April 2023 - CMS’ Emergency Triage, Treat, and Transport (ET3) Model (Mark Gamber, DO)

- And welcome everybody. It's April, April 11th already of 2023. And we're really excited here in our monthly telehealth section meeting to have Dr. Mark Gamber speaking to us about ET3, their experience with it. And I think many of us are aware of ET3. We were aware of it when the applications or requests for proposals went out, a lot of us scrambled to think, should we apply or not? And we now have been through some experience with it now, not me personally or my program, but others here. So Dr. Gamber, I would like for you to introduce yourself and please take it away about the next 15, 20 minutes presentation of your experience. And then we'll have open Q and A time then, so.

- Sure, hey it's great to see everybody. And so my name's Mark Gamber. I'm board certified in emergency medicine. The background noise here, we'll calm down in just a second, I promise. I've been out in practice for about 20 years outta residency. I did my residency at Scott & White in Temple, Texas. I work at a tertiary care center in Plano, Texas. My background is, I served as an EMS medical director for Plano and Frisco fire departments in the North Dallas areas, about 600,000 people. I've been doing that for about 15 years. And I spend about two full days a week just out teaching CE and doing ride out. So trying to be very involved in the EMS community and doing EMS Telehealth has kind of been the perfect synergy of a couple different jobs between practicing clinical emergency medicine and having a love for EMS. And this really allows me to connect with medics in a different way. For years, I would just take phone calls from medics on scene with whatever bizarre situation would come up and I'd guide them through by phone. This has been an opportunity over the last couple of years to actually have an audio video interaction in a formal way with medics and with patients out there that are being treated in this pre-hospital setting. So I've got some slides that I made for this and I've got some slides that are left over from a presentation that we did a few months ago at the National Association of EMS physicians, which I'll just share with you. And then I think Emily, what we're shooting for is maybe I talk for about 20 minutes or so and then take some questions. Is that correct? Okay, perfect. So I'll just kind of motor through the slides and I'll do screen share here with the caveat. Screen share is always funny 'cause you never know which one of your background things is gonna pop up first. So we'll see what the teenagers have left on screen underneath here. Good, the right one popped up. Great, so I like this slide 'cause it's a bit of an intro into the problem we're trying to solve. So as a ground 911 medical director over the last couple of years, the agencies I work with had kind of increasing offload times in ERS. I think we're all probably experiencing that, the cost of labor for medics has probably doubled. The equipment costs and the shortage of medications have all been a problem in EMS, just like they are in the er. We think EMS telehealth of which ET3 is part of that. But I'll broaden the term from ET3 into more EMS telehealth is a good solution for some of these issues. So full disclosure, I work for Envision Healthcare and with this group, I'll show you the picture of all of our docs. We've come together from all over the country to form this virtual emergency medicine group. And just like I have a brick and mortar emergency medicine practice with all of my partners here locally, I consider these folks my partners, even though I don't physically see them very much. We all practice emergency medicine. We cover a virtual emergency department 24/7, 365, taking calls at four in the morning on the weekend, on Easter, et cetera. So it's not just an eight to five gig, this is 24/7 coverage. And with virtual emergency services we do a number of things. So if we get a call from the field from EMS, that's an ET3 like engagement, although ET3 was really started just for Medicare patients. We treat this program like we do the emergency department, we take whoever they send us. We don't do a wallet biopsy, we just say, send us whoever you want and we'll see them. So we have an ease of entry point with that. You call us, we're happy to see the patient. And with nurse navigation, we work directly with dispatch centers that have nurse navigation and they can connect a patient that's called 911 with a low acuity condition that's appropriately triaged over to us. So they're not gonna connect us with a chest pain patient from nurse navigation. But if a patient calls and they say, I've had to fungus for six years and today is the day I'm gonna call 911 about it, they might connect us with that patient to talk to them and we might help avoid all the downstream implications because then you're not even rolling tires out to that call. You're actually taking care of the patient and connecting them with some good advice. We have a prescriptive ability with the software that we use. Somebody calls and said, I'm worried I'm outta my Glucophage. That call from dispatch can be connected to us and we can refill that for them without them having to have an ambulance take them to an emergency department for a refill of Glucophage. We can serve as a virtual urgent care. This is more theoretical, as you think about the use cases for virtual emergency physicians, I think it's a really interesting discussion. I mean there's APPs out there in rural environments that could probably use help with a consult from a virtual emergency physician. So we think there's a use case in that environment, although we're not doing that actively right now. And then as practicing emergency physicians, we all see a lot of referrals from nursing homes. A lot of those referrals typically generate like this, the nurse calls the doc, the doc says, just send them in to get checked out. It'd be interesting if we were available for a video visit. And so we're starting to do that a little bit with some nursing homes to be able to see the patient potentially treat them in place rather than have them transferred to brick and mortar emergency department for a low acuity condition. This is our data for cumulative visits over the last couple of years. We started in February of 2021 and you can see that was a whopping month for us. We saw one patient, so it was slow going, but we had to have 24/7, 365 coverage because that's how this was supposed to start. But it's grown slowly over time. So we're up to about 400 patients a month, which is, multiplying, that's about 13 patients a day. I would say two thirds of those patients call during normal human waking hours and about a third of those are after we're asleep. So we have to have coverage to pick up those calls. And so we, we've got that 24/7 365 coverage. We did divide that out for different ways, different sources of patients. But our ET3 patients are the vast majority of the patients that come through.

- Is that your volume at one hospital or across like all envision sites with ET3?

- So, CMS did about 200 ET3 awards and we're partnered closely with GMR on this. GMR had about 61 of the 200 ET3 sites. So that's all the sites. So we have sites that don't call a whole lot and then we have sites that call more frequently. But yeah, that's our total volume for the program. And you can see from a payer perspective, we're happy to see whoever's sent us, initially, we were just doing this as Medicare patients only. That's a challenging population age 65 plus, generally comorbidities. It's more complex visits and some states are adopting, Medicaid is adopting this process. We're starting to see some commercial payers have interest in this process too. And so really our approach is we're happy to see whoever EMS sends us, whether it's a traditional ET3 Medicare patient or beyond that, we estimate a pretty significant savings from treatment in place compared to transport. We estimate a pretty significant operational time savings as well, particularly as you get into sites that are more distant from hospitals. So if you're out in a more rural environment and you've got a low acuity condition and your transport is 45 minutes to a hospital for that low acuity condition, you're saving an hour or two of round trip ambulance time and saving them availability for the higher acuity call. Our typical time engagement with a patient is about 10 minutes on video. Our response time over the last two years is about 3.2 minutes. So that's from the time EMS notifies our physician group that there's a patient in the queue until the time we answer. And the general concept is my phone rings when EMS puts a patient in the queue. I'm on within about 3.2 minutes to talk to them to engage with the medic and the patient. They do a verbal handoff, fairly similar to what we would get in the emergency department. It's just on video. And then I take over and talk to the patient. We exchange vital signs and if we need to send in a prescription, which I do in about a third of the patients, then we take care of that and send it in for the patient as well. But this is just a general workflow of how it works and I'm just try and keep moving 'cause I know the time is limited. So for low acuity conditions, we're pretty successful at treatment in place with roughly 85% of the patients who have low acuity conditions we're able to do treatment in place. We've got a list of low acuity conditions on the right side over there, highlighted in blue at the bottom left is the states. And that's one of the challenges, right? We have a group of expanding to 16 physicians to cover 24/7, 365 and we're all licensed in approximately 20 states, which takes a lot of time and effort to get that many licenses. So we've gotta be licensed in every state 'cause we're practicing medicine there. And you gotta be ready to cover anything from anywhere, essentially. All of us are board certified in emergency medicine. We're all physicians. This is just a, you may know some of us, Michael Baker's pretty involved with ASEP nationally and he was kind enough to invite me to come to this. And I can say he's been an incredible friend and partner, but just a good group of experienced physicians. One of the things we try and recruit for is to either have a telehealth or an EMS background too. It's just different, talking to medics in the field and understanding the challenges they face and the interactions they're having is important. We try and be involved in sharing data, just like I'm doing with you today. There's not many people out there doing this right now that are sharing a lot of data. So my approach is, here you go, here's the data and here's what we're learning because I'd like to craft an environment in which we can all continue to do this. I think it's valuable for EMS in patients. We put out a white paper, I've got a link there. We are doing presentations at National Association of EMS physicians on our data as it comes out and we're trying to produce some articles on what we're learning so far. Here's just a case example, EMS gets to scene and they've got a 14 year old, the 911 call was initially for some mildly aggressive behavior. It turns out the patient's been out of their medications for a few days. Good conversation with the patient. The parents, patient was alert and oriented. The the parents really what they wanted is to know if they could help get him back on his medications and they were having trouble accessing primary care or psychiatry. So in this case, once we determined the environment was safe and appropriate, we can send in a prescription for that patient and have a discussion about how they're gonna follow up. But we can bridge the gap a little bit. Now that's a little more complex situation but you can extrapolate that to lower acuity conditions as well, such as a sore throat, congestion, et cetera. We do try and absolutely practice evidence-based medicine. We have group approaches on how we're gonna treat things like URIs and sinusitis that do not always include antibiotics as well. Patient experience has been good. We try and measure patient experience as much as you can get people to answer the phone when you call them and follow up and see what they thought. But this has been our patient experience metrics so far, I just wanted you to see that we are trying to track them, operational considerations. We treat this like a real group. We have a peer review or what we call a safe table. Anybody can refer cases to that. Whether it's EMS, whether it's a local medical director. This is an interesting shared practice of medicine. Derek Cooney in Syracuse, New York is the EMS medical director up there. It's gotta be interesting for him to have a group of virtual physicians float in and take care of patients in his environment, right? I I would think the same thing as an EMS medical director in Plano of a virtual group floated in and helped take care of low acuity patients. So I have a lot of conversations with local medical directors trying to earn their trust, trying to have a back and forth discussion, ask how they think we're doing. We try and be involved in front end education with the medics as these programs go live and anybody can refer peer review cases to us for us to look at. There's a lot of technical troubleshooting 'cause a lot of the electronics and software for this are version 1.0 to be able to do audio visual telehealth. I'm on my home wifi right now, so it works pretty well. These medics are not on their home wifi, they're out in the field. Some of them are in the third floor apartment building trying to bounce a signal down off their ambulance and then up to me. So there's a lot of tech challenges to get enough bandwidth to do a good audio video visit. It is very different, you guys can see me, I could have three people standing behind this computer right now who are listening and nobody would know. So imagine if I'm talking to a patient and there's a bunch of family members in the room and I don't know. It's a very different practice of medicine than brick and mortar medicine, I felt like I've gone through a residency again the last two years to learn how to command a room when there's folks in there that I don't know, we're in there. We don't prescribe controlled substances, we just do non-controlled substances and we have to make sure that each patient consents to see us. We have a QA process, I won't go into that too in depth, but I just want you to know we have one and benefits of this, you know, it's patient centered care. Patient's been very happy with it. You think about somebody who doesn't have to leave their house and maybe their children because they can get their issue potentially fixed in place. But I also don't want you to think that we try and treat everybody in place. Some medics, they just don't have the death of experience we do. And when we're talking to them, we realize that that chest pain is probably not musculoskeletal, it's not something that's safe to treat in place, the 21 year old medic that might think dizziness is just vertigo, we know it could be a posterior stroke. And so I think one of the big ancillary benefits of this program is not just good patient care, but it's like virtual shadowing from a medic with an ER doc because they're listening to me talk to the patient, they're hearing what I'm talking to the patient about with a differential diagnosis. And I think they're picking up on that and going, okay, I just heard a board certified ER doc talk about dizziness in the context of potentially a posterior stroke, not just vertigo, I gotta keep that in mind for next time. So I think we're educating the next generation of medics on how we think. And it's not just the medical, it's the social determinants of healthcare that we're educating them on. I can take care of somebody all day, but it doesn't matter if they don't have a ride to get their prescription filled and they don't have anybody to keep an eye on them and they don't have any diabetic testing supplies. And so when the medics hear me talk to patients about the social determinants of care, I think it perks up to some of the things that we think about as ER docs, providing good kind of broad care base for patients. There's really interesting use cases when it comes to public health emergencies. Brian Clemency is the EMS medical director up in Buffalo. We helped them out a little bit I'd like to think, they've done the vast majority of the work, but there are people that snowed into their houses, they can't get out. We can video in and try and help provide some advice to those folks too. So we appreciated the opportunity to talk to them. We've had hospitals, we've had towns where the only hospital in town got shut down with ransomware and now EMS had to figure out if they're gonna transport two hours to the next town. And so we tried to help there with some of the treatment in place decision making as well. Another interesting use case for virtual emergency medicine that we're starting to talk to some locally EMS medical directors about is the high acuity refusals of transport. What if I'm having chest pain and my wife calls 911, she wants me to go to the hospital and I don't wanna go, well you could bring on a board certified emergency physician to talk to the patient and say, hey, now here's your risks if you don't get evaluated for chest pain. And when we're used in that case, we're pretty successful in reasoning with patients about the value of going to the ER. So I kind of think of us as a retriage service sometimes for low acuity patients able to keep them at home. But for high acuity patients who don't wanna go, I'm telling you as in as an EMS medical director, those are the bane of my existence. The guy who's had three beers in his coumadin and fell and hit his head and he doesn't want to go. That guy needs to go. And we can also be used to potentially talk to them a little bit. So obviously I could talk about this all day, but I've hit about 20 minutes so let me stop and hopefully I've stimulated a couple questions and I'll answer whatever you got.

- Awesome, there's actually a few in the chat and several being direct messaged to me too. So I get to be the host and say that or I'm gonna have person writing to me can maybe ask some of these too. But if you wanna look at the chat, there's a question from Alex and Peter about how do you work with all, like you're not just in one area, you're in multiple states as you showed and each one of these states have different cities, different protocols. So how, how do you, in a minute and a half or less, how do you work with all these people?

- So we have a pretty standard protocol that we share with people, if they wanna modify it a little bit, we can do that. But we can't do really broad modifications 'cause you can imagine, I've gotta kind of have the same set of rules wherever I video drop into. So broad strokes, we'll see age six and above for ET3, they gotta have reasonable vital signs and we lay that out, you know, from a pulse of blood pressure, a pulse ox perspective. We lay out high acuity conditions that we don't think we should see and low acuity conditions we think we're good at and we've put that into a protocol. I'm happy to share that protocol with anybody. Emily, I can send it to you and you can disseminate it. The way I look at this is information sharing is good.

- Awesome, thanks for making that quick. We have several others. I have a couple I'm gonna ask, but why don't we have John Berkowitz, do you wanna go ahead and ask your question and then after that I'll intersperse some of the other direct messaged questions to me?

- Sure, so a great presentation, very similar to kind of what I'm doing at Northwell. I'm the medical director for EMS transfer and emergency telehealth and a very similar trajectory. Maybe started a year earlier, so followed the same trajectory out another year. That's where we're at as a system, where we do kind of all the emergency telehealth for Northwell and really with a focus on the EMS component, which is really unique to emergency medicine, the relationship between emergency medicine and EMS. So just one thing I wanted to share 'cause I think you'll find this interesting and we're working on a, a manuscript for it and we presented at NMSP, which is that we moved our medical control from a base hospital to our telehealth program. And we saw a higher transport rate for our high risk RMAs in that process, not even by going on camera, just by actually putting a telehealth doctor who's kinda used to dealing with EMS but also used to communicating with patients and being right with them. To the agency, that translates into institute in both money but also more broadly risk reduction. So that's a big thing. And for folks out there, talk to your local EMS folks, they, they all lose sleep over their RMAs. So this is an important value prop that we offer.

- I couldn't agree more, and it's evolved. We were aiming this initially at the low acuity treat in place crowd and then I had more medical directors as we kind of got to know each other say hey, can you make these like formal visits and start seeing these people? And really I can tell you guys know how to talk to them, try and talk them into going. And so what we try and do is talk to the medics and say, hey, look at me as you've got two front doors to my house. Frame it for me. Am I walking through the low acuity treatment in place door or are you walking me through the high acuity, this needs to go to the hospital door. And now I understand what door I'm walking through. I kind of understand the role I'm taking too. And I tell them, it's okay if you tell me you don't know, but if you do know, please tell me which door coming through.

- So we do direct. So we do ET3 but we also do direct from dispatch to telehealth through the program.

- [Speaker] Yep.

- And I mean there are challenges no matter what you do with EMS populations in terms of doing telehealth. But I think that the way I see it, at least looking at our data, that most of the patients that we do ET3 on would've been applicable to just go straight to telehealth from dispatch. And so when we talk about, and I'm wondering if, my first real question is do you see the same thing that most of the patients are doing ET3 on, you probably could have just done a telehealth visit and been done?

- I think it's a very similar population, right? It's two different engagement points with the same population. Some entities don't have a sophisticated dispatch sort of nurse level dispatch or high level triage dispatch. So they're gonna just roll tires and send EMS to things. But I agree it's generally the same patient population. The benefit of EMS on scene is you can get a facilitated exam and you have vital signs. The the risk of just dropping into a patient's home. Well A, the risk is hopefully they have their clothes on. Okay, I'm saying that to try and make you laugh, but only because it's question sometimes. And then B, there's no vital signs, you can't get a facilitated exam if I wanna ask the medic, hey, can you listen to their lungs? Can you show me the rash? Et cetera.

- Right, right. No, I agree with you on that. The last thing I'm gonna make a point on is just kind of the downstream on the reducing the wall time or how long it takes to offload patients. For as much as I agree that that's a huge trouble and that's a big problem at the state level New York, we're talking about this nonstop. I think the amount of telehealth we would need to do to make a dent in that is like, we'd need to build, I like to think we're almost at the level of a small community hospital for our virtual ER. We'd need to build like a virtual tertiary center in order to even make a dent in that. So I think that that's a long ways away. For everyone here who's an ED chair, an ED director, and if you have problems with EMS offload times, I beseech you, this is probably not the only solution to that problem. Look for other solutions because it's gonna take a lot to fix that problem. And we do need to get our ambulances on the road to serve their communities. And I don't think that this will move fast enough to do that. It is a big problem.

- Awesome, awesome. So great, I just wanna make sure, 'cause we have several people with their hands up. And I also wanted to intersperse a question here that was direct message to me. Mark, what about the billing piece on this? And two questions off this, but one sort of how do you submit it? Are you also doing sort of a facilities fee and or how are the hospitals responding because they're losing facility fees for these patients that are not transported in and not being seen in the ED?

- All awesome questions. So basically we send, we're really just functioning like an ER, we'll see anybody and we'll send anybody a bill and so we just send everybody a bill. Now, if Medicare will pay, Medicaid sometimes, commercial payers, it's all over the map. Whether they recognize what this is or not, we put a telehealth modifier on it because we see everybody, I think hospitals generally haven't, A, I haven't had a ton of engagement with hospitals. I've had some, in some areas, as we offer to roll out the program, I'm asked to engage with local hospital leaders and I'll describe the program. I think they feel a little less threatened when they realize we'll see unfunded patients, self-funded patients, just basically anybody. And they realize we're not trying to just come in and only see commercially insured patients.

- Thank you, and that great question was from Dr. Ernst. I wanna make sure I give credit where credit's due. It looks like some other people's hands went down. Maybe those are some similar questions. Jeff Davis. Oh, here comes the regulatory and legislation side. Let's hear it.

- Yeah, so, hi, thank you so much for the update. So I was around when the ET3 model was first introduced by CMS and thought about and we provide some comments on it. You seem to have a very, really positive experience with the model, but I've also heard from some of our other members that they have not had such a great experience with the model, that the telehealth component, that the treatment in place component has been downplayed. And mostly it's about alternative transport, but with alternative transport, an issue with that is that you have to ask the patient's preference. And a lot of times patients wanna go to the hospital, they don't wanna be transported somewhere else. They, oh, take me to the hospital. So that's another issue that I've heard from some of our other members who are doing this. So I'm wondering, in thinking about if under the CMS statute, these models, if they're successful can be expanded and they can even be expanded nationally and be part of the Medicare program, what are like the success, what do you think are the key things to the successes or sense of failures, is it market by market, community by community? I'm just trying to figure out if this can be, 'cause the idea of being able to in place with telehealth is a great idea, I think it's great, I've heard it's worked in some places and not worked in others. So any key to successes and potentially where others have failed. Have you heard of similar kind of, in other areas of the country not being as successful as you have been?

- Yeah, I think if you stick strictly with ET3 and you're just looking at Medicare patients, A, it's a hard population to treat in place. They're older, they have more co morbidities and it's just challenging. As you get into all comers, you get into a little younger population that maybe they just don't know how to access healthcare. So they use 911, and it's things that become even more appropriate I think for low acuity treatment. So I think you have a conversation with community leaders or EMS and you say, what issue are we trying to solve in your community? Some communities, they have one hospital, it's a county funded facility, that that county or that municipality is trying to manage overall patient flow because they don't have the capacity to take more in the hospital. I think this becomes incredibly important for that entity. Then you take an affluent suburb like I work in in Plano, Texas, we have a cath lab on every corner, there is capacity, the hospitals and it's a highly funded population, so they are worried and they want more of those patients to come to the hospital. So it's kind of community specific about how the needs run. We found from an EMS perspective, when EMS has to ask a lot of questions about insurance, they don't wanna adopt the program. And if EMS doesn't adopt the program, the program doesn't exist. Like there are referring physician essentially in this. And so we have to think, how do we make this as easy for them to adopt? And that's where I think once we move to just send us whoever you think is most appropriate and we look at this as EMS telehealth rather than just a Medicare population. I think that's when we got more adoption. I'm hopeful that with data over time, we can show commercial payers, hey, we're making an impact for you guys. We have taken a couple hundred Blue Cross or United or Aetna patients that might have gone to the ER and 60% of them we treated in place and they can probably run the numbers on that and start to think, hey, this is a viable program, let's support it. But ultimately we're leading with, we think this is the right thing and hopefully, everybody else will follow.

- There's a question that Dr. Lee just brought up in the chat here also about back to some of that billing too. Is this financially sustainable? Like how much are you pulling from other pots of funding to be able to do this currently? Or maybe in the beginning but now you're a little more sustainable and going into the future? I think sort of same with what Jeff was saying, if this is really gonna have legs to it and it's gonna be successful, do you see success in terms of financially sustainable?

- It's hard. I'm not sure if this is gonna be financially sustainable or not. We're gonna need more folks to come on board, because, how do I say this? I don't make near what I make doing telehealth as I would if I were to just go in a brick and mortar ER and work just because the reimbursement for our services is so spotty right now. So we've got a lot of docs who think the program is great and we all take a ton of pride in how much we've covered, but we really, for sustainability, at some point we're gonna need more payers to hop on board to be able to do this, everybody here probably knows whatever you make in your ER to see a Medicare patient or a Medicaid patient and that makes financially challenging to sustain an ER. And so I would say, we're experiencing the same challenges and again, we see all unfunded patients and commercials support of this as spotty. A lot of them don't recognize this. So I hope through leading with our face, that eventually the commercial payers will come on board, in Texas, the state I live in, there's a lot of good discussion right now with the commercial payers in Texas about potentially adopting this. I hope the data we can produce supports it. Yeah, I don't wanna take from ERs. I mean, we will always be needed for sepsis and stroke and everything in the ERs, I totally value my brick and mortar practice of medicine too, but I know as an EMS medical director, there is a low acuity population out there that we can appropriately take care of too.

- And I know this goes without saying, but CMS, they try to get other payers on board with these models, but they can't force Medicaid or prior payers to do it. Well the only thing they have con complete control over is Medicare reimbursement. So you know why they can encourage prior payers and states to have the Medicaid reimbursement for the ET3 model. It's not a guarantee and they can't require it. CMS can require it.

- For the little interface that we've had with CMS, that's been the big ask from the major participants is please help us get other folks on board and Medicaid is starting to make some progress in some states.

- We have one question from Dr. Booker in the chat and then Dr. Ernst, you have a question too, and we're gonna try to wrap these questions up in the next, if I do my math correctly, in about eight minutes here. 'Cause we have a couple of things we wanna touch base on our meeting here. Detailed question, Medicare billing, how'd you set up the billing for this?

- I'm more the clinical guy than the billing guy, I have some understanding of the numbers. My understanding is we do have a location in each state where we've got that set up under. So every state that we have a license, we have Medicare billing set up in there. I have a colleague who has, rather than a physician, he's an MBA, he would be probably most instrumental in having that discussion with you. Happy to connect you guys.

- Awesome, and Dr. Ernst, you had so many great questions in a direct message to me and I think I caught a couple of them, but this is your chance. Oh, Dr, we're not hearing you right now. If you're speaking, even though it looks like you're off mute.

- [Speaker 2] Working now?

- Now we now we can hear you. Yep.

- [Speaker 2] Microphone, my apologies Dr. excellent presentation. Thank you very much, I've always thought the fact Medicare created ET3 in the first place should be a big billboard, emergency medicine that we're gonna do something about unnecessary care in the department, this is our opportunity to jump on board. And hats off to you, just a couple of quick logistic things. How do you generate the medical record? How does that then become available either to facilities, the patient, primary care provider, I'm gonna throw a bunch of these together so I don't suck up all the air time here. But also what's your percentage of treat in place versus transport?

- [Narrator] Yep.

- [Speaker 2] You guys have experienced, and has there been a demonstrated improvement for the EMS guys that you can promote, hey, you're back in service in half the time, whatever, thank you, I'll mute.

- Awesome questions and points. We're on Zoom right now. Zoom is a lot like how I interface with the patient. It's a HIPAA secure portal. About half of my screen is me with a picture and picture and the patient looking and talking to each other. And then the right half of my screen, like where you see the chat, we have an electronic medical record. So I'm producing the same type document. We reproduce if we saw a patient in the ER on every patient, there is electronic prescriptive ability in there as well. So we can geolocate the patient. I talk to them about their pharmacy, as long as it's not a controlled substance we can send it through. Version 1.0 of what we're doing, we do not have a lot of local interaction yet, other than communications through EMS or the local EMS medical director. Where we're gonna be, hopefully over time as we develop relationships, I'm gonna have the ability to send my record to healthcare systems. I don't really have a great way to do that in real life. If it's a different healthcare system right now, and I don't have a way to do it yet, EMS other than the patient gives us their email and we send them a link to their record. And so whether it's a work note, a school note, or showing their doctor what I did, they can log in and get my record and show it to the next doctor that they're going to. I showed you we're at a rate of 13 or 14 patients a day, we've obviously got a little time. This is different than trying to see four patients an hour in the ER. So I'm certainly open if some person says, hey, doc just operated on my knee and it's a little swollen and I think I might need some antibiotics. If I have time, I'll say, what's your doctor's number? And I'll call and make a connection with their doctor. Just being able to say, this is Dr. Gamber and I'm calling your orthopedist in Tampa, sometimes I'll get through and be able to talk to that doctor, there's some connectivity, but there needs to be more as the program grows. There's a lot of interesting experiments that we're talking about, can you help triage psych patients, reasonably low acuity, to an appropriate local resource so that they don't have to go to the ER and dwell for 16 or 24 or 36 hours. We'd be very careful, I get it. But you wanna talk about helping the patient get to the right resource and not help with ed throughput. If we could help with things like site clearance or jail clearance or some of the other things that really challenge both brick and mortar ERs and EMS, I think there's, there's some run room there, but I acknowledge we have to be very careful with that. As far as treatment in place goes, I'm gonna coach you two numbers. If we are taking care of low acuity patients, our treatment in place is about 80, 85%. Sometimes we hear a dizziness and we think that person's 80, that's too risky. They need to go in, 80 year old dizziness. A little different than 20 year old congestion and a little bit of dizziness. So we're 80, 85% treatment in place. If you're talking low acuity conditions, when you start to mix in patients that we're trying to talk them into going to the hospital because they're higher acuity, that naturally lowers our treatment in place number. So if EMS engages me and says, hey doc, this patient's got chest pain, I can't get them to go, can you talk into going that, by talking them into going, I lower my treatment in place number. So I would say programmatically overall when you include that work, probably closer to 65% treatment in place operational time savings, you're looking at about 30, 35, 40% operational time savings compared to a round trip to the hospital. So, for every two or three runs we save, that's another hour or so of unit hour utilization. That's a savings to the community. It's operational availability for higher acuity calls. Hopefully I got all the off questions there put together.

- I wanna thank you, we wanna have some time, we're gonna have a little more discussion on some other topics too. But really, really appreciate you, one, setting all this up, two, maintaining this and three, sort of being that disciple to sort of tell others about it. And I'm sure there's others that sound like on this call that also do this work and just keep doing the good work. And I think the only other thing from another hat I wear too is this idea of how are we gonna make sure that we either not standardize our programs per se, but some of these metrics that you're generating and some of this, when you say low acuity and that, do we need to start saying, oh these are ESI fives and fours or something like that so that we can start saying that this what emergency medicine, not just specific envisions program, but emergency medicine is doing in this space too. So just sort of a call to think about that in sort of these next stages. Again, there's lots of things on your lists, right? Trying to get onto an EHR that's a little more streamlined and so on and many other things. But just to keep in mind so that we can keep pushing forward this needle for our specialty too. So yes, so I'm sure there might be other questions for you if they come across, we might be sending them your way or connecting people with you by email. Feel free if you wanna stay on, we'll be still chatting in the next 15 minutes on some other telehealth changes coming soon. But also feel free to drop off if you have the FedEx finally coming, your dog going crazy with that. So thank you.