Ahmed M. Soliman, MD leads discussion on telemedicine during COVID-19 and beyond.
Hello and welcome to the Houston Methodist Heart and Vascular Telus. TV education. Siri's revolving around digital health and telemedicine. My name's I met Solomon. I'm a cardiologists here in Houston Methodist. Over the last few months, as we have been living through the cove in 19 Crisis, a major pandemic that changed the world in what feels like an overnight storm, many things change dramatically, including our communication with our patients as well as management paradigms. These continue to evolve in a very quick way. Clearly, the world went virtual overnight. It was interesting, interesting to see that many learned and adopted very quickly what some of us have been advocating for many years. The value of telemedicine is well demonstrated nowadays. This is not limited the practice of medicine, but also the practice of cardiovascular disease. Those of us that have been practicing, practicing and trying to advance tell medals for a while will tell you how an uphill battle it has been. This cove in 19 pandemic was a great opportunity to open doors that have been locked for a very long time, and here we are. The implementation of telemedicine has taken off faster than any of us would have imagined in circumstances none of us would have wished for. But it's now out of the box. The recent past will very soon feel like the distant past. There will be a new normal for the practice of medicine. There's always something good and everything. The goal in the Siri's is to discuss and understand the implementation of telemedicine well beyond the current crisis toe. Learn this from A from physicians with expertise in digital health and telemedicine. Administrators and industries that have been in this for a while have been and will continue to be a major impact on leading us through to provide more efficient care. How to adjust the financial aspect of this care, how we retrain the current and train the future generation of cardiologists not just to provide this type of care but to innovate through digital medicine. Cardiologists have the opportunity and should be at the forefront of how things will be changing in our practices in the very near future. Today I am pleased in honor to welcome two very special guests. Today I'll present them both and then we will start with their presentations. Dr. Hibbert Walsh If Dr Walsh if is a cardiologists at the Cleveland Clinic, trained in both general cardiology, interventional at Johns Hopkins and among many titles and responsibilities over the years. The most impressive, in my opinion, is that she is a long time telling medicine. Digital health, avid cardiologists. She has been advancing the field through multiple programs and grants over the years. She is part of the leadership at the Health Care Innovation Council of the American College of Cardiology as co chair for the Digital Health and Devices work group. Welcome, Dr Wasif. Thank you so much for this introduction. I'm delighted to be here. This is certainly a very e. I mean, it's it's a very difficult time, and we did not wish that digital health be advanced in this way. But here we are. Our next guest is Dr William Downey. Dr. Downey is a cardiologists in a very beautiful part of the country, in my opinion, um, at Sanger Heart and Vascular Institute in Charlotte, North Carolina. Trained in both cardiology and interventional at Mass. General. Among his many titles and responsibilities, he is the vice chair quality and care transformation and medical director at Singer Heart and vascular. I had the opportunity to attend the CV summit in February of this year, which, by the way, I would highly recommend if it is held next year to attend Andi. I had the opportunity to listen to him in two different sessions regarding clinical integration. Telehealth Welcome, Dr Downey. Thank you very much. And thank you so much for organizing this so that we can, you know, take this unexpected and unfortunate opportunity to really learn from each other. So thank you, my foot. So I would recommend everybody not Just listen to these two very special guests today. Get yourself a pin and a note pad or electronic note pad for that matter, this will be worth it. Um, I would also like to point out if you you may send any questions at any point. Uh, Thio Text it to debate key text. I'm sorry. Text DeBakey 237607 Orson online to pull levy dot com slash DeBakey We will start with Dr um Wasif first in regards Thio Physician adaptation Adoption, Dr Wasif. Sure, sure. There we go. So thank you. Ahmed s Oh, I'd like to talk about physicians adoption, and this is I have no disclosures in regard to this talk. Over the coming few minutes, I will be describing the technology adoption life cycle. I want to discuss physicians motivations for adoption and provide case use examples, one of them pre cove it and some Post Cove it. But before we do that, I'd like to go to the very beginning with one of our very early innovations with a stethoscope that seems part of our traditional care today, and we don't think twice about it. But when it was invented in 18 16 and and came to use in by 18 19 the early 19th century ah group of American physicians who were studying in France at the time were introduced to this new technology and brought it over to the U. S. However, the process off adoption was very, very slow. The majority off practicing physicians in the U. S of the time were in rural areas, and most of these physicians were in the Northeast, and it took over 90 some years to adopt this technology up to the extent that Osler in 19 or three said it's shocking to say, but you all know it to be a fact that many very many men in large practices never use a stethoscope. So what were the barriers for adoption with? Some of these barriers were investigated by Reinhardt, who reviewed a lot off the literature and medical books and medical curriculum at the time and came up with these three major elements that he felt to be barriers for adoption. One was lack of formal education and opportunities for continuing medical education, particularly for physicians for practicing ruler area, and clearly at that time did not have exposure. Not, as we have it, thes days with all these technologies that connect us the complexity off the interpretation off these Oscar Tatry findings that were recent and a lot of physicians were not able to integrate them and understand them, as well as the hesitancy to change from traditional medicine where a patient and physician were very close and to introduce an instrument in between. And this theme is very common and will be heard throughout this presentation. We move on to the 19 in the 19 sixties with ever trotters and his classic work off the fusion off innovation. He described the fusion off innovation as a process by which innovations communicated through members off society over a period of time, and those members were described in a bell shaped distribution. And as we can see, it seems very familiar. We can even put names on some of these categories. So the changes from the innovators who are highly motivated, high, very resourceful individuals, risk takers the early adopters that have similar qualities as the innovators. But the difference is that they have leadership qualities they're capable off creating change. They can move things along and propagate the innovation. The early majority somewhat pragmatic, somewhat reserved but are willing to adopt if you provide them with a service or a technique that they're willing, that provides value to them, and the late majority will follow with the early majority. And, of course, we end up with the laggards who will never change, regardless of whatever you produce, uh, to them. So those air the individuals in this adoption cycle. But what about the different factors that affect adoption? We always talk about implementation, but we don't talk about adoption where adoption is part off. Any implementation process on this work, from Jennifer Wisdom in tall, reviewed, intensive, uh, had an intensive review of the literature and a different different frameworks in regards to implementation off innovation and came up with this very complex construct on framework, which is multilayered, as we can see for the factors that impact adoption, external factors, organizational factors, factors related to the innovation process, the innovation itself. And I'd like to focus on the individual factors what motivates individuals, what, what makes them ready for change and the capacity to adopt. And it's understanding these factors that would allow us to cross the chasm from the early adopters to the early majority and move on with our innovation. So this question is like what motivates physicians? So the M A asked that question twice in 2000 and 16 and 2000 and 19 and the question was in regards to a very broad spectrum of digital tools. Some of them are very familiar to US. Remote monitoring for efficiency, meaning blood pressure monitoring, ambulatory blood pressure monitoring, absent devices for chronic disease management, clinical support systems, also for chronic disease management, patient engagement and telehealth, which is the, um, the hero in this conversation point off care flu enhancement communication among physicians and consumer acting's to clinical data such as my chart and so forth. And with this very broad clinical, A digital clinical tools, they asked that question. What motivates physician to use it is digital tools and clearly the number one factor that motivates physicians. Because this was a mixture between primary care physicians as well as specialists, it was efficiency. It had to improve efficiency. Second rate increased safety improves diagnostic ability reduced Bernard, particularly for younger individuals as well as women, improve patients adherence and its convenience. And it also maintained the patient physician relationship the traditional relationship that we've talked about. So what were the requirements to adopt these digital tools? And some of these themes are familiar to us. That they'd be covered by malpractice insurance integrated into the M R reimbursement, interestingly, was not a priority in this particular survey. Also, additional factors Some factors related to the individual that will be as good as traditional care that it's safe and it's simple, does not require any special training, and from there I moved from my own experience of the Cleveland Clinic, where some of these factors were mitigated, such as coverage by malpractice insurance, a semi integration in the M or record. And that's pre co vid. The reimbursement was primarily out of pocket and in spite off that and in spite off the exponential growth off our digital health visits across the Enterprise From 2000 and 14 to 2000 and 19 Onley 20% off providers accounted for 85% off virtual visits. So the Heart and Vascular Institute wanted to cross the chasm and improve our adoption for this technology on the way to be able to across the chasm was assembling a diverse group of physicians identifying a champion physician in each section toe to represent the members. This champion was responsible for surveying each section and their needs and their processes. For example, in my section, the clinical section, we identified that our post hospital discharge was, um no shore rate was about 20% compared to 5% in other divisions, and we wanted to target that particular area by using virtual visits. The champion also had a role in facilitating training and demonstrating the east and the use off the technology. But yeah, covert 19 took us by surprise and within the first quarter of 2020 are a number of virtual visits, almost approached the number of virtual visits throughout 2000 and 19 and were expected to continue to see that rice on a national level, though excuse me from the Innovation Council standpoint, we were interested in understanding how prepared physicians were when they were surprised with the Cove in 19 Pandemic and how that impacted their practices and eso. We conducted a survey through the A, C C Digital from digital website and and we asked on We have 342 respondents from a very wide, broad variety of practices across the US over 342 states and 90% of respondents said that Covert 19 has pushed their organization towards telehealth sooner, and only about 14% were using telehealth previously. And that was not much different from the national average, where from the in the a. M A survey, about 28% were using it and physicians adopted very quickly they were willing to provide the services in any way, shape or form, whether it was integrated in the M R or not integrated in the M. R as well as how they would provide the service, whether it's from home or from the office, from a laptop from the desktop, from a smartphone in any form. And there was a wide spectrum off which digital tools was to be used. Yeah, and of course, we talk about barriers and barriers were asked during the survey, and reimbursement was was the number one barrier for not advancing with telling health adoption. Some of the comments that we have heard was liability. Uh, physicians were concerned about outcomes at the same time. Also, the concern about bonding and trust that needs to be established and is better established through a face to face visit traditional care coming up again. So where do we move from here? And as Ahmed had mentioned training, I think it's very important to proceed with medical with telehealth training in our medical schools, which is already happening, and at least 60% off medical school are providing some form off introduction to telly medicine across the U. S. So the take home message is, uh, from reviewing all these case uses and so forth that adoption is not a top down process. Physicians want to be involved. They've always wanted to be involved. The respondents over 90% said they wanted to be involved to underline the motivating factors and the barriers for us to be able to overcome the chasms. Identifying a clinical champion to assist in the process medical school, education and hopefully not quitting for the next pandemic to promote innovation. Thank you very much, Dr Ross. If, um so So, I mean, I think it's clear that, um, physicians that thought in the past that they would not want to do this or really cannot do this found out very quickly that they can, and they actually do want to do this. Um, So Dr Downey will discuss with us and explain to us what what his practice went through over the last few months. Dr. Downey. Wonderful. Thank you. Thank you again for organizing this. Okay. Perfect. Um, so we were in a fairly different place. Um, first, a little bit about sang. Her heart and vascular institute were 37 practices. Uh, encompassing adult and pediatric cardiology with cardiac surgery and vascular surgery is well as pediatric cardiac surgery. Um, comprising about 300,000 visits a year among more than 220 providers. Um, and Prior Thio March 15th Mawr than 99% of our visits were face to face. We had some very rare telephone visits in our heart failure clinics. Um, post discharge. But, um, it was very close to 100% face to face visits. Um, as, uh, Covad came, we realized we had a problem. We've got 300,000 annual visits that we're gonna get, um, should get shut off for the safety of our system and for the safety of our patients. Recognizing the, uh, extraordinary. Uh huh. Mortality rate for the 80 year old patient with heart failure who might get cove it in our waiting room. Um, we realized we had to change something essentially overnight. We, um uh, began working on a tele health strategy. Um, on a Monday afternoon, um, had it in trials by Friday with one platform, early trials with one provider and some education and working on standing things up. But that Thursday before we began the trials, we made the decision that we would be closing. Our office is on Monday to all face to face visits, So we basically had from, uh, less than seven days of total less than seven total days to transition chin from 100% face to face to 100% not face to face. Um, and it's remarkable how quickly you can change when you say you're closing down your traditional way of doing it. Um, things that supported that were one we confirmed, uh, that our liability coverage carry carried us through, uh, both telephone and video visit. So there wasn't a liability issue. Um, as we all felt the waves of regulatory changes. But the regulatory apparatus CMS and are, uh, other commercial payers was evolving very rapidly for us in the middle of that week. Blue Cross Blue Shield said that they would establish pay parity for both telephone visits and, uh, video visits with, um uh with face to face visits, meaning at least for one of our major payers, that became a non issue. And we thought one, it's the right thing to do. And likely other players, including Medicare, will hopefully come along fairly quickly. Um, our system gave support to our practices by saying, For the time being, we've got your back. Do the right thing, and we'll figure out the reimbursement later on. But keep seeing patients. Um, that sort of let us lead the regulatory changes, skate to where the puck will be rather than waiting for the puck to get there. Um, from a, uh, individual provider. Uh, workflow adoption. We really didn't offer much of a choice because we said we're closing our offices. So that whole adoption cycle of early adopters and laggards almost didn't matter because, well, you have to goto work on Monday and now your work is at home, Um, and we will help you, but here's what you got, so that gets all. It didn't feel very comfortable for many of us. I would say it felt quite uncomfortable for almost all of us. But there was certainly not a much of a question of adoption. We couldn't have 20% adoption because we were seeing 100% of our patients that way. Um, but incumbent upon us leaders was to actually make that feasible to simply say, we're closing your office. You have to do something different, and that's something different. Doesn't provide a platform on which to provide the quality and efficiency of care that you're used to providing, Um would be, you know, criminally irresponsible, to be honest. So we spent and a small team spent a lot of hours, um, one testing platforms, but to creating all sorts of auto texts in our e h. R and making the documentation process in the HR as much like the face to face visit as possible. We created new billing codes that looked exactly like the old billing codes and were parallel on the screen. Except they were in a virtual column. If yesterday you click the one on the right, Now you click the analogous one on the left and will work through not the physicians, not the other providers. But the back office staff and leadership will work on, um a, uh, creating a workflow where we figure out what those bills mean later. Just tell us what you did. So we made it pretty easy to provide the care that you wanted. Um, at first we didn't have a video platform that we felt comfortable rolling out to everybody. So he said, provide your care via phone visits for that first several days. Um, we canceled a number of appointments Thio cut back on the number of visits so that we could validate the work flows and then identified a few potential early adopters who on that very first day, ran through, uh, video visits with a platform by, uh, two o'clock in the afternoon. On that first day, it was apparent that the platform that our system had used for urgent care and seemed like the one we already owned and the best thing to use was simply not gonna work for our patients. It was actually just fine from a provider viewpoint, but for our office assistance, getting our patients set up on the platform via email. With our office assistance now working from home, the patients with varying degrees of technical savvy is all ours do, Um, and frankly, our office assistance with, um, essentially no prior coaching on how to coach the patient through the process, we realized that our current platform was just too cumbersome to get the adoption that we needed from patients. We also saw that we really needed to quickly get to video because at that point we didn't think that we would, uh, be where we are now. Where there's at least temporary parody for most players with telephone. Um, we felt like in orderto get reimbursement, we needed to move very quickly to video. Um, so here's sort of a graph of our transition if you this is pre co vid over the year. The blue is new. Visits the orange is, uh, return visits. And, uh, whatever amount of virtual visits in gray and yellow is too small to show up on the graph here for these weeks. Um, within, however, that first week, we first days, we pre pre transition, we cut back on our visits and began doing a little bit of telephone and video when we closed down. Except for some urgent visits, we moved quickly to, uh, telephone with a tiny bit of video, really? Just testing the platform. Um, but in doing so, um, maintained over 45% of our total expected volume on a weekly basis, which we thought was pretty good aan den over time added videos so that now of our total, uh, birth of our total visits, video is now more than 50% as of last week. There are still ah sizeable number of telephone visits and a few face to face visits, which are beginning beginning to grow back as the local guidance on businesses opening and our, uh, remain is loosening a bit. But this was really are very rapid adoption of telephone, followed by video approaches. Um, really. For us, the key driver was making this easy for the patient. Easy for our office staff and easy for our physician, because if it's not easy, it's not gonna work. And I think it was really critical that we stressed over and over that we don't expect our physicians to be I t experts. They need to be medical experts, and this is a tool for them to use like a keyboard, not something that needs to get in the way of the care. And we worked as really hard to make that as come as true as possible, though in a rapid transition. Clearly there are hurdles, and we tripped on a number of those hurdles. But at the end of the day, um, we simply got to a decision tree where our office assistance could find Call the patients say, Do you have a smartphone or a computer that has a camera on it? If the answer is no, you get a phone visit. If the answer is yes, we give you a video visit. We moved, um, fairly quickly to doxy dot me, um, as an easy button for us where you can send the patient a text. Um, all they have to do is receive a text and click on it, and they are good to go. Um, I think there are other platforms that work equally. Well, that's simply one that we arrived at that has worked well for us in this rapidly evolving environment. I think there's been an incredible amount of innovation by ah, lot of these companies that's been been really helpful to us, and I Who knows if the platform we're using today will be the platform we use in in three months. Our current workflow is then such that now 30 maze 30 minutes prior to the appointment or medical assistant calls the patient does the medication reconciliation asked the patient to check their own vitals if they have the capability of doing so and confirms that the patient is in the providers virtual waiting room. Um, so that then I come up and the medications already done, just as the and the vitals already done, Justus. They would if the patient were in the room. Um, I do the video visit document off to the side. This is not integrated into our ph. Arts through a Web browser that we put up on a separate screen from our HR but has worked relatively well. Um, it was, you know, we have felt like just being HIPPA compliant was important. Um, I realized that for the time being, those, uh, regulations have been relaxed, which has helped enormously. But we don't expect those, uh, that laxity to stay for the long term. And to the extent possible, we wanted to quickly get to something that was HIPPA compliant and could be relatively stable for us if possible. So the platform we have chosen is, um, and what was really we discovered very quickly is our patients at least struggled with opening links out of email. Um, they got confused about which email it was going to, and it's it turned out to be more cumbersome than I would have expected. But the text link works very well. And the, uh, scripting we've given our office assistance is to tell our patients. Um, toe, ask them. Do you face time with your grandkids? Well, this is pretty much like facetime. If you could do that, you've got this and that instead of talking about virtual visits, if you talk about facetime, people relax a lot, and it works much better. One of the nice things we've liked about the platform we're using And I think others, uh, do this is Well, is you can have multiparty video calls so that you can actually have, um, patient and their family who themselves aren't in the same place but toe have difficult conversations about procedures. Aunt of Life care. You can have everybody on one call, and I think the communication is, um it can be outstanding. In addition, you can share your screen. And so if with each Denmark created a number of diagrams and things like that where I think actually my patient education may be better than it is with the, uh, poor drawings often do in the patient room, face to face. Um, here, I can use my mouse on some, uh, documents I made for power points or other reasons. Andi, for example, of my last case today showing them what a CFO is and how we would talk about closing it. A tely sta as well as I do face to face. Um, again, we talked about really trying to make it easy as possible so that the using our standard office note that everybody is used to using we needed to have some legalese in there. So we created auto text that said that the patient consented that we did what we were supposed to do, that we're licensed in the state where the patient was etcetera and then document at the time. But this was really we don't expect the providers to know this. We just created and all. The Texan said, filling these two blanks and you're good to go. We also created these new internal codes for our visits so that we could then on the back end, crosswalks to figure out you don't need to stay with the changing policies of payment. Instead, you click on something that looks like the code you're used to kill King on for a given office visit. We'll figure out later what bucket it's gonna fall into for a given pair in short telling our providers you provide the care that is your job to provide. We'll try and make the technology a facilitator of that, not a burden to that. I think that's time thus far. It's worked pretty well. Um, you know, put up here Cem patient feedback because one of the things we did was put in extra patients assessments and provider assessments so that we got okay and, you know, overwhelmingly, people have been thankful that it was safe. Um, but also, I've heard multiple people saying they never want to go back, including patients of, uh would have been very surprised that, um it's been easy. And they've said, You know, it was really nice not to have to get my car and drive an hour to see you for 20 minutes. Instead, I'm here in my kitchen. Um, I must say, as a provider, I've really enjoyed, and I think I learned from the entree we get into our patients homes by seeing what's in the background. Um, and I think it adds a nuance to the care that we provide. So I think you know, there are some silver linings in these clouds. There will be. You know, uh, Mawr Difficult transitions to come. I don't think we are at the final place for this. Um, I think we clearly have Mawr Road to go to a place where we are 100% video. Um, but I think there is zero question that this will be a lasting part of the care. Provide that. When we did none of this on March 15th e think that probably sets up a Hopefully it's a good opportunity for a conversation on dime. Really interested in what other people have learned barriers? They've seen how they've gotten around those barriers, etcetera. E think one other piece I wanted to share is, um, training 222 providers simultaneously when they're all at home. Is not so easy. And one of the things we did to get around that was rapidly produced training videos in Power Point that we pushed out and they showed. Click on this click on this very simple less than five minute videos that you could watch and teach yourself how to do it. Yeah, um, that was also not something we had rolled out previously. Our I T people would take months to come out with videos and this and that. Instead, US doctors put them together with a few administrative staff. We we're not gonna win in the Academy Awards, but they got the job done. Thank you very much, Dr Downey. Actually, that is very similar to my experience. Also, um, I, um I finished fellowship in 2018 and then we started, um I started telling medicine, Um, a few months after I started practice, I also trained here Houston, Methodist. And, um I remember for the last year or so, it's been trying to get people to at least try a few visits that via virtual care, telemedicine or so forth on Ben. Just out of nowhere, spring break came came along. And it was Where are we? We need to do everybody. And by the end of the week, everybody's on board. Uh, just out of nowhere. Um, it z interesting. How And then now when you talk thio any of my colleagues right now, um, they love it on bear. Very comfortable doing it. And they feel that it's a lot more efficient in most cases. Obviously, it's not in 100% cases, but in most cases it is. Um So, Dr Wasif, if you don't mind me asking, um, in regards the physician adoption, um, there's also there's always a question about, um, patient culture. So this is a This is a culture change for physicians, but it's also a culture change for patients. I'll tell you, over the last year and a half, since I've been working, tell me, do you Until medicine, Um, some of most of them. And it was cash pay. So most of the patients that did not wanted to tell them medicine was because of the payment. Um, again, is almost less than 10%. But some of them were like, why would I come into your Not why would I do this virtually? How is it that you would not examine me? And how would that you provide me care how or what do you see? Um, in regards to tools to help patients understand that this is a cultural change, but we're still offering or able to provide you good medical care. Thank you for the question. And I think he I, uh in my experience, I didn't encounter that because initially, before covert 19 I didn't feel that patients were resistant to it. It's all about the proper patient selection. Who would you you have for telehealth, who would be able to use the telehealth. But most of these patients were patients I had seen in the office and before, So they were familiar with me. And most of the visits where visits that we're mostly to discuss, Um, uh, lab results or to discuss imaging results. So actually, they were very grateful that they didn't have to drive four hours from a different state or so forth. Just have this discussion. So I think if patients understand that what the purpose of the visit and the objectives off the visit are clear to them, they're they're they're happy to stay in their own homes. They don't want to drive for hours. And even if you're in an urban area, uh, they don't want to be like struggling to find parking and so forth. So I think understanding what the visit is about because sometimes even in the office, they asked like I'm not sure why I'm here. They need to know why they're there and Post Cove it. I actually also found in that patients were very grateful. They were very happy toe have a physician talked to them and that they're able to discuss their problem with them, and they're also very grateful that we're able to see their homes. As Dr Downey was saying, It was a very surreal experience for us, Actually, they are able to see my office. I'm able to see their home. It was much easier for me. Thio, you know, go over their medication. If they were not sure about the medication, they would go and get their medications, and we would. They would show me on the screen and and we would do the medication reconciliation and and verify it. So to answer your question specifically, I think patients are more digitally in tuned and not this won't not work with every patient. And we have to be very clear on patient selection on. We also have to, um, be quite clear why we're doing the visit. Like, why am I doing this clear with covert 19 nobody wanted to come into the office, but both scolded 19. The purpose of the visit has to be clear, and and there is value, they're much more than the physical exam. A lot of times it's the history that we get from the patient. That really matters because you're ordering a lot of tests. You're getting an echo. You're getting Annmarie there. Other tests that would assist your physical examination. And I think in the future our visits are not just gonna be without semi examination. There will be other tools. The enhanced visit will probably take place. They will be sensors. There may be some facial recognitions. There'll be other tools to assist, you know, to improve the quality off the the platforms in the future. I agree. I That's what I was doing for the last year and a half was at the end of the initial visit, I would tell a patient. So we are going to do, for example, an echocardiogram. We're going to do a treadmill stress test, and by the way, we offer virtual visits so that you'd be able to from home or from work. And I had even patriots were in their car. Uh, Andre will stop somewhere and that we would Yeah, well, actually, a couple of them are on the highway, but it turns out they were there passenger, not the driver. So I'm like, OK, that's fine. But again, it goes back to efficiency and, um, simplicity of the technology and of itself. Um, Dr Downey. So when you are showing your numbers, you almost about 300,000 visits a year or so forth, 60 plus percent or Medicare. Um, what do you anticipate? I know it's hard, but what you anticipate for the future regarding how this is going to go about, Obviously, you know, I can't read the mind of the federal government. Um, and how they may, uh, one of these regulatory barriers they've taken down that they will choose to put back up. Um, I my sense and I think this is ah, sense of many is that the genie is out of the bottle. To some extent, for this, I think it's gonna be very hard for them to go back and say What? We're paying you $14 for a video visit. Or, um, I think my guess is that telephone parody will go away and they will require video to get paid much. Um, that's a guess. Uh, not not any inside knowledge. Um, I think video is likely here to stay. Whether it ends up truly a parody with face to face visits, I think remains to be seen, um, for Medicare. I think for, um, other third party payers, it very likely will, um, Blue Cross Blue Shield. And Aetna and Humana are trying to sell to employers just like we will directly sell our product to employers. What does an employer want out of a health care provider? Um, they want the health care provided as inexpensively as it can be accomplished with minimal lost time for work. If I need to see somebody for their coronary disease and that takes them 20 minutes logging in from their desk over there from their office versus taking the afternoon off to drive an hour to see me for the same 20 minute visit to then drive back home and have missed the whole day. Well, now the employer paid the same thing for the visit, but lost a half days productivity from that person. I think that's ultimately gonna be a significant selling point. That obviously doesn't completely apply, doesn't apply to the Medicare population. Um, but my sense Is that all right, Kobe is not gonna be a three month phenomenon. This is gonna be here for a while. What that means I don't know, but I would be surprised if we weren't still in a similar boat. A year from now. That means will be 14 months plus into, um, an environment where the safe thing to do is virtual visit. Once the field has moved that far and patients are used to doing it for 14 months, it's very hard to see it going totally backwards. I'd be interested to know what others think. I agree with you, Dr Downey. I don't think we're gonna just reset the button to pre March 17th or March sticks with The law was passed. I don't foresee that. I think it's here and it's gonna be here to stay, and CMS and again, I don't have any insider knowledge. CMS had already shown that it was moving in that direction. They were reimbursing for some visits. The virtual check ins. Um, they were loosening the rules somewhat and so and that the fact that they moved very quickly and they were very agile about advancing this waiver. I don't see the US moving. There may be some regulation there. There may be some measures that need to be put into place to ensure that you know that there is value and safety in these visits. Um, and proper documentation. Um, for most of these visits, I'm not sure about the telephone because there remains the question off that not everyone has a smartphone. There are a lot of disparities, and it's been accentuated or pay. Or patients who don't have broadband ruler areas that don't have broadband. Eso there, that the phone. I have a feeling that may stay, but of course, we don't know. And we may be in this for the long haul It maybe a couple more years before we even know where we move. But it gives CMS sometime, Uh, just think this through after this rapid implementation, I think one of the one of the rules on virtual medicine before, um, Cove it was being in a rural area or being, um, a certain distance from major metropolitan city. Um, I anticipate that the telephone visit may require something of that sort. I don't know how they would be enforcing that or how they would be evaluating that, but it's clear that there is a definitely disparity. Socioeconomically. At least, um, we've even seen it in, um um, education at this point in regards thio the the availability of broadband Internet access. So let me ask a couple of questions that we have. I am in private practice. And how do I implement telemedicine? If I'm not a part of a major or large institution? I would say at least the platform we use is actually not made for a major organization. They are are It is an individual provider contract. We just did 222 individual links, and it's a, um, $35 a month subscription. Anybody could do it. Um, it literally signed up online. It's, uh, you know, easier than, uh, you know, buying a pair of socks on Amazon. And I agree. I mean, this is not It's not cumbersome as implementing the EMR, which is very costly. There are many different platforms. I think the key is that these platforms are HIPAA compliant. I think that that's the key. If it's a HIPPA compliant platform, that's what you want to invest in. You don't want to invest in something that's not HIPPA compliant. because if they're gonna loosen, if any rules will be enforced and probably be the hip compliance on I think many of these platforms or a month to month subscription that is, you know, a trivial amount of money in the grand scheme of things. But the fact that it's month to month means that if you make a mistake or something better comes along, you're not married to anything. It's just a website. You visited and paid a subscription. Um, you know, that's frankly, you know, less than the cost of your newspaper. Yeah. Another question that came up is what would I not use? Telemedicine for e mean before covert 19 I would say End of life decisions difficult. Uh, discussions I would have never had to do over telling medicine. And it would not be my practice. Um, under the lock down situation, we've had toe have discussions over the Internet. Um, so the rules, what can and cannot be discussed depends on the situation. If it's a difficult discussion that you want the patient to be there with their family on, you feel that it needs to be face to face. Then it has to be face to face. But if you feel that it can be done on the Internet, them well, that would be output. Um, I think it's end of life decisions. Difficult decisions. Um, multiple. Like talking to somebody about their fifth surgery that they need. I find it very difficult to discuss over a platform, But under the situation, we've had discussions. I think the other piece is, um, where there really is a critical physical exam component. Uh, they can't be substituted. Their frankly, aren't that many of those? I think vascular medicine being able to feel pulses import is important. On the other hand, it can be arranged that you get some testing ahead of time. Andi, make that portion of the physical exam relatively irrelevant. Um, I think, uh, you know the patient, it certainly it could lead to some increased testing for example, the murmur that you might have left but you get an echo because you can't hear it. But it was referred to you for the murmur a little bit. To be honest, the majority of those patients are gonna come to you with an echo, um, for their murmur. Not this is just a patient with a murmur. So I think the liabilities there of excess test sting are modest. The non zero. For me, the bigger one is, uh, one the relationships and difficult conversations that Dr Wasif spoke off. Um, and then two, if they're coming in for a test anyway, if they're coming into my office for the echo today, we'll probably add instead of CIA while you're here other than you drive home and we talk to you virtually tomorrow, I think a lot of the in person visits we've done have been, well, shoot, you're already exposed in the same office. I might as well meet you there as opposed to hiding 10 ft away in my office. And the other thing is that if if I if it's a condition that are not able to diagnose through Italian medicine on that has happened with a few patients, you try to troubleshoot during that visit and they come to your office as soon as it's possible. As a matter of fact, that happened a couple of times where patients with particularly shortness of breath, you're not able to assess their volume status. Um, there, there, there you're not sure what is going on on does patients. I eventually had to bring them back to bring them into the office to examine them. Um so another question which I think, um, many physicians are finding out very quickly burn out physician burnout in regards to outpatient care and so forth. What are your thoughts about burnout? Clinical burnout from physician standpoint, I think the burnout comes from the excessive, um, messages and the e m r. And you spend your majority of the time in clinic, uh, first documentation. And then you spend the majority the rest of the week trying to answer questions and respond to the M R message. That's where, and that's part of where the burnout comes. And I think part of it as well is sometimes the lack of efficiencies in our clinic. The flows, um uh, some things don't flow very well and so forth, and we're telling health. It's somewhat helpful is that there's efficiencies built in it where things are done ahead of time and you just essentially show up and do your visit on the documentation may be the same, but there may be other tools that would help with the documentation. So the burn out, I think is a is a major issue, and we're all suffering from it on. I don't think there's, ah, magical bullet to treat it or a magic pill to treat it. Uh, I think efficiency may help it. Yeah, I think there's it would be a mistake. To pretend like this is a panacea for the challenges of burnout. It's simply another tool for doing the same work that we've always done with most of its flaws, with most of the benefits that we also that we come to work to provide for our patients. But many of the efficiency flaws that have contributed to burn out um, you know, I think you saw on our graph that, you know, we're only still it only about 65% of our usual weekly volume in the outpatient clinics. The reason for that is, um, recognizing the challenges of this transition is we've switched our follow up visits from being 15 minutes to being 30 minutes, and that has and we've kept our new patient visits a 30 minutes. You still work the same number of hours, but you're only getting about two thirds of patients in a given day. Um, that helps with burnout, but ultimately leads toa only two thirds of the visits across the week. That was, um I think, an important thing to do to facilitate adoption and help people get over the hump. Um, but I shouldn't pretend like it's a panacea for burnout. Now, with that said that I had a couple of providers say, You know what? I had clinic today and I did it from my back porch via video, and it sure was kind of nice being at home with my wife and doing it from my back porch instead of in a windowless office. E don't know that that will really last, but if that were one day a month, I think that actually helps a little bit. But by no means is this a panacea? No, I definitely I definitely agree. I think some eventually, once this kind of settles down, it will become some sort of hybrid type of situation where you have one or two days a month where you can actually dio most of your visits from home. Uh, do most of the digital paperwork from from your EMR system from home or so forth. Um, but no, no, I I definitely agree. But I also think that eventually if and when, um, this becomes a lot mawr mainstream, meaning that we have proper devices. Proper data that, I mean, if we have the data in regards to activity, blood pressure, heart rate weight on DSO fourth the and proper accurate information regarding medications, um, and questionnaires beforehand. So you know what this visit is about? Um, it becomes it makes the 10 15 minutes time with the patient, um, a lot more efficient. And I see that I actually I do believe that telly telly medicine. These visits are more efficient than the in person visits you're cutting on. Ah, lot of inefficiencies that you may face in the system. Uh, the delays that happen in the system. I believe that here the clinic, to a certain extent, goes much, much smoother with no delays. For the most part, Andi, that reduces the burn out. I mean, it certainly does. It's not a cure, because it's only one aspect off the reason why the bird y physicians are burning out. And it's not only about the clinic, I'll say I have a lot more or less late shows and no shows. Um, on virtual clinics. There's no reason for it, uh, driving into the Texas Medical Center and trying to find parking and trying to find out where the offices and so forth. And they come huffing and puffing, trying to get there. It's a lot more comfortable, more easier to be on time from home or from work. Exactly. Um, well, I would like to thank you both very, very much. It is. It is a pleasure to have you as, um I would like to thank our guest, Dr Hippo Wasif and Dr William Downey. Um, as we conclude our session today. Thank you so much. Thank you. This was thank you. Um, in the upcoming sessions will be discussing many other aspects of digital health and telemedicine, including presentations about coding and setting up different types of platform, including possibly curbside virtual consulates. How to start implementing new training processes for our fellows and medical students and many other ideas. I'm grateful for the opportunity to direction host this Siri's. Please consider leaving us a review on our web page or YouTube channel and mention any other topics you would like us to consider discussing the near future. Thank you very much. Thank you.