Telehealth will be the new normal after the pandemic

This coronavirus pandemic has been a cruel thing in many ways, one of which is that it's respiratory and infectious, so it demands that we separate. But at the same time, many of us are sick and want to interface with healthcare workers and get to them. Now what? My guest today have an answer. They're all about telehealth and telemedicine which allows you to interface with those healthcare workers without having to get face to face with them. Krista Drawback is the executive director of the Alliance for Connected Care. And Carey Pallacanis is Executive Director of Connected Care at Intermountain Health Care in Salt Lake City, with facilities around eight western states. And I want to welcome you both to, now what, let me start with your Crystal, tell us what the alliance for Connected Care is, what are you guys advocating for and on behalf of whom Brian, thanks for having me today. The like care is an advocacy organization. We're headquartered in Washington DC. We've been around for seven years working to break down the barriers to telehealth coverage, mainly in Medicare. Our members are a mix of technology companies, telemedicine vendors and hospitals. And we can be found at connectwithcare.org. So you guys advocate for the idea of telehealth and telemedicine. What are those two terms mean? We've heard them both bandied around a lot as consumers as patients. And I think a lot of people wonder, is one different than the other? Are they the same thing? Give me a couple of definitions. Unfortunately, I don't have a simple answer on that people in Washington still interchange them and part of the reason is because the word telemedicine is in our statute, so legally, it's telemedicine. We've tried a new vernacular version of telehealth because it sounds a little better. The way I like to think about it as telemedicine is an umbrella for two kinds of Remote care one is a telehealth visit which is a face to face real time video visit and the other is remote patient monitoring which is biometric monitoring of patients remotely. So think of a glucose monitor, sending data sugar level data to a doctor. You know, we often think that telemedicine is a consultation with a doctor but like you mentioned, it can also be the telemetry of our data being better monitored. Carrie, let's go to you in inner mountain when you guys are talking to your patient They're at a large healthcare system. What do you call it? How do you describe it? When you say to them, hey, we could do this as a blank. What do your practitioners and staff say to average people who may not even know what this is? Well, as Chris has said, it is fairly much an interchangeable thing when we speak to patients, we speak about video visits, or we actually do have a very robust remote patient monitoring program as well. So, but when we're talking about having that interaction with your healthcare provider where it's a real time interaction, we call them video visits. Okay, so get down to common language, plain language. Mm hm Okay, now let's go to someone what's happening now that we've got some baselines, we know what we're talking about here, headline in the New York Times a few days ago in the UK that the quote was, telehealth there in that system which is different than ours, I understand, has advanced Ten years in one week in terms of acceptance and use and the volume. Crysta, does that sound like anything similar to what's happening in our landscape or is the UK embracing telehealth and telemedicine much more rapidly in this pandemic? It's incredible. We have, it's the landscape has changed so dramatically more than any of us could ever dreamt. And Kerry will give you the numbers on her system but across the country, numbers are really increasing. And from my perspective, a lot of this is because the Congress, in partnership with the Trump administration. Broke down telehealth barriers very, very quickly over the course of two weeks, all the things that we've been working on for the last seven years disappeared so now providers can get paid. Patients can be restored. Receiving telemedicine visits in their home. Those are some of the examples of things that have changed policy wise that enabled the increase in these visits. So those were Medicare payment changes. Correct. And, do you think they'll stick or is this gonna go back to the old limited payment for telehealth once the pandemic passes? Well as an advocate, of course, I'm getting calls already from people saying how do we make these changes permanent? Frankly, that's up to us. We really need to show Congress and, you know, the Department of Health and Human Services that this was a success that we have, Have patient satisfaction. We have good quality measures, we increase access to care. All of those metrics are going to be important for us to be able to make the case that this should be permanent.>> Carrie give us some numbers of what's changed there at Intermountain health in terms of pre and post pandemic. Adoption and use of telehealth and telemedicine? Well, I've been very fortunate here at Intermountain. We actually have a very robust telehealth system. We actually run a virtual hospital within our organization. But you absolutely hit the nail on the head when you said 10 years in a week prior to the pandemic. We have, A tele virtual urgent care that typically at this time of the year would see about 100 hundred and 20 patients a day. We're now averaging about 400 patients a day in our Teller, urgent care and our video visits that platform. Were Your healthcare provider can see you at your home or outside of the traditional clinic environment. We were averaging about 100 visits a week prior to the pandemic, and we did 40,000 visits last week. It's just been incredible with the change in, Adoption not just from the providers within our organisation, but obviously the patients who are also clamouring for this type of an opportunity so that they don't expose themselves in the environment. So from the point of view, they're on the ground of healthcare providers, what can you do? What is most commonly being done in one of these video visits? Pretty much. There's very few things you can't do. Oftentimes, when I'm teaching other providers how to use telehealth, I always say, just because it can be done through telehealth doesn't mean it should. But most things can be done through telehealth. For very much so follow up visits. So you saw your health care provider for high blood pressure and your health care provider would typically have you come back to the office in a month for a re-check. This is something that can be done now with you at home, we can check in on how you're doing with your medications. We certainly have been and are more active and doing things like visits for rashes, visits for common health conditions, sinus infections, things that you would traditionally have to go into the office for can now be done outside of the office. And a lot of what we're seeing Really used for in the pandemic is people who have chronic conditions chronic health conditions. We don't want them coming into the traditional health care environment and potentially exposing themselves to COVID or any other communicable condition. So we want to keep those folks outside of the system in their homes where they're more apt to To stay healthy, and so we're converting a lot of those visits into virtual visits. Krista, do you have any regulatory shackles on the business that say you can't do this via a video visit or telehealth Is there anything like that out there that you're trying to break free of Medicare does have a list of codes that can be build and just last week the Department of Health and Human Services added another 80 codes to that list. And it took us some probably 10 years to get to 100 codes. So to add 80 codes in one week is great They're mainly the things that you would need to do through telemedicine. You could do primary care, you can do a lot of behavioral health services like counseling. I think we're in pretty good shape and Medicare and and the private payers tend to pick up the Medicare code so it's it's pretty good across the system. I'm looking at a survey here from done by American well and empty research late last year they asked us physicians, what are barriers to telehealth and right up against what you just mentioned. The majority said uncertainty around reimbursement and the second most common response was questions about clinical appropriateness, these two things that just came up in our conversation, doctors and providers Are so busy. The thing that you learn when you start to get into health and technology is not that it's hard to adopt is that it's hard to find time to adopt it. As well as getting it to fit within the codes to get it paid for. If I go with that idea to you Carrie, what are your practitioners going to do post pandemic when they will go back to that Stasis of saying, look, I can see you in person, and I can see you online, and I gotta choose which is right. Do they really have the time to absorb all the innovations in telehealth as they keep coming? I think one of the things that we're seeing is that it really isn't that much of a shift. And if anything, it's easier than most people feel and think. There are a lot of the misperceptions associated with doing video visits come from the fact that as I've said previously that we don't learn to do these in our traditional medical program. And medical education programs. But once providers start using this, and I see this frequently, they don't want to stop. And so, it's gonna be very interesting, if there are changes, regulatory or legislative changes, post COVID. How to convince folks that have for a time period and we probably have to assume it's going to be a fairly long time period with the pandemic. We're managing cases and then all of a sudden have to say to us, no I Know you you're doing fine with that during the COVID pandemic, but now you got to go back to doing it the old way, i think there's gonna be a lot of pushback from providers and I'm hoping that it's going to be a positive push to continue without the regulatory parameters that allow us to provide access to care and that's the key with telehealth. Bringing access to care to folks who otherwise would not have care available to them. Now access to care, we hear that and we say, they can't get to the doctor. They don't have transportation. They're elderly. They live far out and maybe the weather gets in the way. But the access to care is sometimes also mental, right, does connected health care telehealth Knock down barriers to someone's discipline getting in the way. Absolutely, you have, you know, access to care can be as simple as that drive time that you have. But I've also spent the vast majority of my career working in rural and remote areas. And sometimes access to care is that the care doesn't exist in your community, and you have to drive three hours to get to a specialist. And you have the socio-economic issues associated with the fact that they maybe can't afford to make it to that specialist. But also taking a whole day out of your workers school life to get care versus sitting in your home or your local environment and having that care brought to you. very often impacts whether or not somebody will even get care. We have a tele oncology program here at Intermountain. It's very, very popular. We call it oncology at home. And we have heard from about one out of every four participants that Had that not been available to them for them to have received oncology services in their home environment, they would have not sought care. So they would have obviously had a negative outcome from their cancer because they just wouldn't be able to To or couldn't or weren't willing to make the distance strives that would be needed to receive those services. It's so interesting that kind of a stat and then what we hear so much about non-compliance with prescription drugs. These two behavioral issues have such a huge impact on outcomes and the cost of keeping our population well. Though I think people don't think of it, they go diseases cause all these things Our response to them, in terms of our discipline, seems to be a big part of that Krista, as Carrie's talking about rural care, as I understand it, prior to this pandemic, that's just about all that Medicare paid for in terms of telehealth. Is that right? That's correct. Congress really thought of telemedicine as a rural patient going to an institution and connecting with another institution in an urban area. So, like a specialist visit essentially oral patients accessing Specialty care they couldn't get in their area and that's how they set up the payment structure. So if you were a doctor who wanted to practice telemedicine, you had to be in a rural area and you had to be in your office and the patient had to be also be in an institution. They couldn't be in their home. That's alot of hurdles. I can relate that back to the reason why a physician wouldn't adopt telemedicine because the incentives were for a patient to come into the office. I mean, why would I tell you, I can see you when you at home and you can stay in your home when I wouldn't get paid for that. Whereas if you come into my office that I could bill Medicare for that, so the payment issue is really an adoption issue. So let me ask you along the lines of that perception of who's asking who for this telemedicine visit another stat we've got here from parks and associates, it was late last year. Asking people why, as patients, they chose not to use Telehealth and these are in broadband households. So they have relatively decent connectivity, I would assume One of the top ones at the top one was they believe that in person doctor visit would provide better diagnosis and treatment. Or the second most common was I'm more comfortable speaking with my regular doctor, those two kind of go together. Is there anything in there that you think the regulator's and payers are looking at that's going to give them some pause or do they want to push that stat by paying for it? So our biggest hurdle I think in telemedicine has been that first visit, have a perception of telemedicine before they do a visit that often changes after they do a visit so that you if parks and associates took a survey post COVID they would get some pretty different answers because The patient satisfaction rates are very high. And again, it's just the hurdle of having them experience it and what they experience is that you can really get care virtually. So I think that those adoptions. Barriers on the on the patient side will be will definitely be broken down by this pandemic. Carrie, you're sitting in an interesting room there at inter mountain in Salt Lake. Where are you right now? I'm actually in one of the cubicles that our providers have the opportunity to utilize to provide telehealth visits. This is a we don't have a requirement that our providers be in the cubicle but it's available to them. of my 75 providers right now. Doing, Connect care, urgent care. They're all at home. I think I have one across the hall right now is training. So this is a room that we use for training. But then I also have some providers who choose to come in and do some visits from our virtual hospital and that's where I'm at right now. So that's my question is so as I look at you there, I see a clinical setting and it's like I'm talking to a medical professional. At the clinic, something about that, as a regular consumer, I think would give me confidence versus if I'm connecting with a doctor who's in as we've seen in a million zooms these days. You know, there's a bookcase in the back with some family photos, some frames, China plates and wall racks and all this kind of stuff. What do you guys think of the of the evolving policy around the stage craft Of what a medical consultation should look like? We actually have a program that we asked all our providers to go through called website manner instead of bedside manner. Really, yeah. And part of that is, us looking at the environment that's behind you. I mean, I can see the environment behind you and kind of get a feel for the type of individual you have or maybe where your interests lie. And so, we really do ask our providers to pay attention to their environment. We look into it before they're being seen publicly. And then, on top of that, we teach them about talking to the camera instead of talking to the screen, making sure that they do audio and video checks beforehand. That's all part of the preparation for doing appropriate visits. Crystal, let me ask you about who I see when I do a telehealth consultation, some services out there a lot of startups in particular, unlike. Carries healthcare system, they may gather an ad hoc team of providers and say when you call in for us and use our service, we will connect you to a physician. It's a bit of a disembodied thing. It's just a physician within a platform who's signed up to see you, as opposed to being tied to the locus of a physical clinic brand. What does the regulatory landscape say about who can pop in basically and take my console? Does the Is the regulation and the payer schema have any opinion on that? I will answer this in two ways. The decision maker on who can practice telemedicine is the state legislature and the State Medical Board. They make the rules around what we call the standard of care. There are some states for example, Maryland just passed a bill this last legislative session that said any clinician practicing within their scope of practice can do it through telemedicine. They basically believe that telemedicine is medicine. It's just another modality. So it really is a state by state rule. I will say that most consumers, until COVID, experienced telemedicine through a vendor. So there are hospitals like Intermountain that have made an investment in telehealth. But prior to COVID, about 90% of the large group employer market, very large companies, invested in telehealth medicine for their employees. Because they wanted them to not have to take time off, you know to go to the doctor. So for low acuity episodic care like a sinus infection, for example, you could go and do a telemedicine visit but it was through a vendor. So that is when you would, you know, for example, American well or MD live, you would go and sign up through your employer and then anytime you could go and access That vendor platform, and it would be a doctor that you have not worked with, in the past. But that doctor would be licensed, in the state, where you are located. And I think the reason for that again, is if employers wanna encourage telemedicine They're not going to find a lot of providers in their networks that are willing to do it without payment. So they've had to resort to these vendors but the vendors again, not a bad option because they've got a lot of very good doctors who are available 24 hours a day. Let me ask you this and I'm, sure your answer will be everyone. But who is most? leaning into telehealth who has the most, I hate to say to gain from it but to gain from it is it employers? Is it payers? Is it practical Commissioners or is it the federal system and the states I guess that are trying to achieve greater efficiency of population wellness for fewer dollars, who's the most excited about this among the different claims? I don't I'll speak for Carrie because she'll be too modest to brag on her own hospital but. The really large, integrated, progressive hospitals that are thinking about care of the future really have access to telemedicine and inner [UNKNOWN] is an absolutely cutting edge health system. We have a couple of others Stanford and medstar on, opposite sides of the country that are similarly situated. So You'll see a lot of the large health systems that wanna serve patients more than just in the hospital. Who will benefit from this? In large employers, I think will benefit from this because again, they have been investing a lot in telemedicine access for their employees, but They have had low levels of take up because of that first visit problem that I told you about. So now I think that their employees have tried this. Employers are going to see a lot greater return on their investment. And finally patience. I mean, no, I tell them as an advocate, I experienced telemedicine early on and I'm an evangelist to all my friends and family. And I think that now, once they've tried it, they'll be really happy and wanna continue doing it. Carrie, last question I've got I wanna send your way and that is, how do you accomplish or get past the first visit issue at [UNKNOWN] Mountain? What's some best practices you've got that could inform both us as patients and practitioners out there? To get over the hurdle and meet digitally what gets us over the hump? Well, I think the regulations changing have dramatically changed that first visit issue. The other thing that I think it's how you discuss it with a patient when you're talking about let's take, this is an option available to you We can do this in a telehealth visit. And once they realize that it's an option that they have the equipment necessary to do it, and that it's going to be covered by their insurance, the resistance barriers go down. And then the other thing that I oftentimes say to patients is let's just give this a try. If, if this isn't gonna work for you, if you're uncomfortable, that's fine. We can always do fine. Follow up in an in person visit. And as I said for at least the last 10 years of my practice environment. I have had that conversation with patients over and over again. And usually after the first telehealth visit, the question I get from the patients is, do I ever have to come back to the office? [LAUGH] Yes. Well, there's ready acceptance after that first visit and I'll tag on to. Your last question that Krista which is who's most excited about this? I would say me and those of us who've been working in telehealth for the last 10 to 15 years, and really climbing and biting to get acceptance. Now all of a sudden the opportunity. Knees are endless for us. But I'm most excited for my patients more than that, that they now can have access to specialists that would have otherwise not been available to them, or even primary care that wouldn't have otherwise been available to them because of their location and the resources and lack of resources in those locations. You bring up an interesting scenario, they're kind of a fun anecdote is do I ever have to come back again if they like it so much, but. Sometimes they do for certain physical tests or monitoring that we can't do over a screen. And yet there are technology companies out there. Some of the basic wearables that do fitness normally or things that are more specialized like the kit that title care makes that allow me to have some medical instruments in my home. Are those are make or break technologies? Do you guys need that to go forward to the next level? Or is it really about the conversation and the visual? It's both. I'm a huge advocate of remote patient monitoring. Monitoring and integrating that into traditional telehealth video visits. As a matter of fact, one of the things that we're looking at putting together is a package that we would send to a patient that they could utilize for their initial video visit to do a health Visit, and then if that patient has chronic conditions like high blood pressure, diabetes, COPD, they'd retain that kit of devices, and then we would continue to provide care virtually to them. Interesting, so that becomes part of what you do, is provide them with the tools that they normally have to come in for. And therefore continuing the breadth of what telehealth can do.>> Absolutely.>> Uh,so on that line then Krista, tell me about the privacy and security that is out there or I imagine that is not yet out there to allow us to do this remote monitoring and have patients feel okay about it what can be done or needs to be done at the regulatory level. You think? So there's already good requirements in HIPAA, that you use a HIPAA compliant platform. So, the folks who spent time investing in telemedicine prior to COVID all have HIPAA compliant platforms. See DMS did the Department of Health and Human Services did loosen those restrictions. So during COVID you can use FaceTime or Facebook Messenger or Skype, which are not HIPAA compliant. I fully expect those rules to go back into place after the public health emergency So there is a requirement that we have a secure platform and now there's a requirement that it may get delayed because of Covid, but the department of health and human services require that the record, The visit go back to the insurance company or the primary care provider so that you're not being seen in a vacuum that that, that it does become part of your permanent medical record and that is also a secure connection. Sending your personal health information on your channel back to your regular providers.>> Okay, so right now we've got a temporary loosening just to deal with the scale of this that allows providers to use whatever visual audio platform they can but there is a cognizance that we need to make sure this stuff is locked down normally going forward.>> Exactly Great insights from my guests, Christa drove back, the executive director at the Alliance for connected care. And Carrie palitana is the executive director of connected care at Intermountain Healthcare in Salt Lake City we're talking about today has been rushed in a way that no one saw coming. But the muscle memory we're learning now in crisis stage is gonna do us well. For normal and unusual medical circumstances across society in the future, we'll be on top of this here at now one [MUSIC]