The Telehealth Initiative: Implementing and using telehealth

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

In today’s COVID-19 Update, experts discuss “The Telehealth Initiative,” a collaboration between the AMA, The Physicians Foundation, Texas Medical Association, Florida Medical Association and Massachusetts Medical Society that supports physician practices in adopting and adapting to telehealth.

Learn more at the AMA COVID-19 resource center.

Speakers

• Dhrumil Shah, MD, chief medical information officer, COMPASS Medical
• Corey Howard, MD, founder and director, Physician’s Life Centers
• Shannon Vogel, associate vice president, health information technology, Texas Medical Association

Unger: Hello, this is the American Medical Association's COVID 19 Update. Today we'll be discussing The Telehealth Initiative collaboration to support physician practices and implementing and using telehealth. I'm joined today by Dr. Drew Shah, chief medical information officer, Compass Medical in Quincy, Massachusetts; Dr. Corey Howard, founder and director of Physicians Life Centers in Naples, Florida; and Shannon Vogel, associate vice president health information technology at the Texas Medical Association in Austin, Texas. I'm Todd Unger, AMA's chief experience officer in Chicago. Ms. Vogel, why don't you start. Why don't you tell us about what the telehealth initiative is and why it's needed so much right now?

Vogel: You bet. Thank you, Todd. It's a real pleasure to join you today. So The Telehealth Initiative is a collaboration between the AMA, the Florida Medical Association, the Massachusetts Medical Society and the Texas Medical Association with generous funding by the Physicians Foundation. So we embarked on this initiative in January of 2020 to help physicians adopt and adapt to telemedicine. Little did we know when we were developing these resources that we were about to embark on a public health emergency, that would grip not only our nation, but the whole world. So the timing was impeccable.

Unger: So we just couldn't flip that on, flip the switch, so to speak to telemedicine right after this started?

Vogel: Yes, the switch had to be flipped quickly. So we pivoted and made all of the resources we were developing available to all physicians across the country, so they could tap into them.

Unger: A lot of people don't really think about starting telemedicine as a very wide span of things that get involved there. What did you think were kind of the biggest obstacles when we started this process?

Vogel: You know, I think the biggest obstacles were just how to, first of all, find the platform that they could use for their patients. And certainly the waivers that were put in place at the local, state and federal levels certainly helped with that, so physicians could use audio video, or just audio. They could use platforms such as Zoom, FaceTime that may not be HIPAA compliant, but moving forward, they certainly need to think about HIPAA compliant platforms. And then the other thing were policies and procedures to help their patients so that they could be compliant as they practice medicine, but in this new virtual environment.

Unger: Dr. Howard, why don't you share your own personal experience in implementing telehealth during COVID-19?

Dr. Howard: Thanks Todd, for having me on today. And first of all, let me say that I would not have been able to implement telehealth as quickly without this initiative. I'm in solo practice and I do accept Medicare and insurance, and I had a platform before and I failed miserably. And in the beginning of a COVID, my practice was really, came to a halt and I really needed something in these virtual visits, which allowed me to have new patient visits, follow ups, lab discussions and some acute non-emergent medical issues that fit certain criteria really helped.

The thing that really helped me most was really that playbook, because that was the key to everything. And in addition to some pretty savvy lectures on the how-to part of implementation. What I was able to learn is understand the workflow, how to design it, how to select some specific vendors. But more so I was able to hear from some others and understand what they were doing right, what they were doing wrong, what I may have been doing wrong. And even more importantly, in addition to all of that, there was a big section on how to code properly and how to get paid for what you do, which is I think very, very important. Luckily for me, I had excellent buy-in from my patients. So it went about as smoothly as it could.

Unger: You mentioned your first kind of round one, didn't go so well. What was that kind of single biggest point of failure for you?

Dr. Howard: Oh my gosh. It was an incredible number of screens that people had to go on to be put in. And then I kind of got sold on the beginning of how to do it financially and without integration. And it was just a real mess.

Unger: Yeah. Any kind of new adoption of technology is difficult, even under normal circumstances, much less a pandemic intervening. Dr. Shah, was this similar experience for you?

Dr. Shah: Thanks for that, Todd, for having me. In a way, our experience was similar, but nothing what we had expected or imagined. I think being a large group with 80 plus providers taking care of 80,000 patients right around the time of January 2020, when we became part of this initiative, as Dr. Howard said, I think we could not have done it the way we did it without these initiatives. I think we were preparing for it on our own, but this is a venture, which would in a typical non-pandemic era would take a six to 12 months of thoughtful planning. But we did it in three weeks. Whereas some of our peers just closed their offices and became completely virtual. So for us, we had to compress a lot of learning and complex workflows in timeline in three weeks, which 24/7 connected to Mass Medical Society and this DDI initiative became a blessing.

Unger: What do you think? Now you're, let's say, almost a year into this, so to speak. What are the kind of key barriers for physicians and patients that we're still facing that limit their ability to use telehealth effectively?

Dr. Shah: I think the biggest barrier still, believe me or not, is a basic connectivity. The difference between cellular and WiFi connectivity is still becomes a challenge where with the nuances patients are trying to do the video visit on the fly when they are in between their work break or they're going to their car, not realizing the cellular connection is not as reliable. At the same time, the digital literacy is a different beast in itself. It's one thing to turn on the laptop and it's one thing to actually come into my waiting room. So that digital literacy becomes a big barrier. And the access to technology, especially for most vulnerable population is a big hindrance. We are being creative where we are using the homemade resources or friends and family who have technology to do the video visit for someone who's homebound. But I think we need a lot of work in the access to technology barrier for next coming few years.

Unger: And access, it's a word in these interviews that I have, and no matter what that topic is, pops up, as just another challenge in the world of health equity during this pandemic. Dr. Howard, anything to add in terms of barriers that you're seeing? Anything that really needs to happen on the go-forward basis for you to make this work?

Dr. Howard: Sure. I agree with Dr. Shah. And in fact, in my practice, what I do is I actively teach the patients the how-to, and communicate with them with every way they can possibly communicate if they can't come in for a live visit. And I think one of the biggest things that physicians need to be very flexible in their communication style to fit in whatever the patient needs. And in addition to that, I think it's really important to build in enough little bit of extra time to handle the unexpected issues that are pretty much always coming up. The things that are just-in-case things. So I think time and flexibility are our two things that are incredibly important and to overcome, to have a successful telehealth platform for patients.

Unger: It's interesting. We had a specialist on kind of virtual presentation who gives a lot of counsel to physicians, talking about some of the key things that are missing from those in-person visits. It could be, direct eye contact and, dealing with tough questions in a virtual environment, which is very different. And for physicians that are a lot of times having to look at their screens, record information, take notes, and talk to a patient at the same time, is that a challenge for you Dr. Howard?

Dr. Howard: No. You know, I kind of think you have to think of it a little bit like acting. You have to do a little bit more when you're on screen and how you say it and what you say in order to really interact with them. Because I make a big effort to try to communicate with them, not as a kind of I'm here, you're there, but as if we're in the same space. And I think that takes a little bit of practice and I work hard at that.

Unger: What's your secret?

Dr. Howard: Just practice. And actually, honestly, I think it is giving up a little bit of who you are. Just give a little bit more, be more realistic, more real, so to speak, with your patients, which I also include when they're in front of me as well, but on the screen, you got to do just a little bit more. And sometimes you have to direct them, like "Put your screen so I'm looking at your face and not your abdomen" or something like that. But just really get out there and show who you are and communicate at a level that hopefully they understand and look at what they're looking at their language too. Body language, I think is really important. And even on this communication platform, you've got to be reading those cues as well.

Unger: That's excellent advice. Ms. Vogel, what do you think the biggest opportunities for telehealth to make a positive impact in health care are? Where do you see those?

Vogel: I do you think there are lots of opportunities. I mean, look, we're not going back. Patients and physicians alike have dipped their toes into this, or jumped in fully and recognize the value. Patients realize that their time is now efficiently used. They're not having to drive across town, fight traffic, find parking, sit in the waiting room. It's more efficient for everybody. Physicians can overlay this as an efficiency to their practice as well. And also if they're participating in any sort of value-based models, the ability to do brief check-ins with patients can be extraordinarily valuable for those patients that need it the most.

Unger: Well, Dr. Howard, we started to talk a little bit about differences that you're making in your presentation, just kind of practical realities. When you think about some of the systems that are tied in with telehealth, how are you thinking about optimizing virtual visits in your practices?

Dr. Howard: Well, I really love this question because it really helps to push me to constantly improve the access to care and communication to my patients. Of course, the goal is reducing hospital admissions and increasing satisfaction and doing other things like that, but also adding remote patient monitoring, which is what's really new to me before I did this initiative. And the area that I'm really most interested in is helping people stay on track for healthy habits.

I know that we do remote patient monitoring for blood pressure, arrhythmias and things, but in my practice, I'm really focused on trying to help people improve the lifestyle modifications that will help them improve their life. And so I'm thinking that remote patient monitoring might eventually move to wearing, not just wearables, but also interacting with the wearables for steps and metrics for exercise. But I do see it as a possible way to aid patients in improving their dietary habits, which I think is ultimately one of the keys to health. And those are just a few of the concepts that I've been thinking of when I'm looking to optimize how I view telehealth from my practice in the future.

Unger: So someday, I ride my Peloton and download that into one of my many apps. And then they're probably going to eventually feed into your monitoring process.

Dr. Howard: Yeah, or I'll be on my Peloton while you're on yours, and we can see how it goes.

Unger: Dr. Shah, will you talk specifically, Dr. Howard mentioned blood pressure monitoring. I think that's kind of a place where remote patient monitoring is really been playing an increasingly large role. How does that fit into your practice going forward?

Dr. Shah: Yeah, no, I think immediately after telehealth implementation, realize the need that we are missing the key component, which is quite natural in the in-person visit, which is having access to their biometrics. So we, in fact, launched hypertension, remote patient monitoring program, little over four or five months ago, back in October, September 2020. So as of now we have 320 plus patients on the platform for hypertension. And recently we launched diabetes also and we are already seeing a huge value. As Dr. Howard mentioned, we have seen a systolic blood pressure from the beginning till 90 days into the program reduced by 11 to 12 millimeter Hg, and then diastolic blood pressure by eight to nine.

Unger: What accounts for a change like that? What's driving that?

Dr. Shah: And I think a lot of it is what Dr. Howard just mentioned that by sheer measuring the blood pressure at home, our care management team has interacting with them on what's happening between weekdays versus weekend, the compliance with the medication, what kind of food they are eating, they are actually taking the picture of their meal and sending it to us. So we already doing that and we are excited to see the results of which we are already seeing just within 90 days. So I think we are already seeing that cardiovascular risk and cerebrovascular risk reduction hopefully will translate into the reduced TME, total medical expense. And we are looking forward to doing that for the diabetes in coming months.

Unger: Well, at the onset of COVID, in addition to the technology and platform pieces of this and just the changes and what it takes to conduct a telehealth visits, payment was a big issue. And there were a lot of policy changes regarding coverage for telehealth that needed to change to support this. Ms. Vogel, can you talk about what needs to happen to ensure telehealth continues to be an option for delivery of care after the pandemic is over?

Vogel: Yeah. Thanks, Todd. You know, I mean, really payment parity is key. If physicians aren't paid for the work that they do, they simply cannot continue with it. I know a lot of the health plans don't want to pay at parity. They don't think that the resources are the same. But I would argue that if you're adding another type of delivery care into your brick and mortar practice, you're actually bringing in additional resources. So it could even cost more to have this additional delivery type. So I certainly think that having a parity makes sense, and that physicians should be paid for what they're doing.

Unger: Dr. Howard, Dr. Shah, any final thoughts or words of advice for practices that are still struggling with telehealth implementation?

Dr. Howard: Yeah. My advice is, just do it. If you're not sure, or you need a quick jumpstart use The Telehealth Initiative playbook, that'll really help you get started. Understanding how to integrate it, how to select a vendor, how to code properly and give you the confidence to explore what telehealth can really do for your practice. I just want to say a quick, thank you though, to the AMA, the TMA FMA, Massachusetts Med Society and Physicians Foundation for spearheading that project. Because I think without it, a lot of us wouldn't be where we are. And thanks, Todd, for letting me to participate today.

Unger: Absolutely. Dr. Shah?

Dr. Shah: No, absolutely. I think the last word I would share is telehealth is not just during this pandemic. This genie is out of the bottle. If you are not doing telehealth, I don't think you are practicing medicine to the full extent as of now. And think of it as a completely natural way to evolve the care model. And this is not just about doing telehealth for acute pandemic and sick visit needs. I think tying it to the value-based medicine and combining it with the remote patient monitoring and doing it for actually improving the outcome. If that's the purpose you believe in and act with that purpose and take time to reflect in making the change, change can happen. Of course, you need the resources and help from the experts around you, because someone somewhere else has figured this out. You are not alone in this. And I think with that, I would like to thank everyone here too. And thanks a lot for having me.

Unger: Well, thank you, Dr. Shah and Dr. Howard and Ms. Vogel for being here today, sharing your perspectives for all the work that you're doing to enable telehealth implementation. That's it for today's COVID-19 Update. We'll be back with another segment tomorrow. In the meantime, for resources on COVID-19, including a guide on telehealth implementation, visit ama-assn.org/COVID-19. Thanks for joining us today. Please take care.

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