Redesigning Primary Care in 2021

#TelemedNow Twitter Chat Wednesday, April 7 – 8 PM ET Introduction & Welcome: Andrew Watson (@arwmd) Redesigning primary care in 2021

Q1: Why does primary care need to adopt telemedicine? Is it an adoption or redesign of care around telemedicine?

A1 Notable Responses: Jamey Edwards (@JameyEdwards) #PrimaryCare needs to integrate #DigitalHealth to create a new #goldstandard in #healthcare: the digitally driven encounter incl. a #DigitalFrontdoor, digitally enabled inperson visit & #telemedicine follow-up. @kpthrive & @VeteransHealth have shown the way. Andrew Watson (@arwmd) - this if from 2016 ! @Telemedicine_Jn Systematic review of 2005-15 Janice Tufte (@Hassanah2017) In some cases #telemedicine might require a redesign & in other cases with leadership buy in & #patientdemand for #telemedNow then w having the technical ability adoption might be an easy and smooth transition Ashley Dauwer (@amariedauwer) Primary care needs to transform to meet people where they are. Consumers expectations have shifted (especially with COVID) & they’re now expecting the same conveniences and experiences from their doctors. #telemednow Vince Kuraitis (@VinceKuraitis) Primary care is not one unified thing.Many companies have been working on “unbundling” discrete aspects of primary care (see the diagram) Helen Burstin (@HelenBurstin) Primary care has adopted #telehealth. Many PC services well suited to virtual care, including #RPM for chronic care management (especially if used with #AI/#ML). Ritu Thamman (@iamritu) Redesign : Chronic Disease Management w RPM leads to more continuous touch points Referrals to specialists(less wait time/less travel) talking,listening to pts concerns can be less distracting via #TelemedNow eVisit for uncomplicated med refills/minor illness Matt Sakumoto (@MattSakumoto) Virtual Care allows for true continuous care, the backbone of primary care. Let's us move away episodic care, and continuous preventative health promotion! #Telemednow Ceci Connolly (@CeciConnolly) What I think gets lost in this question is whether primary care is working the way it needs to right now? And the truth is, the U.S. just doesn’t use primary care enough. #TelemedNow Ceci Connolly (@CeciConnolly) So, yes, where primary care exists, #telehealth tools should adopt and integrate into existing workflows. We need simple, secure and affordable tools for PCPs to use w/ patients. And that should get easier as more and more companies keep entering market. #TelemedNow Ceci Connolly (@CeciConnolly) But, honestly, it's past time we design smarter primary care options, that combine a focus on value, a patient centered approach and the convenience of virtual care. And of course we at @_ACHP have a few ideas #TelemedNow Judd Hollander (@JuddHollander) Not around telemedicine. Important to integrate telemedicine some of the time for some of the patients. Just one option. Its not all or nothing. #telemednow Stacy Hurt (@stacy_hurt) Wider adoption would increase visit #accessibility for #patients and redesign is needed for which appointment types are most appropriate for #telehealth - would improve convenience #TelemedNow Judd Hollander (@JuddHollander) How much RPM is the right amount of RPM. Need good data not just more data, right? #TelemedNow Dr. Salim Saiyed (@dr_salim_MD) #virtual #primarycare #patients want it & prefer a doc they know even on #telemednow #continuity of care really important to diversify to continue capture #quality during this time & not fall through cracks survival for #primarycare Andrew Watson (@arwmd) Yes, true, and is that because of an access issue? Because, as we know, access is top of the list for #Telemedicine. #TelemedNow Jamey Edwards (@JameyEdwards) Totally agree. Redesign in more about training primary care to perform virtual visits. It's always the culture change that requires the most effort and is usually paid the least attention to. #technology alone doesn't solve the problem :) Helen Burstin (@HelenBurstin) Great point! #TelemedNow can enable longitudinal relationships (IMHO - the best part of PC!) if you get care from your regular clinician/practice. Need to differentiate from #telehealth provided by 3rd party without connection back to PC home. Connie Hwang (@hwangc01) Primary care's future rests in value-based arrangements. Practices that can offer convenient, efficient & clinically effective care via telehealth will succeed best in such payment scenarios. #telemednow Jamey Edwards (@JameyEdwards) The whole current system is built around the in-person visit so path of least resistance is regression. Need policy and reimbursement to catchup and help drive better more progressive behaviors. John Lynn (@techguy) Yep. I think the big winners are going to be the direct to consumer telehealth companies for those patients that really prefer telehealth. #TelemedNow Tricia Guay (@TWG_ACHP) Completely agree. Speaking as a patient, if the only reason I am seeing the doc in person is for med refills #telemednow makes a lot of sense for both the doc and me as the patient. Not missing work, dealing w/traffic & sitting in the waiting room might help my blood pressure. Ami Bhatt (@AmiBhattMD) It’s the new “brave new world# of digital health Helen Burstin (@HelenBurstin) I f health plans incentivize #telehealth away from PC, you risk hurting what makes PC so special - the relationship with someone you know and trust ACHP (@_ACHP) "How" you do something is as important as "what" you do. ACHP plans have spent years building relationships with docs specifically because we understand how important those relationships could be. Sounds like we need to push a model that fosters that same approach #TelemedNow Ami Bhatt (@AmiBhattMD) #telehealth will increase patient convenience improve the doctor patient relationship by showing respect increase patient empowerment All of which leads to truly creating “primary” care Q2: Virtual first primary care - is this our new norm? A2 Notable Responses: Jamey Edwards (@JameyEdwards) Yes. And if not it should be. It certainly would be if we designed a best in class #healthcare system today. It's about #DigitalHealth integrated across the continuum, helping wayfind, match cost to acuity & address disparities through increasing access. Nathaniel Lacktman (@lacktman) For some, yes. Virtual first and then in-person as necessary. We will see a lot more of this hybrid model over the next few years. #telemednow Ashley Dauwer (@amariedauwer) I think it depends on the patient and should be personalized to meet their needs. Some may prefer a virtual first experience, others will still prefer to come in-person first. #telemednow Stacy Hurt (@stacy_hurt) A virtual first primary care could be a value-added utilization of mid-level providers to screen for FTF testing needed for more serious issues or treat immediately as warranted #clinicalworkflow Vince Kuraitis (@VinceKuraitis) Telehealth has become table stakes. 36% of patients would leave their provider to access telehealth Ami Bhatt (@AmiBhattMD) Depends how do we define the gold standard: is it still FTF visit? concern of misdiagnoses due to lack of in-person care; telehealth not option for pts w/o access(computer literacy & broadband) Maybe text-based chatbot post visit will improve pt experience Ceci Connolly (@CeciConnolly) There’s growing demand for that approach. We already have members offering virtual-first products because #telehealth is so popular and it can reduce costs. Examples to follow #TelemedNow Helen Burstin (@HelenBurstin) Patients endorsed virtual PC during pandemic and will expect #TelemedNow to continue. BUT new normal has to include: > integration into care, close #digitaldivide, and maintain payment parity Vince Kuraitis (@VinceKuraitis) Is virtual first primary care our new normal. Yes. The default used to be in-person care. A hybrid model will be BETTER THAN in-person care. Now we should be asking “Is in-person care truly necessary?” Jamey Edwards (@JameyEdwards) It isnt. The gold standard is the right modality for the specific chief complaint as a part of the larger care continuum with proper escalation in place....but I have a tweet on that coming later ;) John Lynn (@techguy) Is this true? I love your last question. I think the answer is probably ~30% of the time it is. We just need better data to know when a patient's situation is in the 30% and when it's not. Ami Bhatt (@AmiBhattMD) #telehealth is worthwhile trying as a triage mechanism is most medical situations as long as there is a clear workflow for who is responsible and what happens next. Helen Burstin (@HelenBurstin) I agree @amariedauwer. Some patients may prefer to meet their clinician in-person first before #telehealth. But you could start using virtual tools like #RPM and #PROs to support the initial visit #TelemedNow Jamey Edwards (@JameyEdwards) Preference is tough measure vs "appropriate". Hypochondriacs would choose to see doctor everyday, but not necessarily appropriate. Also people do what they know so if they haven't had #telemed visit, they probably prefer in-person until they experienced. Thoughts? Nathaniel Lacktman (@lacktman) We need not wed ourselves to archaic medical concepts simply because of tradition. There are always new and better methods to explore. #telemednow Ritu Thamman (@iamritu) Medicine is drenched in tradition; #TelemedNow follows the same hierarchical traditions - & change is slow Dr. Salim Saiyed (@dr_salim_saiyed) while this might sound like a good idea in some scenarios, a lot of #patients have high deductible plans, adding a midlevel just to triage someone that needs ftf doc = 2 office bills for the same issue!! I am sure you would not like that as a patient. nurse triage phone instead Ceci Connolly (@CeciConnolly) That's a fixable problem. Smart health plans are designing benefits to get right care to right patient at right time in right place Stacy Hurt (@stacy_hurt) Hybrid everything should be the new normal Sid Kandan (@Sid_Kandan) What about audio only telehealth mixed with vitals transmitted over cellular (not broadband)? @SPulim has data with bluestream’s success with audio only visits and we have data on vitals data collection. May not behold standard yet, but with enough investment could be platinum Matt Sakumoto (@MattSakumoto) Why can't the patient just self-report their vitals? That's generally my practice Shereese Maynard (@ShereeseMayMba) Because once upon a time, patients weren't able to take their own vitals, and while innovation has moved us along, institutional philosophies and regulatory overreach have not changed. #TelemedNow Q3: Can #telemedicine be a true primary care platform? JAMA BMJ 2018 perspective - A3 Notable Responses: Ritu Thamman (@iamritu) Yes - as the gatekeeper to all other services & referrals Vince Kuraitis (@VinceKuraitis) Can telehealth be a true primary care PLATFORM? A: Yes Worth noting: Many think of “platform” as a technology construct. Many aspects to “PLATFORM”: * Clinical workflow * Social networking, eg, referral relationships * Biz model * Tech Tech should come last. Jamey Edwards (@JameyEdwards) It can certainly be a part of one. 100% virtual #healthcare shouldn't be the goal, it should be an integrated continuum of care supported by #DigitalHealth to reduce friction, create efficiency & drive more cost effective & satisfying encounter. Janice Tufte (@Hassanah2017) #TruePlatform? Ask rural patients who have benefited from Primary Care #Telemedicine for years, they appreciate #virtualvisit opportunities and recent #Tpatients understand as well as us when an in-person visit is required Ceci Connolly (@CeciConnolly) The future is now. Sure, we'll always need some in-person care, but new tech (such as the tools made by @TytoCare) are making home-management easier. #TelemedNow Nathaniel Lacktman (@lacktman) Present day, not everything can be virtual (eg, blood draws) BUT virtual + a distributed care model can provide scale and flexibility. Cost containment matters, but let’s not put profits over people. #telemednow ACHP (@_ACHP) That's right! Telehealth gives patients and their care team the power to choose how care happens; it isn't and shouldn't be seen as an "alternative" or "replacement" Helen Burstin (@HelenBurstin) #Telehealth can be cornerstone of a primary care platform, but sustainable implementation requires practice transformation with workflow integration. Great resource from @aafp:… Ashley Dauwer (@amriedauwer) A true platform play will be the most successful for primary care. Just video isn’t enough. Patients don’t want 1 app to message their doctor, another app for the video visit, and another app to share their data. The better and easier, the more engaged they’ll be. #telemednow Dr. Salim Saiyed (@dr_salim_saiyed) yesssss #primarycare should own #telemednow platform, gatekeepers to #healthsystem & quarterback to other specialties Steve Sonnier (@StevlandS) Iowans greatly appreciate #telemednow. Our telestroke programs have saved lives and driven dollars back into our communities. @JeydithMd @SempriniJason might be able to chime in as well with their perspectives

Q4: How can we best implement #telemedicine in current primary care models? What will it give to patients, MDs? A4 Notable Responses: Jamey Edwards (@JameyEdwards) First things first: we need more investment/incentives for primary care and #telehealth in general. Building out broadband infrastructure would help, but so would payment systems that prioritize value. #TelemedNow Stacy Hurt (@stacy_hurt) PLEASE give us digital second opinions & EMR’s talking to one another so we don’t have to FAX reports and snail mail disks! Continuity of care through #telehealth would be welcomed & appreciated Ritu Thamman (@iamritu) implementation is (KEY) Better clinical work flows, interoperability , less writing in EHR - make it seamless for MD’s Pay for RPM & prevention Use mhealth even for older >60 pts @circoutcomes #TelemedNow Judd Hollander (@JuddHollander) Agree. Much more about work flows and operations than technology. #TelemedNow Dr. Salim Saiyed (@dr_salim_saiyed) for MDs #medtwitter ability to market to a wider population will be critical for #primarycare survival in few years from large @amazon health companies keep #patients engaged improve quality metrics Sherry Reynolds (@Cascadia) “primary care and #telemedicine” will expand to include care provided by family members and patients themselves. I envision online consults for the millions of family caregivers along with health coaches and peer counselors via #Telehealth Janice Tufte (@Hassanah2017) If PCP panels are made up of #patients who prefer #telemedicine and they are asking for the virtual options as well as in person visit options= it should become the new norm.#TelemedNow Accountable Care (@accountableDOCS) Best models for integrating telehealth involve pre-payment to give clinicians flexibility to deliver right time right setting care. #TeleMedNow Q5: What are specific policy suggestions to help #telemedicine become part of mainstream primary care? #TelemedNow A5 Notable Responses: Jamey Edwards (@JameyEdwards) 1) Support movement to value based #healthcare 2) Make easier to collaborate across providers w/ revised #privacy regulation giving #patients power over their #PHI 3) Maintain policy relaxation granted under COVID & expand policies supporting #virtualfirst care. Ceci Connolly (@CeciConnolly) Pay parity now -- and for several yrs -- is key. But we see a path to value payment including #telehealth… Nathaniel Lacktman (@lacktman) IDK, how about adequately compensate PCPs, not just specialists and pharma??? #telemednow Helen Burstin (@HelenBurstin) Need to maintain #telehealth payment parity (including phone), especially for primary care practices struggling after pandemic. Maintain policy fixes that worked while we build newer, more integrated models. Great @commonwealthfnd resource: Ritu Thamman (@iamritu) Continue Pay parity - legislate it & continue to pay for phone visits Fix data interoperability by legislation of data so pts own their data & companies have to compete for their data/business #TelemedNow Ami Bhatt (@AmiBhattMD) Bill by the hour like a lawyer!! ... actually joking aside, more time with patients even at a cost to the system would likely decrease unnecessary testing and resource utilization #TelemedNow Stevland Sonnier (@StevlandS) Most important change is amending Section 1834(m) of the Social Security Act to remove rural geographic restriction. 60+ million Medicare beneficiaries were unable to access Telemedicine before COVID due to geo restrictions. Major primary care opportunity to save lives and $ Vinny Arora (@FutureDocs) Phone only visits are critical. Data from our institution on south side of Chicago shows it’s an equity issue Ceci Connolly (@CeciConnolly) First things first: we need more investment/incentives for primary care and #telehealth in general. Building out broadband infrastructure would help, but so would payment systems that prioritize value. #TelemedNow Andrew Watson (@arwmd) I completely agree about better incentives. Risk arrangements cannot come fast enough. #TelemedNow Sid Kandan (@Sid_Kandan) Completely agree with both points! In the absence of big structural changes, why aren’t we reviewing and highlighting results from the major programs that push incremental changes along the way? Like #fcctelehealthprogram #macra #TelemedNow Vinny Arora (@FutureDocs) Phone only visits are critical. Data from our institution on south side of Chicago shows it’s an equity issue Dr. Salim Saiyed (@dr_salim_MD) health plans need to cover #virtual #pcp - most we talked about had no idea- major ones dont cover cover #preventive visit over #TelemedNow let #pcp innovate & create metrics for #TelemedNow some #phe relaxed rules need to make permanent CME Information For #TelemedNow CME - the website to set up an account, register your cell and / or claim CME :

If you registered your cell text the code to 412-312-4424 Tonight’s code for 1h of category 1 CME: QUDYOM

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