Best Practices for Improving Telehealth Utilization and Engagement

Summary: Learn how Guthrie, an integrated health system, implemented telehealth that improved utilization and patient engagement, with high patient and provider satisfaction, across their hospitals, regional clinics, and skilled nursing facilities.

Hear best practices from Operations, Clinical, and IT, directly from leaders at Guthrie:

  • David Hall, Associate Vice President, Operations & Virtual Care
  • Dr. Jagmeet Singh, Chief of Nephrology, Physician Lead for Telemedicine
  • Alison Bidlack, IT Application Manager, Virtual Care
  • Ryan Hewitt, Epic Applications Analyst
  • Host: Brit Gould, VP Marketing, Eko

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Complete webinar transcript


Brit: "Good afternoon, I am Brit Gould, and I'll be your host today. On behalf of everyone at Eko, welcome, and thank you for joining us. We are thrilled and honored to be joined by this team from Guthrie today. They will share with you their experience at implementing telehealth across Guthrie and how they used Eko in the process. You'll hear directly from David Hall, Associate Vice President of Operations and Virtual Care, Dr. Jagmeet Singh, Chief of Nephrology and Physician Lead for Telemedicine, Alison Bidlack, IT Application Manager Virtual Care, and Ryan Hewitt, Application Analyst Virtual Care. Dave will start by sharing a bit of a background on Guthrie and how they got into telehealth. Dr. Singh will then share his physician's perspective. Alison and Ryan will share their experience of expanding telehealth across Guthrie, including a few surprises that they ran into and had to solve. Dave will then come back and share some thoughts on telehealth post-pandemic. After the presentation, we'll get to a Q&A session. Any questions you have, go ahead and submit them to us. At the bottom of your Zoom webinar screen or window, you'll see a Q&A button. Click that, enter the questions there so we can get to them or as many as possible when we get to the Q&A portion. With that, I'm excited to turn this over to Dave to get this started. Dave?

Guthrie and Telehealth 

Dave: all right thank you Brit so we'll jump right in. Guthrie is a non-profit integrated health system spread across north-central Pennsylvania in the southern tier of New York. We currently have 5 hospitals, about 45 regional clinics across 24 communities. This includes a medical school research institute and then an employee base of about 6,000. That includes 900 RNS, 81 residents, fellows, and medical students, and over 500 providers. So we talked a little bit about our numbers, what do we do per year? So we currently do about 1.7 million outpatient visits per year but 113,000 ED visits and 25,000 admissions spread across five hospitals. And then we have 2 hospitals that are birthing centers, we do about 1,600 births a year as well. We have an array of specialty services such as ambulatory surgical centers, an oncology center, weight loss center, and an award-winning cardiovascular service line. We continue to really invest in our technology, and as a 10-star epic shop, we place the care really in the patient's hands. So we currently have about 113,000 active eGuthrie users, and we continue to grow that number month over month. Right now we are piloting some self-scheduling options and this year alone we've done 22,730 self-scheduled appointments. So we jump right into it and really want to set the stage for my colleagues who will be presenting after I'm complete here. I want to talk a little bit about the continuum of care. So from a strategic perspective, the system decided to start piloting telemedicine programs about three years ago. With some mild success, we began building infrastructure that we felt would enable scalable solutions and really wanted to ensure that those scalable solutions met each of the continuum of care models. It's really interesting to see how our industry is shifting, pivoting very quickly due to the COVID pandemic, but the continuum of care will really never change. So as we continue to retool our industry for this shift, we need to make sure we're efficient in the solutions that we develop across the spectrum and ready to operationalize these programs as we deem necessary for our organization. What's interesting to note too is during the infrastructure phases, we really put a lot of emphasis on the patient and provider satisfaction. So during our original hub and spoke model that we created with a number of our communities, which we'll talk about a little bit later, we wanted to make sure that we captured the voice of the patient. We want to make sure that this was well-received that the care was optimal and that it's a program that we felt was scalable and patient consumer buying would increase in utilization. So we set up a Survey Monkey to start with, very simple, straightforward, and one of the questions was would you recommend this service to others? And we had an overwhelming yes, lots of comments, the total end on this question was 252 over a year and a half, about 2 years closer to 2 years worth of surveys. But it's interesting to know that as we started to shift and put the technology back into the patient's hands, in their own homes that patient satisfaction has dropped quite a bit. So we find that when we control the technology we really provide a superb experience for our patients. When we allow the patients to or we try to shift that technology focus to the patient's control in a very difficult time, which leads us to believe that the knowledge, the technical knowledge across our patients serving multiple generations, is vastly different. So how do we continue to expand and build upon those different technology capabilities to ensure we get the same seamless experience as we do when we control the technology ourselves?

So I'd like to take a minute to just quickly introduce one of my colleagues Dr. Jagmeet Singh who is the Chief of Nephrology at our flagship hospital. He is one of our physician champions, and he's been doing telemedicine for a number of years now, so Jagmeet.

Bridging the Gap in Telemedicine Visits: Physical Examination - Physician Perspective: Physical Examination via Telehealth

Jagmeet: Thank you Dave, and thank you Eko for giving me this opportunity to share my experiences for telemedicine and how we can bridge the gap in telemedicine. So as you can see the topic of my discussion is bridging the gap in telemedicine. So first of all, I want to say that you know we are a staunch believer in telemedicine. We believe that medicine is going to be delivered in a completely different way let's say in 2030 or 2040. You know we are using technology for dating, banking for Netflix for everything besides the medicine. So I think telemedicine is the way to go, and it's going to be completely radically different for how the medicine is going to be delivered. So telemedicine is the future, but what happened with this pandemic COVD-19, we have been pushed into the future and now we all are struggling to see how we can get there, how can we get the telemedicine right. So as I said I'm a staunch believer in telemedicine, but I also am a very strong believer in physical examination. I think the physical examination is really important. Without physical examination, any physician and the patient encounter is just like video conferencing or face-timing. It doesn't have what it needs. You know being a nephrologist you know when I see the patient, I need to auscultate the patient, I need to listen to the heart sounds to see you know what's going on. I want to listen to his lungs to see whether the patient is in volume overload or you know the patient is in heart failure. So physical examination is very important not only for cardiologists, I will say for pulmonologists, even for everyone physical examination is very important. And we in Guthrie also believe that you know physical examination is important for diagnosing but it is also important for patient satisfaction. I think it builds a relationship with the patient when you do the physical examination on the patient. So with this background you know we started our journey and you know for the physical examination, it's not what I think, I think again there's a very nicely beautifully written article by Dr. Paul Hyman about the disappearance of primary care physical examination losing touch. I think we all should read this article, it tells you how by spending more time on the screen we are losing a very important tool for the physical examination. With this, you know with this baggage of losing the physical examination but still loving the telemedicine, we started our journey in Guthrie much before the pandemic happened. You know in the initial times, we started having just video conferencing. It was very good for my simple follow-up patients. You know "hi how are you doing," reviewing the labs, but again we were lacking something you know putting the stethoscopes on patient chests you know. It was lacking in that part. So we thought you know we need to take a further step. So what we did we started using an LPN and a clinical assistant to kind of help me during the physical examination. So she was listening on my behalf, which is good, I trained her, but then again it is to make the diagnosis. I have to rely on patients you know, I have to rely on somebody else, which is not the best one. So then I discussed with my administration, I said we need a stethoscope without the stethoscope. It's just like face-timing on an iPhone, video chatting with somebody else. So we bought some stethoscopes and I don't remember the name of the stethoscope, but they were not really... First, the quality was not good, they didn't have noise cancellation and there were so many wires entangled you know. The regular visit is just boom boom boom, in 15 minutes I can see a patient, but I was requiring more than 20-25 minutes. We have to mute one and then the other one, so it didn't go the way we wanted to go. and then we were kind of struggling, and then we started with an Eko stethoscope. This is kind of a game-changer for us. If you look at this one, it's a very simple stethoscope, it looks like any other stethoscope, but it's like Tesla you know, it is a completely different thing. So first you can amplify the sounds, you can amplify the sounds from your end. If you're not listening well you can increase by 40 times. You know so you listen to very good heart sounds, very good breath sounds. And then it has the option of noise cancellation, which is really good. You know I think all the modern stethoscopes have it, the quality of noise cancellation is really good here which I'll show you further down the presentation so you can look at the sounds, which is kind of very amazing. So you can visualize sounds, and you know we are an academic institute here: we have residents, we have fellows, so it's also very good that you can record this one, you can save it, and you can share it. So that was the one, and this is how we started our journey with Eko. So this is our you know regular clinic setting basically uh if you look at the left-hand side I'm a provider or a specialist. I'm most of the time sitting in the office, and the patient who is generally 200 miles away 300 miles away you know we have a lot of clinics you know smaller clinics we want to provide patients care closer to their home. So the patient goes there and then the nurses, you know if you look at the picture I'm there looking at the talking to the patient, and the nurse comes using the stethoscope which transmits sound to the iPad, and the iPad I can listen to right away. So and we did take the permission of the patient before clicking this picture. So this is a very, kind of a very, very present and very, very nice workflow we have here. So and then we are using it also this Eko stethoscope for inpatient, you know in our institute, we have four sister hospitals these are smaller hospitals who don't have sub-specialists that they don't have cardiologists they don't have pulmonologists they don't have a nephrologist. So let's say a patient is admitted. There, we get a consultation, we do the teleconsultation, the cart comes, we look at the patient, and again the similar if you look at the stethoscope, we auscultate the patient. And you know it makes a visit complete, you know, you feel like you have really done the justice uh to that consultation. So you know we have been using this one both for inpatient and our outpatient telemedicine. So you know they always say you know one picture is worth 1000 words. I would say one auscultation or one listen is worth 1000 words. So let me show you how it feels so let me try to do it but let me try how it feels to hear it so...

So you've got a very good, crystal clear, the sound quality is very good. Okay, let's move to the next slide. So Eko has another version which is a 0.2 version point or an upper version of the Eko. It's called the Eko DUO stethoscope. It looks really fancy if you look at it. So with this again. You can use it as a regular stethoscope, you can put it auscultated, but if you look at the left-hand side the picture, we have this and it is very good and the quality of the sound is 60 times amplified, and it also gives you what you call that one lead EKG which is very cool I think. So Eko DUO, and we have used it in a couple of the clinics, and again it has all the other features which I told you about with Eko CORE, so let's see how it looks and how it feels like. So let's go to that one...

So again you have a one lead EKG a P wave and a QRS complex which is very cool, you know we don't need an EKG so let's move to the next slide, I think you all had a good...

So again, you know so far in our clinics we have been using Eko DUO and Eko Core mainly, and then you know the meat of Eko which I think is really very, very,  you know very futuristic. The Eko AI analysis. So I just got three days back I got a stethoscope with AI analysis which I'm going to use. I use it in 1 or 2 patients, I'm very excited about it. So it detects atrial fibrillation. It detects a heart murmur. It detects bradycardia, tachycardia. So it is really cool and it is recently FDA approved, and it has sensitivities and specificities that are very high. For atrial fibrillation it is 98.9%, heart murmur again it is 87.6%.  Again it won't tell you what kind of heart murmur, but it tells you the initial diagnosis. You know as you probably know that a lot of nurse practitioners, physician assistants, even the young graduates you know, we are not very good with all the things. So it's like and having an assistant helping you, making the diagnosis. And sometimes I tell my residents it's like a cardiologist in your second room. You know you can always call a cardiologist, can you have a look at it? so it gives you the initial stimulus to go further into the diagnosis. So again let me give you a demo of it. So let's go to the next slide. And you know before I go to the next slide, once you put a stethoscope on the patient's chest, you have to wait for 15 seconds. You know for your time, I'm not waiting for 15 seconds. Then I'll tell you how it looks...

So you can see at the bottom it says normal sinus rhythm, no murmur detected, QRS, and heart rate, which I think is really cool and I think this is going to be the game changer you know in the telemedicine world. So I will go to my last slide I guess no I think I have a few more so let's go. So again this is, you know I haven't used it personally, but my colleagues have used it you know with this AirPod in your ears and then you can take the handle and put it here. I think in the way with the COVID pandemic and with this all the infections, this is really cool. So I think this is one. You know this is a very cool feature, and I haven't used it personally but a lot of my colleagues have used it. But I hope that Eko gives a free AirPods with it, but I'm just kidding. So let's go to my last slide so again as I mentioned in my first slide, we love telemedicine we love physical examination, but there's a gap in between, and I believe that to make this telemedicine a success we have to bridge that gap, and I think Eko provides us that capability to bridge that gap. The quality of the sounds is very good. It makes your complete telehealth visit. You know you're satisfied as a physician that you adjusted to it. And the second thing is the virtual exam which we are doing is almost as good as an in-person exam, which is not a small thing, nobody would have even thought about it like two years back, three years back. And then as I mentioned before, the patient has more trust in you and you know you can sometimes share the screen with the patient. So it's kind of really cool and really neat I would say. The workflow is also very good, you know as I mentioned 15 minutes, you're boom, you're done with the visit. So I have my colleague who will be speaking to you about the workflows. So thank you so much, thank you everyone for giving me this chance. Have a good day.

Expanding Telehealth Across Guthrie with Eko

Alison Bidlack: Thank you, Dr. Singh. So we started our telemedicine journey with what we called our clinic to clinic workflow. This is where patients present to the rural primary care office and are able to complete a telemedicine visit with their specialists located on our main campus. The nurse at the primary care office rooms the patient, and is available to assist the specialist during the visit as needed, we begin slowly with one primary care office located about an hour and a half from our main campus with three specialties: neurology, nephrology, and vascular surgery. Although we started purposely small, we had a large impact on the patients who use telemedicine. as Dave showed in his satisfaction scores, patients were happy with this service. In some instances, we saved patients upwards of three hours of drive time coming to our main campus as well as expensive travel and less work time. As we moved forward, we worked on expanding this program. We brought in 12 additional specialties as well as 12 additional patient locations. Each specialty could see patients at any one of those 13 sites. As you can see on the map, we expand across the vast area in both Pennsylvania and New York. We created a standard telemedicine room that allowed patients and providers to have the ultimate visit experience: a large screen tv for easy viewing for the patient with a high powered camera that gives the provider the ability to actually virtually control it. The camera also was equipped with a high-quality speaker and microphone to facilitate an effortless conversation. The nurse documentation station is off to the side and uses a separate monitor to avoid interruptions in the provider-patient interaction. As you see our volumes did start to trend upward, but we were still moving slowly. During this time frame, we had about 40 providers with the ability to complete telemedicine, but the majority of our visits were still being completed by the same five or six providers. After growing the hub and spoke clinical clinic model, we began looking at other types of telemedicine workflows to assist our patients and providers. We established four additional telemedicine options to care for our patients: the inpatient workflow that Dr. Singh talked about, this was originally designed to give consulting specialists the ability to consult it to our patients across different hospitals within our organization, eliminating that drive time again to the other hospital and also quicker response times for those critical consults. The second model gave nursing homes the option to complete post-op visits with the orthopedic specialists, the nursing home residents would have the ability to get their post-op x-rays and then their follow-up appointments without ever leaving their facility. Often transporting these patients from the nursing facilities required an ambulance, and the cost of that fell solely on the patients. The next workflow was designed to assist in filling gaps that we had with specialty provider needs. We currently have a fully virtual provider for both rheumatology and psychiatry. Patients present to the specialty office and complete their visits with the provider who is strictly remote. The final piece in our expansion was the addition of telemedicine from the patient's home to a specialist in our clinic. Patients would use our portal eGuthrie to complete these visits. We were still ramping slowly on all these programs, then the COVID pandemic hit, and everything changed. All the building blocks we had were in place to be able to provide safe care for our patients remotely, we just didn't have the scale necessary for this new environment where we're all in. In less than a week, we scaled from 40 providers to 400 providers. To give you an idea of what a vast change that was for us in January 2020, we completed 90 telemedicine visits. Fast forward to April 2020, 11,000. We began using our workflows I previously talked about in different ways. Inpatient carts now allowed less staff to be required and possibly infected patient rooms. Providers could round on patients virtually and never have to enter the room. All in all, we were quickly able to care for our patients using telemedicine with patients remaining at home, coming to the primary care office, or in inpatient units in the safest of ways. We thought we had every workflow covered, but there was one we didn't account for. What would happen when the specialist was being quarantined but still needed to care for their patients? out of necessity, we rolled this workflow out mirroring our previously existing rheumatology and psychiatry telemedicine design to ensure a continuum of care for our patients. Patients could present to the clinic if the nature of the visit required in-person contact or the patient could be seen completely from home using e-Guthrie. We have the structure in place for our patients to safely complete visits, but we still needed to ensure providers had the tools to complete a comprehensive exam on their patients. I'll hand it over to Ryan to talk about how we accomplish just that.

Ryan Hewitt:  Thanks, Alison. As both Dr. Singh and Alison stated, the physical examination aspect of a visit is crucial, and we needed to come up with a solution that would allow our providers to accomplish this without disrupting their workflow while seeing their patients virtually. Enter Eko. Our solution came about in the form of a four-step process that allowed us to set up and deploy devices on the same day. The linchpin of this process being the plug-and-play simplicity of the Eko device. Using the Eko admin portal, we're able to create a new licensed account called a site that's capable of live streaming. Then we simply take the Eko device out of the box, turn it on, and using the Eko iOS app on an iPad, log in with the credentials generated from the site, and pair the two devices using Bluetooth. Next, an email is sent out with education documentation on how to facilitate the live stream with the iPad as well as how providers can access the live stream from their web browser. After that, all that's left is to deliver the devices to the users. In some cases, this meant literally dropping them off at the front door. The question then became how do we take this process and align it with our already established telehealth workflows? Our clinic to clinic hub and spoke model allowed us to simply deploy the devices to our satellite primary care clinics and have the nursing staff leverage the Eko and the iPad combination as part of their standard workflow, with the provider listening to the Eko live stream remotely. Utilizing an iPad really made this system practical and that it allowed the nursing staff to be mobile and use the Eko in any exam room. In the case of the fully virtual rheumatology provider that Alison previously alluded to, we actually deployed the devices directly to the rheumatology specialty office. The inpatient workflow was a little bit different in that rather than using an iPad and the Eko ios app, we paired the Eko CORE device directly to that inpatient cart via a Bluetooth USB dongle, and we leveraged the Eko Windows app to facilitate the live stream. This allowed our consulting specialist providers to auscultate if needed. Similar to the clinic to clinic model clinical staff at the skilled nursing facilities in our community were also able to leverage Eko Cores and iPads with their residents to allow for a more comprehensive exam with their providers. Now we also mentioned the particularly unique scenario in which we had a provider that needed to self-quarantine for 14 days. Not only were we able to create a workflow that allowed that provider to complete visits from home, but we also deployed an Eko CORE and an iPad to that specialty office so that the provider could also auscultate from home. Now we previously mentioned some of the challenges and needs that were presented with the onset of the COVID-19 pandemic. One of which was ramping our telehealth program from 40 providers to 400 providers as quickly as possible. And not only were we able to achieve this, but we had 335 providers actively seeing patients via telehealth within 10 days of the start of this initiative. One of the needs that was quickly identified was how we are going to provide safe and effective care for not only our patients but also for our providers. Utilizing the Eko CORE Livestream functionality really allowed our patients to achieve the quality care that they deserve while also creating a safe environment for our physicians to provide effective comprehensive exams. When COVID-19 hit, the skilled nursing facilities in our community were severely affected, and we needed to respond quickly. Being able to rapidly set up and dispense Eko devices with ipads allowed us to get those facilities up and running within 36 hours so that our patients could receive the crucial care that they needed. Additionally, due to the immense increase in telehealth volume, we established a hotline that served as a sort of white-glove service that our patients, providers, and other clinical staff could contact if and when they require technical support. The COVID-19 pandemic has really put a spotlight on the value of telehealth, and with that, I'd like to pass it back to Dave to look at what the future of telehealth might look like.

The Role of Telehealth Post-Pandemic

Dave: That's great so uh thank you Jagmeet, Alison, and Ryan. Excellent job, I'd like to kind of wrap up here with a little bit around a subjective opinion of what we see in our organization as the future of telehealth and what it looks like going into this post-pandemic, to use a hot word, new norm. So we really feel telehealth will continue to grow, but it's highly volatile still. The maturity of telehealth from an industry perspective will take years to establish, but at the local level be primarily driven by market competitive dynamics and consumer adoption. And in real community settings such as ours, we have seen substantial growth, but we saw barriers that remain in place such as broadband connectivity and consumer distribution. It's interesting to note the generational shift that we are seeing right in the midst of this pandemic as well. So we have the millennial generation will be the largest generation by 2021, and we are seeing the baby boomers entering Medicare. So millennial values are vastly different from their parents, they focus on access and convenience. Millennial looks at care as 'when I need care, I will go find care, and I want care now.' They place less value and emphasis on the development of a patient provider or relationship that we've typically seen in the primary care setting. The healthcare industry in general is really a legacy-based industry, but we must also move all the baby boomers through medicare without bankrupting the system. This means moving care into a lower-cost setting, providing efficient predictive care, and removing that legacy of reactive care. So no longer are we reacting but we are predicting what the complications would be and reducing complications by acting proactively instead of reactively. It's also interesting to note that we started to enter a brand new competitive landscape where geographical boundaries no longer really exist. Driving your organization through this evolution of telehealth is more important now than ever, especially if you want to create a sustainable model and remain competitive in the market in the coming years. I think the next three years are really going to define what telehealth potential is, and how far, how quickly we can ramp up quality initiatives and legislative activities to meet the demands of a new population of a new industry standard. So thank you for joining this webinar, and I think we're going to go to a Q&A session now.


Brit: Thank you so much, Dave, Dr. Singh, Alison, and Ryan. It feels like every time we talk, I learn something new. I'd like to invite all of our presenters to come back on camera, turn on your video, unmute, and to everyone in the audience, go ahead and send in some questions. We've got a number already so we'll start tackling those. If you have more, please do submit them in Q&A. I'll do my best to direct the right questions to the right people. If I don't please someone else of course jump right in and take it. We'll start with one for Dr. Singh: 

Q: Can you use Eko devices or the Eko stethoscope for auscultating lungs, especially at the time of the COVID pandemic?

A: Dr. Singh: Yes, we can use it like a regular stethoscope. You can use it to listen to the heart, and you can use it to listen to the lung sounds, and you know so it is kind of very simple in the case of the pandemic. you have to have your Airpods on and you give it to the patient like I have this one, you give it to the patient, hand it over, he puts it over there. You can use it within your limitations. If you're worried about that isolation and stuff like that, you have to have a proper workflow for that part.

Brit: Thank you, Dr. Singh.

Q: Alison and Ryan you mentioned skilled nursing facilities, one question was can you clarify please when you mention community skilled nursing facilities, are long-term care facilities or nursing homes for the elderly part of that group? 

A: Alison: Yes, as well as assisted living rehab centers. There were about 12 facilities that we rolled out telemedicine to assist them.

Brit: Thank you for that. Continuing through more questions and thank you to our audience here, keep them coming, we'll answer as many as we can here. One question, a technical one: 

Q: What if any challenges do you experience with bandwidth requirements and um either Alison Ryan or Dr. Singh from your experience? 

A: Ryan: So we actually didn't experience any issues with bandwidth. Again the majority of our workflows kind of ran through an iPad, so it was all via wi-fi rather than being hardwired in, and fortunately we didn't really experience any issues with bandwidth.