February 1, 2023

January 2023 - How Telemedicine is Going to Change Your EM Practice (Judd Hollander, MD, FACEP)

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- Welcome, everybody. I'm sure there's others that may start streaming in, but thank you for those who've already joined. Welcome to today, January 10th here, on the new year, 2023. And we are now gonna have Dr. Judd Hollander speak to us about his thoughts on how telehealth's gonna change our specialty. And so, obviously, many of you have probably seen his presentations in the past about this, and we'll see if he's reimagined or been looking at things a little differently from his role there as the associate dean. I have to get it all right right now. So it's associate dean.
- That went away. Now, it's easy. I'm just a senior vice president.
- You're just an SVP. All right, well. All right, well demoted to SVP, right? No. And so from his perspective, from the healthcare perspective, and, of course, all the expertise and views of what it's like in emergency medicine and telehealth. So John, I'm gonna hand it over to you. And do you want us to hold our questions until the end, John, or do you want people to...
- No. I think it's okay to interrupt in the middle. I have multiple screens and I can't tell which one are you seeing. Are you seeing the slide view or just the big slide?
- We're seeing the presenter view. So I'm seeing slide one of 33 on the screen right now.
- All right. So it happens when you have too many monitors. Let me see if I just shut one off if that'll change 'em. Not really terribly helpful, huh? All right, well, I'm a telemedicine guy, not a PowerPoint guy.
- [Kelly] It swap displays.
- [Judd] Let me see if this works. No, no.
- Go up top and hit swap displays, that third from the left. Oh.
- Where are you talking about?
- Go back to the view you're in. And then top third from the left, it says swap displays.
- [Judd] Beautiful.
- There you go.
- All right, great. That's terrific. So anyway, this is actually a talk that I give at the emergency department. I'm gonna see if I can use my other monitors at the same time. At the Emergency Department Directors Academy as well. Can you still now just see the one thing? I see the presenter view on another slide. Yes? Okay, cool. And really, you know, you guys know everything about telemedicine that I do. In fact, half of you have taught me half of what I know. So it's kinda nice to chat with you all and I'm interested to hear your thoughts as much as I am mine, 'cause I know mine. I stole the next slide which summarizes the healthcare system. I think I stole it from Augene Venkitesh. This pretty much clarifies everything we do in the healthcare system. It's a beautiful slide. But now that we got that out of the way, you know, I like to say when I talk to ER docs that really what we need to do is pause and figure out what's our real value. Because particularly, when we're young and we're just out of residency, it's like rah, rah, critical care and trauma's really exciting and ultrasound's cool and putting in the central line is the best thing in the world. But you know what? When you sit at a health system level, nobody cares that we could do those things. I mean they care for the few patients that need all that stuff. But our value in a health system, and this is the table I sort of sit at now, is really we're the available list. We're there all the time. We're there 24/7, 365. We don't care or know whether people have insurance. We don't care or know where they came from. And we actually work when other people, you know, want us to work. And don't lose this value, because, you know, I spent a boatload of my years being really annoyed that I'd call someone at two in the morning and they wouldn't have the, oh, thank you for letting me sleep till 2:00 AM, I'm glad I got all this sleep and you're only waking me now attitude. But from a health system perspective, letting that surgeon do their procedures the next day when they're relatively rested is a big value in emergency medicine 'cause we let the health system tick. So don't lose that. Our perspective outside of the four walls of our emergency department is being available, taking care of people when other people may not be available to take care of them. And when other people would rather be home getting some rest so they can be useful the next day. But telemedicine, and you all know this really well, the medicine's the same. It's just a care delivery model. It's not about technology. And I know some of you on the call have your own technology companies. Sorry, hate to say this, unless you come up with the perfect workflows and operations, it doesn't add anything. It's another video thing. I don't care if we're on Teams or Zoom or something else right now, it's all about how can the technology get into workflows and operations. We have spent too much time, you know, and Jeff probably talks about this a bit too, comparing ourselves to an in-person visit that's totally irrelevant and I'll explain to you really quickly why. It's because if you look at the alternative for a hundred patients who have an appointment tomorrow at your institutions, only 72 of them are gonna show up for the appointment, which means 28 will get no care tomorrow even though today they have an appointment. Patients either no show or cancel the last day nearly 30% of the time depending on the specialty. So even if we were 90% as good as an in-person visit, if there was such a measure to tease that out, we're still providing it to many more than those 72 patients. In fact, our case cancellation rate at Jefferson is actually 14% compared to close to 30% for in-person visits. So we see more people. You all know you're doing a physical exam, but the rest of the world that hasn't embraced telemedicine yet doesn't. And then we get to look into somebody's home, which gives us maybe a ton more information than an office visit or an ER visit where we're sitting looking at the patient and they've got their clothes cut off and they're in a gown and everybody looks the same. So it's really helpful to us to be able to see into somebody's home when we're doing this. And then I make the concept that we live with all the time that actionable information is way more important than diagnostic accuracy. We don't always get it right in the ER. We have people sent to the ER from the primary care offices, they didn't get it right. They knew that they needed more help than they could deliver to them right now in their office. And we admit people to the hospital sometimes without a diagnosis because we need more stuff to happen. So the problem is if you miss cauda equina and somebody says they have low back pain and you don't get the MRI, that's a problem. You didn't get the right actionable next step. But if you thought they had lumbar sacral sprain and for whatever reason you got an MRI and you found the spinal cord compression, you did the right thing, you got it right. So we just need to get to the right next step. And everybody who talks about are we diagnostically accurate, I believe that's silly because we're not diagnostically accurate in the ER. We're ruling out badness and getting people to the right next step. So let's think the same way. This is, I think all of us have a little schematic that we use, okay, to describe our programs. This is one that summarizes about 2/3 of the Jefferson program. And if you look in the gray at six o'clock, assuming it's a clock, at baseline, patients are at their baseline, the first thing that happens is they fall off their baseline. And Brendan Carr, when we were putting this together, we were trying to think of a name for that. And he just wrote, okay, for now, let's just call him a little sick and move on. And those of you know Brendan knows he was in the Department of Health and Human Services and the Emergency Care Coordination Center and they actually now talk a little bit about the little sick patients. And so we kept that term. So people, whether they're a perfectly healthy college kid or a hypertensive diabetic patient, they get a little sick. If they get more sick, they get moderately sick. No coincidence for all of you, that where the clock strikes 12 is when they get sick enough to go to the emergency department. About 25% of patients across the country get admitted to an acute care setting. They almost all get better and go home and have a post-acute care phase and go back to their baseline or near their baseline. And the programs we built out around this, I will highlight, the whole world at the time was focusing here, right? Decreasing readmissions, post-acute care. And we said let's just begin by accepting the fact the best way to prevent a readmission is to prevent the first admission. And so we focused over here and we started growing out. For us, our brand is JeffConnect. So our urgent care app. We're in Philly, so we do Pennsylvania, New Jersey and Delaware. And we began with all ER docs 24/7, 365. You could hop on, you didn't need to be in Jefferson, you could be anywhere in the tri-state area and we would take care of you. We grew that out to a virtual emergency department, which in essence is the app. But you can order a CAT scan and circle back and close the loop. So, you know in the ER, the majority of people who get a CAT scan for an appie don't have an appie. Why not get that as an outpatient if they're not really sick and they're low risk and keep 'em out of the ER? We had for a long time, and I know Ethan's on this call, and we both have tele-intake programs where you could come into the emergency department and be seen by a remote physician who can write your orders, write your note, get your work up started. We have a 38 hospital neurostroke network. I'm not actually gonna talk that much about this. Our neurologists and neurovascular specialists handle it, but they've actually given TPA to a handful of patients within 30 minutes of the phone call to the ambulance because they have a stroke ambulance. So you can really expedite care nicely. We had a virtual rounds program, which is the simplest concept in the world to improve patient experience. You walk in the room to see the patient and you put their family on video, so mom and dad know what's going on or the kids know what's going on and everybody's engaged. Really simple way to keep the family involved. Post-discharge management and remote monitoring and, you know, scheduled visits and e-visits, another way to provide, you know, care outside the walls of the emergency department or hospital when people go home. And we had our residents in emergency medicine doing post-ED visit care, learning to use telemedicine and close the loop worked very nicely. So we were doing this starting in 2015 and, you know, Brenda and I wrote this article that most of you have seen in the New England Journal years ago where COVID really accelerated telemedicine. And what we did is we took our baseline program I just talked about and we messaged, if you remember, March of 2020, stay home, don't leave the house, you know, don't even go get your mail, Right? All this stuff we were doing then, that you could just call our on-demand program. And we went from 20 to 300 visits in a weekend. And bless Adidi's heart. Adidi did the smartest thing. She was with us, then she went right into the film studio and we created training videos because we couldn't individually train enough people to do visits. And so over the course of that weekend, we shot the video, we got it ready and edited and we were able to literally train a thousand people in the next two weeks. We used the virtual ED concept for all of our COVID testing in the region. Remember, COVID testing used to be hard, there weren't rapid tests. You would call in, we would write the order and we would get you your PCR. We took tele-intake and moved it outside the emergency department. And if people came in, we could send them to urgent care or ortho or derm or someplace else if they could be triaged their safely medical screening exam and go on their way. We use this entity called interprofessional collaboration, which I would hazard a guess most of you are not familiar with, but should be your best friend in the emergency department. This is where your consult can give you a consult and bill for it without actually seeing the patient either in-person or face-to-face. Medicare pays for this. It's not a boatload but they pay something. So the simplest way to think about it, particularly for those of you I recognize from academic medical centers, somebody has a seizure and they're on a drug and they say they're taking the drug, and all you wanna know is what's the next drug you wanna give them, 'cause they seized three times this week on a therapeutic dose? They don't need to see them. You write and you probably shouldn't be doing a...

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