

And then between May and September and that's continued in our latest survey of our members, just a significant decrease in the number of telemedicine visits by volume. And I think that's definitely because of the increase in the number of in-person visits in the last several months because of the decreased lockdowns that we had to have, and across the nation, which are all great things. I don't have good data to know what the post-pandemic volumes would be, but all the anecdotal information and talking with experts, the numbers that I've heard around is somewhere between 20% to 30% of visits will continue to be telehealth or virtual moving forward. After the pandemic, we saw in May about an average of about 28 to 29 visits per week that were being done by telehealth and only 19 in September, so a significant decrease from that May to September time frame.

Payers are also really embracing the technology. Back in May over 40% of our members were doing telehealth and not getting paid to do it by plans and that’s well over 90% by time of September that were getting paid to do telehealth. And we've seen a lot of signals in the marketplace that they want to continue. Medicare has sent some really good signals in the physician fee schedule this year, and the plans have also in the private sector sent those good signals. I think one of the challenges moving forward is this new kind of virtual-only insurance products that are into the market and what does that mean? And we're also seeing a lot of the large plans are really investing heavily in kind of standalone telehealth companies. So for us I think one of the challenges is this direct to consumer. While we're seeing that significant investment in VCs, in addition to those large plans and startups, and we're seeing them being very aggressive in the way that they expand in the marketplace. The question though is will that can get a more fragmentation in primary care and loss of continuity and coordination, which we know are two of the big components to really driving value in primary care? In addition to first access, which I think these type of solutions have a potential to improve, but then the other, of course, fourth C of primary care is that comprehensiveness, which also is I think a challenge if that telehealth is not being provided by a patient's usual source of primary care.

So I think that'll be one of the ongoing issues we'll have to deal with as a nation of making that balance between making sure there's great access to telehealth and choice for patients, but also at the same time making sure that we're not degrading that longitudinal care for the patient around that continuity and care coordination.

So for us who are thinking about how do we at the AAFP help our members grow telehealth and primary care? We need appropriate payment. So we, and I know the AMA has done this as well, continue to advocate for current payment policies post-pandemic. We're also seeing that our docs that are in some type of value-based payment where they have a prospective payment that they're able to integrate innovation into their practice significantly more easily than fee for service. And we saw that during the pandemic with our folks that are doing either direct primary care or high value-based payment arrangement were able to integrate telehealth sooner.

There's a lot of challenges. I mentioned that survey that we just did. We focused on a lot of the challenges that our members have and they have a lot of challenges just navigating the payment policy, understanding what they can and can't do as it relates to getting paid. The other is understanding the clinical appropriateness. So what should I or should I not do via telehealth?

And lastly is what I call kind of optimizing operation. So how do I really integrate this into my workflow? How do I co-mingle in-person and virtual visits in my practice? And how do I do it effectively and efficiently? And how do I onboard patients really well? So I think in the pandemic a lot of our doctors say like, well, we know how to do it now because we've been baptized by fire, but how do we do it well and do it efficiently? And that's where we'll be trying to focus our efforts.

And then lastly I think there's a need to continue to build the evidence around the quality and value of telehealth as we move forward because I think in my view, telehealth today and in the post-pandemic is not going to be the same as telehealth in the pre-pandemic world. So all the evidence that we have in the pre-pandemic world I don't think is going to be adequate because we're adding a lot of chronic disease management and additional primary care services that are being delivered by telehealth today and tomorrow that they just weren't deployed like that in the pre-pandemic world.

So for me, I think about a couple of things, so while we've not seen that, we won't see that sustained levels of telehealth that we have now in the post-pandemic. But the levels of telehealth is going to be significantly higher than it was in the pre-pandemic. So in my view, telehealth is and will be a prominent component of primary care moving forward. The question is how do we do it well and how do we integrate it so that we continue the four C’s of primary care, first access, first contact care coordination, continuity of care and make sure that we're doing comprehensive care and primary care, which we all know is where the value in primary care is? So I look forward to the other two case studies and the questions at the end. So thank you very much.

I don't think we can hear you, Bernadette.

Lim: Can you hear me? OK, apologies for that. We have just a minute here. If anyone has any questions for Dr. Waldren, we invite you to use the Raise Hand function and we'll just wait a minute before moving on.

All right, and it's so nice to see everyone introducing themselves in the chat. We even have someone joining us from Thailand, which is great. So thank you so much. Keep that going in the chat.

I will introduce our next speaker without further ado, Dr. Sakumoto. Dr. Sakumoto is a primary care physician at Tera Practice, a virtual-first primary care practice in the Sutter Health Network in San Francisco. He is fellowship-trained in clinical informatics with a focus on virtual care. And prior to joining Tera Practice, Dr. Sakamoto has also worked as a virtualist for telehealth startups including Teladoc and Plush Care. And with that, I will turn it over to you.

Dr. Sakumoto: Thank you so much. Super excited and I see a lot of international participants so very excited to see that as well. So let me do … I'm not sure if I'm able to do Control Screen here. Actually, I could just call it out if you could. As Bernadette said, I’m Matt Sakumoto, a primary care virtualist in clinical practice at Sutter. Just some quick disclosures, I'll mention a bunch of different specific vendors but this does not imply any endorsement from my end and then my views don't represent that of my employer.

Thinking through the road map, I really kind of want to share high level experiences from Sutter, but also in my prior roles at some of the other companies that were mentioned. And I'll be talking through components of the virtual primary care stack. But I wanted to keep this front end high-level and really kind of save time for questions to do deep dives to really let the audience guide things that you want to know more about.  

I like to utilize the chat features. In addition to introducing yourself I kind of want to know what is your role? Since we have a lot of clinicians on board today, but if manager, patient as well, kind of what is your role? And then really on a scale of 1 to 10 what has your experience been with primary virtual care? And then sort of the bonus question is would you pick a primary care doctor that you would never get a chance to meet in person? And really seeing how far we can push the boundaries of what we define as virtual primary care. So I look forward to seeing what that chat looks like and we can circle back to some of those discussion points during the discussion time.  

So for virtual primary care, and I loved Steve's kind of setup for this, my favorite framework is by Zeev Neuwirth over at the Atrium, and it's a reframing of primary care. So we kind of use it as like a monolithic dumping ground for hospital followups and coordinating care between specialists. But as you can see, if you discretize out some of these things, there's actually ways to again, as Steve was mentioning, optimize what we're doing. How to provide the right type of care, the right type of modality for the right patient. And all of these things can be powered by what I/Julie Yoo calls the virtual-first tech stack. So there's different components that can create this coordinating platform, and I'll talk about what I've seen and what I've seen to work.

So for Tera Practice, Dr. Yumi Taylor actually developed this over three years ago. She was way ahead of the curve. The model was developed back in 2018 through Sutter as a virtual first practice serving the Palo Alto kind of Stanford area. It's team-based care and it's always been team-based care. So as you can see, it's the primary care doctor. There's a nurse practitioner, a nurse and a health coach all really serving the patient. And again it's a virtual-first manner. So we do 90% of our care by messaging, video, audio, but we all have―I have a half day of clinic that I can see my patients in person if needed―if they want to, and if it's needed. And they're really trying to prove out that the model is replicable and scalable, so their initial setup was in Palo Alto near Stanford. But I am leading up the San Francisco city expansion. And I think they're up to three pods now. So it's really kind of testing to see how does this model work across at least the California region.

The theme of today's talk, LEGOs and Layers, and the main thing I want to stress is while it's taken over three years for the Tera Practice to kind of scale out to the practice it is today, I want to stress that practices of any size can start with just basic building blocks. So you take early wins, you build out your communication infrastructure both with the patient and with your virtual back office or office. Demonstrate some value and then you can add on as you get wins. You can add on layers either through your health system, through the payers and things like that. So the three areas I want to focus on today, at least, are again patient communication, the virtual back office of what does that communication look like on the back end and then what hybrid care looks like.  

The thing about the virtual clinical workforce, this is a busy-looking slide, but the main things I want to focus on is that looking at how much work happens in the pre-visit so the virtual visit itself is maybe 15 minutes. But there's a lot of things that have to happen up front and really encouraging everybody to focus on both the pre- and post-, as well as what actually happens in the direct communication between the provider and the patient.

So thinking through the continuum, virtual care at least to me is not just video visits. Steve mentioned as well audio is a large component, but it's really a whole spectrum of communication. And I want to highlight really everything from texting, sending pictures in the store-and-forward manner. And the two things, if you look on the left side versus the right side, is how the technical and human resources increase as you move from left to right. So you're kind of needing more time and more direct resources as you move from texting to tele-presenter. And if you look across the bottom the way that they split as well as asynchronous messaging and modalities really allow for multitasking and team-based care. I'll do a deeper dive on this when I talk through how we provide team-based care, but that really allows for scaling out of time. On the flip side, the synchronous mode, the communications of phone calls, video visits allow for a more high fidelity conversation but also that time is spent with one patient minute for minute.

So thinking through webside manners, how do you improve connection through a video screen or through the phone? I just want to stress that this topic in and of itself is actually an hour-long lecture that I give. So I'll start with some of the high yield topics, but definitely happy to do deeper dives again when we go into the discussion section.

A couple of things like how do you create connection at a distance? One model that I use is the TelePresence 5 developed by Abraham Verghese out of Stanford. But really thinking of how to center yourself and the patient prior to and during each visit. So preparing for the visit, listening to the patient, agreeing on an agenda, making that connection with the patient and really exploring what's most important to the patient. Principles that work well in person but I think are even more important when you're in a virtual conversation.

And the other thing, too, is just thinking through webcam placement and lighting. A lot of connection is done through eye contact. So making sure that where your video screen is, where your webcam is and how you're interacting with the patient really makes a difference. Lighting―same thing both for the patient and for their provider. So these are just small things that actually have a pretty large impact when it comes to connecting and communicating with patients.  

And the final element I want to highlight is that virtual care has kind of revived the home visit. So one thing that I want to add is that I've actually added an environmental scan as part of my note template. So what that allows me to do is I can see family photos. Just kind of what is the home environment that the patient's in-home and/or work environment? But it gives you a little better sense than the clinical environment when you only see a patient in the clinic room. And even for myself, another thing I'll point out is in the same way that I can share in a patient's home, I rarely use a virtual background for myself, as you can even see here. So when I work out of my home office, it allows for that same level of, I think, personal connection. So you can see either art on the walls or things that I have in the background. So these are two ways that I think you can connect on a personal level and build some empathy with the patient in that way.

So that's a kind of covered quickly the patient provider interaction, but the virtual back office is actually something that is new with the pandemic. So how do you keep that coordination with your team, with your care team and clinical team in a virtual world?  

So one way that we've really found to improve communication is to hold space for the daily huddle. In the in-person clinic days we'd often huddle around a board, kind of talk about what patients are coming up for the day, what things were needed. And again it really helps to make team-based care work. So we have our four members of our team that are there and we take this and do it in a Zoom world. So we have a huddle board in the same way here and during the review of the huddle board we also really focus on data-driven decision making. So we have many reports that we're reviewing on a daily to weekly basis, be it our patient panels utilization, any health equity opportunities, care gaps that need closing for hypertension or diabetes management. So all of these things allow us to stay in touch as an office but also while doing it all remotely.

And the final point I want to make is that Tera is a virtual-first, not virtual-only practice. This level of hybridity, I think, is super important and something to think about because it's hard to provide virtual care purely in the virtual realm.

So particularly in the pandemic and all the shelter-in-place, learning how to provide continuity of care at a distance was very important. And as you all know, many elements of care still require physical interface with the health care system. So we found ways to connect with mental health, with the patients from their couch rather than our couch using remote patient monitoring tools for diabetes and hypertension management. A lot of home monitoring from that standpoint.

And the other thing that I really want to stress is the partnerships that we have. Again within the Sutter system, it's a large health network but partnerships with our walk-in clinics with some of the standalone labs and having my own clinic days to really provide that care in-person care if needed for the patients.

So as you can see, many components that I kind of went through, but each of these things are pretty modular. That's why I like to use the LEGO analogy, so you can kind of pick which ones are most important and then slowly build on top of those kind of over the course of months to years and really tailor which ones you think are most important for your practice and your patient population.

The last thing I want to stress―and this is circling back to some of those asynchronous methodologies and team-based care―is time can help make up for some of the touch that is missing in a virtual interaction. So traditional primary care, health care in general, tends to be pretty episodic and fee-for-service. And the barriers for follow-up often include lack of patient provider time and rapidly extreme copays for the frequent check-ins. So in the virtual care environment this time can make up for the touch. For example, if a patient has a cough or sore throat, I don't have to make that decision at the end of that 15-minute visit. Should I get a chest X-ray? Should I prescribe antibiotics? I can actually wait and let the disease declare itself with some of these frequent check-ins. So with virtual check-ins, I can potentially avoid unnecessary care, unnecessary X-rays, unnecessary antibiotics and sort of let time be the judge.

On the flip side, kind of on the less acute things, chronic care management, interstitial care as I call it, the stuff between the stuff. Usually we see a patient every three months, every six months to see how they're doing. Having virtual options for outreach of the patient really allows for proactive monitoring and probably a course correction and/or changes if needed at a sooner pace than in our three-month check-ins. So I think virtual care really opens up and creates time in different ways. So that's the one reason why I really focus on that, particularly the asynchronous modalities. And again, that really makes my point there.

So kind of just to recap and again, I really liked this return on health framework that the AMA has put together, so kind of mapping Tera onto this frame, so the environmental variables that we have, actually it's important to note that we do adult primary care, we only take HMO insurance. That helps a lot with thinking through what the cost savings are and gives us that flexibility to think through adding on the health coach and additional health benefits for the patient. And we have a diverse, complex patient population, for sure.

This is our tech stack, so again, happy to talk through each of these, this is what we use. We're on an Epic as a system here, Canto and Zoom our video platform. Jabber’s what we use for phone and most of our messaging with the patient is through MyChart.

And finally, what does this virtual care value stream look like for us? So we have data-driven daily huddle, so a lot of our clinical quality metrics are looked at and looked at closely and we're actively and proactively working on those. We have very increased access for the patients. So they can message us, phone, video and in-person for the patients across our region. And then very high satisfaction. I can personally say I'm very satisfied working there and our patients also have given us good satisfaction surveys. And then the financial impacts, even just kind of increasing emergency room visits, working on our pay-for-performance goals and quality metrics have had a positive financial impact as well.

So with that I'll pause and I went through a lot of stuff, but I did kind of want to just give a high level on the front end and really allow for audience questions to drive the rest of the discussion. Thanks so much.

Lim: Great, thank you. Dr. Sakumoto. We welcome any questions at this time. You're welcome to raise your hand and ask your question live or type it in the chat and I can verbally ask Dr. Sakumoto on your behalf, so we'll just wait for a couple of questions to come through. And in the meantime, I think just a question for you. For me as a virtualist, what are some key takeaways like if you just had to give someone just three tips on key things for a successful visit, like what would those be?

Dr. Sakumoto: I think to be honest, it's don't rush it. I think it's one of those things where like, this is my transition as well. So it's like one, don't rush it. You can go back to that repeat visit. The barriers for a follow-up is pretty low. So I think embracing that and being OK with it and then two is just get really, really good at history-taking skills. There's a level of, you know, you see the history and physical exam. And we don't have much of the physical exam. So really honing in on the ability to take a good history and ask questions in a different way, I think there's another big learning point. And then the third one would be to learn new elements of the virtual physical exam. So I think for me, in the same way, I've probably done about 2,000 hours worth of virtual care over the last year and a half or so. And it's a learned skill. It kind of felt like medical school in the same way that you kind of feel more comfortable. You do enough of different virtual exam maneuvers and it takes practice.

Lim: And then just follow up to that from a workflow perspective, how are you collecting that information? Are you asking patients that in advance or right before the visit? Do you have a care team member that signs on a few minutes early to ask those questions? Anything around workflow that you might want to share?

Dr. Sakumoto: Yeah, for sure. And kind of going back to that, thinking about looking at that busy graphic I had, what does that virtual clinic workflow look like? That pre-work makes such a big difference. Then one, having a team to do that―we have a pre-visit questionnaire that goes through a lot of these things. So the patient kind of mostly metrics themselves and highlights any concerns and things that they want prior to the visit starting. So I kind of have a head start and thinking about what that might be. We don't tech-check with our MA’s, that’s something to think about as well for a patient's first time to have that 5-minute period be like, make sure that they can connect, but once they're on I tend to run my own patients.

So those are really the biggest ones―really utilizing that previous at time and that takes a lot of work because you want to make sure that the patient has a messaging interface that you can message them with and that they're checking it. But that's another area that we spend a lot of time doing is making sure that patients’ MyChart access is turned on and helping them through that.

Lim: Awesome, all right. We've got a couple of questions in the chat here. One from Anthony Holbert. Can you speak more about your experiences with hybrid care in partnership with urgent care clinics?

Dr. Sakumoto: Yes. So again, I wander the wilderness a bit. I've done a bunch of different models. I think the best ones are when you have a partnership, when they can see your records. The biggest one I've heard from patients is if you kind of send them to an urgent care clinic versus an urgent care clinic that you have a relationship with is they feel like they have to retell their story when they get there, if we have to refer in. So the upside again of Sutter is that we exist within kind of a large health network, so we're all on the same version of Epic. So if they go in they can see my notes and that saves a lot of time. A couple other hybrid clinics, I worked, it worked at the same thing. It's like you can send them into a physical location that can see the record. So I think that's probably the biggest one, and I did feel that disconnect when I worked on some other startup platforms that again, to Steve's point, caused a little bit of fragmentation of care because I saw them, I get my recommendation, but there's not that handoff to the in-person. If and when you can integrate it, maybe direct integration of EHR or having a way to at least send your progress note to them on the way in is hugely helpful and I think a big patient satisfier as well.

Lim: Yeah, definitely lots of work in progress and ways to optimize in the future. We have another question. How do you identify an optimal panel size?

Dr. Sakumoto: For sure. That's always a tough one to be honest. It depends on the team size and the team structure, right? So for myself, I mean, some traditional primary care panels go as high as like 3-, 4-, 5,000 patients, but it depends on one, the complexity of the patients that you have and then two, the team that you're surrounded with. So for myself I have myself, a nurse practitioner and a nurse so we can actually expand pretty big. I think our current one, Dr. Taylor's panel, is kind of the original and I think she goes up to like 2,500 patients. But you can expand that out if you add additional nurse practitioners to your team or the way that you kind of slice and dice it. And obviously if you have very complex patients, that total number of patients is going to go down with that, you know, the complexity goes up.

Lim: Awesome, we have another question, and Dr. Waldren, I don't know if you're still on, I think maybe I'll pitch this one to you. We've got a question around just statistics on patient satisfaction, as well as clinical satisfaction in regards to receiving providing virtual care. So any insight from your end?

Dr. Waldren: Yeah, so let me answer the patient one first. That's the one I can't answer as well. So in our surveys, both in May and September, we asked our members how satisfied their patients were. And it was about 80% that said that their patients were satisfied. So again, that's kind of second hand. And their interpretation of that, so put a little grain of salt relative to that answer. On the physician side then, in our May time frame, 74% said they were either somewhat or very satisfied. And in September, that was 78 percent, so not a lot of change regards to who was satisfied or not. But as you look at the difference between somewhat satisfied and very satisfied, so very satisfied in May was 17% and in September it was 26%. So I think we saw an increase in the level of kind of very satisfied. And again, these were folks I would say in a traditional kind of primary care practice adding telehealth as opposed to, you know, folks that were a virtual-only. So also use that as kind of a grain of salt as well. But I think we've seen high levels of satisfaction across the board.

Lim: Yeah, thank you so much for that, and just to add, it's somewhat similar, but we've asked questions―I can share this also in the chat as a resource―the COVID-19 Health Care Coalition, and we’ve asked questions around what's your interest in continuing to receive care in the future? So somewhat similar, but we do have high percentages around patients being interested in continuing to receive care virtually in a variety of settings. So thank you, Dr. Waldren, for that.

All right. A couple of more questions for you, Dr. Sakamoto.

Dr. Sakumoto: We had, I think we had one up top as well.

Lim: Oh, go ahead. Go for it.

Dr. Sakumoto: I'll take that. Any recommended model for evaluation of telemedicine with regards to quality improvement? Actually, if you wouldn't mind either coming on or dropping into the chat, what do you mean in terms of traditional quality improvement or like quality metric reporting?

Neil: So Dr. Sakumoto, hello, this is Neil. So in terms of the overall quality improvement from the receivers as well as care providers, and I'm really focusing on the educational model that they have implemented from last semester, which is a telemedicine model, educational model for medical students, and they are visiting an ambulatory clinic here on Barbados. So we are trying to look for the tools or kind of rubrics or any system which can lead to quality improvement of the overall program.

Dr. Sakumoto: Got it. Excellent question. Some of the other work I do is with UCSF and across the board I'd say the use of telemedicine for just education in general I think has really led to interesting shadowing opportunities and just kind of ways to get involved that students couldn’t get before. So I think there are a lot of ways to plug telemedicine into quality improvement. No specific ones off the top of my head, but also feel free to reach out offline because I'll think about this a little bit more, but there's a lot of opportunity there again particularly in the med-ed realm for telemedicine and incorporating that.

Dr. Waldren: And I would just add on the education piece, I know the Society of Teachers of Family Medicine just published a new telehealth curriculum. At least they're piloting it right now in several different residencies. And I think there's a module there on quality, too. So if you want to check that out, you can hit me up if you can't find it.

Dr. Sakumoto: And like I mentioned too, our daily huddles, that's basically a quality improvement every day, right? There's our different metrics that we're looking at and reviewing, so I'm sure there's a way to again incorporate either shadowing of medical students into that and/or having them take on pieces of that and do report-ups on that.

And I see Blake's question here. Hello, Blake, and that goes actually really nicely into Dr. George's portion of it. I personally don't really use that many peripherals specifically. We have a couple of partnerships with kind of Apple Health Kit and Onduo in terms of doing some blood pressure monitoring and diabetes monitoring, but no kind of specific ones. Actually, I'm super excited to see Dr. George's presentation as well.

Lim: Yeah, I was going to say, I think Dr. George might be able to help answer that one, too. All right. And then Dr. Sakumoto, I think only one person responded around your initial question that you had asked around their comfortability around seeing a physician that they've never met in person. And I think it was kind of a lukewarm―they weren't totally sure if they would be interested. But personally, from my end, I've had great experiences meeting virtual physicians. And I think sometimes just convenience and access sometimes outweighs the wait times that are more present and seeing someone in person sense. So that's just my two cents. Not sure if anyone has anything else to add there.

All right. I'm not seeing any other questions come through, Dr. Sakumoto. Any final comments before moving to our next speaker?

Dr. Sakumato: No, nothing specific. As I said, I love the chats more than the talk itself. So thanks, everyone, for engaging.

Lim: Yeah, again welcome anyone who's brave enough to share their video or turn on their audio during the Q&A portion, we absolutely encourage that.

All right, our next speaker, I'm incredibly excited to introduce Dr. Diane George. Dr. George is the chief medical officer for Henry Ford Medical Group Primary Care. She oversees close to 300 primary care physicians and advanced practice providers in clinic, virtual, home, work and skilled nursing facilities settings. Her focus is on the development of value-based care models that facilitates excellent results, better serves our diverse patient population, improves the work environment for staff and enables growth. Dr. George is a graduate of Michigan State University College of Osteopathic Medicine and completed her residency at MSU and is board certified in family medicine. Thank you, Dr. George, and I will turn it over to you.

Dr. George: Thank you very much. I actually requested control, but it looks like it's not working so I will have you forward for me. All right, well, I am super excited to be here and actually very glad that I got to hear Dr. Sakumoto’s presentation. Very much food for thought for me and once you start to hear where we are you'll understand why that is.  

So Henry Ford Medical Group, to those of you who may not know us, we are based out of southeast Michigan and thereby have a lot of patients who are really in difficult circumstances. So as we design we try to think about how are we going to improve care across the continuum for all of our patients, those who have that flexibility to go wherever they want and those who might be very ill and trapped in their homes, and you'll sort of see that.

I'm going to give a brief overview of our approach and our journey, but really brief because we could talk for a long time. We have about 300 primary care physicians and we are really trying to do something that we can apply across the board for all of our patients, but also using that segmented approach that Dr. Sakumoto is talking about. You'll see that reflected in these slides as well. We'll talk a little bit about challenges and solutions and then spend most of the time really looking at what is a device-enabled exam, why are we doing it and how does it actually work? What's the experience like for the provider as well as for the patient?

So our guiding principles at Henry Ford Medical Group Primary Group, when it comes to things that we do virtually or things that we do in person really is we want to align around the quadruple aim. We want to make sure that we're integrated across the continuum. In fact, that's kind of our secret sauce. If you're a medical group and you don't integrate, you missed an opportunity. So we really want our patients to want to use us for telehealth, for urgent care, et cetera, and for all of their care rather than fragmenting their care and going elsewhere.

The integration in the EHR is really fundamental. We've had experience in trying things. Like we partnered with a telehealth company in the very, very early days and our docs participated. But we had low uptick with our patients. And it didn't integrate into the EMR, and it wasn't perceived as very high value.

Safety and clinical appropriateness are really prime concerns. We also see that consumerism and value interdigitate when it comes to virtual care because you can provide care that is appropriate at a lower cost and more convenient and a better experience for the patient if you choose correctly. So there's a consumerism piece to it as well as a value piece. We do strive for radical convenience as well as radical personalization. And as we go forward in virtual care or digital health, I see the future becoming more and more personalized. We're going to stick with the things in green today for the most part but you'll probably hear echoes of some of the other things as we talk today.

So what does integrating across the care continuum mean for us? So I'll start with on-demand care. We have walk-in clinics and urgent care. They are all integrated into our EMR. It's all Henry Ford Medical Group. We developed some time ago MyCare On Demand. It’s 24/7 virtual visits with a physician. And we chose at that time not to use practitioners or PAs because we didn't want to limit artificially the use case. We didn't want to say, “it can only be used for these kinds of conditions.” And we found, as Dr. Sakumoto was talking about, you have to have a very high clinical index of suspicion. You have to really understand what questions you need to ask and that experience that physicians have. It gave us security that we weren't going to be bridging any boundaries here in terms of safety. So that could change in the future as we develop and create more sort of a digital navigation so patients can get in with the right people. But for now, that's how it is.

And then we developed rapid response e-visits, so that's another version of on-demand care. I'm sure you all know what e-visits are. They’re asynchronous visits, really probably underutilized and very much loved by patients. I'll tell you a little bit more about the rapid response e-visits in a little bit, but those are done with the first available person. The school-based, employer based, we have providers on-site―that was our original model. And now we're really shifting more to the only person on site is a medical assistant who can do vitals, who can do immunizations and things that employers want and employees need. But we're using the virtual exam kit on site and then doing visits with our on-demand docs.

Then there's that continuity care, traditional continuity care. And people can do in-person, obviously scheduled with or without the exam kit e-visits. And we have 100% integrated virtual behavioral health across all 300 of us in medical group primary care. Then lastly, there's this what we call complex primary care services and that mobile integrated health is really part of that, even though I gave it its own banner there, just because we're going to talk about that in a little bit more detail.

We have comprehensive care centers as well as home visiting physicians to serve these more fragile folks. But first we decided well, we need less windshield time and more interaction time for our home visiting physicians. And so we started incorporating more virtual and it really doubled their reach. We can impact more patients that way. And then we added that with the comprehensive care centers as well. We use a MA/CHW as a tele-presenter and those are done with a device that enables the exam. And the mobile integrated health is with paramedics who go into the home. They tele-present, they provide treatment and they partner with a remote physician. And this is a different group of physicians than the on-demand docs because they have to be very familiar with dealing with people who have high acuity needs, which we'll talk about a little bit more as well.

All right, so the rapid response e-visit―we really didn't know when we went live with this that it was going to be impactful to our patients. These are safe, convenient and integrated, and it provides really high quality, convenient interaction. It's less than a two-hour turnaround time and it uses our on-demand physician pool, who by the way are mostly docs who also have regular clinic time. They just do this as part of their FTE. We quietly turned it on in MyChart and patients loved it. They found it themselves. They clicked on that and they were provided when they went in to look to do an e-visit with a choice to do a rapid response visit, getting less than two-hour turnaround with whoever was next in line now, whichever physician was up, or they could send the message to their PCP if they had one and get a turnaround within one business day. And clearly people wanted two-hour turnaround because with no promotion at all, just with people finding it within MyChart, they did over 550 in the first six weeks and it continues to be very popular.

So this is what Bernadette was talking about. Sometimes convenience trumps knowing the person. But these also can be highly personal and the story that you can see here at the bottom of the screen really illustrates how being interconnected with the EMR actually made this better. So this is a patient who has a Henry Ford Medical Group primary care physician. They launched an e-visit because they were feeling really tired in the morning and feeling nauseous. The doc did a really quick review of the Epic record, which she could do quickly and in detail, and found that Trazodone had been prescribed with a starting dose of 100 milligrams, which any clinician on the line knows can cause those symptoms. And the physician advised lowering the dose and then following up with her PCP after that once she was used to the low dose. Well she was very grateful for this quick turnaround, but then replied back that the next morning she still felt nauseous and so another doctor was covering the pool and provided that work note that she needed based on the documentation of the previous doctor. So that I think is a really good illustration of the convenience, the safety and the integration. And we'll go further, I think, into doing some more of these asynchronous or chat-type visits in the future.  

So a couple more rapid response e-visit stories. I won't spend a lot of time here, but the first one is a person who had only been to a walk-in clinic. They were struggling with GERD symptoms and the walk-in clinic had recommended over-the-counter PPIs but symptoms seemed to be progressing. He did not have a PCP, so he was referred to one that was closer to his home. The next one is somebody who had recurrent problems with anxiety and couldn't get into their PCP for six weeks. And given the history of panic attacks, insomnia, irritability, etc., all the doc had to do is restart the SSRI that the patient had been taking, and then they were to follow up with their PCP as well. I like that there are three different examples here because it shows how these rapid response team visits can be used, whether or not you actually have a primary care physician. And we were able to serve the patient well and get them back to the appropriate care that they needed.

So going beyond asynchronous, though, so when we started to go into video visits―and we had this vision of doing video visits for all of our primary care docs … and we still have that vision―we came up against some barriers. One is that providers worried that patients would choose the video visits for inappropriate conditions. And so how we dealt with that was we said, “OK, let's start by allowing the doc to choose virtual for a return visit.” And it was one way to sort of ease them into, “this isn’t that bad.” So if you saw a person with hypertension, diabetes today and wanted them to follow up, their next visit could be virtual. And as docs tiptoed into the waters that way they started to give up that fear that they were going to be used inappropriately and also get more comfortable with saying, “Hey, I think you need to be seen.” And now that we have a virtual exam kit, we have another option as well. But that's how we sort of eased into it.

Now patients choose virtual themselves, they schedule themselves. We actually initially had been using blocks on the schedule because docs were worried that if they ran behind with their in-person visits the person who was waiting online would be upset. And so we blocked time slots at the beginning of sessions right after lunch or first thing in the morning and that worked fairly well. We opened up the slots if they weren't used. But then patients started requesting, “Well, can I have virtual instead?” And so they started flipping visits into virtual visits. So now they are scattered throughout the schedule and patients are allowed to slot themselves through MyChart into whichever type of visit they want.

Providers were really worried about navigating the technology. I have no special expertise in informatics or virtual care or anything digital. I'm old school family medicine but oversee a whole lot of docs. And I might have had this worry a little bit, but not as much as some of the docs that I oversee. But they were really worried about navigating the technology. What if they couldn't do it? What if it didn't connect, right? I haven't been exposed to it―what do I do here? So our virtual care team actually has a very high touch approach. So the docs can be trained using just a video, but they also can be trained in person. And then when their first visit comes up that's virtual―so we're past the video visit thing now and now we're starting to use the virtual exam kit for their first visit that utilizes virtual exam kit―the virtual care team reaches out to them and says, “Hey doc, I notice that you have this patient on your schedule. Do you feel comfortable and want to walk through one? Let's do a fake one, et cetera,” and the docs can even have somebody right with them as they initiate those first visits.

That high-touch approach is also applied to patients. So we have MAs that are there to help patients to set up their devices, to navigate the technology. And we also have virtual rooming. For us MAs help with med racks, they tee up orders. We have a lot of standing orders in primary care and they were really concerned that it was going to be shifting work back to them that MAs had been helping them with. And so we actually just provide virtual rooming instead.

Despite that, it was really the lack of physical exam that has limited provider adoption, and it's to us limited the use cases. So we think about OK, yes, there are a lot of things that you can do looking at a video, you can look at the skin, you can see somebody’s affect. We've had people do some amazing things. We had a doc diagnose appendicitis just with video because he was very clinically astute and he knew what to tell the patient to try to do in order to discern what's going on. That said, sometimes you just really need to listen to the lungs or listen to the heart, maybe look in the ears of that crying child, et cetera. And so that's basically why we decided to look into some kind of device that would help with an exam.

So a story to illustrate why we like this. So a 90-year-old patient, this was one of our actual first virtual exam kit visits with one of our PCPs. So we had already done this with our MyCare On Demand docs, so they were using them. But this was one of our very first and probably our very first visit with a real PCP for continuity. So a 90-year-old patient had physical decline in her condition and she had to move in with her daughter 50 miles away. She was very upset about losing this PCP that she had this long-term relationship with, and these are the situations where those relationships matter. So her daughter purchased a Henry Ford virtual exam kit and uses it to do virtual visits with the PCP that included an exam. Patient is extremely happy that she continues that trusted relationship. It supports the continuity of care, obviously minimizes change for that patient and doesn't have to inconvenience anybody to drive the 50 miles to go to see and do an in-person visit.

So prior to the device, this was basically what a virtual exam looked like if you wanted to look in the throat. Can you hold your phone up and say, ah, let me take a peek? Certainly you could look at skin and stuff like that as I mentioned. So what do we mean when we say a device-enabled exam? It's a diagnostic device, you can see it's about the size of a tennis ball maybe. It allows for the examination of heart and lungs, skin and abdomen. You can check temperature, ears, nose and throat. It’s a live video feed. There's also a store and forward version that we haven't used yet but has some possibilities. The patient can use the device, record the exam and forward it. And we have not enabled that for our docs yet but that's something that we could certainly do in the future.

So there's a home version of this kit that the patients use or their family members can use. And then in some situations, like mobile integrated health or our virtual home visiting physicians, et cetera, there's a care coordinator that acts as a tele-presenter that is in the home. And then docs are on a computer and very soon we'll be able to do that from their smartphone as well. That’s an upgrade that we're getting in the near future just to make it easier for docs as well.

So these are the attachments. The device itself is there on the left, there's an otoscope, stethoscope and tongue depressor. There are attachments that you can put into the tongue depressor and actually replace. We tell people they can take a tongue depressor like just the plain wooden ones and break them in half and that works as well. So what the patient sees on their phone is they actually see this ability to navigate. So their instructions show up on the phone as you can see on the right.

There are also devices that can integrate with this, and there are only specific devices at this time, so specific around blood pressure cuff and scale, a pulse oximeter, I guess two options for the blood pressure cuff, but there are selected devices. There's also a dermascope that's available for folks who really want to do a lot of dermatology this way.

So one nice thing, I mean, people think, well, how easy is this to do and the reason that we have tele-presenters do it for some people is partly because it's hard for some people if they have cognitive decline or limited physical skills. It also could be hard if they don't have the right wi-fi access. But mostly we have tele-presenters when the person is so sick that they actually need additional assessment within the home and may need treatment as well. So for anybody else, it's really pretty easy. So it comes with audio and visual instructions. It comes with arrows that kind of guide the person to the right area. Then when they're there, they get a checkmark. If they wanted to they can take a snapshot but they don't have to if they're on with the physician. The doc will get the view. Every physician that's looked at these, you're looking at basically an ear, a tympanic membrane on a computer with optics that are amazing. The view is way better than when you're looking into that screaming child's ear canal. And so we've gained a lot of doctor acceptance just by them trying out the device and getting to see what the pictures look like.

So real quickly, we'll show how a throat exam works. So we'll click on that video and you'll see. So it gives you some navigation, this is what it should look like. You got it. Awesome.

So this is a patient who is connected to the doc and you're not going to hear the audio. This is just the video, but we want you to see how it kind of works. As the doc logs on, they start to talk and you can go ahead. And as they're talking the doc can take control of the device. And this is really just to tell the person what to check next. So the doc is saying the patient connects the stethoscope. And then in front of her, she'll see on her screen this body of a person, and it shows where to put the device next, and records. That does require headphones to really hear this well, but you can get very good heart and lung sounds through this. She's changing attachments to the otoscope attachment. Going to check that left ear. And there's a picture. Now for us we have this totally integrated into Epic, so we do our notes in Epic. But there are people who use this and do their notes right into this platform. She's doing temperature now and the doc is about to add some notes.

Great you can go to the next slide. I think we might have skipped one. Yeah there we go. All right, so mobile integrated health, what is it? I like this example because it's at the very opposite end of the continuum from the on-demand. We have paramedics that are employed by us. We send them to the home when a referral is made by a physician―it can be an ED physician, discharging physician or outpatient physician. They go into the home, they evaluate, even for social determinants. They've provided food boxes to patients when needed, but they connect with our physician virtually. They use the device to do an exam when it's appropriate. The device is not always needed. Sometimes a phone contact with the doc is all that's needed. And then under the direction of the physician the paramedics can provide treatment―diuresis, hydration, breathing treatments, IV antibiotics even. They can return and re-evaluate the next day.

We actually were planning this pre-COVID, and we were trying a discharge pilot pre-COVID, where patients who are discharged from the hospital were seeing using this type of a process and the virtual visit was done with the discharging physician. That was really, really hard to coordinate. Now we're looking to be more on the front end. And so this one is somebody in the ED and the doc doesn't feel comfortable sending them home. Unless somebody is going to check on them, they can avoid an observation. They can avoid an inpatient admission. Discharging physician can do the same thing. In our outpatient docs when we found people who've had trouble, we can send the paramedic out as well. We are right now creating criteria so our MyCare advice line nurses who are 24/7 can make referrals to MIH as well, and they're going to launch on Oct. 1st. They're extremely excited about this because the kinds of things that the paramedics can do are the kinds of things that will keep people safe and at home, and you know, very, very well cared for. And the only option for some of these people in the middle of the night otherwise would have been to go to the ED.

So here's a couple of stories, this is one of our PCPs right here in Sterling Heights, Michigan. A 70-year-old patient, very sick CKD stage three meningioma causing some cerebellar compression had been treated with steroids and radiation and was recently hospitalized for cellulitis. The antibiotics caused diarrhea. He was having poor oral intake and the doc got a call on Saturday saying this guy's BUN is 100 and creatinine is 3.5. He had the paramedic go out. The paramedic gave fluids. He left the line or the access in and returned in several days. They can draw blood as well, I forgot. I forgot to tell you that part. And they monitored the labs and vitals, adjusted the meds and within a week the patient would return to baseline.

Another one, not as intensely ill person, but four family members with COVID, the father with comorbidities and the paramedic and the doc cared for all four patients on five occasions. Mother and one of the daughters required fluids several times due to the GI effects of COVID and the decreased PO intake and this device was used to allow for an exam with the physician in this situation. So I think you can see this is different than when you're just going to do it for yourself. It's really having the paramedics lay hands on and be able to give treatments is really helpful.

So when we decided to roll out this device-enabled virtual exam, as I mentioned, we started with tele-presenters, a process using 12 presenters and not a home version of the kit where you bought your own. So we started with those virtual home-visiting physicians and doubled their ability to see patients and that we also at the same time launched this in school-based health, where the RN in the school is the tele-presenter for a physician or nurse practitioner in another area. This was important to us from a mission basis because we do have a school-based health program. We have nurses in some schools and we have NPs in others, but we really wanted to be able to expand the reach of the program, especially within our Detroit public schools where there was less access to health care.

Parents sign a form at the beginning of the year that allows for this care to be provided. MyCare at work―same kind of thing. The MA is on site. We talked about that before. And then we started doing the mobile integrated health for those people with high acuity needs at home. But what happened next? How did we move to using a home device that a person can purchase for themselves, use on themselves or their whole family? And that's what came next.

So first, we used this with MyCare On Demand. These are a group of docs who love to do virtual visits. They cover all hours of the day or night, and a person who purchases this device can make a choice to connect just by regular video, visit or connect with the device. So the patient themselves are the tele-presenter or their family member, depending on that patient's age and other issues. And absolutely that went fine. No issues there. Our virtual MA team helped to make sure that people got connected quickly and that they didn't have any trouble navigating their visits.

So then we rolled out to all our PCP. We trained them all. But people forget because this is a slow process. We have to get the devices into the hands of patients. It takes a while. They have to buy them. And so everybody was worried, OK, what happens when one of these shows up on the schedule? Well, the virtual team is actually combing the schedule so when a physician has their first device-enabled video visit scheduled, they reach out to the provider and they walk them through it.

These are integrated into Epic, so it's just a click within Epic and the visit is launched. Patients purchase this and the typical cost is a little bit less than $300. This device can be used on multiple family members, so there's no limit. You want to use on any friends, you can do that, too. It's covered by a health savings account or flexible spending account, which is I think a serious benefit. We have our virtual care team help the person pair the device just as soon as they purchase it, because if they don't pair the device, when they are sick they'll go back to what they normally do, which for some people is go to the ED. So that's a really, really important first step. The patients launch their visit through the Epic MyChart as well.

What's next for us in this regard is we're working with our development department, I guess philanthropy is out of favor. I shouldn't have put that. But to get donor support for the device. I don't know about you folks, but around Christmas time I'll buy a goat or chickens or whatever to help sustain families. It's the same kind of thing―people often like to know where their money is going and we have a lot of families who would otherwise not be able to afford this. So if there are current patients of ours who meet certain criteria we want to be able to provide those devices to help them. We do have some value-based contracts, but we're not deep into it the way the virtual first clinic is that Dr. Sakumoto is talking about. We aren't in a position to purchase these for our patients, so we're looking for donor support to do that.

So what are our lessons? Virtual care can be very personal. We've had patients so grateful, in tears, sometimes with the doc they know, sometimes not with a doc they know. Sometimes it was our behavioral health. That integration into the EHR is really critical for providers. Otherwise if you have to go to another website, click on a different place we are met with more resistance. It's also safer for patients. That integration across the continuum, it's really our secret sauce. It makes us a differentiator. It makes us different than some of the companies who just do virtual and just do virtual urgent care. Just knowing that we're integrated and patients choose us for that reason. Because we are trusted, that technology can make or break the experience with that, personal navigation really helps. It helps to go overcome technological barriers as well as digital literacy. And you know, I guess never underestimate the effort required to change clinicians’ behavior―it really took a long time. And we can design with equity in mind.

There's one more I probably didn't put on here. There are myths out there about virtual care and some of those myths are things like older people won't do it. I have a 89-year-old patient who can do this. I'm sure others do as well. We have to kind of keep ageism out of this and know that we can really make this available to pretty much anybody if we can help them navigate past some of the barriers that they may.

There are a couple more slides in the appendix, which when you get these slides you can look at yourself. It's how we put a couple of our programs into that return on health framework and a little bit of our statistics for our mobile integrated health, which actually is seeing very low income and very high minority percentages.

I do believe that's it, and I want to thank you for your attention. I appreciate this, the opportunity to talk about Henry Ford. I'm proud of what we do but I am by no means an expert in anything except leading a bunch of docs. And I appreciate being able to share that with you today.

Lim: Thank you so much, Dr. George. Incredible presentation and incredible work. I echo what Dr. Sakumoto’s mentioned here, just incredibly inspiring from many facets. I think you have an incredible portfolio of virtual care offerings and the embedding RPM technology into your HER, that's something that we're hearing a lot from physicians that are interested in furthering their telehealth programs. So I think hopefully that's given some insight on what's out there and how to integrate that and some of the challenges.

Let's see, Dr. Sakumoto, if you're on, I'd love for you to pop on and ask your question around financial support.

Dr. Sakumoto: For sure. I was looking forward to this. It exceeded expectations―this is amazing. But I think from my standpoint, thinking through I guess where did you get sort of the financial end like internal political will to really do this kind of transformative work because this is head and shoulders above almost every organization I've seen. So I just kind of want to get where did that seed come from, from that standpoint?

Dr. George: Force of will. No, are you actually asking about all of our telehealth stuff that we're doing in primary care or are you talking about the device integration specifically?

Dr. Sakumoto: Kind of more all this stuff you did. Because I mean I can tell there is a bigger vision and like you said, you're using this as a differentiator. So is this kind of coming from a design and innovation group, is this coming from just primary care leadership? You know, where is this drive coming from, because there clearly is one?

Dr. George: Yeah, good question. We at Henry Ford, we're used to having very few resources and so for the length of time that I've been with Henry Ford we always try to think lean, we use lean principles and we try to figure out how can we do something better and easier. And we also embraced virtual care. Actually back around 2007 prior to us even going on Epic we had a homegrown EMR and we partnered with a company that actually integrated e-visits into our EMR. They were amazing e-visits, quite frankly, the branching logic was super. And so when we went on to Epic, sorry to Epic, but we were not happy with the e-visits we had in Epic. So we started to create our own e-visits within Epic.

So I actually think it's just our culture. I think it's the culture, not so much of HFMG overall. HFMG overall is very into innovation, but also very tertiary-quaternary focused. But our culture in primary care is also very focused on innovation and innovation within our world. So I think that's probably all it is. We just saw that we could do something differently. We do not have the resources. We don't use the resources of an innovation team, per se. I have a think tank team that I pulled together that helps with thinking some of these things through. But we have highly motivated leaders that help to create the on-demand program and highly motivated leaders working on mobile integrated health. And then we look, OK, how do we make sure we together look at how do we make sure that we're doing what's safe and clinically appropriate and integrated into the continuum? And I guess it's really not. I wish I could tell you. I wish I could provide for you a structure that says, do it this way, have people doing this, this and this and this, but we just don't have it. We don't, we don't have it. But I have absolutely great team members who do lots of jobs within their scopes and beyond their scopes, actually.

Lim: Dr. George, so I just want to call out, I know we had a question here around I think it was how much the virtual visit kit cost and is this covered by insurance? So you did answer that question during your presentation, mentioning that it's covered by from HSA accounts or FSA accounts that individuals can use. And you've got full philanthropic arms of Henry Ford that potentially can contribute to that, but it is purchased by the patient themselves, and they bring that to the visit.

Dr. George: We’ve also had, though, I forgot to mention, payroll deductions. So for all of our Henry Ford employees, they can purchase a device using payroll deductions. So they can pay it off $10 a pay or whatever until it's gone. We also have been able to offer various specials that take down the price and then gift cards for after people pair their device and those kinds of things.

Lim: Got it. Really helpful. So there's a question that came through around just the data, right? So you've integrated it with your EHR. Can you talk a little bit more about is this continuous transferring of data? Is this a one-time transferring of data, like how does that data collection happen and have there been any demonstrated value through outcomes and/or costs that you've realized through this experience?

Dr. George: Yeah so we are not at the point where we have a continuous device integration. We would like to get there so that you can do that remote monitoring kind of thing. The device integration, the integration in our EMR and the transfer of information really comes during the visit or while the device is being used and we have chosen usually to not store that information in the EHR, but we can if we want. So if you want to take a picture of something that can be stored in the EHR, but for the most part we're not. Because we don't want to be … when you see somebody in person, you don't record every element of the visit in terms of the heart sounds in the picture, you record it in terms of your note saying what you see. So we didn't want to collect unnecessary data in that sense. So that's what I meant by integration.

In terms of keeping people out of the hospital, in terms of satisfaction, some of those data are on the slides in the appendix. But this is both actually MyCare on demand, as well as rapid response team visits and mobile integrated health have kept a lot of people out of the ED and kept them from getting readmitted. And so we do have for the patients that we've touched, we have a decreased utilization. Additionally, our equity numbers are really good. So we've designed in a way that helps us to capture the right populations and not skew towards people who’ve got money or people who are in well-off zip codes or that sort of thing. So we've seen that kind of benefit. And then our Net Promoter scores are good―they're great, actually, that kind of thing we're doing well on.

I don't think that we have enough visits to say yet for all 400,000 of the patients who are aligned to us, we've cut the ED use rate this much. But for the patients that we've touched, we have definitely avoided that. They would have had to have gone to the ED if they had not been able to have these services. So probably one of those things to come back when we've touched more patients and we'll continue to monitor that. We are collecting the data as we speak.

Lim: Absolutely. The question back to what Dr. Sakumoto is asking around, like your entire portfolio. For context, can you just help people understand when did you start rolling out some of these programs, like just for some contextual purposes? Maybe when did you start rolling out the Henry Ford virtual exam kit technology? Just again, I think everyone's very eager and excited to integrate these things, and what's like a realistic time frame for planning purposes should they be expecting or can they expect? I know we've got several people joining from larger health systems as well.

Dr. George: Yeah, it depends. So I actually am seeing that I didn't completely answer Dr. Sakumoto’s question about finances, so we can come back to that if at some point if you want. Asynchronous visits we started doing in 2007 back in our old EHR, we charged a small amount of money to patients. To do it was like, I think, $30 at that time. They weren't being covered by most insurance companies, but patients chose to do it still. And then we realized we started getting payment from insurance companies. So we stopped charging the patient and we started billing insurance companies up front and then only charge the patient otherwise. With our current events, we do the same thing. So even as we have a very long history, but rapid response visits far and away, basically that took we had a pool of on-demand docs. We said, look, that pool, whoever's not doing on-demand video visits that whole time, and Dr. Sakumoto mentioned this asynchronous. You can squeeze that in, right? Not his words, but mine. You know, that asynchronous work. You can work that into your schedule pretty easily. So we turned that on and people grabbed it and it went. There was nothing to that. Nothing to that at all except having the docs who were watching the pool, so where did that e-visits land? And then grabbing them as they came in. Then our internal Epic team just building that ability for somebody who selected a rapid response, even for that to go to this pool instead of going to that person's PCP. That was the absolute fastest rollout of anything we've ever had.

The MyCare on demand, on-demand video visits. We launched, I think, late 2019 I want to say, and we were covering sort of normal business hours kind of thing. I want to say normal business hours. Maybe it was the flip. I'd have to go back and look. But yeah, we definitely weren't covering the weekends. Then COVID hit, and within a week we covered 24/7. We flipped it to 24/7 and got very, very busy. And kudos to Dan Passerman. He's probably not on here, but he figured out how to get docs to sign up and we paid them in various ways. So some people, it's part of their FTE. Some people it's like a back-up call fee and then a per-visit fee. We figured out ways to get people to engage in that. But really, figured out how to do 24/7 within a week's time when the shutdowns from COVID hit and then it got it got wildly popular, so that one was different. If you're using virtual with a group of physicians who like it and are engaged and you can get the build done, you can do it pretty quickly. The trickiest part is getting continuity care docs, docs who are used to in-person thinking about how can they do things virtually. And so that that's trickier.

Mobile integrated health is also a group of people who think innovatively. There are people who are used to taking care of complex ill patients love the idea of being able to do that from the home. And so that actually wasn't that hard, either. We sort of flipped that and turned that on. We had the bones, sort of the back, we had the foundations built because we were doing this emergency disposition and support pilot where the docs would send paramedics to the home. We just we took that structure and we created something bigger and better out of it, allowing more docs to refer into that. And that was a COVID response. It was. Well, we've got to take care of more people, we've got to get them out of the hospital faster. How can we innovate something really quickly? And now we've tweaked it. And so with that one, the hardest thing is about changing frontline docs behavior. So if you have never had the opportunity to refer to a mobile and graded health, have a paramedic go to the home. When you're speaking with a physician or your nurse in a patient or your nurses speaking with a patient, you might first think you need to go to the ED, but once you're aware of mobile integrated health and then you make a referral to mobile integrated health, then the next time you're going to think more easily and mobile and great health, so that patient that I shared a story about with the CKD and the dehydration, the doc that oversees our mobile integrated health works in that clinic. And so when his partner had this patient, he said, you need to do this and that and collecting and sharing those stories actually helps. But then you have to get the word out over and over and over and over again until people try it. Once they try it, they're fine with it.

Our virtual care was a very slow rollout. And I think with physicians, we started rolling out into our clinics, probably it might have even in 2018, and it was just slow with some people saying, you can't make me do that. And then patients wanting it and then COVID hit and everybody wanted it. And so it really broke down a lot of barriers. I think that the hardest ones are really the ones where you're trying to get a lot of primary care docs to think differently. Does that answer the question?

Lim: Yeah, that's super helpful. Really appreciate it. And then if you want to touch on just the financial piece, we've got some time.

Dr. George: Yeah, OK. So I mentioned how we got the visits paid for in the beginning. We actually partnered with a health plan in the beginning and they said, for your contract, we'll cover these because they wanted to help us innovate. And now obviously more contracts do. We're in this tough place between value and volume where we want to perform the value. But a lot of the payments still volume or the value-based dollars come in after the fact. And then when you're in a big health system, how do you take those dollars and actually invest them? So really it has to do with the leadership in our system that they understand and understood the need to invest in these things, even if initially it might look like we're losing money, even if initially we're not seeing an ROI because they're kind of low cost to implement, but ultimately can be very, very high value.

So we have leadership within Henry Ford Health System that was really committed to letting us go ahead and try these things and then look at the finances later. Which is really saying something when you have a very low margin like Henry Ford being in Detroit, it's one of the worst markets. We've got a very low margin, so it really says something that our system will, our system leaders will support us in that way. I don't underestimate the value of that and, you know, people in private practice or in other systems may not feel that kind of benefit, but we definitely have it here.

Lim: Yeah, absolutely. I mean, absolutely the mission, focus and mission, right? Just being front and center is really clear in your presentation, and I think that's a great way to end today's session today. Thank you.

I just want to say again, thank you so much to Dr. Waldren, Dr. Sakumoto and Dr. George for joining us. Thank you all for participating in the Telehealth Immersion Program. We hope that just by sharing these case studies you have some just insight and some information that can help you further telehealth and virtual care in your organizations as well.

So with that, I just want to share that our next bootcamp session is coming up. As part of this program the AMA will host a mini boot camp to wrap up the American Telemedicine Association Telehealth Awareness Week. During the session, participants will have the opportunity to discuss health at home models and strategies and dive deeper into telehealth use. We've got two breakout sessions, OB/GYN and renal medicine nephrology, where we'll specifically have conversations around telehealth use in those medical specialties. This event is designed to engage various stakeholders to support long term, sustainable telehealth programs across the industry, and we invite everyone to join us on Saturday, September 5th from 10 to 12:30, and you can register on our website at www.ama-assn.org/telehealth-immersion. Thank you all so much. We hope you have a great day.

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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.