Improving Quality Through Telehealth

#TelemedNow Twitter Chat Wednesday, September 16 – 8 PM ET Introduction & Welcome: Ceci Connolly (@ceciconnolly)- Moderator Improving quality through telehealth Q1: How has #telehealth created new possibilities to improve care for particular populations, e.g., rural, low income, mobility-challenged and what does this mean for improved patient outcomes/experience/health?

A1 Notable Responses: Jamey Edwards (@jameyedwards) #Telemedicine brings care to #patients where they are, when they need it. Whether beaming specialists to underserved hospitals or facilitating home access & ⬇️ need for travel, parking or time off, #telehealth is #healthcare's #Digital Frontdoor🚀 Evan Kirstel (@EvanKirstel) accessibility to care has been key.... new doors opened

Ceci Connolly (@ceciconnolly) #Telehealth gives people the flexibility and control they need to manage their own care. Hopefully will help in shift to preventive care and boost outcomes for #telemedicine users. #TelemedNow Ceci Connolly (@ceciconnolly) By expanding access to care through #telehealth, hopefully will let vulnerable populations get smarter, more consistent care. Could play a big role in mitigating widespread delays in care…both before and during #COVID19 #TelemedNow Salim Saiyed (@SalimCMIO) - health systems can target population by leveraging #telemednow - while moving away from brick & mortar infrastructure, digital infrastructure can close care gaps - most importantly during #pandemic we were continue to provide much needed #healthcare Aditi Joshi (@draditijoshi) we still have some ways to go but has given more access to those areas. with that we can get some better data, whether in health disparities or general health trends within the population. this can mean better health if disseminate it better Andrew Watson (@arwmd) Jamey, Is it digital front door of the hospital? Or digital screen door of the home? Andrew Watson (@arwmd) And with #Telemedicine, we need to make sure that access is both video visits and remote monitoring. Sometimes we think only a video visits. #TelemedNow this will all be combined with call centers and patient portals in the future. Maybe even chat bots. ?? Helen Burstin (@HelenBurstin) Given #COVID19, #telehealth can improve care for at-risk pops. Too many patients are missing/delaying needed preventive services and treatment. #Virtualcare can help ensure patients know what they need and get it done #TelemedNow… Ritu Thamman (@iamritu) Engagement in self-care can improve outcomes & #TelemedNow may allow mixed-methods to measure self-care & social-support data Recent survey:Black respondents are most likely to report using telehealth because of #COVID19 ACHP (@_ACHP) Nailed it. We need to ensure people get the preventive care care they need... whether or not there's a pandemic. #Telehealth makes that a lot easier. Torshira Moffett (@torshira) Better support for patients and caregivers - families can participate in discussions about care from different locations #TelemedNow Andrew Watson (@arwmd) So true, for my role clinics we estimate patient save about $120 per encounter. @UPMCpolicy #TelemedNow Michael Bagel (@MichaelBagel) Critical link to addressing social isolation, especially at a time when seniors are some of the most susceptible and must socially isolate. #Virtualcare is a tremendous tool for both PHYSICAL and MENTAL health. #Telehealth uses are endless! Great examples from @achp. #TelemedNow Sue Woods (@SueWoods) #telehealth #mhealth possibles remote access. from home. work. a car. any device. less hassle. (patient/caregiver users). shorter interaction time. on a menu with in-person will #Rock #TelemedNow Assuming connectivity Torshira Moffett (@torshira) #Telehealth has helped practices reduce no-show rates due to increased access to care #TelemedNow Ceci Connolly (@ceciconnolly) We hear from community health plans about so many seniors on #MedicareAdvantage that only have phone option -- critical link to clinical team, esp now Helen Burstin (@HelenBurstin) Agree. We need to ensure payment parity for #telehealth, including phone only for those who don't have broadband access due to #digitaldivide which affects rural AND urban pops Andrew Watson (@arwmd) Payment parity is a difficult issue, esp if we’re trying to use #Telemedicine to bring down the total cost of care. But as a heard on the @ncqa report yesterday, there’s a different way to think about this. By episode. Some more some less $$. #TelemedNow variable rate card. Paula C. Henderson (@pchenderson_LV) They need to get this in the nursing homes. My ex-mother-in-law still has to be wrangled into a van and taken to the doctors office. She cannot walk, wheelchair bound, is not always clear on what is going on and sometimes gets very scared and confused when they take her. Tricia Guay (@TBG_ACHP) Some nursing homes do have #telehealth options right now. But I agree it needs to be available for them more widely and definitely beyond COVID. Wrangling patients with mobility and confusion onto those buses is horrid. Jessica Spencer Castner (@DrCastner) Care-between-the-care follow up for pts just discharged from #emergency department, in vulnerable time for complications or revisits when either waiting for outpatient specialist appointment or not yet motivated/able to schedule the outpatient appointment. Matt Sakumoto (@MattSakumoto) Even in-between chronic care is SO much easier. As a PCP, I can actually say "Take 2 pills, and VidChat me in the morning" #TelemedNow

Q2 How do we begin to understand differences in quality measurement between care provided via office vs #telehealth What are best ways to assess impact of telehealth expansion on quality & patient experience? A2 Notable Responses: Jamey Edwards (@jameyedwards) Whether in-person or via #telehealth, quality measures in a value based world remain the same. Did treatment resolve chief complaint? What were satisfaction of patient and care team? Did we #HumanizeHealthcare? Ceci Connolly (@ceciconnolly) Just to underscore "in a value-based world." YES Michael Bagel (@MichaelBagel) #telehealth #mhealth possibles remote access. from home. work. a car. any device. less hassle. (patient/caregiver users). shorter interaction time. on a menu with in-person will #Rock #TelemedNow Assuming connectivity Ceci Connolly (@ceciconnolly) #Telehealth is NOT a 1:1 replacement for in-person care. With that in mind, think the focus needs to be on measuring OVERALL outcomes… NOT individual visits. Helen Burstin (@HelenBurstin) Ultimately, #telehealth should be woven into full care continuum. New @NCQA report states #telehealth is not a type of care. Office v remote care differences less important. Key metrics remain the same: access, experience, costs and effectiveness Torshira Moffett (@torshira) we should collect results on patient outcomes and experience with #telehealth Sue Woods (@SueWoods) Agree. Don't make tech the issue, with some exceptions (did it work? how and for who?) I don't recall anyone evaluating my in-person visits Salim Saiyed (@SalimCMIO) #telemednow is really now & should not be. few ways we measure - #preventive #healthcare visit over #telemednow - #cancer screening ordered via #telemednow - no show rates for #TelemedNow - reducing exposure for #covid #flu visits via #TelemedNow - monitoring return rate NCQA (@NCQA) We should definitely do more research around #telehealth expansion’s impact on quality and patient experience! Andrew Watson (@arwmd) I think disease specific quality metrics that are measured against the standard of care is one assessment. The other is payer-based claims management systems, at least 60 days run out. What do other payers think? Matt Sakumoto (@MattSakumoto) Moving toward Outcomes and not just Process measures is BIG step in Qual. For ex., performing a PHQ2 dep scr every in-person visit is fine, but if you can do frequent outreach and tele-psych, I think actual PHQ-9 scores can improve due to ˅ barriers to care Helen Burstin (@HelenBurstin) Completely agree, Matt. Some measures work to drive internal QI (like collecting PHQ), while focus should be on whether high PHQ triggered more accessible referral to #telepsych with improved outcomes as ultimate measure Ritu Thamman (@iamritu) Key difference is b/w quantitative endpoints like death or admits qualitative methods that use analytical methods to study complex causality & identify pathways to an outcome as opposed to list of factors in traditional analysis. Aditi Joshi (@draditijoshi) as referenced earlier, community effects including saving to travel/employment/childcare. evaluating triaging, including PI similar to inperson care i.e. evaluating in-person referrals and if patient needed it, or did and was not sent. Andrew Watson (@arwmd) Aditi, Do you measure travel costs and report them out routinely? Aditi Joshi (@draditijoshi) not specifically for acute care, but our surgeons doing post-op visits within various surgical specialties do as they are in a larger catchment area. we look more at referral rate, abx stewardship and what patients self report as their other options for care Peggy OKane (@PeggyNCQA) Couldn’t agree more. Dying for someone to step forward and challenge others to compare outcomes.#TelemedNow Q3 How can we optimize quality measurement (e.g., MA Stars & @NCQA accreditation) to ensure ALL people benefit from #telehealth? How do we ensure universal access to tools for effective quality measurement? A3 Notable Responses: Jamey Edwards (@jameyedwards) Need #healthcare access for #healthequity. Part of our performance measurement should include scores rating efforts to resolve #disparities, how easy it is to access care. #broadband, #smartphone penetration & other metrics should be included. Helen Burstin (@HelenBurstin) Agree @jameyedwards. We must reduce barriers and be accountable for improved access and outcomes for pops at highest risk, including ensuring access to #broadband and #RPM for chronic illness. It will save lives (and $) in the end Salim Saiyed (@SalimCMIO) agree, but who is doing it out there ? Ceci Connolly (@ceciconnolly) Two thing: First make sure PATIENTS have access to #virtual tools. Can’t measure effects if people can’t use the tools. Not to harp on this, but Congress must prioritize #broadband access. Ceci Connolly (@ceciconnolly) Second, industry needs to focus on building robust #HealthData infrastructure. Development of easy-to-use, interoperable tools are good first step to ensure right data gets captured Matt Sakumoto (@MattSakumoto) Let's harmonize the quality measures first :) for ease of reporting (and better comparison). In my QI role keeping track of measures is like herding cats Ritu Thamman (@iamritu) Allow the Broadband Community Act to pass & close the loopholes that allow incumbent ISP to block internet for communities that want to form their own networks rather than wait for the ISP( like WaIting For Godot by S Beckett) Andrew Watson (@arwmd) This may be a boring answer, but I do think we have to have a clear way to assess the operations behind #Telemedicine and especially the workflow. As technology is such a key part of care delivery here, unlike most other areas in healthcare. #TelemedNow Impacts outcomes 100 Stevland Sonnier (@StevlandS) Critical for us to accurately monitor, collect, and evaluate REAL data (race,ethnicity, & language). We cannot change what we are not measuring. Incorporating these measurements can help direct service design and deployment Eva Powell (@CPurposeHealth) Healthcare stakeholders must use their wealth and influence in new ways. Partnering across sectors and with state and local govt ESSENTIAL. Salim Saiyed (@SalimCMIO) I think a lot of #healthplans & other regulatory bodies have not kept up with their #quality metrics to adjust to the new way of delivering care via #telemednow. I think it has to start there to change to this new reality Sue Woods (@SueWoods) Some ideas #Telehealth quality - Separate out digital inclusion (connectivity, device, capacity to use it) as a #SDOH - Solicit same quality & satisfaction questions regardless of services delivered Torshira Moffett (@torshira) #telehealth and #COVID19 have highlighted variation in access from rural areas to underserved populations. It’s a modern #SDOH

Q4 What are barriers to a more integrated quality measurement system, data sharing & patient-centered care for remote services? A4 Notable Responses: Jamey Edwards (@jameyedwards) The #culture of #healthcare Most of the issues we face in #medicine aren't #technology, but human behavior, information silo's, competitive dynamics & regulation. Patients should own their data & opt-in to #hospital record & gov't databases. Ceci Connolly (@ceciconnolly) The @CMSgov and @ONC_HealthIT interoperability standards are good 1st step to streamlining process. We need a simplified, standardized approach to data sharing. Andrew Watson (@arwmd) We spoke about this a lot with @NCQA+ broader alliance @AmericanTelemed @PeggyNCQA we have to get some sense of #TelemedNow standards in place. facilitate interoperability. @DavidBrailer @TheHealthSummit Or have the experts carefully craft the path now. Like DICOM Ritu Thamman (@iamritu) Data collection is key: 1.Make data collection denominator disease not intervention based ( ie all patients who could have received it) 2 need the right exposure & outcome variables 3 need data that are absent from EHR :frailty,SDH #TelemedNow NCQA (@NCQA) We should adapt, not reinvent, quality measures and keep the same quality standards/expectations as #telehealth is another site, NOT TYPE, of care, & compare results. Salim Saiyed (@SalimCMIO) the #technology is there to support #telemednow, its in the #implementation & operationalize collection Andrew Watson (@arwmd) I go back-and-forth on a different type of care versus a different site of care. Again, it takes me back to laparoscopic surgery. Is it a different technology of surgery? Or a different surgical approach overall? Aditi Joshi (@draditijoshi) different surgical approach using technology! (says the non-surgeon). good point. Q5 Will #telehealth change how Americans view #MentalHealth & what does this mean for improved patient outcomes/experience? A5 Notable Responses: Ritu Thamman (@iamritu) If the pt has access #TelemedNow it can be a boon for those w #mentalhealth problems: Australia Lifeline's text helpline trial has shown that #digitalhealth, particularly text-only chat, is one of best ways to reach young people facing a mental health crisis Aditi Joshi (@draditijoshi) if have increased access, more treatment and discussion can lead to less stigma and people continuing treatment with better outcomes. seems counterintuitive: doing it on telehealth keeps it private but still opens up discussion. hmmm... Sue Woods (@suewoods) if have increased access, more treatment and discussion can lead to less stigma and people continuing treatment with better outcomes. seems counterintuitive: doing it on telehealth keeps it private but still opens up discussion. hmmm... Stevland Sonnier (@StevlandS) It already has! 74% of large employers are planning to offer telehealth plans w/ #MentalHealth services, up from 27% in 2015. @BCBSMA and @AtriumHealth are developing novel ways to offer telebehavioral health services as well. Read more here: Ceci Connolly (@ceciconnolly) @commonwealthfnd has a fantastic brief on this: great breakdown of how #telehealth has been leveraged in states across the country to meet #mentalhealth needs #TelemedNow Helen Burstin (@HelenBurstin) Dramatic increased use #telementalhealth during pandemic. @APAPsychiatric survey: 32% psychiatrists said ALL patients showed up for appointments v 9% before pandemic. Timely access to care (maybe less stigma?) should improve outcomes #TelemedNow Ceci Connolly (@ceciconnolly) tracks with all the data from our community health plans Andrew Watson (@arwmd) Mental health is perhaps the best suited profession for #Telemedicine. #TelemedNow. @PeterYellowlees @APAPsychiatric it just makes so much sense, especially for longitudinal and touch and tune type care settings. Also for integration into medical homes. Jamey Edwards (@jameyedwards) ˅ barriers to mental health & ˅ obstacles to visit (privacy, doing from home, etc...) can increase access & reduce stigma. Mental health should be the next #vitalsign. Mental issues manifest themselves physically. We all could use a little therapy. NCQA (@NCQA) #Telehealth is already increasing behavioral care uptake likely due to #COVID19 stress, relaxed rules and less stigma in getting such care at home online. Behavioral providers raving about #telehealth benefits to their clients/practices! #TelemedNow Salim Saiyed (@SalimCMIO) #behavioralhealth #psychtwitter is easily & widely adopted on #telemednow - #patients appreciate #privacy & comfort of own space - easy access to #therapist - #healthcare can create further access points - multiple modalities beyond live, text etc. - outreach to underserved Connie Hwang (hwangc01) Already seeing progress in #telemednow improving access to mental health care. @CDPHP 's partnership with @ValeraHealth launched this summer during #COVID19 w/ many virtual appts aimed at initial therapy and timely behavioral health care post-hospital discharge. Sue Woods (@SueWoods) It's been exciting to see people who provide or receive care for #mentalhealth issues have already change their views about #telehealth. Caring for folks in #recovery has a whole new dimension... It's fun, if you ignore tech hiccups #TelemedNow #telehealth #mhealth Torshira Moffett (@torshira) Agree, I think the pandemic has opened people up to the value of seeking help if you need it

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