June 26, 2023

June 2023 - ED on Demand Northwell Health’s Experience

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- Recording. Welcome, everybody. A nice June day, depending on where you are in the world or country right now. We have Dr. Berkowitz here to speak to us at our telehealth section about his program at Northwell Health. Jon, I'm gonna let you go ahead and give yourself an introduction and jump right in. We'll hopefully, you can keep going 'til about 20, 25 minutes or so, and then we'll have some Q and A, and I'm sure there's lots of questions. So gonna hand it over to you.

- Awesome. Well, thank you so much. Really an honor to be here. So I am Jon Berkowitz. I am an EMS and ER physician outta Northwell. I'm the medical director for emergency telehealth, EMS and transfer. And it's really an honor to tell you about our program here. Hopefully you see my slides. And so I'll start by saying NETS is young. Like, our program is really young. So I think a lot of folks here have actually been doing this longer than us. And when Emily said, "Hey, can you talk about your program?" I'm like, that's like taking a fetus. Like, we didn't even know the one. And so I said, "Put me at the end of the year. I hope we'll have more to talk about." And I think I have more to talk about. But, you know, it really has been an exciting journey. And I really do think that we're on the young side of this, which might be fun. Hopefully makes this more fun. You know, we've been doing this just for less than three years. I'd love for folks, some of you folks on the call, if you wanna put in how long you've been doing this, I'd love to hear that because we are young to this journey, but I think we've had a unique experience, and hopefully there's something to be shared. So we started really from the pandemic. You know, Northwell EMS is the largest voluntary ambulance provider to FDNY. And they came to us and said, "We can't handle all these calls, and one of the things we wanna do is we wanna take some of our 911 calls and send them to our voluntary partners for telehealth," which made a lotta sense. We were already doing all the stuff with cardiac arrest and field triaging and whatnot. And that was just the next logical step. And obviously, these kinda programs were in discussion already. And I went to my boss and I said, "Hey, you know, I'd really like to help them out." And he said, "Oh, not a problem, go for it. But by the way, you know, you know that we're on, you know, Sunrise and Allscripts, and these systems were not meant to do anything like that. And so we've tried before and failed. Good luck." But, you know, really through the dedication of our team at our emergency communications center, we're able to piece together a way to deliver the service to those patients. So just a little bit about Northwell EMS, a little bit of a public service announcement. We are hopefully, I think we're the largest hospital-based EMS agency in the country. These are old numbers, but we're very unique in kind of the number of missions we provide. And the backbone is our communications center, which houses our transfer center as well, and really was the bedrock for the formation of this program. And so we took all of these technologies here. And, actually, it was Amwell, now it's Teladoc, but we took all these technologies and glued them together in a very EMS way to create an acute unscheduled telehealth program, and because none of them on their own could do it. And the thing I'm actually forgetting to put in here is actually our EHR, 'cause the EHR was really just the documentation and billing component. Our EHR is Ambulatory EHR from Allscripts, otherwise known as TouchWorks. You may have heard the announcement that we'll be moving to Epic, so that will be super exciting, to have something from this millennium. So, but it really is, it really forced us to be creative. When we started this program and FDNY came to us, we were kind of in a, actually were in a good position from a physician staffing perspective. Two of our hospitals, Valley Stream Hospital and Forest Hills Hospital, were in the epicenter of the first wave. And there were doctors in our health system that couldn't work due to their medical conditions. And they were essentially lent to our team to help us find ways of moving those patients. So we had a bunch of FEMA ambulances. We built up this whole infrastructure to move patients. At times, we were moving 50 to 60 patients out of those two hospitals alone. And there were weeks where we literally cleared out the entire hospital and just like cycled. And so we had docs helping us with triaging, physician communication, you know, hospital selection. And those docs had some extra bandwidth, and those were the initial docs who were doing our emergency telehealth. After this, as COVID died down and people started going back to work, we got down to as few as two doctors, me and another doctor, covering the service as we were working on building up our volume. And really, we built up the workflow, we proved that we can do it. And then it was our partnership with our emergency medicine service line, which manages our 17 ERs, that really helped us kinda take us to this next level and is a really important part of the story of NETS. So now we're like a, you know, we're a real thing. You know, we're 24/7, 365, staffed by emergency physicians. And we call our program NETS, but we have a lot of other things within the NETS umbrella. And I'm gonna explain what that umbrella looks like, and it's an important part of our operations and our strategy and how we've gotten to the point we are. And we're at the points where, depending on how you look at it and how you round things and, you know, whatnot, we're actually sustainable, that we're actually bringing some revenue into the system. And a lot of that's because we have a good structure and we have, you know, we have operational experts in EMS and we have administrative experts in the emergency medicine service line. And we come together, we built something that I think will stand the test of time. So the basics, I think a lot of what we do is very similar to a lot of what other folks do, you know, acute unscheduled access to an emergency physician. You know, I think our relationship with EMS is unique. So, you know, we can just say, "Hey, this patient needs an ambulance," and they get an ambulance and it's not a problem. And, you know, we call ahead to our ERs, and that's a big patient satisfier. We have the ability to send work notes and school notes and discharge instructions. We can even do some pharmacy delivery, depending on what's going on, on where the patient's located and the time of day. We can send patients for outpatient labs or imaging, ambulatory referral. And we do call our patients the next day, especially the sicker ones. And a repeated theme is we've always been very committed to the idea that this is emergency telehealth, and not virtual urgent care, because that's where we see the future value. And I'm gonna share some stuff that makes me really optimistic about what we, as emergency physicians, can offer this. All right, so this is like the crazy slide where I try to put everything that we're doing on one slide. And it's not even everything, but I do wanna, this is like everything that falls under that NETS umbrella. So we are an acts and escalation point for our transfer center when there are issues with transfers. ER on Demand is our direct-to-consumer product. That's how we market ourselves when we do, you know, outwards marketing. We do medical control. Most of that is for Northwell, but we actually have contracts with local agencies. We obviously service our employees. We have a bunch of these EMS-based programs. So whether it's the stuff coming right from dispatch or whether it's our ET3 program or whether we're acting as medical control for our CPs for our other partners, we do a lot of that. Our ambulatory partners are really important to us. They love the fact that we're awake at two in the morning and we're willing to help with them. This same thing is true for our transitions of care team. They love the fact that on a Saturday, we have a doc when there's a patient that has, a STARS patient or whatnot, they can get some help. We have a fantastic relationship with our cancer institute. We started this program maybe seven or eight months ago. We're seeing their patients when they have questions. But I think the coolest part about this is that for the patients who have chemo-associated nausea or vomiting or breakthrough pain, we're able to send a CP to their house and hydrate them and treat them. And just from a patient satisfaction, we know we're doing some real good with those patients who really, for just the quality of life, should not be in the hospital. I'm gonna talk about house calls some more, but this is our advanced illness management program that focuses on patients who are chronically ill and really home-bound. One of our coolest new programs is Department of State. This is more of a bigger contract, but we're an important escalation point in that program. And we do have some other global telehealth stuff that we're doing, and we've done consults in Ukraine and some other places in the world through our relationship with our own Center for Global Health. TeleSNF is like just on the cusp of existing for us. Right now, our EICU docs are doing it. We had to redo the whole workflow, but it's like just there. We are doing some work in our ERs. Probably the biggest one we've done as of yet is when the RSV surge happened, and we were seeing kids in the waiting room at Cohen's. But we're building some asynchronous workflows that we feel that we can see patients in triage without disrupting our other streams of workflow. So a lot of our operations, people love this asynchronous. How do we maximize the amount of patients we can see? We have relationships with a bunch of assisted livings. We are the clinical entity for the remdesivir home program. We have a really nice relationship with the New York State Troopers organization. So they call in for help. We have, our community health division has all these relationships and they, you know, we work with them and we're an access point for them as well. And then we're working with kind of our for-profit ventures arm at building businesses where, you know, this could be part of the business. So this is kinda the NETS umbrella. So it's not just ER on demand, it really is NETS. And hopefully, that kinda makes sense. So I'm gonna talk about this partnership because this is really fun for me. So we have this contract, we provide telehealth for our Foreign Service corps all around the world in our embassies. So, you know, we joke that we take care of spies. And it is a really unique experience. A combination of second opinions that go to specialists, kind of just basic e-consults. And then some virtual emergencies, where they're calling in and they say, "Hey, I need someone right now. I need to talk about this case." And those cases go right to one of our ER docs where, you know, sometimes we're getting calls from, you know, South Sudan or Azerbaijan or whatever. Actually, from a map perspective, I think Africa is the number one country, continent, that we receive calls from. But it's really all over the world. And there's all sorts of interesting technical and operational challenges, especially around the image sharing. We've built a really great relationship with our imaging service line. And, you know, we've done, in the seven months, we've done over 300 consults. A lot of ortho, a lot of imaging and a lot of emergency medicine. So this is just one example of a partnership, but we have partnerships like that all over the place. And it's an important part of us. For our ER on Demand and for our base-level product, for lack of a better word, the basic workflow is the patient calls into NETS or they can online book or go through the app. They get triaged by a paramedic, if it's a call. They'll get registered and they'll see us. And it sounds like a bit of a clunky thing, all these steps, but what's amazing to me is our patients, we send a survey after every encounter, our patients never say it's clunky. They say it's seamless. They talk about other people and they say it's clunky. And so I think that learning what patients think is seamless is not what we think is seamless. We see the duct tape and the Popsicle sticks and we're like, man, this could be really seamless. But the patients don't experience it that way. We've never had a patient, and we've had some negative feedback, but we've never had a patient say that actually the process was clunky, which blows my mind. Visits, as I mentioned, are in TouchWorks. And we do use outpatient billing codes for these visits, for a variety of reasons, which still works well for us. So one of the things that's really unique about us is that we have a paramedic who answers these calls. So, you know, we call them our virtual first responders. Early in the day, they actually used to get on camera with patients. I wanna bring that back at some point in time. I think with some of the technology I'm seeing coming out regarding the ability to see, to get patients' vital signs from images and other things like that, I think we're gonna see a whole change in how our communications centers work and are able to get patients to the right level of care. But they already do a lot for us. They help us triage the cases. We do get cases that should not come to, should not even wait for a doctor, and they can help them. They can get them an ambulance, they can say, and they can educate the patient. Sometimes the patient will refuse to go to the hospital, and they can, you know, try to convince them. And sometimes they'll just call the doctor and say, "Listen, I have this 70-year-old with chest pain. Doesn't wanna go to the hospital. What do you wanna do with them?" And we'll try to navigate it with them. They function as an interface with our EMS partners and they also do a lot of workflow support for us to make sure that things go. So in a lot of ways, the call center is our glue that keeps everything running. The physicians. So we've grown a lot since we started, right? I mean, we started with a bunch who were kind of lent to us, and we went down to me and another guy and we're just like keeping the dream alive. And then we've kind of built back up, and now we have about 15 members on our team to cover 24/7. We have a fair amount of per diem. Some have dedicated FTE buy down. Everyone works from home, except for me, 'cause I go into the call center most days and, you know, I'll take calls when I'm there. But otherwise, everyone works from home. The compensation is not the same as an ER hourly, and our goal is to get close to an ER hourly, but, I think, you know, we never wanna, you know, exceed an ER hourly 'cause that kind of changes how our friends who are actually in the ERs, you know, would probably feel about it. And I could get it, like, right? Like, if I'm seeing a patient and I send 'em to the ER and I'm like, yeah, I'm sitting at home in my pajamas, or at least from the bottom down, and, you know, and I'm speaking to someone who's, we're getting paid the same, it's probably not right to get that. We do have, you know, scheduling can be challenging, especially with sick calls. You know, we're not quite at the level that we can have a great system for managing sick calls. But everyone pitches in, and I'll talk a bit about our team culture, but we all do pitch in. And then some of our calls do have backups. So house calls can actually back up to a geriatrician if we can't get to it. Our transitions of care management, likewise, they have some backups. And depending on the medical control calls, some of them have a backup, too. The Northwell ones do have a backup. So through it all, we are staffing 24/7, 365, and it's a dedicated doc. No one is ever working in an ER. Early on, we have a couple of shifts where someone might be working in the ER and trying to help. We think that does not work for anyone. And now we've built up enough of a book that we don't need it. So we can, you know, we have a couple dispositions. 8% we recommend go to the hospital, a lot of prescriptions. But we also do some, and these are old numbers, it's increasing, the number of patients we do labs or imaging. And the referrals, about the same. So I mentioned I wanna share some stuff about the higher acuity side 'cause that's one of the things that really excites me, and I think that really we get to really, truly be emergency physicians. So I mentioned we cover our house falls program, chronically ill, medically complex patients, long histories, lot of shared decision-making. And we started supporting them about a year ago, and at night, mostly at night. And the way it works is a lot of times, the decision to send a community paramedicine, a community paramedic, is actually from the nurse. So they call into a nursing call center. The nursing call center will triage it, and they'll triage it and say, "We need a paramedic." So we did a retrospective look at the past roughly year, about 1,350 CP responses, and to look at how many patients were transported, whether it was a geriatrics physician or a NETS physician. And it's like it couldn't be more similar in terms of the performance. And I'm super proud of this data. We're working on the paper, I have to do some severity adjustment or look for severity adjustment and do some of the academicky stuff. But ultimately, I think that we're showing that, you know, our skills of our physicians do extend to telehealth, and this is a really good example of that. I also wanna talk about some of the patient side of this, the patient experience side of this. So we send, like I said, we send a survey for every case. And one of the questions we ask is, were you planning on going to the ER prior to calling NETS? And 45% said that, yeah, they were planning or considering going to the ER prior to calling us, but we only referred 8%. So this is a really interesting finding as well. You know, there's a lotta follow-ups I wanna do. I wanna understand what gives patients the comfort. Do patients understand that it's different to speak to an ER physician than another physician? And are they comforted by the fact that they're speaking to an ER physician? We do talk in our team meetings, we meet twice a month. So it's a little of a drag. It's Friday afternoon, twice a month, but we all show up. It's amazing. And, you know, we do make a big deal about telling patients things like, "Well, if you went to the ER, this is how we would probably work you up. You know, this is what the kind of things we'd be looking for." And I think that matters. Being able to say that, I think matters. Obviously, I think being seen quickly helps. Having access to patient records is really important. Another one of our things that we really encourage people to do is to say, "I looked at your last note from so-and-so." And just to acknowledge it, that there's a history there, does a lot to inspire confidence. And, you know, having a brand is not a bad thing, right? You know, we're a known entity. So I think these are some really interesting things about where we provide value to the patients. And when we look at our survey data, you know, roughly 88% of our patients strongly feel that they would recommend us and that it was valuable to them. And some of the things we do to really get that value to our patients, is one is our docs have to help navigate the patients, okay? We're not saying you have to be a full-on Geek Squad and there's no technical competency as part of the process to join the team, but to learn some basic things to help the patients, about privacy settings on their phone, about using other links and about not just throwing up your hands when there's a technical problem. Teladocs are primary, but we have backups, and then we do, you know, if worse comes to worse, we will just do a phone call. Even though we know it's not the same, but we wanna get the patient to care. And obviously, we have, we encourage standards, but we encourage standards really by keeping ourselves to the same standard and all of us really being passionate about emergency telehealth. These are like, whatever it's called, a word map or something, I can't remember the fancy name, of some of the comments that patients have said. So I just wanna take a second to talk about our strategy. You know, this was coined by Jud Hollander and Sharma about this idea of being the availablist. And that's really what our strategy is, right? And so everything under that umbrella, we've said we're willing to catch that and we'll figure it out. That doesn't mean that all emergency physicians can take this role, but I do think that emergency physicians are the best suited amongst all specialties to take this role. You know, and there's a couple things that we do to get 'em there, right? So we select, we are very rigorous with our selection. I'll talk about that in a second. We do a lot of preparation and training. And then we have just-in-time training. As you're going through some of the forms that we built for our docs, it will tell you, this is the next step for doing a remdesivir at home patient. Or if you need to send a referral for this patient, this is what you do. All the, you know, the just-in-time training really helps so we don't have to. You know, the medicine, we expect everyone to know, but the operations is built into it. There's a lotta support. People will ask for help on our channel, and another doc will volunteer and answer. And it usually won't be someone in a leadership role. They usually will actually be just another doc who's just part of the team. And our culture is really special to me. I can't say more about this. This is the part that makes kind of this really joyful. And so really, I've been working up this lecture to this kinda slide of Pac-Mans, I guess, to talk about what I see in the food chain, right? We talked about the technology and the troubles we had there, and we solved some of that with operations. And then we built a really good strategy, which is really just being there. Being available is the strategy. It's not rocket science. But the most important part is the culture we built. And I think that this is really important. As we try to take care of sicker patients at home, I think the culture is the part that's gonna be more important than anything else. So I'm gonna talk about two parts of our culture, and then I'll wrap it up. So one is there's, at the executive level, there's me and Sarah Healey Herod. So it's kind of a dyad leadership, but it's a flattened team. Like, there's ideas bouncing around from everyone. There's no like, you know, there's no palace. I mean, listen, we're all ER doctors. There's never a palace in emergency medicine, but there's no palace, there's nothing like that. It's all very much, we're all on the same team. We really value our emergency medicine experience. We work with our, even folks who have never helped us, we seek their input. Whether we're doing quality stuff, we're trying to improve our quality, we'll learn from our quality councils, and everything like that. We learn from our emergency medicine experience. And for our administrative teams, this is an area of a lot of growth and excitement. And so we want our managers in the administrative side to grow and to see this as an opportunity for them to have a, you know, to help their career. And one big way that we do that is that we really disseminate our relationship-building, right? So each of those little cards, whatever, there are 18 of those, each of those has at least one or two relationships, and we've encouraged our managers to build those relationships without us. We don't do the stove piping, where you have to go to the top cheese and all this. We trust people. Go out and do your thing. You know, this is a startup within a health system and, you know, we know that folks need to kind of just, there's a little bit of guerilla warfare that needs to happen. And lastly, we really focus on the shared wins. We want our partners, whether they be the cancer institute, the ambulatory home care, which I didn't mention, but they're an important partner, whoever it is, where we want this to be a win and we want the patient to win. And when that does, really, the engine of our culture is positivity and that's what keeps our team together. That's why when, you know, like just today, someone called out sick and we already had three people volunteer to do their shift, all of whom are per-diem doctors who just do this just to, you know, as a side gig because it's that positivity that is really important to us and kind of holds it together. And the same thing is true with our docs. We actually have a bunch of docs who have little leadership roles, and we're trying to build them as leaders within this arena. And when you're on duty, you're not on call. You're on duty, just like you're working in the ER. So we have that mentality. And we also, we disseminate our relationship-building amongst the physicians. I don't wanna go to every meeting. I can't understand all the webs of relationships. You know, how do you create physician leaders? By letting the physicians lead. We do have really rigorous screening of new physicians. We just hour upon hours. And we have a lot of support. And again, that positive shared mission. And from here, we're actually gonna, we're hiring into an ACP role with PAs and NPs, hopefully to do some work around also not just seeing overflow, but to do some work around results management from our ERs. Because some of our ERs tend to have a challenge with this, and the chairs tend to do it, but that's not so great. So we're trying to go into that space a little bit and build some, hopefully sustainably build something that can support our ERs with that task that is not really meant for a chair. So that's where we're going. And the last slide, I just wanna talk about like what do we think is next? Obviously, I've talked about a couple things I'm dying to put into research. I would love there to be some sort of a registry or something where we can pool our experience and our knowledge so we can really drive the policy and advocacy because, you know, I'm more confident than ever that, you know, we have a role. I mean, you think about, as a kind of an EMS guy, I think about telehealth as starting off in EMS, and I feel like us pushing as emergency physicians into telehealth is really just coming home. So, you know, I really think we need to keep on doing that. And then, lastly, we have this fellowship. You know, I think there needs to be more in the academic arena for training, and I think we need to cross-fertilize with our other specialists and other teams that are doing this. It's important for people to understand the virtual landscape and be able to operate within it. Just like kind of, you know, back in the old days, when I was in residency and you did like, you know, the systems-based care type of stuff, you know, learning how to operate within a health system, I think people have to start to learn how to operate in a virtual health system. And one of the ways, you know, one of the reasons why everyone rotates with the ER is to learn that systems-based approach. And I think that there's value in kind of rotating in the virtual ER for that virtual systems-based approach. So, you know, I got my stuff out. Thank you so much. It was a great honor and I really look forward to any discussion and, yeah.

- Amazing. Wow, that's impressive. I was thinking it was gonna be, you know, when I reached out to you, the ED on Demand. And if you're saying that this is new, in infancy, with how many things and how many relationships you've built, I think for many of us on the call who have spent a lot of time. When you had asked, we didn't actually put in the chat how many years, but for many of us doing this for several years plus, knowing how much energy it takes to build those relationships, to create all those programs, like kudos to you. And I think two things that I heard that you said that were just really poignant were the piece that you said it's sustainable. I was like, wait, wait, wait, how is this sustainable, right? So I got a little bit of it, that you're doing office-based care, but I think there are probably other maybe more detailed questions or specific questions others may have, but I'm just highlighting it right now. I think the other piece, too, is that cultural piece. As many of us are feeling it in our clinical emergency medicine care, the culture of our emergency departments, not so great, right? So like the idea of having almost like a regenerative-type nature to a clinical program is so refreshing to hear. And just, I don't want you to short sell it, and you weren't, but short selling the idea of how much work it took to reinforce such a regenerative culture. So kudos to you on that. I am gonna open up for some specific questions. If not, I've got some questions, too. But really appreciate you sharing this with us. And speak, anybody, for what questions you may have for Dr. Berkowitz. All right, fine, I'm gonna ask some. So the sustainability piece. Oh, there's some people putting some in the chat here, so I'm gonna let them do this. So a national data registry, Satta's asking this here. And I've got more from earlier, and I'll get to those, too. Or, Jon, if you wanna look at those, too.

- Yeah, I'm looking at it right now. So, you know, I don't know what a national data registry on tele-medicine would look like, to be honest with you, right? This is all in its infancy. I mean, this is the group to figure out what it would look like. But I think that we have to start pooling together our experiences in order to build the narratives that we need for the advocacy for the future. I am an operations guy, right? Like, I'm an EMS guy, which means I love operations, you know, and things like that. I am not an academic person, by any means. So I would love for someone to think about that. But I do think that we have all this cool data, and I'm sure all of you have cool data, and we probably should start pooling it at some point in time to make even cooler data. And again, that's just speaking, I'm an ops guy. In terms of the sending to our bounce-backs, so we know from a few ways. We do have some dashboards. We do also call our patients back. And so we will escalate if someone ends up going to the ER. It's vastly lower than ER return rates, but I'd actually have to, we'd have to pull the data to really look at it. Whenever, you know, we've had a few cases of patients who have been sicker and end up going to the ER. Obviously, without, you know, we haven't seen any harm from that. But, you know, more often than not, it's actually patients fighting with us about going to the ER. I'll give you just an example. I had a patient a few months ago, and we actually have a home lab service. So I saw her. She was like, "Oh, I've used LabFly before." So she had LabFly come. She was having some vomiting and dehydration, and she had a sodium of 119. And I said, okay, I called her and I'm like, "You know, you can't stay home with a sodium." We were all surprised, right? It was very minor symptoms, but I was like, "You can't stay home with a sodium of 119." And that's more common, to have someone who's sick who doesn't wanna go to the hospital. And so in the end, I, you know, basically, you know, her family packed her bags and said, "We're just gonna wait for you to seize and then we're gonna take you to the hospital." And then she was like, "Fine." But, I mean, we see a bit more of that. So the average wait time is, it's under an hour. Sometimes it's faster. I think that when we move to Epic, it'll actually speed up as well because we're doing a lot of our queuing based on a system that was not meant to queue. And so from an operations perspective, Epic seems to do a better job at some of the queuing stuff that I think will allow us to do that. So I'm optimistic on that. And then, so for ET3, and programs that have EMS there, those go to the top of the queue. So then now we have to reshuffle our queue and see them right away. So we don't leave our EMS waiting, although we do make sure that when one of those calls are coming down the pike, the doctor's aware of it so that they can manage their queue. Future state. You know, I wanna get to the point of doing what we do in the ER, right? In the ER. we're walking, we're running around like crazy people, kind of bouncing our workflow, saying, "Oh, well, there's a trauma coming in 10. Well, I can see that belly pain in five. Get the orders in and put on a blue gown. I'll be good." So like all that kind of stuff of how we navigate ourselves, I do think that skill is really valuable. And we've all known, you know, we've all known other specialists, I'm not gonna say whom, who don't know how to do that. And, you know, I think that's actually, you know, more than the clinical knowledge, the ability to navigate that is something that we've all learned and is priceless. So I just can't do it in our current infrastructure. It is not possible. When we get there, I think we're gonna do all sorts of cool stuff. And then physicians being a conservative. So, I mean, the way we got our docs, so everyone who's in this program really believes in telemedicine. No one is doing this because I'm getting tired of night shifts or I have a bad back. That's just, that's not. Now, we have some patients who are not young in their career and they do a great job, but they're doing it because they love this. And, you know, they've always been people who have been annoyed with the patients that came to the ER that they didn't think needed to come to the ER. And that's like, it's not a true screening question, but it's the question that I like to ask, is like do you ever get annoyed with patients show up in the ER that don't need to be there? And I like someone to say, "Yeah, I do. I don't want them to wait in triage for two hours to see me for 10 minutes. That's not good." So there's a selection thing. For physical exam, you know, I would love to get more into RPM. We do routinely ask, you know, "Do you have devices at home?" Everyone now has a finger pulse ox. Most people have a, you know, some sort of a blood pressure, a sphygmomanometer. I would love to do more remote physical exam, but, you know, don't discount the guided exam. I had a patient three days ago who, belly pain and upper abdominal pain and vomiting, and she had right lower quadrant tenderness on her self-exam, and she had appendicitis. Don't discount the value of your exam. I had a patient like two years ago, but still, I'll never forget this, who had massive photophobia and she was calling in for food poisoning, and she, and I realized that she wasn't making much sense and she was kinda confused, and she had a head bleed. You can get a lot out of, you know, don't discount what you can do without having hands on the patient. All right, so hopefully, if any more questions, I love answering them, but, Emily, you had some questions, too.

- No, this was some of them. I'm curious, just organizational structure that you're in, was this something you decided that like we should be doing this? It sounds like you said in the beginning that this sort of started from the COVID and some of the telehealth that you're doing in COVID. Yeah, you really went going like a freight train after that, right? And was this something that the health system C-suite was saying, "We want you to do this"? Or were you having to tell them like, "Wait, wait, no, we can do this. We in EMS and emergency medicine can do this." And had to keep sort of advocating for that piece? I'm just curious of how you were able to really flourish, it looks like, on the screen, in a short amount of time, and how much grassroots and how much was it from the C-suite?

- So senior executive leaders, I would say, were doing the blocking, right? So they were protecting us when we're in the womb and letting us just do our thing. But we weren't asking for permission. Like, we didn't say, "Oh, someone else came to us with another idea that they want us to work on. Is it okay that we do this?" 'Cause we know that if we say, "Hey, this group wants to work with us," and if we go to the senior leadership, they're gonna say, "Well, you probably need to have a series of meetings to discuss whether that's a viable idea. And then we need to include, you know, five other VPs" and this, that and the other. And then it's never done. So we were kind of protected and blocked by the executives, but the senior leadership didn't come to us and say, "Do this." There was an element of we just did it and, you know, a little bit of, you know, ask for forgiveness.

- Awesome, and then back to the question of sustainability. I had assumed when you said a sustainability that, oh, definitely, you're billing for the emergency medicine level codes for the virtual ED visits and so on, but you're truly sustainable without subsidy from the healthcare system and hospital? Is that true?

- So the subsidies, so, again, it all depends how you look at it. So we get subsidies for the transfer center work and for the medical control work. And depending on how you value those entities, it changes, but we're like, we're just there. So at some point in time, we're just gonna end up, and my goal is actually, to shed all of our support at some point in time and have those elements just be free to the health system as we built a good enough program that we don't need to be. And we do get a stipend for the medical control piece, which there has to be anyhow, right? I mean, you can't not, you know, you should have something for that. And we do get something for the transit center piece. That's kind of where the fudge factor is, but it's not a huge number, but we're right around that area on the line where we're like just getting there. So it really depends on how you look at it. And then the trajectory is fantastic.

- What other questions do people have for him? All right, well, we'll take the silence as maybe no other questions right now, but I'm sure people may think of others and may reach out to you. But really impressive program, really appreciative for you presenting this. Just a couple of things for the section, if we just shift over to that for a moment. Oh, there's another message coming up here. Oh, there we go.

- That was from me.

- There we go. Here's his email right there if you wanna reach out with other questions. And I really do hope that you are able to get some of this stuff out there in the literature soon, too, just to have more pieces for the rest of us to use when trying to encourage our systems to take things on, so. From the section side, just a couple of pieces here. Scientific Assembly is gonna be coming up, Philadelphia for ASEP 2023, and this is in October. So keep an eye out for that, and hopefully you will be attending. There was, I didn't see him on this list, but Peter Greenwald and the crew from Weill Cornell, which I'm looking here quickly. I don't know if I see anybody right now. Actually, Peter is, I think it's, not "West JEM," but one of the other journals is looking for AI articles, AI and emergency medicine articles, and those will be due in February. So I'll send an email out to the listserv on that, as well as I think the Weill Cornell group is also doing some research, and there might be a recruitment letter that I'll be sending out to the section for people doing direct consumer telehealth, too. So otherwise, resolutions, any information for Aditi, due in five days. So these are resolutions that are specific more to sort of home-based care and telehealth. So if you can go back to Aditi Joshi's email about the resolutions, in case there's any concerns people have. Otherwise, we're gonna be supporting these resolutions as are, as stated, as written for council in October. And newsletter did come out in May. So thank you, Satta, for the awesome newsletter there. So we have that out. And, yeah, I know that we have just a couple of extra minutes. We can give some extra minutes in the day. But anything anybody wants to bring up or any new cool stuff people have heard of in the telehealth world, other than what we just were hearing about? Opening up the floor. I think, I don't know if I see anybody on here. I know that there's also the Stanford StEMi X coming up later this month, also, from the Stanford group.

- I think we're all in a little in awe of what our speaker's put together this time. I mean, the entire thing of involving the community as well, along with all these other different ones, I think it gives us a bar that we need to jump for.

- [Jon] It's honestly the culture. I cannot speak more about the team we have here. It really is. I'm blushing beyond belief because it really is like you put the right people in a room together and good things happen. And you empower people and set them free, which I don't think health systems do that as much as they need to, to be honest with you, but that's just a little commentary. Maybe take that off the recording, Emily. I don't wanna get in trouble.

- We'll bleep that out, don't worry.

- [Jon] Thank you.

- All right, well, everybody, enjoy a few more minutes in the day. Get outside, do something, and we will see you next month, in July, for our next meeting. Take care, everybody. Bye now.

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