Rural telehealth: How to expand access to quality care for rural communities

See the full recording of our rural telehealth webinar below.

Telehealth may be the answer to expanding access to quality care for rural communities and increasing throughput for rural hospitals. However, standing up a wide-scale telehealth program comes with its own challenges. Hear tips and learn some best practices from departmental leaders at Renown Health, Mercy Virtual, and Bellin Health on how to effectively implement and scale telehealth services in your organization.

About the Panelists

Aaron Bates, Sr. IT Service Specialist at Mercy Virtual

Carter P.Fenton, Jr.,D.O., Board Certified Emergency Medicine, Medical Director vAcute at Mercy Virtual

Karen Kielar-Moes, Telemedicine IT-Coordinator at Bellin Health

Mitchell Fong, Director of Telehealth at Renown Health

About the Moderator

Jason Bellet, Co-founder and Chief Customer Officer at Eko

Updated 04.28.21

We followed up with the panelists to get some of your common questions answered after the event. See the summary below:

1. How do you work with remote locations where the internet isn’t good?

There are multiple types of solutions that can be considered. One solution is to look for external resources, such as local or national grant funding opportunities and to work together on community outreach. Another is to directly re-look at how to bring access to the community. This includes looking for common areas in these communities, such as libraries, recreation centers or other local hubs that can provide a way to bring this level of care in a centralized but accessible location. Additionally, establishing additional telemedicine sites or setting up independent rooms in other clinics or community sites that offer stronger internet connection and privacy for visits to occur effectively. Patients can also use Doximity that requires low bandwidth.

2. How does a rural community and FQHC set up a telehealth service when they don’t have a large IT department?

Take a look at cloud-based options or looking at outsourcing and partnerships can help alleviate constraints and maximize the existing IT department.

3. How have you trained or provided access for those who don’t have literacy or technology for telehealth?

Differing levels of education can be made available to support your patient population’s understanding and capabilities with telehealth. One basic step is to use phone calls to support setup or even hands on face-to-face training to support that initial familiarity and ongoing education. Multiple mock runs with providers has also been a tactic to enable providers to more quickly perform telehealth visits themselves. Additional online modules, continued education and videos on demand for refresher training can reinforce those learnings.

4. Like a stethoscope, what other equipment is essential and feasible to set up in a telehealth center?

Knowing when a patient needs for their evaluation and when an in-person visit is required is essential to care delivery for telehealth. In considering what the clinical team needs to determine the above, along with the Eko stethoscope, other equipment has included eye lens, otoscope, pulse oximetry, blood pressure, scale monitoring and even additional pieces that operate independently like a tuning fork and doppler. Another consideration is whether or not your team wants to replicate on-site peripherals as well as other lab / diagnostics specialties.

Full Transcript 

Jason: Good morning, everybody. And good morning to this incredible community passionate about telehealth, thank you so much for joining us here today. My name is Jason Bellet. And I'm the co-founder and chief customer Officer here at Eko. And over the next hour, I'm sitting down with an incredible panel from Mercy Virtual, Renown Health, and Bellin Health to reflect on an unprecedented year for telemedicine and the role it's played in expanding access to quality care for rural communities. Before we dive in, I want to give you a quick overview of how the next hour is going to flow. We're going to start off by giving you a really quick introduction to our mission here at Eko and how we partner with some of these incredible telehealth programs. We're then going to dive into hearing from each of the telehealth leaders and experts on our panel today, around how their programs have responded to the challenges of the last year, and the work they do every day to deliver care across a vast geography. We’ll then dive into a few key topics we've prepared and want to save some time at the end to open up the conversation to you all. If you have any questions and we hope you do, please type them into the q&a section at the bottom of your zoom window, and we're going to do our best to get to them at the end. If we don't get a chance to answer your question live. We'll be sure to follow up after the show with thoughts from either our team or the panelists. But since we haven't had a chance to meet everyone on this zoom call and this would normally be the time when we'd be gathering at ATA together. We wanted to start with a really quick introduction to our team here at Eko and why we're hosting a telehealth panel to begin with. So at a very high-level Eko is a cardiac screening and monitoring company based in the San Francisco Bay area that combines digital stethoscope technology with powerful software to enable providers to deliver a higher caliber of cardiopulmonary care whether they be in person or 500 miles apart via telehealth. In short, we enable a more comprehensive telehealth exam by providing the physiological information often missing in many virtual consults. It's in addition to the providers at 4000 hospitals who use our devices as their primary stethoscopes, we've partnered up with over 300 virtual care programs at health systems to help them move beyond video, enabling real-time streaming of heart and lung sounds during a virtual exam. We've learned that to drive provider and patient confidence and telehealth, which is critical to the success of telehealth as a whole, it's critical that we move beyond video to enable providers to actually listen to the heart and lung sounds they need to make more informed clinical decisions and even go beyond that by allowing them to visualize what they're listening to and analyze the data for the presence of abnormalities using AI. Most importantly, we're able to do this right alongside the telehealth video solution. Because we're in a video call right now, we figured we'd give you a really quick sneak peek of what a distance site provider would experience in the middle of a telemedicine visit. So if we go to the next slide here, you'll actually see the real-time hard sounds and lung sounds and ECG that a telehealth provider would experience on the receiving end of the telemedicine visit. I'll stop talking for a second so you can hear the sound.

Now without further ado, now that you've had a chance to listen to a little bit of a product demo, I'm really excited to turn this over to our panel of experts joining us today to dive into the power of telehealth to improve the quality of care for rural communities. From Mercy Virtual in Missouri. I'd like to welcome Aaron Bates, Senior IT Specialist and Dr. Carter Fenton, who is an emergency medicine physician and the director of the vAcute program. Thank you both so much for being here today. From Renown Health in Nevada, I'd like to welcome Mitchell Fong, who is their director of telehealth, welcome, Mitchell. And from Bellin Health in Wisconsin, I'd like to welcome Karen Kielar-Moes who is the Telemedicine IT Coordinator over on their team. We have a national panel today. It's really fun to have you all here. So thanks for turning on your video. And to kick us off, we're gonna do a quick round-the-room introduction of all of your programs. So I'd like to turn it over to Aaron and Dr. Fenton at Mercy to tell us more about their program.


Aaron: Yeah, sure. So we're with Mercy or Mercy Virtual specifically, which is our telehealth wing. But Mercy serves about six states right now, 44 hospitals, around 350 closer to probably now 400 outpatient clinics, we have both internal Mercy facilities as well as commercial customers. We've been in the telemedicine game for quite a while, we were really the first true kind of virtual Care Center approach. We open the virtual care center oh what about six and a half years ago, the time flies but it's a dedicated building, it's basically a hospital. You know, without any physical patients. We've got a full staff of nurses, sitters, physicians that are strictly 100% focused on virtual care. We offer about 13 different defined solutions in that, everything from your traditional, you know, V hospitalist, or vICU, stroke care. I mean, you can kind of see there, it's a little bit of everything. But then we also have a lot of kind of outside-the-box solutions and one-offs that we've developed over the years on the virtual side. So chances are we've probably dabbled in it if if you're thinking about it.

Jason: Yeah, can't wait to pick your brain on a couple of the key topics we prepare here. Thanks so much, Aaron and Dr. Fenton. Mitchell, over to you tell us about the amazing Renown Health Program. 

Mitchell: Yeah, thank you. So I say at Renown Health, we're based out of Reno, Nevada, which is in the northwestern part of Nevada. And what's very interesting about the state is that there are two urban hubs and the rest of this state is actually rural or frontier. So telemedicine is extremely important to bring access to those rural communities that don't have that same level of connectivity, direct access that we have today. Additionally, because of where we're located right next to the Sierra Nevada is a lot of the communities go through weather challenges, particularly in the winter months. So those natural barriers really push the need to leverage technology. And so a little bit about myself, Mitchell Fong from Renown Telehealth been in the role little over two years, but my passion and dedication to telehealth started almost a decade ago when I wrote my master's and did the research on the need for telehealth in rural Nevada. So for me, this is a huge passion. What you can see on this slide now is our program, we offer 20 plus different services in the outpatient setting, we do have some inpatient services, remote monitoring, pursuing hospital at home. And so we're really trying to work with all those communities to understand what is the need that you guys have? How can we work together to help bridge that gap to get the patients what they truly deserve, which is the right care at the right time. So thank you, Jason. And I really look forward to the rest of the discussion with the panel today. 

Jason: Thanks, Mitchell. We're gonna have some time to talk about sort of the adoption of these 20 plus specialties, which is really incredible. Karen, I'll turn it over to you from Bellin.

Karen:  Hello there. Well, we’re not as large as Mercy. But we follow more like Renown where we are two major hospitals we manage or support most of northeastern Wisconsin, but we do go up into the UP. So we also face many of those weather conditions that Renown was talking about where it's challenging, and they're very remote areas up there. So connectivity is definitely our biggest challenge we are facing. But we do manage probably 1/3 of the market share in this area for our PCPs but in our specialty group, it's much larger. Bellin has both the Bellin hospital as well as a clinical care hospital in oconto. We have 20 primary cares, but 22 of those 28 are located in rural communities that we try to service and provide them with a full service of care. We also manage a behavioral health hospital and two behavioral health clinics, we are involved in a SNF program, urgent care, as well as employer clinics. So we too dabble in a lot of different areas. And we are kind of new to this telemedicine adventure. I have been in the role for three years. They started prior to that, but it was really just before I started but then COVID has really forced us to pick up our game and think outside the box. But I'm excited to be here. And thank you very much for this opportunity to share what I know.

Jason: Thanks Karen, and actually one of the questions that we're going to ask the audience later on in a poll is how COVID-19 accelerated the adoption of telemedicine within their institution. So it's gonna be really interesting to kind of get a poll of a broader cohort of those in the audience today. Before we dive in, we actually have another poll for you. We want to understand who's joining us. And so we're gonna put up a quick poll. Let us know which best describes your organization. Are you a health system Rural Health, FQHC, physician private practices, it's fun to see this come in real-time, and I think will help inform the panelists, as we go through some of the topics here. We'll give it about 10 more seconds. That's great about 20% Health Systems, 10% rural hospitals. 5% of qH sees that 12% coming from physician private practices or private clinics. And then a mixed pretty evenly distributed across skilled nursing education, solutions and others. So I'm going to go ahead and end the poll. But this was really interesting to see who's joining us today. And we want to go ahead and share the results. Whoops. All right. I may have just killed the slides. But that's actually okay.

So, let's see. What we want to do is actually dive into the main questions that we prepared for you all today. So we've put together and it's really hard to consolidate the multitude of questions that we could dive into with three amazing programs like yourselves into 25 minutes of content. But the main theme that we want to focus on is discussing how telehealth is advancing care to rural communities, and each one of your regions, what tools and solutions you've been able to implement, that has led you to deliver care to this particular population. And certainly, it spans a number of different specialties. How have you been able to drive telehealth adoption, and then ultimately want to take a step back and look at what your visions are for the future of telehealth post-COVID-19. And then ultimately, we'll turn it over to our panel. So for our first theme here, I want to start off with Aaron and Dr. Fenton, tell us about how Mercy Health and Mercy Virtual is advancing the delivery of care to rural communities and really focused on serving the access issues for those populations.

Dr. Fenton: Yeah, so I can jump in. So you know, a large part of this is really a large part of Mercy is actually very rural. So you know, it's the south-central portion of our geographic kind of footprint is very rural communities, a long-distance get to providers, etc. And we, we realize this, so, you know, this is where Aaron gets involved the connectivity and things like that, however, you know, even in our more metropolitan areas, so a patient that doesn't have transportation doesn't have access, etc, is, is still in the same boat of accessing healthcare is really still a big task. Regardless of that, they're surrounded by offices and hospitals right around their area.

So it was a big approach, we took it for the complex, chronic group of patients as kind of the first step in this path, because those patients do need the frequency of the touchpoint, but these are also the demographic patients that really can't get access to care because of transportation, lack of funds, et cetera, et cetera. So they started with they called the V engagement platform. And it's a, it's a program where patients are selected based on their comorbidities, disease state, and they get enrolled in basically they have access to health care. at their fingertips, these patients get the iPad, they get a Bluetooth, scale, pulse ox, and blood pressure cuff. So there's a team that's in house that's able to track this group of patients and get parameters or vital signs, You know, they get history from them, they can kind of get a reference point, they can work with them. Now, when we first started off, this was Monday through Friday, a kind of operation with a loose call schedule on the weekend. And we saw going for that, you know, healthcare doesn't stop at Friday at 430 in the afternoon. So we've continued to expand our service lines. And what we ended up doing and kind of the department that I'm over is the vAcute of February of last year, we actually set up a 24-seven in house team that is led and anchored by a board-certified emergency medicine physician, the supported by advanced practitioners, RNs and what we have navigators and so we realized that access to care needs to be consistent, you know, my background in emergency medicine and I see a lot of patients that I understand whether they're being seen in the ED, but I also know that that's really not the most appropriate access point, but it's the only access point. And also you see patients that waited too long, but that rural that drive from a rural spot in Missouri for two hours away to the hospital is like do I really need to go, do I really need to go? And a lot of these patients miss the opportunity. So providing access to care from the telehealth platform and perspective has really allowed us to be able to intervene at the right time. And that’s often in a patient’s home, it's an easy call for them, they can reach out they contact us. And so it's allowed us to reach patients so much earlier in basically to halt the process of decline that is occurring because it's easy for me to admit somebody to the hospital for a COPD exacerbation, heart failure exacerbation, but the reality is, I know that you know, a very, very low-cost medication intervention provider intervention two or three days earlier, would have probably staved off ICU admission innovation, long term care, skilled nursing admin. It's the whole ripple effect that follows. And so that's, that's been the huge thing. So that's been our big approach. And we started with the most complex group of patients, and then realize we can take this even further down downstream. And even though the patients aren't that sick, we've started to create platforms that allow access for patients into our services. And again, the same premise, if we can intervene early, that is always going to be the best case and best thing for the patient.

Jason: Yeah, I mean, you hit on so many different points there the power of remote patient monitoring the power of improving patient satisfaction, can you do something from your couch versus driving three hours for a 15-minute visit? And certainly, sort of the ability for providers to deliver the sort of pre-emptive care that they can to prevent the compensation events? Mitchell, you know, heading over to you for a second, Renown covers pretty vast geography over in the western states here. Tell us a little bit about your approach to rural telemedicine? 

Mitchell: Yeah, absolutely. I don't think it's very different from what Dr. Fenton shared, a lot of it is creating that access, determining the right care at the right time to streamline that, because we don't want patients to delay and not get that care. But, you know, one question that I saw that came in and the chat was a great question is how do you work with some of these remote locations that have internet connectivity issues? And that's one of our biggest challenges. And so what we've done is we look for federal funding as partnering with these rural sites, we understand what's the challenge, What's the need, what's the opportunity. And so we've actually worked with our Governor's Office of Science innovation technology to help apply for these grants to build a broadband network to these communities. At the same time, if we're able to get those funds, we partner together, we'll have Oh sit come in and build the broadband and put the fiber in, right before we come in and do the deployment of telemedicine, where we're just working with that clinic to get that last mile bridge gapped. And then we can create a private connection with that site with fiber so that we have the right level of reliability in the clinic. Now that becomes a challenge as we think about the future, and how do we bring the care to the patient home? And I know that's another topic that we'll be discussing later of what's that future model? How do we use remote patient monitoring hospitals at home with all the technologies in the AI? Super excited for that topic. But that's a little bit of our approach of creating that consistent connectivity bridge. And after that, it's about supporting the community. What are your needs? Is it cardiology? Is it neurology is outpatient? Is it inpatient? What type of coverage Do you need 24- seven, referral-based clinic hours, and really tried to cater our program to help meet the needs of that community. Understanding every rural community has very different challenges, different capacities within their facilities, and different skill levels, as well as staffing levels. And so it's very challenging to have a one size fits all approach. And I really believe it's about having a template and I know the 80/20 rule, we use it a lot. But 80% of what we do is kind of standard template from the Renown programmatic standpoint. 20% of it is working with that partner through an implementation process to understand what are the co-accountability metrics for success? What are the services? And how do we routinely continue in process improvement programs so that we're continuing to refine that?

Jason: super helpful. And I will actually want to come back to you in a minute to talk about sort of those internal stakeholders, those 20 different service lines that you're supporting, and sort of how you intake and really digest the needs of each one of those different stakeholders. But Karen, switching gears over to you. I mean, obviously tons of similarities with the regions that you're covering, but how would you sort of describe the intention behind the delivery of telemedicine, specifically to rural communities from an achromat improving access to care perspective? 

Karen: You're right, we follow a lot of what we've already heard from the two organizations. One of the things Bellin does do is we do send a lot of our physicians up to those rural clinics. But what we're also trying to do through our virtual platform is to allow accessibility beyond when that physician is sitting up there. So if a cardiologist travels up there once a month, we still can do virtual visits to those clinics, you know, every day of the week, we have a lot of connectivity issues. And that's why we do what we can, until we can we also apply for grants and try to get some of this broadband access for all of our patients. But we also try to create a full-service clinic, in our clinics that are located in those rural areas. So if the providers and there is still does not delay care, because they can get in and be seen virtually on other days of the week. So we're always trying to think outside the box to what can we offer when we have some of these limitations occurring?

Jason: Thank you. Yeah, that's really interesting. Mitchell, looking at sort of the 20 service line stakeholders. First off, that's incredible. It's a lot to manage. Tell us a little bit about kind of the various departments that are using your telehealth infrastructure today, and sort of what's been the key to making that kind of diverse stakeholder implementations really successful. 

Mitchell: Yeah, thank you. I appreciate the question. And, you know, I, I think it's about being consistent in understanding the needs. So for some of our distance site specialties, like cardiology, for example, they used to fly out to these rural communities on private charter small jets, and then deliver care. And so a way in the past, we decided that that's too expensive, let's cut costs, we started driving, and then it became Well, how do we reduce the windshield time to create more efficiency and prevent burnout for those providers. And so it's really based on the specialty, the reason why they're getting into telemedicine, but the biggest part about it is not every service is appropriate today with the tools that we have for telemedicine. So it's about creating an appropriate algorithm, that you can take the referral, you can look at the diagnosis and look at the information and determine do I think this will be successful via telemedicine? Or do that? Does this need to be done in person? Is it something that I can maybe Schedule A 15-minute check-in first and determine if they need to come all the way on site? And so that's one of the most important things for being successful with each of those specialties is working with those clinical leaders, determining what are the appropriate diagnoses that we will see via telemedicine, and then refining that algorithm over time. And so we kind of started with a large gray area of diagnosis codes that we weren't sure with. And over time, we've worked together to try to shrink that gray area. And it's not perfect science. But I think we're starting to see some enhancements with through the program and improved efficiency. I think as long as you're trying to work with those specialists to understand what their needs are, what the goals are for each of those communities, it's very helpful, and you can develop it. And so specifically, on the flip side, when you're working with an originating site, it's very similar about those needs. Do they have a clinic Do they have some cardiologists that come on site, but they only need neurology and neurology, they need both inpatient for stroke services, as well as continuing consults, right, that's very different from only needing outpatient neurological exams, which you likely can do a lot of those via telemedicine today. So hopefully, that hits that on the head. But that's a lot of our strategy is really partnering with the physician champion over every specialty, refining that program, and bringing them into that stakeholder meeting with our originating sites to make sure they can speak to those providers in those care teams to make sure it's clear what the limitations are, and that they're willing to see those patients and check in if they can't see them completely through telemedicine and tell them why they feel like it's most appropriate to come on-site.

Jason: Absolutely, very well said. It's the Mercy team. Dr. Fenton and Aaron, I know you also, you know, what's interesting about rural health is it's really a type of telehealth. But within it, there are so many specialties and applications. So it's definitely not one particular type of specialty. But you know, Dr. Fenton, I'm curious from your perspective, as you've helped other providers across different specialties think about how to adopt telemedicine what’s helped Mercy Virtual be so successful in sort of driving physician adoption across a number of different service lines? And to Mitchell's point, it's not a one size fits all solution. So I imagine that you're having to build sort of custom workflows depending on the stakeholder. 

Dr. Fenton: Yeah, it really does depend on the stakeholder and so and I'll be honest, it was it seems like an uphill battle at many times along the way. Because just the whole telehealth perspective in general, you know, you have service lines that existed before that we're not really part of the healthcare system. And so we're always kind of get this point of reference that might look towards that as what we're providing. And then it just it was a slow, slow adoption phase, but we really focused on what our mission was, we chose the right service lines, we chose the right approach. In it, it was getting basically really well adopted COVID has helped us tremendously because it really introduced the concept to all parties. And I, the thing was is, is really getting somebody to even accept the introduction to it, and then be willing to see the process through. and COVID forced the end of that a lot of the offices across, Mercy ended up being close to early during the pandemic. And Aaron can attest to that. And very quickly, they offered up this opportunity to do video visits. And so now you have cardiologists, you have surgeons, you have specialists across the board, attempting to do video visits in getting over that hiccup of this is new, this is unique, haven't done it before, because it is it does take a unique skill set to actually now try to replace your hands with a visual cue, and then walk a patient and sometimes, and a lot of times use the patient's hands to be your hands and guide them through.So COVID as bad as it is, has really been great for us. Because it's it's allowed everyone to see what video visits and virtual health can provide. And then it really is it limited to such things as the ICU, which is Mercy's been doing for well over a decade, you know, it is kind of something that can be spread across. And it's nice because now we have so many divisions reaching out of like, Hey, we as kind of this specialty group would like to see what can be done from the virtual work perspective. And so now you're really having the initiation driving from that specialty source, because they know specifically what we need, as opposed to us trying to tell them what we think would be a benefit. They're reaching out saying this is where our gaps are, and what can be done. And a lot of times we do have a solution for them. Because we've been trying to explore that. So it's funny, but both patients and providers were some of the barriers that existed to virtual health. And so now we've created what I call the new norm. And it's a push because you'll see patients that really just want to prefer doing a virtual visit because they've experienced that they've been through it, they see that yes, this is something that can be done from that perspective. And really, they don't feel like they're missing anything. So on both sides. And so that's the biggest win that we've come out of with this, this pandemic as bad as it's been.

Jason: I mean, the idea that telehealth has accelerated in the last year is faster than it probably would have accelerated in a decade is just mind-boggling. And you also touched on sort of the need in many ways to go beyond video and have video certainly takes you pretty far along down the path in terms of being able to deliver virtual care to patients, but it's the hands of the surgeon that years of a cardiologist, the eyes of you know, dermatologist, whoever it may be being able to really give them the ability to emulate the physical exam that they're used to performing in person through telehealth and Aaron before we move on to Bellin, I would love to just learn a little more about the infrastructure that you've helped deploy across Mercy of certainly over the last year, but over the last many years to help enable this sort of more advanced level of telehealth services.

Aaron: Sure, well, we've definitely made mistakes along the way, over the last 10 years. But then you know, anytime you jump into new infrastructure, new technology, you know, you just that's part of it, you know, and we've kind of, you know, make, like I said, we've made mistakes, we've gone down the road of, you know, trying to do a proprietary solution. And you know, it really where we're at now, what has really worked well, especially the last three, four years is having a mix, because like Dr. Fenton said, rather than the IT team trying to tell your physicians what they need and how to do it, you know, it's really Hey, you come to us, tell us what you need. And then we'll design the solution around that rather than, you know, here's what you get, now figure out how to, you know, create your clinical workflow. But the key to that, and from an infrastructure perspective is, for us has been finding something that's agnostic enough to be able to, you know, go on multiple devices, it's not just locked down to an iOS or an Android or, you know, it may be a browser on a Windows computer, it may be a browser and a Linux computer. But having the ability to have that connectivity Whether it's a patient device or whether it's you know, dedicated hardware endpoint on a wall in an ICU or a mobile cart, it's been moved around, you know, really having whatever solution you know, you're going to implement, having it fit, at least in you know, in the scheme of things, having it fit to be able to connect all those things. We've had a lot of programs where we'll start it up and it'll go for, you know, six, seven months, and then they'll kind of pivot. And all of a sudden, they now don't need a mobile cart. Now they need, you know, 14 rooms, you know, with dedicated stuff in it. And so it's, you know, that's, that's always gonna happen, you know, healthcare changes. And so having solutions that you can quickly and easily shift and pivot to and use for other things that that's key for us. 

Jason: Yeah, absolutely. Karen, in our past conversations, we've talked about sort of the need for providers to get clear heart and lung sounds as part of virtual consult. And certainly, you know, full disclaimer we’re biased on this particular topic. But we've we've spent a lot of time sort of thinking With you around sort of the power of that to enable virtual cardiology pulmonology, could you just share a little bit about sort of how you ultimately decided to sort of implement and what would you think, is not the ideal situation where you would implement a separate stethoscope solution from your video conferencing solution, but sort of the power that’s been able to bring to your visits? 

Karen: Yes. And like I said, I've only been in this room about three years. And I knew because it was pre-COVID. And because we're by far more mature than the groups that are presenting today that solid equipment was the key game to getting this going. And they had already gotten a grant and invested in this equipment. But the stethoscope provided low-quality sounds for our providers. And so when I stepped on board, I knew that if I couldn't raise the bar in that level, that was going to be an easy reason not to do it. And so we introduced the Eko to our program, and it's made the difference. And, and as I said before, that you've made my job that much easier. Because is the first important piece, if you don't have equipment that works, the hill to convince someone to do a tone medicine visit is even greater. And providers of my cardiologist have said, my goodness, the scope is better than what I have here in my own clinic. So that's where I'm on an advocate of you get that solid equipment in there. And then hopefully, that's half of your battle. And then it's working with the providers to try it. For patients to accept it. We had a patient that really wasn't convinced telemedicine was for him. But once that provider could say, Oh, I can hear the crackling in your lungs, made all the difference for that visit and became a telemedicine believer. So I am a strong proponent for having solid equipment to help those visits become successful because the provider can offer all that his skills and knowledge. But if your camera's glitching, or he's not really catching those sounds and you know, you kind of can see it since that is the questions he's answering, it is hard to make that a successful visit, even though it still was maybe a very successful visit. But the scope has opened that door for us to provide a great visit and a confident visit for all those involved.

Jason: I mean, it's certainly an example our team is proud of but the reason I bring it up is that it really goes to driving physician confidence. And, you know, if providers don't fundamentally believe that they can emulate the same quality of care that they could in person, it's unfair to ask them to really do telemedicine consults both to the patient and the provider, despite all of this sort of other ancillary benefits.

Karen: And that's what they were, they were using those elements as a barrier. No, I need to hear that long song. And some of the groups we brought up that are almost 100% rule is our prepare group that is key to that visit. So these those visits wouldn't be taking place if we didn't haven't deployed the actual scope. Because the other one was just such a weak quality I kept, you know, thinking there was something wrong with the equipment, but I think that was, you know, just the level it was at, but it definitely builds that confidence that they are standing right in that room almost with that patient here and what they need to hear.

Jason: Mitchell, you know, outside of just cardiology and pulmonology with these 20 specialties, what has been sort of the, launching the program is one thing, but have you really worked with the clinical stakeholders to make sure that they're getting the level of data that they need to make the decision really derive confidence in the infrastructure? 

Mitchell: Yeah, it's a great question. So for every specialty, we still have what we call our special handling instructions in our previous requirements. And so with that, for telemedicine for every visit, there's a certain labs diagnostic based on the diagnosis for the referral, that we're using an algorithm to request the patient get those tests done in advance, that allows the provider to review that just as if they would for an in-person exam that also keeps revenue in those rural communities because of those diagnostic tests that they're able to bill for. And so with that you're creating a sustainable structure that scalable across both the rural partner site as well as the urban hub site. And so that's a lot of what we've done. And as we do that we bi-annually review those expectations, the labs, the workflow with every one of those specialties, clinic leaders, as well as administrative leaders, so we can understand, are you guys being able to build successfully, what has been the reimbursement what's your payer mix, and really look at the capacity. one thing we're really big at right now and trying to improve on is our demand-supply curve across all those specialties. And with that, we're looking at the completed visits based on the block time from providers in comparison to the referral volume for the demand. And we know that one referral for somebody’s specialties can be multiple visits. And so it's not apples to apples. But given that our access, our demand is much higher than what we're able to deliver today, it demonstrates the need to expand and become more efficient. So from that part, that's some of the metrics that we use with each of those individual specialties to look at, is it successful. But on top of that, we have provider feedback, presenter feedback, and patient feedback from every visit that we request, as well as specific technology challenges that our IT team and the partner IT team should be reporting on. Daily, we do QA tests, prior to every morning of scheduled visits, and weekly for the on-demand services such as telestroke, and tele psych so that we are staying continuous with the quality of technology and making sure that providers are re-educated retrained on the workflow, as well as having the opportunity to check in with the providers and see has a service been working well, what are some opportunities for improvement. So that's typically how we try to gauge the feedback and continue to improve the program over time.

Jason: That's great. You transition perfectly into sort of our second to last topic here, which is sort of tips and tricks and strategies to help other telehealth programs really begin to think about how to how to track and demonstrate value, not only to the clinical stakeholders into the patient but even the broader health care administration. And you want to turn it back to Mercy. You all have built certainly one of the largest virtual care and telehealth programs would love to understand sort of how you continue to track the value across a number of different axes that the program is delivering. And without going into too much detail, sort of what advice would you have for other telehealth teams really looking to report up? How this is changing, not only the quality of care but also from an economic perspective, the value in striving?

Dr. Fenton: Yeah, I can say Mercy actually has a lot of at-risk contracts. And so really looking to transition from volume based to value-based care has been the drive. And so they the initial startup with the whether we call it the engagement or the chronic care program was really tried to take a look at this and that and it's kind of a moving target. And in regards to we were looking at, are we able to reduce hospitalizations, are we able to reduce, you know, if the patient was hospitalized, did they have a shorter hospital stay, because we actually were able to get them into the right place at the right time. And Ed utilizations one of those things. So that is a very hard thing to track. You know, we with the primary care physician started doing the video visits and their billing for those services, we're currently not billing for a lot of the care that we're providing out of the hub, the virtual hub itself because we're looking at it from the perspective of like, we need to create patient access. And so, you know, we will be looking towards leakage, you know, if we've got patients looking for access to care somewhere else besides Mercy, why is that? What can we do? And so we're those are some of the pieces that we're really starting to look towards. There, there was an analytical approach to this. But there's also a lot of really get it got to have some faith that what we think we're doing is the best thing in and realistically, we can wholeheartedly say, this is the best thing for the patient. And we're very confident from the financial perspective, it will show back in the returns does in regards to our overall spend per patient. So they've demonstrated there's been about a 50% decrease in Ed utilization and hospitalization when a patient is enrolled in that V engagement platform because there are frequent touchpoints. We can follow vital sign trends, we can intervene much earlier. And so that's been an ability to grab that some of the other programs and platforms are a little challenging my 24-seven program is we're here to provide access to patients. And you know, I look at it we actually launched we launched the beginning of February of 2020 And then COVID hit. So we quickly ramped up a COVID at-home monitoring program. So patients were able to receive text-based messaging for a two-week interval. And if they alerted, then that would come to our team, and we'd reach out to these patients. And so we had 40 plus 1000 patients enrolled in this platform, we spoke to over 6000 of those patients alerted, there was a higher need. And of those 6000 plots, were able to keep the vast majority of them at home, because a lot of it was trying to say, hey, do you really need to go to the hospital, what level of care Do you need? And our ED physicians were on the front lines too. So they work both in clinical as well as virtual. And so we were able to attract these patients say you know what your two sets are actually at a point where you're not going to qualify for hospital admission, so you're safe to stay at home. But then again, we can track and you can reach back out to us at any point in time. So from a healthcare perspective, you know, we have less than 400 patients who were referred to the ED during this timeframe from our platform. So we're able to really triage through several 1000, whittle it down to a small group. So from that impact, we're at a point where the hospitals are filled. They're struggling, you know, from a bed capacity perspective, with many different factors. And so we're able to keep a large number of patients from going to the acute care centers because these patients were being treated in the PCP offices, they were being directed to these higher levels of care. So even though you can't, you could say that financially, we, we may have taken money out of the health care system, health care system didn't have the capacity to manage these patients anyway. So ultimately, again, what was the best thing for the patient, keeping them at home when it was appropriate? So we know there will be financial benefits along the way because it just exemplifies what the virtual platforms can do.

Jason: Yeah, super helpful. Before we move on to our next topic, any of our other panelists want to offer some perspective on sort of the quantification of value, either from an economic or you know, from a more value-based type model for your respective programs? Then we're going to talk about life after COVID. But I think this is a really relevant topic for a lot of folks. Yeah, Mitchell, go for it. 

Mitchell: Yeah, we have, I think we're in a very similar boat as Dr. Fenton, the transition from volume to value. But a lot of what we're taking is using those surveys, you get some anecdotal data about where would you have gone for care if telehealth wasn't available specific for urgent care? And so with that, we can kind of model out what would that expected cost of care be based on that setting that that patient flag there? And so that's one way that we can look at and try to quantify the impact across Urgent Care specifically. But in other areas, it's very similar to what Dr. Fenton said, it's really about just trying to define what those success metrics are. And look at what drives the most value. One way from a population health perspective that we look at it is what's the decrease in windshield time? And with that the pollution? I mean, as a country, we really need to think about that more and more, how can we reduce that pollution that we're all exposed to? And so I think that's maybe not at the forefront of what we're thinking of because we're so focused on managing the care that patients, but it's those social determinants, those other factors that a lot of times drive the necessary care and utilization for those patients. So I think that's another way we're trying to explore what's the public benefit of using telemedicine and how will that holistically change the care for the community?

Jason: Yeah, I love that. I hope someone comes out with a report on the environmental benefits of telemedicine. I'd love to blast that out. That's amazing. Karen, any final thoughts on this particular topic?

Karen: No, I strongly support what the two other presenters have said you know, that it is just really trying to be more efficient. And give the patients as early as we can in their care and prevent them from consuming the urgent cares and the ER rooms when most of the time they're being turned away anyways, so now they were exposed to anything else that might have been there. But you know, it's a tough challenge because especially here in the Midwest, you know, when they're not a lot of those usually using those technology pieces, it's hard to convince the patients that this you get a still solid visit in this using a virtual opportunity.

Jason:  Absolutely. I want to take the next three to five minutes here and we're going to put up a quick poll and get thoughts from our audience but also from you all and sort of where we're heading next. So I think, first off, it'd be great to understand what percentage change in telehealth visits do you expect as we move past the COVID-19 pandemic, so I think it's probably safe to say you saw a pretty extreme spike during COVID. But where do we see us going from here as an industry? To give folks a couple, couple minutes to answer the questions, but while we do I mean, let's survey some of our panelists here. Mitchell, what are your thoughts as we sort of recalibrate post-COVID as sort of the new normal, as Dr. Fenton said. 

Mitchell: Yeah, you know, it's really interesting, we've seen our rates of total utilization for outpatient be below 1%, when COVID hit to upwards of 50 to 60%, at times when there were the largest spikes. And so we're seeing that kind of renormalize in between there, I think for us, it'll probably be somewhere between 20% would be a fair target for this next calendar year. But as we continue to think about moving further and further into the future, I think we're just going to see that number continue to increase because, at the end of the day, it's about getting the right care at the right time. And we don't want time or place to be a barrier to care. And so the more that we think of it, the more I believe care is going to go into the unknown setting, which is the patient's home, the patient's care, the patient's work, and that's where we really are going to see an uptick of utilization with virtual services.

Jason: Absolutely. How about for the Mercy team?

Aaron: Yeah, I agree. It's from a technical perspective, I mean, just look at the raw numbers. And in the summer, we definitely spiked, you know, in the summer, but we didn't go right back down. I mean, we're still up there, even as things are coming down from a COVID perspective, but we're at least triple the number of video visits on a daily basis than we were in February of last year. So it's, it's not going down and the number of requests for new telemedicine equipment on my desk, it's definitely indicating that as well.

Jason: Yeah, yeah, when you look at the results, I mean, upwards of let's just say 60%, say that it's either going to stay the same or increase. And if it is going to decrease, not by a whole lot between 10 and 20%. So that's really interesting. Karen, curious to get your thoughts on this.

Karen: I know Bellin strategy is that we're going to continue to push forward with the video visit opportunity for all patients, you know, we're doing, you know, going into the homes, getting into those nursing homes, whatever it might be, because that's kind of the wave of the future, too. We need to stay as aggressive as what other organizations offer. So we definitely have increased immensely with our video visits versus pre-COVID. We have dipped slightly, but the push from leadership to all those below our we need to continue to offer and to encourage patients to consider it, you know so that we can give them the care that they need.


Jason: Absolutely. Well, on that note, I want to thank you all for this phenomenal q&a or panel discussion in the last 10 minutes here, opening it up some questions from our audience. So I'm going to quickly sort of peruse some of the questions here.

Q: One of our audience members wanted to understand the role of telemedicine to enable virtual neonatal and prenatal care in rural communities. I think that's a really interesting conversation. I would love to see if anyone has specific thoughts on that particular use case?

A: Mitchell: I could jump in from a high level say that's a service that we are still actively trying to get back relaunched. It's a service we had available for a brief amount of time. But unfortunately, just because of capacity, we weren't able to continue expanding. I think prenatal care is something that is often overlooked. And so for us, that was the goal intent for why we wanted to pursue that and are looking to pursue it, again, is to bring that prenatal care to those communities. And really, you don't want a pregnant mom to be driving in two hours. For a prenatal care visit, you're going to have potential complications, advanced risk, or increased risk, I should say for that member driving all the way in and driving all the way home. But at the end of the day, if we can keep them comfortable and get them the right care, they're more likely to receive the right level of care and support. And so they're more likely to have successful delivery and outcome at the end.

Jason: Absolutely. Dr. Fenton, just some thoughts on that. 

A: Dr. Fenton: Yeah, I was gonna jump in on that. It's one of those where, when I first was introduced to the concept of virtual, there are so many things that we wanted to explore and go into and in and I can say we've tried some programs that we've had to temporarily kind of shutter just from a volume perspective because it is each of these little entities really has the need. And we can define the need it starts to become though, do we have the volume to do it? And can we start to cluster? Because behind the virtual visit is always a provider? And where does that provider come into play? Is that a portion of practice or kind of like our virtual Care Center is this our primary practice. So as we get bigger, it allows us to now start to cluster some of these platforms together from a, say, a pediatric perspective, we don't have to just focus on this type of Pediatrics, can we expand it to a full-fledged pediatric service offering that cover each. And that way, you're not so isolated, so specialized and in, and that's been the value over these past years, as we've grown bigger, our team has taken on many, many things that we couldn't do before because it did require the 24 seven commitment piece to say, we're going to do this, we have to do it the correct way, and really not provide subpar service. And so, but there was there we used our NICU, there was some approach in the NICU and trying to get expert advice in there. But again, it was such a small niche that it was hard to really provide enough data, enough information to say is this really something sustainable? But as you start to now say these three offerings together can equal a full, like full-fledged service line. Now it's time to start approaching that again.

Jason: Yeah, what one of our, one of our audience members, Stacy, brings up a really interesting point and that there are many FQHCs out there and provider groups who do not have robust departments that can help enable these telehealth implementations.

Q: What resources would you recommend a turn to really launch sort of lower touch not as their lower touch but simpler telemedicine deployments that are potentially easier to get up and running?

A: Aaron: Cloud, That's my answer. Yeah, don't mess with trying to host your own. Anything cloud-based right now is going to be your key and trying to quickly and easily deploy and support. I mean, we are a fairly big organization, but still, there's only about six of me covering 44 hospitals and you know, 400 clinics, so it can be done. And you know, the remote aspect of it is also key, you know, just like it is for the care, the support as well. And so, you know, finding solutions that are easy to remote control, and that is easy to remotely manage and monitor is will pay off tenfold. You know, we've had systems that weren't that great at it being in remote monitor and manage and so much time wasted, just physically driving decides to, you know, to reboot machines and things like that, that now, you know, we have one maybe once every three months now, that that I can't fix remotely, you know, one device that I can't fix remotely. So that's a huge piece of it. Especially if you're a smaller shop and you know, you don't have a whole lot of resources, anything you can do to make it more efficient, and being able to remotely manage and control those is going to be key.

Q: Jason: Robert from our audience asks about the interoperability of telehealth distance AI providers being able to use the medical record and I know everyone on the panel today as sort of an integrated telehealth program with the health system and likely access to the health record. But I don't want to make that assumption. So we'd love to hear your thoughts on sort of access to the medical record. And then your thoughts on on sort of more broadly, telemedicine even direct to consumer apps that are swept somewhat disconnected from the medical record and sort of what the what your thoughts are on that.

A: Dr. Fenton: I can jump in because I kind of will talk when I'm discussing virtual health. And not that it's an exclusion point. But I say the reason we are able to function to the level that we are functioning is that we all share the same medical record. It's imperative for us to do it. And it slows us down when we don't have access. We try but that's the key. This is where, you know, I come from the paper charting era where we had carts of charts wheeled off to us to look through. But we couldn't live without the EMR now in the medical record is not only a source of information about the patient, but it's also our communication tool. So when we're evaluating a patient and we're adjusting diuretics or starting the patient on steroids and antibiotics, we will then message the PCP the cardiologists pulmonologists. And so it is our common thread which allows us to function at the volume we're addressing, but also at the level that we're trying to attain. We've got some platforms where we do have patients that that don't really have distinct ties to Mercy that come in. And it does pose a challenge. Now that being said, it doesn't mean you can't do it, the bigger question is, what is the focus of what you're trying to achieve? So is it for your patients that are existing? Is it for new patient acquisition? And then you really need to tailor your platform and your overall design to accommodate that, knowing that there are limitations from either way. 

Jason: Mitchell, go for it. 

A: Mitchell: Yeah, I love the job. Because we actually have that challenge across our program, where we have a handful of the sites in the real community are Renown clinics, a majority of our partners are standalone, rural health clinics, rural hospitals, the prison systems in Nevada, California tribal health communities. And so with that, we have this issue of working across multiple disparate EMR systems, and it is a challenge. But what we've done is we've created a process that requires an EMR, it's not the best process, I'll admit it, we want to improve that making it more automated and digitize. But to Dr. Fenton's point without having that medical record, the provider can't make the best clinical decision. So we're getting that sent over with the referral. And in addition to all the lab results, their EMR record from that originating site, we've stored in our records, and we provide access a view only to our partners so they could look in. But we also make sure that our providers, we have a team that assists with ensuring that that is sent back to that originating site after the conference so that there is that exchange of EMR information and documentation, absolutely want to automate that as we move forward. That's a big gap for us. We'd love to be where Dr. Fenton and Aaron are where they're fully integrated. But that is a huge challenge. But I think you can create workarounds. And if you want to get it down, you just need to find points of contact that can hold the teams accountable to get that information flow across because it is very valuable.

Jason: Absolutely. And time for one more question. And we received over 30 questions. So there would be no human way to get through all of them. But I’m really so happy to the audience was engaged. And we will do our best to follow up with these either ourselves afterward, or hopefully lean out to some of our panelists for expert advice.

Q: But you know, the last question is, many patients in these rural communities do not have access to the bandwidth, or the technology they need in order to leverage these telehealth services. And I'm sure each of you has sort of touched on this in your own department. So give us your 30-second insight into sort of how to overcome some of these technical issues. Mitchell, we'll start with you because you're unmuted.

A: Mitchell: I think it's uh, looking for opportunities with grant funding, as was looking for opportunities for centralized locations, in some of those rural communities. Maybe you don't have access at every patient's home that you can build. But can you put a presenting location in a library in a school in a place that everyone can access it, that so that it's easy to get to, for those that can't do it at home? But just the challenge for any vendors that are on the call? One area that I am struggling with? is seeing if we can create a proactive predictive model that can say based on the patient's experience, the social determinants the type of phone they have, where they're located, what's the likelihood of success for them to connect via telehealth and or what's the likelihood of support that we need there so that we can engage and staff that appropriately and for some of these elderly patients that have connectivity issues? Can we connect with them 20 minutes prior to help them and guide them through the process and make them an expert for the future? So if there's anyone out there that has an algorithm that can do that, please reach out to me, I'd love to hear about it. 

Jason: Me, too, would love to. Karen, we'll turn it over to you. 

A: Karen: We, just like Mitchell said, we are definitely looking at grants to see how we can support our patients in those rural areas because most of them don't have the bandwidth or they don't have even any of the equipment. So we are definitely doing that as well as trying to create that central location so that if patients don't have it, they can go someplace and receive it and even use in some of the clinics as even if they're coming in not to see those providers, can they come in and use the bandwidth for other visits that they may have? But then we also make sure that we have that strong program that's within the clinics that if they need to provide a connection with another provider, they can come in and receive their care that way. I mean, it is trying to think outside the box as to what can we do to make a positive change?

Jason: Mercy team, anything to add on to those great ideas? 

A: Aaron: Yeah, I mean, I 100% agree with all that. The thing has been helpful for us as the clinic-based, you know, the central approach, even if it's not, you know, necessarily where that patient normally goes. But having an exam room. It's kind of a dedicated, you know, telemed room with a, with a full set up in it. That's, that's been helpful. But even like on the, you know, the engagement at home piece, you know, we've got customers that are in patients that are, you know, in the middle, you know, Valley, you know, there's just no signal for you whether you go LTE or anything. And, you know, unfortunately, it just, it's that last mile that is still struggling, but you know, not to to tout a specific one, but there is a very big, upcoming solution out there via satellite that you guys should go check out if that is if you've got one of those areas that you just can't get into.

Jason: That's awesome. Yeah. Well, we're looking into it. I couldn't have imagined a better panel. Thank you all Aaron and Dr. Fenton, Mitchell, Karen, it's an honor to work with all three of your systems. Thanks to everyone that tuned in today, we will put up a recording of this webinar for folks to lean on for advice and as a resource later on, and I hope everyone has a great rest of their week.

Thank you so much. Thank you, Jason. Appreciate it. Thank you.

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