2018 Telehealth Trends You Need To Know — Kristi Henderson, Seton Health

[00:35]: Milton:
Kristi’s so famous within the telehealth industry. As we start, one thing that many probably know her professional reputation. But some may not have know Kristi is an avid runner, she runs 5 miles per day, super healthy. Kristi tell how did you get into Telehealth space, go back to your career, how you come into here.

[01:11] Kristi:
Well, first of all, thank you for having me. I really appreciate it. I’ve been working in telehealth since the late 90s. In 1999, it was truly just a concept and an idea of how to solve a problem. So myself and other colleagues really just sat around a table trying to address access to care and challenges with the health of the state that we’re out lived at that time. And so we develop the program and started out as a pilot and took quite some time to be able to develop the idea into something that medical boards and nursing boards and others with support, but it worked and it worked very well. And so in the early 2000, started that program purely to address access care issue and then evolved it. At that time, I had been working in an academic medical center, a trauma center. So I was running the ER as a nursing director. So we were challenged every day with backlogs in the waiting room and people having to travel long distances to get healthcare very similar to many areas across the country and internationally as well. And so we solved it with technology, we brought the health care to the individuals and it worked, and then we spread it from there.

[02:37] Milton:
If you’d go back to early careers, where you’re the Nurse director, what do you even do before that, how you career come to that point.

[02:48] Kristi:
I’m a nurse by training and have always had a career in emergency medicine, so have been practicing in that area and in urgent care centers all of my career, and then became a nurse practitioner, a family and acute care nurse practitioner. I’m still practiced in those same settings, so we’re dealing with really the most vulnerable population and an area of urgent need around immediate care needs. And so it evolved from there, took leadership positions and stayed clinical throughout most of my career until now transitioning over to Ascension Health, where I have an administrator role leading virtual care innovation here and the taxes administration. It’s all been an evolution. And interestingly, it always was trying to challenge the health system to take on a new approach. And so whether it was a new workforce and really trying to spearhead and lead the use of advanced practice nurse practitioners, PAs and others that weren’t fully integrated into the health system, or if it was to the other side, using an integrating technology into the system to try to look at a more efficient operation that can be scaled and reach more people with good outcomes, and so all of this has really led to everything building on every experience one on another and didn’t realize how much my nurse practitioner experience would be important in this work, as well as the collaboration and team approach to healthcare is so important in telemedicine that allowed that to happen.

[04:43] Kristi:
I’m gonna focus really on what I think about 2018 and go through some highlight of that.

[05:09] Kristi:
So I would say that for us, many of us who have been in the digital health space, and have been integrating technology for a long time. When you look back in hindsight and look where you have come, it’s so much progress. We have a long way to go. But one thing is that acceptance of digital health has dramatically increased in for a lot of different reasons. But I would say that digital health is here to stay. There’s not the question of, is it safe or should we use it? It’s, how do I use it? How do I make it sustainable and how I really integrated into the system of care.

We’ve really moved across this whole technology innovation curve or pathway to get to this acceptance. So we had this trigger of, here’s a new technology that we can use in health care and went around and probably had some disillusion that where we thought it could do more than it did, or we thought it was gonna be adopted quicker than it was or wouldn’t have the challenges around reimbursement as it does.

[06:14]
And so then it came through to a realization of just probably unrealistic expectations to some more of a realistic view of how technology can play into healthcare. And so we’ve passed that into our now n this phase of enlightenment. Okay, we get it, we trust the technology, we see how it can be used. Consumers want to use it. And so I’d say that it’s here to stay. It’s no longer being looked at as the black sheep in the crowd. It is truly here to stay. Now, systems are really thinking that mobile health care is healthcare. And so it’ll be exciting to see systems and payers and other healthcare providers really rethinking how they do their work. And so the technology has been there. This was never an issue around technology. It’s definitely gotten better and less expensive so we can scale it. It’s really been around integration and workflow transformation and a trust that has it coming. So it’s exciting to think about where we’re gonna go from there.

[07:27]:
I also say too that there is now enough literature in publications and research that has shown the positive outcomes, whether that’s positive outcomes clinically or around access to care or around the value that it brings to a system. But now people are saying, okay, we’re letting go. They’re not pushing back. And they’re saying, okay, let’s track. Let’s put it in our strategic plan. Let’s implement this in a smart way. And so health systems and providers are using it in a much broader way. It’s exciting to think about that. We’re truly revolutionizing how someone accesses care, how they access health care, as well as when they access it and where they access it. Those limitations are not there anymore, and we all know that intellectually. But I think that there’s this aha moment of enlightenment to truly know, okay, wait a minute. I really can integrate this into my entire operating model of healthcare, which is exciting to think about. This increase comfort and trust.

[08:30]:
I used to get “the standard that’s nice. That’s really cool. But my doctors or nurses aren’t gonna use it, and the patients don’t want that.” And move past that, there’s a balance of in-person care and the use of digital health that has to exist, and I think people are becoming more comfortable in leading more with digital health. So that’s exciting. The consumers are responding so positively and really driving a lot of what we do now as there’s this consumerization of healthcare.

[09:03]
I think that what we’re gonna see over this year is a real focused on integration. If you think about when we implemented electronic medical records, people held on to their paper charts kicking and screaming don’t take it away, and then there were incentives or penalities around not using it. And so it became kind of forced on a lot, and now it is mainstream. Telehealth doesn’t have that same pressure. Except that as we’re looking at value based care, I don’t know how you reach value based care without delivering care when and where are people need it in the most cost effective way, never sacrificing quality or the standard of care. But this is really gonna be a year focused on integration into the workflow. Approaching different hospitals or clinics, practice groups, whoever it may be that delivering health services and say, think about what you do and what has to be face to face where there’s touching or procedure being done and what can be done through digital health. And so operationalizing that and putting that support around digital health services, like telemedicine is critical to get integration. And so a lot around workforce, on work-flow analysis, and really creating a natural flow to using virtual care, so it’s not seen as another… You shouldn’t have to think to be able to get access to virtual care if I call to get an appointment with my health care provider, I wanna be offered that through virtual care or in person. And so this is gonna be a year of a full integration and deployment in a more streamlined approach around healthcare delivery, so that it’s not a separate department, but it’s just how healthcare at one more modality of how to deliver healthcare.

[11:00]:
We have never really seen the full benefit of what is possible with virtual care. So it’s gonna be a year of unleashing that full potentials and really realizing, how can it impact access to care? What can it mean for care management or even empowerment of individuals to manage their own health through apps and sensors and other devices like that. And so as it’s fully deployed, and as we have a better ability to analyze the data to know control group and comparing those that got care through virtual care and those that get it in person and look at that over a longer period of time, we will be able to see the true impact to the total cost of care, which is gonna be really exciting to see. And I think that before, because it was a pilot or because it was not fully integrated, it was always hard to get real good data analysis to look at that full potential and the impact on the whole system as well as to the cost of care.

[12:05]:
We had a lot of barriers to being able to look at that return on investment. We may deliver access to care through telemedicine that was once not available, that then ultimately prevents an ER visit. Well, avoided cost is not looked at the same as revenue. And so really being able to start looking at value based model is exciting to think about… And so I think we’re gonna start seeing more of the full potential of a digitally enabled health system start to show some outcomes. They’re gonna help us understand how to use it.

When I think about what’s happening in the market and across the country around healthcare, it’s exciting and scary all at the same time. The competitive landscape is changing. There’s new entrance into healthcare before it was the traditional health systems, retail clinics, federally qualified health, and these traditional health sites of service, sites of care. And now we have new entrance into the system. And so we’re gonna see a rapid acceleration because there’s competition and with competition, hopefully all both arriving and we’ll start being new things happen.

[13:26]: Health system merging with non-healthcare system.
The other piece is that with all the mergers and acquisitions that are happening across the country where not only is healthcare partnering with other systems, but across sectors and so non-healthcare entities, private and public sector, whether that is a company that is a pharmacy or an insurance company or something else like that, that changes the players and the power of the players in the healthcare arena. And so that’s exciting to think about and thinking, if I’m gonna deliver care to population, where’s my weakness and who shall I partner with, to be able to achive better care in a smarter way. And so as we think about healthcare systems partnering with non healthcare entities, it’s exciting to see what’s gonna happen there. So there’s a lot of new players.

[14:14]: Consumer.
The consumers are driving change too. So it’s not just a change in environment of healthcare because of new partnerships between health systems and payers or whatever it is. Consumers saying, wait a minute, I trust this technology, this is what I wanna use. I wanna use my phone. And so as that pressure, and they’re seeking that out, leaving their traditional healthcare providers to go to somebody that will provide health care in person or through virtual care. So we’re gonna see that pressure influencing decisions that health systems make as well as well as providers who really wanna be on the cutting edge to differentiate themselves in the market.

[15:00]:
And the other big piece is that all of us in the space I’ve been working on so hard is around the policy and the regulations that influence how we can deliver healthcare, how we can get reimburse for health, delivered it through virtual care and who can deliver care where. So I think as those continue to advance, we’re gonna see this accelerate even more, but so many of those barriers have cleared of, I think back to 1999 and the barriers that we have been and now I would say I don’t have any barriers. It’s really just about persistence and delivery and execution, but they’re still work to be done on the policy side. But you’ll see that influencing a lot of what we do as value based care and macro. Some other things like that continued to move forward. Virtual care will be a key component of that.

[15:52]: Use of sensors and remote monitoring as prevention.
So then I’ve sitting there thinking about what am I really excited about in 2018? Virtual care is not new, telemedicine, digital clinics through your phone, remote monitoring and sensors aren’t new. I do think there’s some really exciting applications and ways to use that, that our system was just not ready for before our consumers weren’t ready for that. We’ll see. But if I think about some of the ones in most excited about the use of sensors and remote monitoring is incredibly exciting to think about how I can manage the health of the population that I serve in the most convenient way and is ubiquitous as possible. So that as a patient or an individual is going through their lives, I’m picking up data points that are helping me know if they’re getting sick before they even know if they’re sick or what I can do to intervene to keep them healthy and well, so that it’s more of a prevention instead of a reaction when they’re showing up in the ER. Its very exciting to think about it and really trying to seniors live longer at home independently. All the way over to of course the prime disease management challenge and crisis that we have across the country.

[17:08]: Use of AI.
Augmented intelligence, I like to say, augments so that it’s really augmenting our healthcare team and our systems. The possibilities there are increasing productivity and improving accuracy with machine learning and other things are phenomenal, scary and phenomenal all at the same time. It will be exciting to be a part of creating what that looks like in the future, so that we know that health care is safe and this is maximized to help our systems deliver better care and have better outcomes.

[17:43]: Face Recognition.
The work in facial recognition has a lot of uses that I’m excited about. Everything from quicker registration to be able to get an appointment or be admitted to the hospital over to really assessing different indicators for certain mental health or neurological conditions, so that I can have subtle cues, maybe that there’s issues with depression or dementia or other things that I can then intervene on. And then you can think about it all the way over to the side of some of the challenges we have around insurance fraud abuse. With spatial recognition that really addresses a key component of that challenge that we’re dealing with.

[18:29]:
and then I put, of course telehealth and I’ll put telehealth instead of telemedicine, just because I think there’s gonna be an increase use in our additional services, not from just our providers or our physicians and nurse practitioners, and PAs and in pharmacist, but really around dietary, dietitians and health coaches and rehab, OTPT, speech therapy. I think that regulatory changes are advancing to allow them to really advance their specialty in their services through virtual care. And so telehealth will be exciting for 2018.

[19:08]:
Precision medicine. I probably don’t have to say too much, but it’s all about data data data. And if we know more about an individual and can customize care to be right for the individual then we have better outcomes. So that’s an exciting space with some of the genomics and pharmacogenomics that are available now.

[19:30]:
Socially intelligent robots. How do we think about automation and healthcare? Every other sector in the world is using automation, where do socially intelligent robots fit in, and how do we make sure to balance that human touch, that ability to discern and really have emotion that I’ll be exciting to stay up. Start some research in that space and excited to think about the possibility is there to really allow our clinical teams to focus on the patients and get rid of tasks that are not necessary for an individual to do.

[20:02]:
The list of others so long that I’m just gonna highlight a few because I know we wanna to just Q&A poprtion of this to really dig into what people have on their mind, but this is where everything from blockchain and fintech and bitcoins, and some of the augmented reality of the heads up devices and things that are really gonna transform healthcare and even the financial model of healthcare. And so things like life fire or the life based wireless connections that have data speed so much faster. If you think about the possibilities with that and what it means for virtual objects and virtual reality, there’s really no end inside here. And so I think the exciting part of that is what we can build and how we can improve health in a whole different way. The challenge will be do that in a socially responsible and safeway. So that’ll be exciting. I think we’ll push envelope and we’ll probably see it come back after some regulations come around that.

[21:08]:
And so I’ll end with a slide around what I’ve put on my watch list for 2018. What am I thinking about? There’s all these exciting new things that I wanna implement use, but then there’s also some things that I’m gotta watch’ cause it may have pivot or adjust my strategy. Cyber security is on the forefront of everybody’s mind. It’s not when you’re gonna have a breach, it’s not if you’re gonna have a breach, It is when you’re gonna have a breach. And so how do we think about that with virtual care and how do we safeguard ourselves for that. The impact of net neutrality, we don’t know fully what that mean yet. So we need to keep our eyes on that to understand how it will impact virtual care. FDA regulations, and on digital health, still more to come on that as well, but looking to really have an easier way to be able to implement innovative products and some exciting things happening there. When you think about even the european union data protection regulations and just over 100 days, that’s gonna go into effect and how that enforced, and it’s really a goal to make sure that data privacy is maintained across all of Europe to protect citizens data. So that’ll be interesting to see how that may influence other things across the world.

[22:31]:
The ONC pending definitions of data blocking and ORG, kick off enforcement of that, what all that means, we just gotta keep our eyes on that. And then I can’t end without speaking about data analytics and how much that’s gonna play into everything we do, not just around what I mentioned earlier around precision medicine, but really around value based care and around really redesigning our models care, rethinking healthcare based on data. So it’s exciting to think about that. I think it will be a priority for all of it. They’ll be a lot of investment in that, sharing of data, and how do I make smart decisions? And so 2018 gonna be an exciting year, and I’m looking forward to all of this and more.

[23:35] Milton:
Right now the legislative filing ACA, seems to be lot of turmoil, what’s some of your prediction what will happen, will the market stabilize?

[23:56] Kristi:
If I can answer what’s gonna happen with ACA, I’ll probably, I’m gonna have a whole change in my future, so I don’t know. What I do know is that virtual care is supported in the bipartisan issue, and it addresses the needs of so many of our challenges in healthcare in our financial crisis around healthcare. And so when you go to congress and you are on the hill, testifying and communicating the stories around how virtual care is addressing access to care, care coordination, vulnerable populations, whether that’s middle-health crisis in our country, or it’s around rare diseases in a clinical trials or whatever it may be, a virtual care plays into that. And so the exciting pieces is that at whichever direction the ACA take of, virtual care is gonna be a component of that, how we’re gonna ever achieve value based care without that, I do not know. How physicians can manage a population and a patient without virtual care and meet mac or on needs, and all the care coordination challenges, I just don’t know how that can be done without it. So that’s exciting. I don’t know where the future goes, but what I know is either way virtual care is a piece of that got.

[25:27] Question:
So what do you recommend as a minimum qualifications for therapies for providing telephsycho therapy?

[25:48] Kristi:
if we look at virtual cares as a modality of care, the requirement of an individual to provide a certain service in healthcare are established by their governing board, whether that’s nursing, medical boards, physical therapy, whoever it may be. All of those associations and boards are guiding that. And so I wouldn’t deviate from that. However, when I do saying virtual care allows us to do is make sure that we have everybody practicing to the top of their license, so I don’t have to have a psychiatrist doing all of that. We need a therapist, we need psychiatric social workers, we need all of this team. But the interconnected nature of what we can do with virtual care is so empowering for a successful outcome for patients. And so I would say that in addition to just making sure you have the license necessary to do the service that you want to deliver, having some basic training around virtual care is so easy, that’s the great part. We all are used to, we’re doing it right now, teleconferencing. I think this a challenges around making sure that everything’s firewall in safe and HIPAA compliant, and making sure that you think through the web etiquette around making sure eyecontact and lighting is right, and things that are really the same things we teach healthcare team when they deliver in-person care. There’s a person at the other side of his camera and then how do you maintain that relationship and that integrity to that relationship through video? And that is a special skill set, but one that people pick up very quickly because they’re using this technology for even non-healthcare services.

[27:49]
Do you have a general rule of thumb how much training or how many hours to become confident for a therapist?

Kristi:
I think everybody approaches is a little different. There are formal training classes across the country. There are some educational centers that actually incorporate training to somebody that could go for a couple of days and learn telemedicine 1 on 1 and etiquette. I try to integrate it into an orientation process that any healthcare provider or new employee would have in the healthcare system, so that it is truly another tool in their toolbox. And so they do their regular job, but they can deliver it through this mechanism. We do customize that to some level. So if for instance, a dermatologist wants his practice to his or her practice that come on using in telemedicine. We have to understand what their clinical needs are so that we make sure we have the right technology. Do they need a thermal camera? Can it be just face to face? Does it need to be a higher resolution camera? So those things are part of that orientation, but it’s not long. It’s truly, we’ve downloaded what you need on your computer’ cause we want them to do this wherever they are. It didn’t have to have a provider down to a certain location either, so we make sure they understand that they understand how to document this work that they do, understand billing and reimbursement implications of it. And that can be done in just a few hours.

[29:29] Question:
Within telehealth you can do synchronous like video telephone, or we can do this like asynchronous. Is synchronous or asynchronous more important?

[29:50] Kristi:
It all started in asynchronous, there wasn’t a trust factor to virtual care, and so it had in many state it had to be equivalent to face to face, and you had to have the video component to it. And that doesn’t mean a synchronous can’t have video to it as well. So it can be both. I think the interesting thing is that asynchronous interactions with patients have occurred since the beginning of healthcare. People left messages, I need this, I have these symptoms, and there was this communication back and forth, and portals is an asynchronous in between patients and their providers. I think that that’ll grow more and more. The hardest part with all of that is if you have all this data coming in and these store visits over here, so maybe you have three or four patients sending in information asynchronously which become new visit for you for the day. So you’ve had 30 patients for the day, and then all of a sudden you’ve got another pile of them in your inbox to handle on an asynchronous basis. So it’s really, again, around integration into your workflow and making sure you a lot time for this because these are visits just like in your regular office. And I think that the piece about that is where you see providers not wanting to adopt it because we haven’t integrated it into their operations in a fair way. How can we expect them to just do 24 hours work because it will pile up. So thinking about that when you implement asynchronous is important, how do you operationalize that and sustain it? But I think if that asynchronous gonna grow.

[31:39] Question:
If you provide as a physician, you need to have license of the state as telemedicine is regulated by the state. What about in terms of therapies like marriage counselling are they government by license of the state?

[32:02] Kristi:
Every profession has different rules about that, but every state does as well. So whether they fall under the department of health or some other board that has to be able to state by state basis to understand that. Understand the certification and licensure scope of practice for each individual and counselors is different in every state as well. So that brings a lot of complexity to using virtual care, if you’re looking at implementing this on a national level, you truly have to understand those unique differences state to state. So there’s the federal governance from whatever regulatory board represents them in their state requirements. There may even be facility requirements as well. So if you work for a health system, they may further restrict it or may keep it to the broadest in the state. So those are three critical areas to look into when you’re deploying telehealth for whether it’s physicians or a therapist.

[33:09] Questions:
What about using robot to do physical support, what other exciting development you have seen?

[33:24] Kristi:
A study I did last year and one were approaching for this years. The focus was really around as patients are getting sicker and sicker in our hospitals and our staff, whether its nurses or whoever has a more complex population to take care of. There’s a lot of tasks like fetching and gathering. There’s a lot of looking for certain pieces of equipment. There’s all kinds of things that I want to explore, how could a robot help me with this. And so we actually had some researchers come in who had a socially intelligent robot, but had them actually follow staff around and asking these questions. Let me just watch you and see what’s happening on a day night evening, weekends, and see what your challenges are and see what about low hanging fruit around what a robot could do for you to make your life easier. And so for years, we’ve had things delivering pharmaceutical and mill trades and things that are robotic. More of a patient’s admitted for certain diagnosis, you have a high probability of knowing what kinds of supplies they need and what frequency they need them and so how can we do better supply management, fetching and gathering, and I even way finding in hospital, it’s pretty cumbersome going through a health system. So I think there’s a lot on operational efficiency and even interacting with patients directly. I did not go into any of the robotics where robot were going into patient rooms, but you could easily refill water bottles, you could bring livin in, there’s all kinds of things that can be done. I’m just on the tip of the iceberg. There’s several other facilities that are doing similar research as well. Trying to think differently about robotics and what’s the balance between the human touch and where automation can play in into healthcare.

[35:38] Question:
In the healthcare is the largest employer in america. People worry about then you have too much robot that would take away people’s jobs. Do you see if there are certain robot can be very helpful in certain setting at the same time it didnt’ take away people’s job.

[36:06] Kristi:
I think the first or second highest number of jobs are drivers in our country. You think about self driving cars. What does that do now to our taxi industry? Same thing. I don’t know that answer this, but just yesterday, I was talking to a lot of our leaders here thinking about I need new skillsket. I mean there’s more work that needs to be done and ever before. So the workload has increased for an individual. So how can I make sure each individual is doing the things where I really need them focus that really takes a unique skill set and discernment, and emotion and all kinds of things that robot isn’t able to do. How can it automate and matter of fact I put the things I hate doing in my job on the list and give that to a robot. I think our work course is gonna change. I think we do have to diversify talents and make sure that we remain valuable and needed. Robot, hopefully, will just pull off and augment our efficiency and quality of life. We all work really hard. How can robot balance that and make us healthier as well in the work balance? So more to on that one.

[38:17] Question:
In terms of reimbursement like in California still seems to biggest barriers to telehealth. You have many insurance company that will say they allow telehealth but they don’t want to pay for it unless you’re in rural area. What are you thoughts how we get around that to getting all these payers to fully paid.

[38:45] Kristi:
I’m not gonna minimize the challenge there. Insurance payers like CMS and Medicare have a huge impact on the speed at which this grows. And when I started this, and when many of us did, there was no reimbursement at all. And so it was always funded by grants. And so if there’s think nothing worse than starting a great service and having to take it away from the people you serve, because the grant ended. So building sustainable business models that will boom, the reality, which is reimbursement is not there fully. Where I am now in austin, texas, none of the areas that we serve are truly designated as rural areas. Where I came from before was a state where almost all the state was considered rural. So I had more reimbursement mechanisms there. Your business model has needs to have multiple different streams of revenue. So that is one impact of the other one can help balance that out. But I’ll tell you, payers are coming to the table now. They’re very interested in talking about how to deployed where they have a high need. And so I would tell you to go sit down with your payers and have that conversation where you’re members as an insurance company, where do you have challenges? And let me tell you how we can solve that for you. I think the biggest component to a successful negotiation around this is to show how this service is substitutive and not additive. And so the total cost to the insurance, I should come down and be willing, if you’re confident in your program, be willing to go in and go at risk for that and just say, you know what? I’m so confident. Let’s change this payment model of this so that we benefit as we show that savings. So I think that you’ll have to go out and take some risk. I think that having those conversations and being willing to commit to not being additive to the system is important. No one wants a transactional telemedicine visit. It’s just another cost to the system.

[41:03] Question:
What are your thought for your organization think about using telehealth as a follow up communcation after patient discharge or leave the clinic?

[41:16] Kristi:
So we are using it on the whole across the whole continuum of care. And so a good example is in the pre-operative experience. So a patient needs surgery. We’re using it on the front end for pre-op of patients all the way to follow up with patients after their surgery. One of our most exciting programs is our whole care coordination program where we are interacting with patients outside of the system. And so whether that outside of the clinic, outside of the hospital, understanding the needs of our patients and building technology solutions that are very simple and not on too heavy for a patient. So if you have a patient that is post surgical, you’ll need to call them every day for three weeks if everything’s going fine. Making sure you use data and patient information around their symptoms and where they are and what their needs are to really meet them where they are. But we’re doing an enormous amount of work in that whole post transitions of care after they leave a hospital or clinic and supporting patients in the home, through sensors, through app, through remote monitoring kits. So we really seeing a great response, what’s interesting is comparing the groups that we do care coordination with the compliance or the engagement of patients when we use tablets with video enabled, or if we just do phone management, there’s about a 20-30% increase in compliance when You use the video application. And so a lot of people think people don’t want to do video, they’d rather just talk from the phone, in some cases that’s true. But what we’re seeing consistently now is a relationship and an accountability that comes in when we have a face to face conversation with somebody, it’s resulting in good compliant. O.

[43:24] Question:
How can you pay for it like do the CMS or payer pay for that.

[43:32] Kristi:
Yes, every state is different on commercial payers, but Medicare does pay for it. And if you haven’t seen the new remote monitoring codes that were effective, january 1, it’s worth looking at. But there are a couple of different ways you will get paid for this whether that through CCM coding or care coordination management codes from Medicare or now through the Medicare remote monitoring code, there is a mechanism for reimbursement. And then your other third party payers are all you have to go and negotiate that make sure you contract with them for that. There are codes out there, you just have to make sure your contract with the payers incorporate that.

[44:19] Question:
Do you have any tips or recomendations for introducing telehealth to these older population who may not be comfortable with technology.

[44:32] Kristi:
it’s no different than in person. So if I am the nurse taking care of a patient that leave the hospital. I just that education to the health literacy level, to the age of the patient, how they like to receive information and to make sure it’s culturally sensitive as well. So it’s no different deploying telehealth or telemedicine to a senior population. It is intimidating to some of them the technologies, but it just takes a little bit more time and we’re not having that challenge. In a matter of fact, one say they are confident in it, they’re so excited to have somebody to be able to interact with and that socialization it can come from any of them who may be alone at home has proven to be actually a motive for them to connect with us and want to use the video. So I would just say adjusting and being patient and making sure your technology is one that is adjust for seniors. So the colors that you use the size of the font and even implementing audio instead of them having to read in case their visions not as good. So there’s a lot of ways you can adjust to be able to accommodate their needs, but we haven’t seen a problem when we implemented that.

[45:58] Question:
the audience say he’s compound pharmacies, so he’s looking to collaborate with physician to extend their telemedicine practice. His question is more maybe like a startup type of question. What are some a suggestion for? How does he go find out? What are these people who think or collaborate with.

[46:20] Kristi:

Yeah, so the first thing that comes to my mind, there’s a lot of different ways you can approach that. But if you’re thinking about it from bringing your pharmaceutical expertise to health systems and providers to really be a true part of the team and collaborating provide information, then I think that you’ll probably have most, the earliest success and practices that are a part of accountable care organization or some that add value at least for their population, as we all know, one of the number one reasons for re-admissions into the hospital or a pharmaceutical medication management issues. And so I can tell you that I’ve incorporated pharmacists into our care coordination and remote monitoring program, because when patients leave the hospital and they have questions, the majority of those questions are about medication. Some around just as simple as I can’t get my medicine, but often times is questions about, can I take this medicine with food or with this other medicine? Or maybe they have the same medicine provided by different physician, and so they need somebody to do a med reconciliation. And so we’re using pharmacist through a telepharmacy program to do med reconciliations on all of our admission to our hospital, but we’re also using them to handle all of our pharmaceutical and med management questions after people leave the hospital. So if you think about in those contexts, you could provide your services to hospitals, you can provide your services to physician groups. And there’s a huge search for that because we know it’s such a big culprit for people, health declining and re-admission to the hospital.

[48:21] Question:
A question from robert, this is also maybe along the startup type of question. So he’s asking, He want to approach healthcare system and hospital to add in a service line, like telehealth service to them. So where do you start idea, do you approach the chief medical officer, or do you approach the IT or how do you get the insurance company to get on board and pay for it.

[48:43] Kristi:
So it depends on what service line it is. It’s always good to come after approach with a business plan that shows the need, even if it’s a great idea. If you’re not solving a problem, this is not a day and age where there’s extra revenue sitting around in health system, they’re very lean budgets and the decisions that they’re making to partner and start new projects are all very laser focused and have to be able to show a return and address a problem that they’re challenged with. And so if it’s a service line and especially say something around cardiology, there’s a lot of focus around heart failure and heart failure readmissions to the hospital. And so I think that you need to make sure you’re aware of the challenges in the health system that you’re approaching and even the health of the community. So doing that community assessment to say, okay, in this zip code, it’s got the highest rate of attention deficit disorder and the highest use of ADHD medications. And so this is around combating that and addressing that. Then you can start showing your business case and the return on investment that the system may have, I would tend to always go toward the clinical side, and the executive team with a proposal to try to get in front of the leadership team to pictch case. That’s not easy to do. And so having a champion inside the system to partner with you to bring that forward, it’s important. So it’s all about relationships and in understanding the business case and what it matters to the people you’re pitching to. So that’s where I would start.

[50:30] Question:
How do clinical lab using telehealth collect blood pressure, urine sample?

[51:04] Kristi:
What you do on your smart phone is limited unless you have other diagnostic tool. And so whether that plug in stethescopes and echoes, and whatever else we can do with this ultrasound, you have a lot of capabilities, but no one has at their fingertips. And one of the other limitations to your smart phone being a much broader use is not having access to a lab. And so a lot of people have done this in different way. It may be that I would say the majority are probably, if it needs lab or x ray, then a lot of times they’re converting that visit and redirecting that person to in person care. In the more advanced telemedicine program, they are saying, hey, I need you to have the blood work done. I want you to go, here’s the closest lab to you. I’ve already put the order into that lab, go get that done in outpatient lab, and then they’ll send me the results and then we’ll schedule a follow up in the next three or four hours. We can review the results of that and can complete that visit. That is not happening as much because the coordination of that can be difficult. There are technology platforms out there that allow that to be a component of the virtual visit. So if I had a virtual visit, I could send the patient an order and that they could have on their phone that has a qr code, so that when they go into the lab, the lab can scan that, pull up the order, know exactly what to do. So that helps facilitate that. So some people are converting it to in person visits, some are partnering with labs to be able to do that. And then the third one is what you mentioned, which is the deployment of somebody to the home. And so we really not doing a ton of that at all. I do have a group that had been going to do home visits with our most vulnerable, so maybe they couldn’t get to us, they didn’t have transportation, or maybe they were even homeless, and we were going to see them out where they reside in the community. So we have mechanism to do that. I would say that more people are partnering with community paramedics and deploying them to home or either partnering with home health companies to make that an extension of their program. So I think the sky’s a limit, all that. I think you can do it in phased approach. And so it may be that you provide the virtual care and then partner with a retail clinic thats in your area, in case you do need this, and then they can complete the visit. There’s a lot of ways to do that. Now I would based a lot on the community. The other resources that are available and the sophistication of your virtual care program.

[54:01] Question:
As soon as you deal with EMR, it will become very slow, because these thing are difficult to dealth with. So how important it is to have your telehealth to integrated with your EMR, what it’s okay to leave them semi-separated?

[54:19] Kristi:
if you talk to the providers, they want it integrated because it’s easier. So if I’m in my electronic record, I do everything there, my schedules there, I click on that patient that opens the record. And then if I have to minimize that and throw a video up to another portal that has a different password that becomes a little friction that sometimes can result in not being adopted. Saying that many health systems, large ones especially, are still doing with multiple electronic medical records. So I know we have really two main ones, but four are utilized across our system here just across our hospitals. And so our providers are used to going in and out of multiple different EMRs aand so if I integrate, I have to integrate into a lot of different one, and then that becomes can become cost prohibitive. So we’ve chosen to keep it separate. And then now we always document in our native EMR. So I don’t wanna change that. I don’t wanna make my provider’s document in another EMR or an EMR associated with a telemedicine application, but that’s not how everyone’s approaching it. You’ve gotI think that’s while there’s all these different options is because one may work for one health system and another for another. So understanding the barriers or friction that you might come into for any of those, it will help you make your decision. I just wanted it to be as simple as possible for everybody. So I chose to do mine separate from my EMR.

[56:30] Question:
If audience can learn one thing from you today, whats that one thing?

[56:38] Kristi:
The virtual care and mobile health is healthcare. Don’t look at it as anything separate. Don’t make barriers that aren’t there. This is a modality to deliver healthcare. So anybody in your system, they ought to rethink what they do on a day to day basis, to see how they can implement it into their work, to improve the health of the people they serve and make their operations more efficient. This is no longer a side project. This is how we deliver health care.

[57:16] Question:
What is the one thing you believe in telehealth, that no one else believes in yet?

[57:29] Kristi:
I think that we are under appreciating the impact and a disruption that is about to occur and the healthcares ecosystem. And that is not just from technology, that’s gonna be a huge driver from the financial thought of it to the clinical delivery. But I think that the mergers and acquisitions and the partnership and the new interest into healthcare is going to change everything as we know it, the rules of how we had to do certain things are kinda getting blown up and those barriers are going away and people are working around the barriers that we’re causing them not to be able to deliver health care through virtual care. So I think we’re gonna have a much bigger disruption than we anticipate.

[58:22] Question:
If you can whisper one thing to Trump ear, what would it be?

[58:32] Kristi:
We really have a virtual solution that is bipartisan. The barriers need to be cleared, so the benefits can be fully realized, and so that people will truly integrate it into operation. It is truly being delayed only because people can’t figure out how to get reimbursed for and how it fits into the system of care. This really solve so many of his issues when it comes to healthcare in the cost of healthcare. So I really wanna provide a blueprint of how we can do this. We can change healthcare for the virtual care.