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As we race to post C19 recovery, what is the incentive to maintain virtual care?



#TelemedNow Twitter Chat Wednesday, July 1 – 8 PM ET Introduction & Welcome: Ami Bhatt (@AmiBhattMD) – Moderator As we race to post C19 recovery, what is the incentive to maintain virtual care?

Q1 As we race to post #COVID fiscal recovery, what is the incentive for leadership to maintain virtual care?

A1 Notable Responses: Ceci Connolly (@CeciConnolly) #COVID19 has shown how flawed FFS is: it drives unnecessary care & leaves providers vulnerable (even as they see patients digitally). #Telehealth is an opportunity to show how value-based approach works more effectively Helen Burstin (@HelenBurstin) If telehealth payment and parity are made permanent, clinicians and health systems can begin to fully embrace #telehealth and build into workflows. Without certainty, system change not likely to maintain/drive adoption Andrew Watson (@arwmd) Great point Helen, and the payment parity is quite interesting. Does a phone call = video visit = face to face visit. This is a key issue. @UPMCpolicy Payers see this very different than providers. As Tmed leaders we need to think through this. Helen Burstin (@HelenBurstin) Key use case: Save money AND lives by checking if patients need meds/ immunizations / screening AND encouraging them to safely return for necessary in-person care & procedures to prevent delays in diagnosis and chronic illness exacerbations that lead to ED/hospital #TelemedNow Ceci Connolly (@CeciConnolly) As we expand #telehealth, it’s important we don’t just repeat FFS mistakes we’ve made in the past. Need to shift to value-based model, rewarding outcomes. This ensures appropriate care is delivered AND give practices financial reliability—regardless of tools used. Matt Sakumoto (@MattSakumoto) Realistically, are there any incentives for leadership other than financial? Andrew Watson (@arwmd) Here is a great article by one of our senior most executives and CMSO at @UPMC Dr Shapiro. Shows the impact of #TelemedNow in reopening AMCs - https://jamanetwork.com/journals/jama/fullarticle/2766527 Ritu Thamman (@iamritu) asynchronous communications may offer better patient engagement & adherence, eliminating the stress of travel & costs of parking, #RPM saves time Only downside: lost facility fee: In-clinic visits also bill for facility fee (even w/ E&M parity for video now) Jeremy Louissaint (@jlouissaint89) short-term, it would be very wise that (Hospital emoji) continue to ˄ telehealth expansion as the possibility of 2nd (Microbe waves emoji) is real Helen Burstin (@HelenBurstin) Really important question. What will move a health system beyond finances? Upcoming question! Ceci Connolly (@CeciConnolly) Question for the group: did we all get lulled into #coronavirus complacency? (ie see spikes) Because if we did, the need for safe #telehealth is even more urgent than we may have thought Ami Bhatt (@AmiBhattMD) Yes, there is a real need to continue to pursue #TelemedNow as we are not out of the woods yet with #COVID19 .. allows us to learn of more use cases as well! Matt Sakumoto (@MattSakumoto) I would love to move away from the nickel/dime game of "worth" of video v phone v face-to-face. The true transformation day is when "telehealth" is no longer a term, and it just becomes "care" Jamey Edwards (@jameyedwards) #Telemedicine allows us to #LoadBalance the #Healthcare system, building capacity where we need it, especially in underserved communities, at a reasonable cost. Making #medicine more efficient makes it more cost effective at every level. Andrew Watson (@arwmd) The current trend is worrying and may give us a second opportunity to really push #telemedicine forward. Although, I am very worried about health disparities for minorities and underserved communities as we have seen in past chats. #TelemedNow. What can we do now? Ritu Thamman (@iamritu) This is key point: will payment all be based on time or on outcomes Salim Saiyed (@SalimCMIO) The way to convince leadership - 1 build #TeleMedNow #coalition of willing 2 Demonstrate it is critical to sustain #business 3 #patients prefer to stay safe & avoid care, if no other option 4 #Telemednow generates referrals 5 can save on #ppe & #exposure to staff Salim Saiyed (@SalimCMIO) @AmerMedicalAssn shows $250 billion of #healthcare to move to #telemednow #PostCOVID19 , compared to $3 billion before https://bit.ly/38iU7qt No one wants to left behind from that pie! Lets get it #healthcare Ankitkumar Patel (@DrAnkitKPatel) Patient satisfaction. During the #covid19surge - patients were so relieved that they had access to their hea lthcare providers via virtual care and felt abandoned by those providers that were not available. Ami Bhatt (@AmiBhattMD) #PatientCare includes patient satisfaction! Not only do we want patients to be and feel safe, but #medicine has become a consumer industry and unhappy patients will go elsewhere. #TelemedNow #consumerforum #healthcare Sam Lippolis (@samiamlip) Because the US isn't managing COVID there's incentive to ensure ways to keep O/P & clinics running as we safe more shelter in place and for high risk patients. Jamey Edwards (@jameyedwards) Provider Satisfaction too :) Quadruple Aim enabled by #Telemedicine allowing clinicians to practice from where they & bring in specialists to support their care so they are making "risky" decisions but rather practicing as part of a care team at the top of license Ami Bhatt (@AmiBhattMD) We need to remember that Physician #burnout was the last epidemic before the #COVID pandemic. #TelemedNow allows for physician versatility in practice! Ritu Thamman (@iamritu) #TelemedNow will ease provider burden & #burnout by streamling data capture, improving/automating #workflow Helen Burstin (@HelenBurstin) It should ease burden and burnout if practices can stay afloat. Sadly, it still comes back to adequate reimbursement and new payment models that integrate telehealth Matt Sakumoto (@MattSakumoto) That's true, the plummeting no-show rate, great appreciation from patients will all be huge drivers of telehealth adoption and will keep the momentum going. Sam Lippolis (@samiamlip) You could have financial incentive on no show rate alone. Every no show = negative dollars. Lost time AND lost patient = no show Ankitkumar Patel (@DrAnkitKPatel) Absolutely true. Also no show is double negative - as a patient that could have been seen is also not seen. Judd Hollander (@JuddHollander) Payers think they can pay less since you dont need real estate. Pretty sure none of us have leases we can end tomorrow. Transitions take time. Health systems just took a bath. Need payment parity. Ritu Thamman (@iamritu) This is critical - what if you need less face to face time but more asynchronous time to get better outcomes- like DM & hmgb a1c - will payers be able to see long term outcomes as a key parameter ? Martha Gulati (@DrMarthaGulati) If we change how we deliver ‘medicine’ we can actually effect change. I have a hard time understanding why we can’t get this going and paid for. It’s like office hours. We need to disrupt that to work for patients Q2 Which #TelemedNow use cases are most likely to save the system money in the long run and how? A2 Notable Responses: Matt Sakumoto (@MattSakumoto) Avoiding ED and Hospitalizations. Tele-triage, avoid transfers from nursing homes, remote monitoring for the hospital at home. Anything that avoids and admissions saves $$$. Andrew Watson (@arwmd) We are looking at tele-triage for surgery. @chadellimoottil @MarkCohenFACS @JuddHollander @draditijoshi - learning from my peers. And @AmCollSurgeons @SWexner Aditi Joshi (@draditijoshi) Hopefully we will see the correlation to improve throughout eventually. How are you using for surgery? Matt Sakumoto (@MattSakumoto) This is a dream scenario of mine (inspired by @JuddHollander talk last night for @emresidents) Dx appy by telemed. Order CT and call surg while pt is en route to hospital. Direct admit via telemed and skip ED entirely (no offense to ED) Ankitkumar Patel (@DrAnkitKPatel) In #InterventionalCardiology we have been doing this for #STEMI patients - in field ecg activation and transfer to patient directly to cath lab. #SkipTheED If I could get a #telemednow visit with patient while in ambulance to the lab - I could get brief history, etc Jamey Edwards (@jameyedwards) Cost savings from #Telemedicine can be felt throughout #healthcare care continuum. From #SpecialtyConsults to #VirtualVisits, #PopulationHealth to #ChronicCareManagement, #telehealth is accelerating #medicine's #digitaltransformation, saving $ & increasing access Andrew Watson (@arwmd) This bundle is a great one. . https://bit.ly/2VDXNhn Always has been. . https://bit.ly/2VDXNhn As more risk through IDFS like @UPMCpolicy @Optum @Intermountain and the VA expand, bundles and total cost of care will drive this to new levels. Ceci Connolly (@CeciConnolly) Big smile on my face seeing the shoutouts for great work by our members; investments in #telehealth years ago are paying off now for patients and these organizations Ceci Connolly (@CeciConnolly) Urgent care, managing chronic conditions & behavioral/mental health are immediate opportunities. Virtual prescreens can reduce costly, unnecessary visits & remote monitoring can help prevent escalation of existing conditions. Helen Burstin (@HelenBurstin) Prevention and early intervention is a key use case. @Cutler_econ: “If you can use telehealth to do that, you can both improve people’s lives and save money on things like heart attacks and strokes and related conditions.” Andrew Watson (@arwmd) True @HelenBurstin #TelemedNow I wish we saw more primary care, #telemedicine first offerings, and preventative care….. Ritu Thamman (@iamritu) #CIEDs remote f/u is safe & economical c/w conventional in office f/u @CirculationEP https://bit.ly/3ioqIQ #CHF home JVP/ Physical exam @JAMA_current https://ja.ma/2VBWdMO #TelemedNow JK Han MD (@netta_doc) Yes! But absolutely needs strong infrastructure in place to handle all of the CIED remote transmissions that are taking place of an in-person visit. Otherwise work is just shifted around! Sam Lippolis (@samiamlip) Here's an out of the box but $ saver. Telemed for on call docs, reduces burnout because they visually assess patients before docs drive into hospital. Physician burnout = turn over = $ spent to hire new docs. Burn unit oncall attending's life totally changed by #telemednow Salim Saiyed (@SalimCMIO) We are seeing this as well! It has even changed perspective of few doctors from retiring out completely. - prevents #physician #burnout - flexible scheduling - recruitment from out of area - prevent full or partial retirement all $$ savings Rashmi Mullur (@rashmi2008) In #diabetes, increasing use of #CGM paired with #Telemedicine visits can not only improve access, but the CGM feature can also provide an estimated A1c —helpful for pts w/o lab access during the pandemic & will prevent increases in morbidity later Ankitkumar Patel (@DrAnkitKPatel) The applicability of #telemednow is beyond anything we imagined a few months ago and in a few months we won’t be able to imagine how we provided care in 2019 (it will feel primitive - like #DialUpInternet from ‘90s) @ACCinTouch @MonaliShahDO Ami Bhatt (@AmiBhattMD) What amazes me is how agile we were with changing workflows during #COVIDー19 when we just weren’t like that as a discipline before!! Ankitkumar Patel (@DrAnkitKPatel) Same patients in March that struggled with #telemednow were telling me in their June follow up appt about #ZoomBirthdayParty #FacetimeWithFamily #SkypeGraduations The human mind and behavior has great plasticity for change and innovation. #Necessity @DrSheilaSahni Q3 What outcome data would convince you to utilize #telemedicine even if it were reimbursed at a lower rate? A3 Notable Responses: Jamey Edwards (@jameyedwards) To me it shouldn't be tied to reimbursement. #Telemedicine is a modality & tool that makes #healthcare more efficient, creating value through getting #patients the right care at the right time & the right place. Could save billions while improving quality. Andrew Watson (@arwmd) Procedural volume impacted by telemedicine is a KEY data point for any hospital or doctor group. Procedures drive a lot of revenue. Therefore, any #Telemedicine that impact procedures is critical. Martha Gulati (@DrMarthaGulati) 1. Improved control of risk factor 2. Reduced events 3. Patient engagement and partnership/SDM/empowerment with above 4. Patient satisfaction Martha Gulati (@DrMarthaGulati) Also improved access to care for those who need it most. The most vulnerable populations. Who have less access to broadband and #Telehealth JK Han MD (@netta_doc) #EPeeps looked at this with remote monitoring - proven to show morbidity, mortality and QoL improvement. Reimbursed less, but remote monitoring has become a Class I indication for patients with CIEDs. Jorge Rodriguez (@translatedmed) Realizing the potential of telemedicine bridge health disparities. Aditi Joshi (@draditijoshi) improved patient compliance/outcomes/access. There are a number of vulnerable populations that are not cared for within our system. Better allocation of resources. Ceci Connolly (@CeciConnolly) #Telehealth can play a prominent role in managing chronic conditions. Shift to value-based model that emphasizes outcomes would reinforce use of #telemedicine while still giving doctors flexibility they need to choose tools that meet the moment. Helen Burstin (@HelenBurstin) In FFS, outcome data w/out $ parity not likely to drive telehealth, though APMs could drive >telehealth/RPM integration into care models w/right incentives for improved pt exp/PROs: recommend to friends/family, better function, fewer symptoms, fewer sick days Sue Woods (@SueWoods) medicine never required an outcome for having a F2F visit. Pet peeve: when something is digitized and clearly needed but has a higher bar Jasminka Criley (@criley_md) A3: Prevention! Prevention! Prevention!

Q4 Which industries do we need to partner with to ensure virtual care becomes an integral & feasible part of healthcare delivery?

A4 Notable Responses: Jamey Edwards (@jameyedwards) 1) Real Estate: Wiring Homes & Office Buildings w/ #Telemedicine Suites & #RPM Capabilities 2) Communications: Integration into Cable Boxes, #TV's & other appliances 3) Transportation: Integrate w @Uber & @Lyft to get #patients where they need to go Andrew Watson (@arwmd) https://bit.ly/3dRpk5p I think retail and telco. #TelemedNow. Esp Telco. There is so much innate throughput and traffic here is simply makes sense. We have tried and failed before here but now with better and cheaper and more portable technology we must revisit. Matt Sakumoto (@MattSakumoto) Agree especially with the TelCo. There are already so many @Xfinity hotspots around the city. Can we subsidize for #patientaccess to help bridge the digital divide? Maram Museitif (@MaramMPH) Covid19 has amplified the inequities people experience especially among the underserved and uninsured. We need to be innovative in partnering with non traditional partners in reaching people where they are and meeting their needs. Ami Batt (@AmiBhattMD) All companies need to save personnel time to get out of the red and Back to black .. #telehealth can be effective for financial recovery https://www.healthcarefinancenews.com/news/how-telehealth-can-help-hospitals-improving-billing-and-payment-collections Helen Burstin (@HelenBurstin) Partner with industries that maximize ability to provide virtual care w/RPM for ALL pts with affordable peripheral devices to monitor BP, glucose, weight, digital thermometers, & spirometers. Partner with labs to draw at home Ryan Louie (@ryanlouie) #cybersecurity #infosec community. Security - digital, physical, mental - is key for patient care. Sam Lippolis (@samiamlip) I know it's our own industry but we've got to do more for docs to be comfortable and onboard for #TelemedNow Tradition is deep with providers. Change is not embraced. Salim Saiyed (@SalimCMIO) Agree we have to support our #physicians #nurses & all other clinicians such as #pharmacist #physicaltherapist who are all offering #telemednow but don't have always have the necessary tools or. buy in Rashmi Mullur (@rashmi2008) We need better integration with EHR’s (&AI)—visits could be transcribed in RT to decrease provider burden and ease use. We also need to better integrate RPM data into the EHR.

Q5 For our last question, let's get introspective. What are we missing? What aspect of delivering effective #telemedicine is eluding us ... and needs more study?

A5 Notable Responses: Ritu Thamman (@iamritu) #Virtual waiting room as #healthliteracy school where we teach patients virtually while they wait to “see” us Need to study #BehavioralEconomics & see if paying pts incentives will improve outcomes using #TelemedNow Need more #Virtual #cardiacrehab which is underutilized Andrew Watson (@arwmd) I think we need more payer claims run outs / UM reviews. @UPMCHealthPlan@UPMCpolicy - we need to as an IDFS help define this. #TelemedNow. #telemedicine can’t be additive care; it need to be a replacement cost. Supply induced demand hasn't surfaced fortunately! Helen Burnstin (@HelenBurstin) We need more study of what can be done with #telehealth & virtual exams. New @JAMA_current study showed high correlation between in-person v virtual JVP assessment for CHF. We need more for #TelemedNow Jamey Edwards (@jameyedwards) Just need to find the right partner. Virtual waiting rooms and workflow exist on many platforms. @CloudbreakHLTH Ankitkumar Patel (@DrAnkitKPatel) Workflow - virtual waiting room with anticipated wait time. JK Han (@netta_doc) Infrastructure, infrastructure, infrastructure. Can't say it enough. Need institutional buy-in & support for #telehealth to flourish: clerks to make appts, techs to help patients navigate platforms/equipment/test calls, RNs as critical part to help w patient intake. Helen Burnstin (@HelenBurstin) Yes! Healthcare is a team sport and we need to build the team for #telehealth, including patients, families and clinical staff. Infrastructure and costs aren't just bricks and mortar - there are costs associated with people that make it happen Ankitkumar Patel (@DrAnkitKPatel) Appropriate physical space in hospitals to do private #telemednow visits Nicholas Morrissey (@nickmorrisseymd) deployment of and training on home based physiologic sensors (EKG, O2 sat, digital stethoscope.) And we need a groundswell of support from all specialty societies for the maintenance of all tele-health waivers beyond the Covid-19 PHE Ankitkumar Patel (@DrAnkitKPatel) Agreed - but that is the transition from #telehealth to #virtualcare Chad Ellimoottil (chadellimoottil) #TelemedNow More research on the substitution vs expansion concept. Is telemed a substitute or an additive service with no net benefit for outcomes? I think the answer will vary by specialty, by diagnosis and by how healthcare providers ultimately use it. bloomrhealth (@bloomrhealth) access to services that can be delivered cost effectively to larger markets Rasu Shrestha (@RasuShrestha) We just need to get going! ✔Enough talk, more action. ✔Enough complacency, more #innovation. #Telemedicine can't be the exception. It has to be the rule. Salim Saiyed (@SalimCMIO) Few things - ✔#patient voice & #experience & how do we improve it for them ✔#Telemednow platforms are at 1.0, we need to demand more to get to 2.0 & beyond ✔This is still new to many docs & patients alike, it will take see one, do one, teach one to get comfortable!

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