Clinical Case Study: Telehealth for Allergy, Asthma, and Immunology

This virtual session discusses telehealth allergy, asthma and immunology care. Explore the AMA STEPS Forward® Innovation Academy on-demand library of webinars on physician burnout, digital health, private practice, BHI and more.

Speakers

• Tania Elliott, MD, chair, Telemedicine and Technology Task Force for The American College of Asthma, Allergy, and Immunology (ACAAI), chief medical officer, Virtual Care at Ascension
• Sofija Volertas, MD, assistant professor of Medicine, associate program director, Allergy & Immunology Fellowship, UNC Medical Center–Chapel Hill

Hosts

• Bernadette Lim, program manager, digital health strategy, AMA
• Jennifer Pfeifer, director of practice management, ACAAI

Explore the AMA STEPS Forward® Innovation Academy on-demand library of webinars on physician burnout, digital health, private practice, BHI and more.

Lim: Good morning, everyone, and thank you for joining us for another telehealth immersion program event. Today's session is focused on telehealth for allergy, asthma and immunology care, and we are honored to host today's event in collaboration with the American College of Allergy, Asthma and Immunology. So, if you could go to the next slide.

During our 90 minutes together this morning, we'll start off with Dr. Tania Elliott, chair of ACAAI Telemedicine and Technology task force, who will share an overview of allergy immunology telehealth use trends. She’ll then switch hats and share insight on the virtual care experience and program at Ascension. And then we have Dr. Sofija Volertas joining us, who will share the allergy and immunology clinic operations and workflow at UNC Chapel Hill, and who’ll also dive deeper into how to leverage telehealth and RPM technology across a number of specialty-specific use cases.

We also have several Q&A sessions dedicated throughout today's event. During these times, we welcome you to ask any questions live. You can use the Raise Hand function. And then again, we really encourage for this to be interactive, so feel free to type in the chat any questions that you have throughout the presentation. And without further ado, I'd like to introduce Jennifer Pfeffer, who will introduce our speakers today. Jennifer is the director of practice management at ACAAI and has been instrumental in making today's session possible in our collaboration possible as well. So, Jennifer, I'll turn the floor over to you. Thank you.

Pfeifer: Great thank you. Good morning, everyone. And on behalf of the American College of Allergy, Asthma and Immunology, I'd like to take a moment to thank Bernadette and the AMA for their partnership in today's program. ACAAI is so pleased to be a collaborator in the telehealth immersion program and we appreciate the AMA’s important work in this area.

Now it's my pleasure to introduce Dr. Tania Elliott. Dr. Elliott is chief medical officer of virtual care, clinical and network services at Ascension. In this role, Dr. Elliott leads virtual care services, including advancing the adoption of virtual care across the continuum and collaboration with the ministry markets and digital teams. Dual board-certified in internal medicine and allergy and clinical immunology, Dr. Elliott embraced telemedicine first as a physician and then as medical director of Doctor-on-Demand, developing the nation's first fully-employed, nationwide, virtual physician workforce.

Dr. Elliott has published multiple peer reviewed journals on direct-to-consumer health care delivery and implementation of virtual care into clinical practice and was named a top health care transformer of 2019. She frequently serves as a health care broadcast media expert and is regularly featured on top shows, including Good Morning America, Rachael Ray, Dr. Oz, Dr. Phil, The Doctors and CBS This Morning. Dr. Elliott is currently chair of the American College of Allergy, Asthma and Immunology Telemedicine and Technology Task Force and was instrumental in developing the college's position paper on the use of telemedicine for allergist, among many other critical resources. Dr. Elliott, welcome.

Dr. Elliott: Thank you. Thanks so much for that warm introduction. I'm excited to be here today. We can dig right in. So first, we're going to just start with some trends in telemedicine use for allergy and immunology. This is based on a survey that was conducted by the college. And you know, it's interesting. You know, way back in 2016, only 6% of allergists were using telemedicine for patient visits. And the bulk of that work was probably in the facility-based realm, meaning patients in rural areas where there wasn't access to an allergist, a patient would physically go to a facility and then a remote allergist would be sort of beamed in, for lack of a better term, to be able to see their patient in what is traditionally called a facility-based, telehealth visits. Interestingly, though, allergist were a little bit behind because across all specialties, the average of telemedicine usage was about 15% for all specialties. Now, that said, you know, in 2013, 2014, 2015, that's when we really started to see the rise of direct-to-consumer telemedicine and telemedicine usage for virtual urgent care. So, some of those numbers are skewed by the fact that payers or employers were offering this telemedicine carve out service for virtual urgent care services. But again, I think allergists may have been a little bit slower to adopt telemedicine technology. That was all pre-COVID. So, we can move on to the next slide.

And now let's look at our members survey that was conducted both in April and August of 2020. So, YOU know April of 2020, it was a little bit skewed because a lot of our ambulatory practices were closed down, so only 30% of visits were conducted in person and 70% of visits were telehealth. So, we remember there was a time where no primary care practices were open, ambulatory surgeries were shut down, and telehealth was the only way in which we could see our patients. Fast forward to August of 2020, there was still almost 40% of visits being conducted through telehealth. You see 66% of them in August were in person. The of telemedicine visits overall were 23%, either audio and visual and then 11% were audio only. But it's really important to note that we're still seeing sustained adoption of telehealth services. And COVID was really a turning point where, I think there was a lot of skepticism around whether or not the technology was going to work, whether or not patients were going to be open to it, whether or not there is going to be a barrier from a workflow perspective, And then when telehealth was the only option, physicians embraced it and said, hey, wait a second, maybe this isn't so bad And it actually is easier to use. And the proof is in the pudding that even when our doors opened again, there were still significant proportion of visits being done via telehealth. So, we can move on to the next slide.

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So post-COVID, when we conducted a survey, allergist expressed a strong support and over 90% of survey respondents said they plan to continue telemedicine use in their practice post-COVID, assuming that the reimbursement continued at current levels. So, think about that compared to 2016, where only 6.1% of allergists were open to or interested in using telehealth services. We've seen a lot of great advancements from a reimbursement perspective as well. So, all of the ties are reassuring that telemedicine reimbursement is going to continue. And we've also just again, removed a number of barriers on the part of the physician and workflows, and it's what we'll discuss a little bit later. Some of the best practices and things we've learned at Ascension and some of those clinical pearls will share with you. But at the end of the day, telemedicine is here to stay, both because clinicians have adopted it. And recognize that it can actually make for an easier workflow and improved overall care and also because patients continue to ask for it. You move to the next side.

So, what types of visits are being seen through telemedicine? So more than 50% of respondents were comfortable addressing new patient problems during telemedicine visits. And I'll just pause for a moment and talk about why that's important. We are specialists, and so we rely on referrals from primary care physicians and pediatricians. But oftentimes it takes months to even get in, to see a new patient, to see it, to see an allergist. Also, you know that oftentimes patients are just kind of doing a Google search and trying to find access to care and trying to locate an allergist. So why not remove that barrier, make it easier for that initial touchpoint to be with an allergist through virtual? If you actually think about what happens during that initial encounter, over 90% of what we do is history taking. We also know that oftentimes patients are already on an antihistamine or some other medication that prohibit us from doing testing.

So, there's no reason why you couldn't do an initial intake and get a full and comprehensive history, because we know that patients, by the time they come to see an allergist, they've probably seen a number of other doctors and hit a lot of I hit a lot of dead ends. So, to be able to take a comprehensive history, perhaps review records in advance, use that time for care coordination. There's tremendous value for patients. So, it's reassuring to see that over 50% of our respondents are open to seeing new patients through telehealth. And I would expect that number continues to improve because again, we need to improve access to the allergy specialty.

The other piece around that is if allergists are open to and again, it's just a lot of paperwork, but if allergists are open to getting multi-state licensure, there are only 3,000 allergists in the country. So, there's a real opportunity to open that aperture and improve access to allergy care for people who don't live in close proximity to one. Around established patients, new problems and existing problems, reassuring to see that 97% of respondents said, hey, if this is an existing problem and I know my patient, I'm happy to see them for follow up care through telehealth. And again, in one of our case studies, we'll talk about how you can actually make that possible. And make virtual care the standard, as opposed to the exception. And I was also really reassured to see that over 81% of respondents said that for established patients who have a new problem, there was also an openness to see patients through telehealth. Now, initially, if you ask me what I thought people might respond to that question, I might say, well, if it's an established patient, but it's a new problem, I feel like clinicians would probably skew, oh, we'll have that patient come in because we need to do some diagnostic testing.

But I think it speaks to the doctor patient relationship and knowing your patients. And then if it's a new problem, that doctor patient relationship will allow enough kind of information exchange video will allow for the right type of physical exam and you have laboratory diagnostic testing that can serve you. So, I think it's reassuring to see that even for established patients who have a new problem, there's a lot of comfort in seeing patients virtually. You can move to the next slide.

So, what are we seeing patients for? So, I'm not surprised that the lowest number here is for new onset asthma because we rely on diagnostic testing to make that initial diagnosis. So, if you had an easy way to get at-home PFTs or perhaps somebody could go for PFTs in advance of the visit, I would anticipate that number would be higher. But because we do rely on diagnostic testing pre and post bronchodilator, it makes sense that for a new onset asthma case, that would be something that folks would be a little bit less comfortable seeing. For all follow-ups across the board, though, you see for follow up asthma, follow up food allergy, follow up, allergic rhinitis, significant comfort with seeing those patients virtually. And again, we should talk a little bit and we will talk a moment about how to, again, make that the standard of care as opposed to the exception. Because oftentimes, if you leave it up to the front office staff, who's so used to just scheduling patients for their next in-person visit, that's what you're going to get. That's what's going to happen.

So, there's a little bit of a discrepancy here, whereas when I showed a prior slide and we looked at August of 2020, where 66% of the visits were in person, you think, well, wait a second, if 96% of your allergic rhinitis visits and 91% of your food allergy visits and 80% of your asthma visits could be virtual, then why are you still seeing 66% of your patients in person? So, it's a little bit of work to do there to make virtual care the standard of care. But at the end of the day, at least, we know that there's an openness around and a comfort around the clinical quality that can be delivered, virtually, for the follow up of these conditions.

One other thing I want to point out is for new immunodeficiency. While I can understand why a physician might feel that initial visit needs to be in person, especially if they want to feel the spleen and do other sort of aspects of a physical examination for the patient. We know the types of patients with immunodeficiency when they're coming in and they've probably seen five or six other doctors by the time they've come in to see you. I think that there is tremendous value in actually having that first visit, because you know, it's a very long visit, those patients take about an hour and a half to get through that full and comprehensive history, there's tremendous value in building that relationship, that initial relationship with that patient, virtually. Again, it allows you to go through a comprehensive history. It allows them to even share their screen, share records with you.

Again, do some additional detective work and care coordination, perhaps while you're on with that patient getting on the phone with their primary care doctor or maybe even having that initial visit be a three-way consultation with other physicians who may have been involved in that patient's care. So, there's no reason why, for an initial immune deficiency, you can't leverage the power of a virtual visit to do a comprehensive and thorough history and then have them come in for part two of the visit, which would be a review of diagnostic testing and further physical examination. So that's one where I think we want to maybe rethink the patient experience and the value of being able to have that one-on-one time with that patient to review their extensive history. We can go on to the next slide.

Sorry you know what? I'm going to if we go back for one moment, I do want to say something also about new onset eczema, which is another one that I'm a little surprised to see that the numbers are a little bit lower on. Granted, there might be other things in a differential diagnosis. Maybe you want to do a biopsy, but for the most part, especially for pediatric atopic dermatitis and eczema, that's pretty textbook, we should really be leveraging asynchronous technologies and the power of video. Absolutely if you don't have access to video, if the patient doesn't have access to video, that's a different story. But you can get a very, very thorough assessment of patients.

And you look at the American Academy of Dermatology and all their work that they're doing with atopic dermatitis and eczema and asynchronous care, where patients can upload high-resolution photos for you to review, and then you can even Zoom in on areas of focus. So, there could be some additional work to be done there to increase the access for patients with new onset eczema. And remember, it's not one or the other. It's not if this then. if I see them virtually, I can't see them in person. It's, would there be value in an initial evaluation of a patient for this condition? And would there perhaps be value above and beyond what I can do in my office?

And I'll say for eczema, especially if you're concerned about maybe some of the skin treatments that they're using, doing a walk with them to their medicine cabinet and looking at all the medications that they're taking and looking at all their personal products. Otherwise, the way that we do that in the office is a little bit backwards. We take the full history and then we ask them to come back next time and bring a few personal products that they use. Or we ask them a history and we ask them to recall or remember what they're taking. So again, when you're thinking about seeing a new patient, think about where there could be incremental value add of a virtual visit above and beyond which you can do in the office. And then think about how the office visit can supplement as opposed to an either or. If I see them virtually in person, then I can't see them in person. It's not it's not an either or. It's really about longitudinal care delivery and what's best for the patient. So, we can go to the next slide.

You just want to bring to your attention some resources that have been put together by the college. So, we have comprehensive how to conduct a virtual physical examination. And I cannot stress the importance of video. There is a significant difference between doing a telephonic encounter and doing a virtual video encounter. If we want to talk about telephonic encounter, then we can say that Alexander Graham Bell was a father of telemedicine. I believe the story goes that I think Alexander Graham Bell's first phone call was to his doctor because he spilled something on himself and he wanted to get some advice about a triage about how to handle the situation. So, while telephone is important for patients who don't have access to care, there's a significant difference from a clinical quality perspective when we're talking about laying your eyes on patients and doing an actual virtual physical examination.

But there's training that it takes, that it requires. And one of the things we're doing at Ascension is actually creating a graduate medical education curriculum to assure that our medical, medical students and our residents know how to do aspects of a virtual physical examination because it's a little bit different and it requires the assistance of a patient. So, we call it a patient assisted or patient and guided physical examination. So, there's great resources there.

Also, how to conduct a visit using professionalism and what we call website manner. In medical school, we're taught a lot about how to make physical contact with a patient. Put your hand on their shoulder. If they're feeling sad, hand them a tissue. So how do you convey that same level of respect and compassion for a patient when you're conducting a visit virtually? So, those are really important skills that you want to make sure that you've mastered. How to use telemedicine with your asthma patients, specifically. Also, lessons learned during the COVID pandemic and best practices, as well as some guidance around billing and coding. You can go to the next slide.

We also have a robust education on conducting a telehealth visit for eczema and skin of color. And I was kind of doubling down on the fact that for eczema, patients say atopic dermatitis, it's really important to be able to leverage asynchronous video and video to be able to assess those populations. But it's also important to understand that there are different lighting considerations if you're handling skin of color or darker skin. There's a number of other things that may not translate as well as they do in the office. And so, we've put together both assessment and management of eczema in skin of color, along with allergy and asthma network. So those are also some great resources to look at.

We also have a tool kit. So, for allergists that are looking at implementing telemedicine, they're just getting started or maybe they've dabbled in it in the pandemic and they're starting to see their in-person numbers rise and they want to be able to do more. They can look to our position paper. We also have guidance around laws, reimbursement and licensure requirements, as well as some education on the efficacy and clinical quality of telemedicine for asthma, specifically. We can go to the next slide.

Here's also some resources for the American Academy of Allergy and Immunology, they also have a great telehealth toolkit as well, and we are also always available for questions. So please don't hesitate to reach out if you have any questions. And hopefully we hope that this is an interactive conversation where you could start to ask your questions and we can answer them in real time as well.

So now I'm going to move on to a case study. What we've done in Ascension. So before March 1st of 2020, we saw 16,500 virtual visits. And I think our goal was $20,000 for the year. For 2020, our goal, we were going to double down on virtual care, we were going to see 20,000 patients. Fast forward to our most recent numbers. This past February, over 3 million patients have been seen virtually. So virtual care is not going anywhere. It is here to stay. And we are excited to share with you, ways in which we've been able to sustain telehealth momentum at our organization. So, I think a lot of you are already aware of this, but there are kind of three buckets of benefits here. I always talk about there's the patient experience, which is tremendously important. There's the clinician experience, meaning us as the physicians and telehealth, I absolutely believe could help to reduce physician burnout. But then there's also the non-clinical care team, the operational benefits of this as well. Just some statistics on the operations side, we've seen much higher conversion for same day office visits, meaning if somebody calls in and they want to be seen, getting them in for same-day virtual is a lot easier than getting them in to be seen for same-day in person.

The other piece that is tremendously important is we have 50% fewer no-shows.  50% fewer no-shows for virtual visits than in-person visits. And we found that it's highest and best use of our office time or in-office time to focus on procedure-based care. And for allergy, and this is across Ascension, not specific to allergy immunology, but for allergy immunology, if you think about it we're very procedure based, right? You have your skin testing, your drug testing, your food challenges, your allergen immunotherapy. We are very procedure-based practice.

At the same time, we have longitudinal relationships with our patients. And we need to do comprehensive assessments for our patients for initial intake. Because one of the reasons I became an allergist is because we have to do a heck of a lot of detective work to figure out what's going on with patients. So, the best value, the best bang for your buck is to consolidate your in-person days for the procedure-based days and then have the rest of the days: the office visit follow ups, the longitudinal care delivery, the new patient encounters, intakes assessments and detective work, for virtual.

And that's where you can get the most highly effective and efficient practice in terms of patient benefits, meeting them where they are, avoiding unnecessary in-person visits. We do a ton of work with social determinants of health and we have patients who have real barriers with access to care. They have transportation issues. They have childcare issues. They can take off of work. And we ask them to come in during our 9 to 5 business hours and miss a day of work and a whole host of other things, throw their day upside down, just to accommodate us in the office. It shouldn't be that way. We need to improve access to patients and meet them where they are.

And then in terms of clinician benefits and reducing burnout, we all know what we need to do during allergy season and opening up evening hours and weekend hours. Well, maybe we could rethink that and say, we can offer our weekend hours, but we could be working from home in the mornings and/or maybe we work in the weekends, but it's 5 to 7 PM working from home, after a full office day. So, there's ways in which you can schedule blocks of virtual time so that you're not also compromising your personal life.

And improve coordination is another really important piece, which we don't think about a lot, but it's really important. I recently had a group visit and I found it to be tremendously impactful for my patients, whereas myself, a GI specialist, the patient's primary care doctor and the patient are all on the call at the same time. That's virtually impossible to do when the patient is physically in the office with you. What ends up happening is, oh, let me call your primary care doctor and figure that out after the fact. Let me call your GI doctor. Let me review these records. But wouldn't it be a heck of a lot easier if you were all on a four-way conference call and actually discussing the patient case?

I can't think about it more of a patient centric way to deliver care, and it's way more effective and efficient for us. And it allows us to create a comprehensive treatment plan. And this is something that I think we as physicians and just as large organizations really need to advocate for. There should probably be certain types of reimbursement around that specific type of visit, that care coordination visit, where you have multiple specialists on the call at the same time delivering that care to the patient and coming up with a comprehensive treatment plan, especially for those patients who have complex conditions. We can move to the next slide.

So, this is a little bit more bird's eye view from a health system perspective, because what we found at Ascension, we're one of the largest health systems in the country. We've got 150 hospitals, 2600 ambulatory facilities. We employ 5% of the physicians in this country. So, it would be silly of us to set a virtual care strategy and say that every market across the board has to deliver on the same thing, without understanding the underlying infrastructure that exists within our markets, within our ministry markets. And it's the same thing if you have multiple practices, not every practice is operating in the exact same way, has the exact same resources, has the exact same patient population. So what we did was we developed a maturity model and we did this with some support from the American Telemedicine Association. So, here's sort of the stages of it. We considered Basic telehealth to be telehealth that's offered maybe by a couple of doctors, but there's no formalized program in place that's supported or operated by the organizations.

The clinicians say, oh yeah, I use virtual care during the pandemic, and maybe I'll use it if my clinic closes. But otherwise, I have my own way of doing things. I see my patients in person. Then there's Basic+, which would be considered going from ad hoc to identified. So, the organization and again, we use this for our entire health system, but the organization can be your individual practice, your group of practices, your hospital system. But it recognizes and acknowledges the value of telehealth, and it's taken some steps to formalize and manage it; offering some resources and support, maybe you have identified some champions. And clinicians are open to exploring telehealth, but it's not front of mind, it's not top of mind for them. And then we have Advanced, where the organization actually has a well-defined, strategic plan, is actively working to advance the use and position telehealth for success through training, shared best practices and the organization is engaged in collaborations.

So, this is, have a set strategic plan, you have your 2022, your 2023 goals, and you're starting to think about how virtual care can be embedded within those goals to help you achieve those broader initiatives. Advanced+ is that the organization is actually taking some steps to measure telehealth effectiveness, both from a clinical perspective, from a quality perspective and from an operational perspective. And then Best in Class is really you can see this is your telehealth center of excellence and the organization and clinicians are focused on quality and growth and expansions of your own telehealth programs, to other organizations and other customers. So, this is where your physicians are opening up virtual practices in neighboring states, for example. And you go to next slide.

So that's sort of the framework. So, what exactly do we mean by this? So basic, and by this point I believe that all physicians should at least be at this basic level. You should be offering telehealth services, because if you don't offer telehealth services, you're going to your patients are going to stop seeing you. I don't know how else to say it, but I think that there is such a demand now from a patient perspective. They want their physicians to be offering telemedicine. They want this as an access channel. They want there to be that interaction between doctor and patient through this modality. So same-day, virtual visits, patient calls and says, hey, I really want to get in to be seen and your practice says, great, I can get you in virtually. Converting cancellations to virtual. So, someone calls to cancel to say hey, I can't make my appointment.

Offering that, offering them a virtual visit instead of saying, OK, I'll reschedule you for a week or two weeks later. When your clinic closes due to inclement weather or a pandemic or something, converting your entire clinic in-office hours to virtual visits. For patients who are no showing, similar to the cancellation model where if there are no showing after 10 minutes, you call them up and you say, hey, would you like to convert this over to a virtual visit instead? And then also identifying a lead, somebody who's a champion either within your practice or within your organization. And then also starting to think about inpatient specialty consults. So not a lot of allergists offer inpatient services, but now that they could be conducted, virtually, you should start to consider offering inpatient hospital level consultations for penicillin allergy, for example. An advance is when you have a telehealth infrastructure and expansion beyond just basic. So, you have dedicated leadership.

You're actively tracking data. You're tracking consults maybe beyond just the telemedicine or synchronous video visits, but you're starting to dabble in E-consultations, which are specialists, second opinions or remote patient monitoring, which we'll talk about in a moment. You also have a council or a structure in place. So, this is more the organizational level, at the health system level, where you actually have a multidisciplinary counsel and you're starting to think about strategic growth areas to leverage virtual care. And then best in class is really saying you've got dedicated programs and you're leveraging those programs for expansion and growth opportunities. So, you can go on to the next slide.

So how have we done that at Ascension? It's a combination of objective data and then having the right structure in place and then specific programs. So, around engagement, we look at it at Ascension as the percentage of ambulatory visits that were conducted virtually, whether or not there are any inpatient virtual services provided. Again, we're an integrated delivery network, so we have 150 hospitals. And then physician engagement, which is a little bit different than just saying percent of ambulatory visits. You're looking at the number of doctors that have had virtual claims.

So how pervasive is telehealth within your organization and your new clinicians that are coming on board? Are they adopting virtual? Are they continuing sustaining the momentums and those best practices and learnings from COIVD? So that's what we've looked at. We have our targets as at least 50% of our clinicians should be offering virtual visits and 70% of all of our new doctors. So, we've actually put together a comprehensive training and education program to help people understand what virtual care means at Ascension. And for us, we're beyond telehealth and we're beyond synchronous video visits. And we're thinking about E-consults and remote patient monitoring and digital therapeutics. And then from a structure perspective, what we put together is a requirement for operational and clinical leadership.

So, assigned just means someone in the market has raised their hand and said, yep OK, I'm your virtual care person. Dedicated means they actually are part of their role, part of their job is actually dedicated to this. So, it's maybe a 0.25 FTE, for example. And then employed, which we consider best in class, is you have a medical director of virtual care, you have a medical or you have a director of virtual care operations. And I can tell you right now, those director virtual care operations are extremely busy because we're leveraging virtual care to address our physician and nursing shortages across our country, across this country. And thinking about programs where you have centralized MAs, centralized nurses, so you don't have to staff practices with nurses who we don't have today because there's such a shortage. And then around governance, whether or not you actually have a counsel. So again, if you're a small practice, then at least putting together your office manager and one or two physicians and maybe your biller together, to just sit together once a month and think through opportunities from a workflow perspective, from a billing perspective, from a growth perspective.

And then if you're in a larger organization, a multidisciplinary counsel bringing together strategy, operations, technology teams, legal compliance, marketing, all together to talk about virtual care optimization and growth strategies. And then we have growth and we just kind of I'm sorry, programs on the right-hand side. And what we did was we said, look, if a market doesn't have the right level of engagement and the right infrastructure in place, then we're not going to ask them to implement a best-in-class program. We're going to say, hey, what will it take for you to have a basic infrastructure in place? And then let's now set your targets or your goals to be basic level goals. So, it's really helpful to kind of understand where your organization is and then help them get there from an infrastructure perspective and then from there, set reasonable targets for them and go on to the next slide.

So, what we've done in Ascension, again, as we said, well, what are our priorities? What is what is inherent within our strategic plan? What are our broader goals across Ascension? That don't relate to virtual care, just our broader goals. What are we looking to achieve within our organization? And then we look at our market virtual care and maturity level, and then we say, from there, let's create some realistic virtual care initiatives with some core KPIs and targets, and the markets or our practices will be signing up for them. But we want to make sure that whatever is being created, number one, is consistent with a level of market maturity. And number two, isn't just a one off, carve out of, oh, this cool little virtual program here off to the side, it is embedded into a strategic plan. I'm sorry. So, if you have a goal of improving asthma action plans, for example, then how will virtual care help you get there as opposed to having one goal that's improving asthma action plans and then your virtual care goal is something around virtual urgent care. So, you want to make sure you're thinking about virtual care as an enabler to help you achieve your broader goals but make it a realistic enabler based on the level of market maturity or practice level maturity of virtual care. You can go on to the next slide.

OK, I'm going to cruise through the implementation guide because we'll make sure these resources are available to you. So, we put together a memorialized best practices. And we put it into a ready set go format. So Ready is engaging and preparing your office, your staff and your schedule for virtual visits. Set is preparing your patients and Go is planning before, during and after the virtual visit. And then, of course, how can you measure and maintain success? Because it's really important. We don't want just anecdotally, oh yeah, virtual care is great. You want to set your goals, those KPIs, and then you want to see how you're tracking towards success. So, we go to the next slide.

So, in terms of education, I mean, a lot of this, I think most organizations have done so far, but I'm going to double click on selecting the hippo compliant platform for visits. What we've done at Ascension is we built a proprietary video visit solution that was simple, slick and easy to use, and all of our other documentation occurs and scheduling occurs in our native EHRs. So, it's really important that when you have a system for virtual, that it's not a replacement and it's not redundant with something that you already have today.

So, doctors are used to documenting in their own EHR and your schedulers are used to their scheduling system, let them do everything in that system and then leverage a HIPAA compliant Zoom for virtual visits, for example. Or you can look to the EHRs that maybe have embedded virtual visit capability. But I would caution against anything that requires a patient to have to download an app or log in to anything. The quickest and easiest way to make virtual care sustain successful is don't have the docs log into anything, don't have the patient's log into anything.

Something that's a quick and simple email link or a text message would be of most value. And I can also tell you that I've heard stories from physicians where they say, I want to do more virtual care, but our technology systems and infrastructure in place are so challenging that my hands are tied. So now is an opportunity. There are lots of lightweight solutions out there that are quick and easy and inexpensive to use. So don't bound your clinicians down by a very cumbersome or clunky platform. We can go on to the next slide.

So, this is what I was just discussing before. I think virtual visit blocks are really effective. Again, I think it could help to reduce burnout. I offer early morning hours from 7 to 9 in the morning and 7 to 9 at night. But I'm doing that from the comfort of my home and then I'm coming in for traditional office hours if I want to offer weekend hours, I'm going to do them from home. The other thing that's of value is the on the fly visits in between, when you have some downtime and somebody calls in offering those same-day virtual visits.

And then the last piece is for overnight, when a patient is calling in overnight and they're having an issue, instead of using the nurse call line or sending the patient to urgent care, why not just convert that to a virtual visit? You're going to be on call anyway, so you might as well just shoot a quick video link. You could even embed that into your on-call center where the on-call center could shoot a video link to the patient and a video link to you. You guys connect. And then you conduct that and you bill as a visit. So, there's tremendous value in doing that for the patient where you actually can lay your eyes on them as opposed to telephonically triaging, especially if it's somebody that you're cross covering for and it's someone that you don't know, a patient that you don't necessarily know. You can go to the next slide.

This is just a few buckets are important patient outreach again like a really quick win is all patients that are calling to cancel an appointment. It's probably because they're stuck in traffic. They couldn't get child care, they couldn't get off of work, offer them a virtual visit as an alternative. And then track your no show rates and what's happened in or cancellation rates and see whether or not you've had improvements. Again, the no shows, call them to rebook same day or next day. Virtual visits, proactively call those patients who haven't been seen in over a year who are lost to follow up. We know the list, right? Because they call and they ask for renewal on their allergic rhinitis medications.

And you say, oh, well, it's been over 12 months, so you're going to have to come in for a visit. So maybe from a patient experience perspective, proactively call those patients and offer them up a virtual visit so that they don't have the poor experience of calling an office for a refill and then not being able to get it because they have to come in. I think we have a couple of questions. So, I'm just going to cruise to this slide, and then I can pause for questions.

But from a marketing perspective, I think for new physicians coming to your practice that are joining your practice, offering and touting that they offer virtual visits and also talking about whatever that physician specialty is. If you have somebody coming in who's an expert in atopic dermatitis or immune deficiency, you should say, hey, we have a new physician, they're an expert in xyz, schedule your virtual visit with them today and welcome to our practice. And I think it's really important for you to market it in a way that's an entry point for patients not as an either/or like oh you can just see this patient virtually. This is an entry point. This is a way for us to get to know you and then we'll see you in person for your continued care needs. I can pause for a moment and look at some of the questions. We can go we can go on to the next slide here.

One other thing I just want to suggest. I just want to mention, actually, is that for follow ups, we already see in the data that 90% of the time allergists feel comfortable having follow up visits, be virtual. So again, making that the routine, making that the standard as opposed to the exception. Maybe you have something in your practice where you tell your staff, make all of my visit, my follow up visits for my patients virtual unless I say otherwise. That way your staff is empowered to say, OK, Dr. so-and-so would like to see you for a virtual follow up on this day. When you leave it up to the staff and the patient, what often happens is the patient thinks, oh, well, I should probably come in. I mean, the doctor usually sees me in person, so I don't want to do anything wrong. Or maybe I get better quality by coming in person. But if you position it in such a way, it's behavioral economics. Doctor so-and-so will see you in three months for your virtual follow up. Then it becomes the standard of care.

Dr. Elliott: OK, I'm just going to look through some of these questions. There is a question, Eliot, we have.

Lim: John's raising his hand here and is on video.

Dr. Elliott: Great question first.

Ovretveit: Hello I'll be brief. I work for Stockholm Health Care, but I'm over here with Kaiser, on the West Coast, at the moment. We in Europe use a particular definition of telehealth or E-health or digital health. Now, in the data you've been presenting, I wasn't clear whether you just mean video consult visit numbers or whether you're adding to that telephone numbers and indeed whether you're adding to that total number in telehealth, things like emails and chat, because there's very different definitions and it's the very different numbers involved. And you presented your association and you also presented Ascension, and I just didn't know what the numbers mean. May I also say this is easily the best presentation I've seen on this subject, and I'm not an allergist.

Dr. Elliott: Yeah, those are great questions. I'm really glad you brought them up. What we're talking about today. And the numbers I shared today are four synchronous encounters. And we did have a breakdown of telephone and video. We may want to just go back up to the slide to share that. But we are not including email or messages, or portal consoles or anything like that or text-based interactions. We are strictly talking about synchronous interactions, either audio only or audio video. So, when I shared the 3 million visits through Ascension, 70% of those were video visits and about 30% of them are audio only.

Ovretveit: Because most European PCPs are much more comfortable with telephone and have been doing that for years. And really what's new is doing the video consults and navigating the different apps. You are so right about the logins. Thank you.

Dr. Elliott: Thanks and Thanks for the feedback.

Lim: Any other questions for Dr. Elliott? We have a couple of comments in here, but not any additional questions. And again, feel free to raise your hand.

Dr. Elliott: So, Bernadette, how are we doing on time? Because I can go on forever. And I wanted to do. I did want to discuss remote patient monitoring quickly, but I could be really fast.

Lim: Yeah, that sounds good.

Ovretveit: Let's keep the lights on these equity issues, although it may not come up for you guys much, but it's a big issue for us in terms of health literacy, computer literacy and actual ownership of smartphone.

Dr. Elliott: Yeah, it's an important, it's a really important point. We do have data. It's not in this talk. But I will just share with you that when we look, Ascension's mission is to service poor and vulnerable populations and health equity is tremendously important to us. And it's something we look at from a data perspective regularly. And what we found when we looked at social vulnerability index and people from disadvantaged zip codes. The people from the most disadvantaged zip codes use virtual care at the same rate as they use in-person care.

That's not to say that we are not missing a significant proportion of the population who don't use the care at all. But when you look at the people who are engaged, they use virtual and in-person at the same rate, which is reassuring. With regard to telephone encounters, we see telephonic encounters to be a little bit higher with our older populations, with our Medicare patients. But what's really interesting about those numbers, too, is that was much more skewed telephonic at the beginning of the pandemic and decreased significantly today.

And I think a lot of that was because we were going into it with an assumption that so and I think it's important for us to think through our assumptions, oh, these people may not use smartphones or they may not have access. And what we found was they figured it out.

And I always say, I can't believe I got it. She'd make fun of me saying this out loud. But my 70-year-old aunt who’s on Facebook all the time, looking and scrolling on Instagram and Facebook and commenting and hearting all these things. So as much as we may think that they may not utilize technologies, they are. They do. But I think it's also really important to engage caregivers, you know, family members to say, hey, we would like to engage your patient, not your patient, your family member in a virtual visit. Can you facilitate that? And leverage them as facilitators for virtual care.

The other piece is to make sure that we have solutions for hearing and visually impaired patients. And so, one of the things we've done is we've made sure that we have closed captioning available for our virtual visits, in large font. And translation services is another thing that we are working on for this year is to also assure that we're offering translation services for all of our virtual care visits.

Ovretveit : When will we have automated translation services for most popular, you know, I mean, we can see the tracks and everything and there are some, I mean Google is almost there in doing it quite well. Is it good enough for clinical and when do you expect to fold that into the system?

Dr. Elliott: Yeah, you know, I don't think we're there yet. Right now, what we're doing is focused on a person being available for the translation services and including them in video. So that's what we're focused on. But I don't think it's too far away. I would probably say in the next two to three years, they’re some great startups that are out there doing that. But for us, for now, we're focused on actually having a person join in the visit that's a certified translation specialist.

Ovretveit: I think Melinda has a question.

Volertas: And I just wanted to piggyback on one thing Dr. Elliot said that I see also often in my clinic is that I love the fact that the telemedicine that you can really engage the whole family support system. For a lot of these elderly patients who may be having difficulty, as you were just mentioning, if you think about that issue with patients connecting their family members or their other support systems at home, they might not always be able to take off work, even though, you know, multiple of those providers, if there's different people at home, it's a lot easier to get the engagement of everyone else in the family or the whole patient life that really is impacted by their disease. And so, I just really want to piggyback on that and say that that's been a really great use of telemedicine that I've seen as well, and engaging the whole family or the whole support system that's around the patient.

Lim: Melinda, we'll go to you.

Rathkopf: I just wanted to add some comments. This is a great discussion and thanks, everybody. But I think the ability to pivot and be flexible in just some examples that I've had this week, a patient that was on my schedule, been on my schedule for a while for a follow up, she tested positive for COVID that day. She felt well enough to do a telehealth visit, and it wasn't related to COVID, but she wouldn't have been allowed in our clinic. Right? She had to be at home and then just got a notification now, we just had an avalanche and our road is closed for the next 8 hours. So, no one, none of those patients would be coming into clinic today.

And even when I myself got COVID, felt well enough to be able to do clinic, but had to stay home, able to pivot and move all that. And it also goes back to the telephonic and I think Tanya was right about not assuming people, certain people wouldn't be able to do the virtual, but the ability to pivot like we try to do the virtual, we try to do the Zoom. But if that's not working or the connections badly. I'm in Alaska, so we have some pretty remote areas. Then it's like, I can sit there on the video and motion, I'm going to call you, kinda pickup the phone. So, I saw you briefly and being able.

So, I just think the I love patients in person, I love physical exam, I love that time and space. But the ability to be able to be flexible with telehealth and to be able to pivot quickly has been remarkable.

Volertas: I also. Sorry I'm also jumping in here to Dr. Elliott. But also, Melinda, thank you for that because I think one thing that I've seen also and I don't know if Dr. Elliott has seen this as well, there's the pivot and that part of things that the pandemic really unveiled for us and how as physicians who use telemedicine quickly, as you just mentioned, other people are testing positive for COVID or even physicians or even your nursing shortages, people around. Also, when we had this surge of omicron, many people were out for COVID related leaves. That was really important.

But I think also it's really important to think about how we're going to integrate telehealth for the future beyond the pandemic, beyond these pivot points, what does this do to actually improve patient care overall, and how do we do this digitally-enabled care together to actually access points of a patient and their home environment that we've not been able to do in the sterile clinical space. And that aspect of the longitudinal thoughts of how telemedicine and telehealth is transforming health care is really, I think, the next few steps as well.

Lim: Great Thanks so much to Dr. Volertas. I want to keep us moving just watching the time. Dr. Elliott, you've got a couple more slides here.

Dr. Elliott: OK. So now we're going to move on to another frontier, remote patient monitoring. We are heavily focused on this. I really like what Dr. Laura just said, which is like virtual care, synchronous video visits is here to stay. But here's a whole spectrum of connected care, virtual care services. So, we just heard a little bit about what about portal messages or E-consultations. So, in our world, we consider that communication technology based services, that's CMS is definition. So that's things like image or video uploads from a patient.

So, any piece of information that's initiated by the patient to the clinician, so that could be an email that's sent. They can send an image, a photo, and then the physician writes back, those are all reimbursable services, not much, but they are reimbursable services. And then E-consultations, which is extremely important for specialists to be embracing, both in value-based arrangements and then also as sort of new relationship building opportunities with primary care and pediatrics.

I'll just ask you, how many times have you seen a patient in your office and said, oh, my gosh, this patient didn't need to see an allergist like we just wasted that patient's time? And now I actually feel bad for them. So, with an E-consultation or provider to provider interaction, that's actually where the primary care physician or a pediatrician or another specialist sends you a clinical question and the patient's record. You get to review that information and then make a recommendation and answer that question to make a recommendation on next step.

So, I've done e consultations for primary care docs in rural areas across the country because I have licenses in 15 states and I'm able to say this sounds like allergic rhinitis, ordered these three tests, try this medication empirically and if it doesn't help, you can send the patient in to me. I've also managed chronic urticaria patients and it really feels good for me because I feel like I'm empowering PCPs and pediatricians to appropriately manage and treat patients.

So instead of them sending a whole slew and panel of tests, for sometimes a patient comes to me with 50 different food tests, IgE tests or IgG tests, I'm actually able to empower that primary care physician to be able to do more for those patients and practice evidence-based medicine and develop a good relationship with me. So, it allows me to get the right kinds of patients into my practice. And for anybody that's in value-based arrangements, this is going to be the future of health care delivery and way in which we can get highest and best use of our specialists’ time.

So that's communication technology-based services. Then we have the synchronous video telemedicine and then we've got this whole spectrum here, remote monitoring services, remote patient monitoring services. Patient surveillance. I'm not a fan of that term. Think about remote care monitoring, but this is where we're monitoring and reviewing patient self-reported data. So maybe we're asking them the asthma control test or we're asking them how are they feeling? If they're more short of breath? If their medicines are working?

And we're actually monitoring that data that's coming through, via text message in near real time and then making treatment decisions based off of that. And then you have connected device monitoring, which is how CMS defines remote patient monitoring, and that's near real-time monitoring of streaming data from FDA approved devices. So best example would be a glucometer that's Bluetooth enabled, but biosensors, you know, a digital inhalers and things like that. And then there's facility patient monitoring, which is out of scope for this discussion. But this is more when a patient is physically in a facility and we're remotely monitoring biometrics. In order for these programs to be successful, you really need to focus on the clinical experience of the patients, the people, meaning the care teams, and then the technology. That's really the underpinning that can facilitate that. So, you can go to the next slide.

I will just tell you, remote patient monitoring is the next frontier of health care delivery. It's sort of like telemedicine. If you're not doing that, you're way behind the times. And remote patient monitoring now is where our focus needs to be over the next two to five years, it's the next frontier. And if you don't believe me, ask CMS, because they have reimbursement codes for remote patient monitoring and new codes for remote therapeutic monitoring, which is that patient self-reported data that just came out in 2022.

So why is it important? Patient engagement: it allows you to interact with patients in between visits and educate and change behaviors. Timely treatment: iIt equips us with near real-time data for early insights and intervention. It also allows us to longitudinally monitor patients in a much more effective way. I'll get to an example of that in a moment. Keeping people healthy at home. Patients report improved quality of life. They don't have to keep going back and forth to the doctor's office. The doctor has objective data to help to manage and inform treatment decisions, and it can reduce total cost of care, meaning reducing unnecessary testing. And again, allowing for early interventions. If a patient doesn't seem to be doing well, doesn't seem to be doing well on their asthma medications, instead of waiting for them to show up in the emergency room, you can be proactive about the treatment.

So, I'm just going to give just an example about the importance of remote patient monitoring and how much better it is than a standard of care today. If you think about a patient and your asthma patient that comes into your office, right. You see them every three months. They show up, you say, hey, Tim, how have you been the last couple of months? Have you used your inhaler more than two times a week in the last week?

More than two times a month at night? And you're expecting that patient remembers all of that information, with precise accuracy, and then that's what's informing your treatment decision. So, if the patient forgets right, then you're out of luck. You're actually working off of incorrect data. It's like relying on the eyewitness testimony of somebody in court where it's just like you have to rely on whatever it was that person remembers at that given point in time, you have to be asking them the right kinds of questions. That's what we're relying on today in clinical medicine now with remote patient monitoring.

And I'll talk about a digital inhaler, for example. You can tell with accuracy how many times they've opened up the inhaler, how many times they pressed the button, and what the quality of their inhalation was. So, it takes out all the guessing, you know, how many times they've used their inhaler.

Now overlay that with a daily text message or weekly text message or symptom score with an asthma control test or a rhinitis control test and you have objective, accurate information to inform your treatment decisions. So not only are you not playing a guessing game, trying to hope that your patient provides you with the right historical data, but you're also not wasting a heck of a lot of time trying to guess and plug out of people or pry out of people the right information. You could have it all lying in front of you in a spreadsheet, tracking and trending what the medication usage was, what their symptoms were over a period of time.

That's the future of health care delivery, and that's why we all need to, this is kind of my call, the call to action that I'm already reaching to the punchline for. We'll talk a little bit more about it in a moment. But that's the future of health care delivery. We have this objective data now it's, how are we going to harness that data in the right way? How are we going to make sure we're looking at the right data? And there's definitely going to be a signal noise problem. And I'm certainly not saying that a patient should be pinging you and sending you information every day. But there's a right way to harness that data to truly inform our treatment decision and improve overall patient outcomes. You can go to the next slide.

We've put together a framework for how to think about a successful remote monitoring program. You have to make sure you identify and engage the right populations that are most likely to benefit. You have to have the right kind of clinical intervention, and it's not always the doctor, you might hire in a nurse. And those RPM codes are billable by nurses. You don't have to be a doctor. And you need an integrated care team or you have a nurse maybe on the front line monitoring, reviewing the data, preparing the data for the physician so the docs not on the front line around all that, or maybe it's even a non-clinical person or maybe it's a coach. It's outcomes that have clearly defined success metrics. So, we're not just putting patients on program and not thinking about clinical outcomes and then the right technology that enables your programs to scale, you can go to the next slide.

This is the future in our mind. And what we're working towards is a digital formulary. It's not going to just be, we prescribe people medications; we're going to prescribe them wearables, we'll prescribe them patient reported outcome text messages we'll prescribe then digital therapeutics, smart bottles, visual medication adherence. You're not sure if your patient is taking their asthma med., well, maybe they should send in a video recording of it. FDA cleared devices, digital coaching biosensors, artificial intelligence. It's all coming.

And we believe that this will go through a similar process of FDA approval process. There already is one, the pre-check process, just like medications. But this is what we need to start getting used to as a specialty and not just an allergy, but across a number of other specialties as well. But specifically for allergy, because there's such a focus on digital therapeutics and remote monitoring for respiratory disease, specifically. You can go to the next slide.

This is my last slide, I promise. But these are the CMS codes that exist for remote patient monitoring. So, there are two codes that exist just for setting up a patient with a technology and handing them a device. And then there's management, meaning spending 20 minutes per month. So, they're similar to our care management codes where you're actually interacting with patients and making treatment decisions based off of the data. And those do not need to be billed by a physician. The only code that needs to be billed by a physician is 99091, which is where the data gets reviewed and the physician spends 30 minutes per month, actually reviewing whatever data comes through.

So maybe that's a spreadsheet with the patients, whether or not they're using their asthma inhaler or the quality of their inhalation or maybe it's whether or not they're using a pulse ox and you're just actually looking at that data for 30 minutes per month and you're able to go for that.

And then remote therapeutic monitoring, these are very new codes that just came out in 2022, but really pertinent to allergy and immunology. There's only two conditions. One is respiratory monitoring and the other is musculoskeletal. Well, there's 3 because the other one is medication adherence. But we really need to think through how this is going to impact us as a specialty and how we're going to incorporate and embed this into our routine workflows. Just like we've had to figure out how to incorporate weekly allergen immunotherapy and other things that are unique to allergy immunology, remote patient monitoring, remote therapeutic monitoring. We need to start thinking about how we make that part of routine care delivery. And with that, I think I'll pass it over to Dr. Volertas.

Lim: Thanks so much, Dr. Elliott. And Jennifer, I'd love for you to just quickly give a little bit more of an introduction for Dr. Volertas before she starts.

Pfeifer: Great Dr. Sophia Volertas is an assistant professor of medicine at the University of North Carolina in Chapel Hill. She is triple board-certified in internal medicine, pediatrics and allergy immunology. She did her internal medicine and pediatrics training at the University of Chicago and allergy training at the University of Michigan. At UNC, she is the associate program director of the Allergy Immunology Fellowship and is involved in medical education on all levels. She has helped implement telemedicine in the day-to-day of the allergy clinic and trains both students and her physician colleagues on website manner, appropriate use of telemedicine while recognizing possible disparities and uniquely utilizing telemedicine for assessments and medical education. She gave a Tedx Talk on humanism in telemedicine last year, focusing on embracing telehealth as the new house call for patients. Dr. Volertas, welcome.

Dr. Volertas: Thank you very much. I know I'm requesting control of the slides here. You know, Dr. Elliott gave a great overview and really dived into a lot of examples through how telehealth has really transformed a lot of allergy and immunology care, specifically within our specialty. And she was really, gave a great job looking at it as Ascension also and what they've done on a broader level. And I was hoping to really go through this of how we've used telehealth at UNC and our allergy and immunology clinic. And this is more on the nitty gritty side of actually implementing this because there's all this excitement, there's all these thoughts of how are we, with these new codes and using remote patient monitoring, and we're thinking about using telemedicine. But it's really hard sometimes I think, when you're a smaller practice and a lot of allergist are private practice, small groups of how do we actually implement this, and what areas make allergy and immunology so perfect for telehealth.

So, my clinic at UNC is a physician-based clinic, and it's part of a larger academic hospital system. But really there's only two fulltime clinical allergists and immunologist, me and one other physician. We've got three part-time clinicians, meaning that they're parttime clinical and the rest of their time is actually research at our academic center. And so, a little background on what we did in March 2020. And this was something that, again, Dr. Elliot really touched on, is at the very beginning of the pandemic, we looked back at what we thought was important within our allergy visit, and we realized, as many allergists probably have, there's a huge chunk of what we do that is just history taking and counseling.

Because if you think about it, allergy and immunology is how our immune system interacts with the outside world, whether it's overactive or underactive with a person in the outside world. And so, understanding that interface and the environment is incredibly important. And then there's this kind of dual edge of allergy and immunology where we are though also very procedure-based and need to be in clinic. And so, we decoupled those and we split those into two separate ideas in the way that we created our flow in our clinic.

So, we had our traditional, face-to-face visits where we'd be seeing patients, new patients return visits, a follow up, the longitudinal care. And we did all of that virtually, and we actually did that when we transitioned initially in March 2020, we kept that for almost a full year before we started really more routinely bringing patients back in. We were doing them more on specific patient instances. And again, in allergy, your environment matters and the history matters. And so that's why this was so perfect for that.

And then in immunodeficiency, again, these are things that were touched on earlier, but this is a very particularly vulnerable population with their infection risk. You know, your immune system doesn't work. These patients are, understandably, very nervous about COVID and the pandemic. But also beyond that, just exposing yourself to different risks. So that was perfect to do telemedicine. And then we split this from all of our procedures, allergy shots in clinic, you know, the subcutaneous immunotherapy, biologic agents and then our skin testing and oral challenges. And we kept that going in person.

Now how to establish this telemedicine clinic. There's a lot of resources to AMA’s Telehealth Implementation Playbook. And then again, as Dr. Elliott mentioned, there's the college and the American Academy of Allergy, Asthma and Immunology that both have these wonderful resources on how to actually do this in allergy. Here it is all laid out. So, I'm not going to deep dive into actually what to do in your clinic.

But I did want to mention kind of some pearls that I have seen as one of the two really implementing this in our small practice and highlight again, these are things that I think Dr. Elliott mentioned, too, and these things come up frequently and they come up in some of the other webinars as well. And so, as you're trying to implement this really look at these few pearls because I think many people bring them up. So, these are some of the key lessons that we learned for success of our telehealth clinic and really thinking about before the visit, as has been mentioned, you know, really assigning a particular person to be a telehealth champion. I think it's important that not everyone in your clinic has to do telemedicine.

Not everyone has to be really invested in telehealth. I think everyone should know how to do it. And a practice should be able to implement that. Patients want it. But not every physician has to be doing a huge chunk of their time for that, if you want to be flexible in that. But you should have at least one person who's really invested, who is trying to stay up to date on all of the changing regulations around that and understanding how to continue to implement new innovations in your practice. So that's one thing that I would really highly recommend as you're doing this.

The second piece is scheduler support is so critical. Again, I think an exact example of this was mentioned to, you know, we started finding, about six months ago, as the end of the summer, last summer, we started finding patients when they were calling in, less were filling into our blocks. We have blocks of telemedicine time. And we looked back and we realized, you know, maybe our schedulers didn't have quite a normal script or they were falling back on what they were used to.

Just, first option would be in-person because that's what physicians always did. And we created a script and I think that was critical for actually, immediately, once we implemented that script for the scheduler to utilize, that had an actual list of specific diagnosis that they felt empowered that they could tell the patient, actually, our physicians have reviewed this. These are the diagnoses that they know are appropriate. Which, kind of disclaimer here, I think all allergy immunology diagnosis is are appropriate, but having that as an actual list to tell patients and to make schedulers feel empowered in that setting within days changed the way that we were filling our telemedicine slots. And so that is so critical to making this successful.

The last piece of before the visit is, again this was mentioned, but creating a provider template. I don't like ad-lib tossing in patients here or there of telemedicine then in-person and telemedicine because it is a different flow. It's a different feel. There's different resources you need from your support staff.

You need your nurses to be doing some things on the telemedicine on the front end and helping schedule follow-ups on the back end while you can actually run through visits in a much more directed way. But in person, there might be some lag time, a little bit of delay, as the nurse brings a patient back, just the walking, the getting vital signs and there's a different flow.

And to keep that efficiency the best, we really found keeping a chunk of maybe whether it's an entire half day clinic and you're doing it from home or just the first two hours of your clinic day or the last two hours of your clinic day being telemedicine blocks and the rest in person with the flexibility to add in ad-lib if you need to, but the expectation to be these chunk and these blocks. And that has really improved the logistics and the flow in our clinic. And what knowing the entire team, what they can expect from the physicians and the doctors and what their responsibilities are when you're managing a small clinic.

During the visit, again, this was mentioned, but a direct link for patient ease is a game changer to make sure that patients are really easily accessing. And then one of the biggest things that I try to impress when I am doing more of telehealth education with, excuse me, medical students or residents or our Fellows at UNC is that telemedicine is not a replication of an in-person visit. It is not subbing in the exact thing that you would be doing in person. It's an opportunity to have a different lens to the patient.

This is a time where you can focus on more of their social determinants of health. Their more patient education, medication use going through how they actually use their inhaler, their nose sprays. Looking at the support of the family, doing a home visit, an environmental assessment that's very valuable and relevant to our patients and what's going on around them that you just don't get when they come into our environment.

And so, recognizing that telemedicine and telehealth overall is a supplement to in-person care and you use both of these tools in different areas, is one of the first perspective shifts that I really try to impress on trainees that you're not just subbing in everything that you'd be doing in person over the video. You're actually trying to access different aspects of the patient's care or their health and their journey and their story through telehealth.

The last thing to do is always at the end of every visit addressing a virtual follow-ups appropriate and then again getting that bye and write them there with the patient. Or really understanding, maybe they're traveling six hours, three hours to come see you and three hours away. We actually see that very often at our center at UNC. And so, I think that's a really good way to continue to make this flow well that you can do right now in your small clinic, if you're starting to really build this in your own clinic.

As you know, our clinic, we’re two small providers and we're attempting to shift from this virtual care maternity model that Dr. Elliott mentioned. You know, we're trying to still just shift from basic to advance, and we're working on it. And I think, you know, the allergy community is small. If we look at the AMA has developed in their playbook, excuse me, this virtual care value stream.

This is a great structure and framework to start looking at how can we actually assess how telemedicine is or telehealth is actually bringing value? And you can look at these major domains of clinical outcomes, access to care, patient experience, clinician experience, operational impact in health equity across the board. And I fill this out just for how our clinic is, but we're still starting off. I think we're still just transitioning to that advanced model, advanced in that place.

But what we have seen is, in the patient experience perspective, you know, our comments that we've seen and what we've gotten, this has been more qualitative, more than quantitative assessment, is really ranging from patients love it to they prefer face-to-face. These are things that I think are consistent across all telemedicine encounters and all subspecialties. Patients love the decreased travel time, flexible schedule. Someone's always going to see problems with technology.

But I want to call your attention to some things that we've seen come out in these patient experiences that are very allergy specific. So, a patient said, you know, they appreciated the option of a digital visit. They don't tolerate fumes and new facilities.

This is, again, touching on the idea that our patients’ problems come from the way that their bodies are interacting with their environment and they might feel much safer and more comfortable in their known environment of their home when they're first establishing and really trying to figure out what's causing major allergic reactions or causing all of their difficulty. Another patient, again, this idea of they have a lack of an immune system, they lack of autoimmune system, but lack of an immune system, you know, immune deficiency where they're not able to fight off infections as well.

And so, the safety of providing care in their own home and not coming in, regardless of COVID, whether that's just during the winter, during a higher viral season, it’s important. And then again, another patient specifically mentioned how it's about receiving information and counseling. So that's a lot of what we do in allergy and immunology.

Something that I just wanted to touch on from the provider experience that we've seen has been some of our providers absolutely love it. It's great to see the patient in their own home. But I am coming from an academic institution and there have been some providers, where I think we have to recognize some of the limitations or impacts it might have on some physicians who have funded research that is involved with biological samples and how to know, they've kind of had difficulty with seeing a lot of their patients on telemedicine, but for their research, trying to gather biological samples and kind of catching people for research as they're in clinic.

And maybe this is the setting where not everyone does telehealth, especially at an academic institution. Maybe the people who are more focused on needing more of that interaction for their research on that side, do less telehealth, whereas those who are much more clinically based may be able to incorporate more of that for the clinical care and those improvements. Next one.

So, I know we're kind of going quick on time here, but I did want to touch a little bit extra on very specific, our six main diseases. This was mentioned at the beginning when Dr. Elliott went over the survey of looking at what allergists were comfortable treating; new and returned patients in which diseases. But I wanted to give some nitty gritty examples of how you can use telehealth in each of these diseases that is unique. You know, the particular advantage of how telehealth might not even necessarily be appropriate, but even more so better, potentially, for getting access into different data points, in particular allergic and immunologic diseases.

So, asthma was mentioned a lot. Someone is supposed to check in with them every one to six weeks, as part of our guidelines, checking in, seeing if we're able to adjust their medications. That's very frequent for a patient and to take time off work and to come in and frequently check in as we're adjusting medications. That's really where our practice should be. And then checking in every three months to try to wean off medicines as well.

And we might not actually engage with patients as often as we should to tailor our treatments very specifically to how that person's asthma may flare or be improved. And with telehealth, you can access this. You can touch base with them much more frequently in a much more easy venue, so that they're not necessarily burdened by taking time off, by having to travel, it’s a faster visit for the physician. And that's a really particular point where I would emphasize using it in asthma care.

Also, really focusing on these standardized surveys. You can send these in an asynchronous message to the patients frequently. You can have it automatically sent to your electronic health record and getting these asthma control tests just returned. This is very simple to do and you can start getting an actual tracking of where their asthma control test is. Review their inhaler technique.

The home visit with a review of environmental triggers has been such a game changer for me with some of my patients. You know, you can again in allergy, I've seen pets jumping on the bed with the patient. I've seen backgrounds with tons of plants that maybe had mold spores that were triggering a patient's more asthma that they didn't realize.

You know, there are these aspects that it's hard for a patient to recount their entire environment to us and they don't know what's important. But we're the physicians and we can see things in the background. We can just get a sense, as you're discussing. This idea of home visits that used to be so integral to how physicians practice medicine has really fallen off. You know, we don't go into a patient's space anymore.

But in allergy and immunology, that is so critical to understanding how the patient's life actually is and how they're having their symptoms come up. And so, you can see these environmental triggers. And then, as was mentioned, I think this is the area where there's the highest potential for the remote patient monitoring as our future going forward. And asthma is really where a lot of that research is being done.

But beyond that, some of the other common diseases we see allergic rhinitis. More than 60% of people have allergic rhinitis in some form. Again, we found that the access to the physician with telehealth has been much faster. We can get in to see a physician very quickly because you're competing with less people who may need to come in person. Anyone can come in person, but only those, you know, there's less people that may be appropriate for telemedicine.

And so, we are getting sooner appointments with physicians and we've decoupled this from skin testing. So, you don't need to stop medications. How many times did we have allergist, again, have patients come in stopping the wrong medicines? I had a patient just the other day stopping all of their asthma inhalers, thinking that they had to stop every single allergy medication for skin testing, as opposed to just their oral antihistamines or antihistamines. And they started to flare and have worse asthma. And they were very uncontrolled from their asthma because for the past week they had not been taking their inhaler.

You know, there's a lot of confusion around these medications for patients and sometimes agents don't even need skin testing, depending on what's going on. And so, you can have that first appointment, that very first evaluation, and then bring them in her skin testing. Because we've decoupled the procedures from our visits, though, our skin testing, we've got five slots a day, five to seven slots a day that are just run by our nurses.

It doesn't even matter on the physician's schedule. So, the physician still seeing patients in person that day and the nurses and our support staff are just running through those procedures on the side. And so, we're able to actually have a better turnaround. Patients are able to come in. And when they have more time, potentially, they can do the quick visit during a middle of their Workday with the physician on telehealth, and then they can find when it makes sense for them to take a larger chunk of time off, to come in with more flexibility around all days of the week, at all times to come in and have that procedure done of the skin testing with our nurses, separately.

You can also check in with patients right before their worst allergy season. And again, have more of those touch points and then environmental assessments of what's going on in their home.

For dermatitis, again, eczema was mentioned a bit by Dr. Elliott, but chronic urticaria, I think, is the biggest place where there's not a lot of data on this yet. But this has got such potential for telehealth. You know, a reminder of our Choosing Wisely campaign, patients having chronic hives all the time, chronic urticaria. They come in thinking they absolutely need testing. They need all of this. But don't forget our Choosing Wisely campaign where we, as allergist, we should not routinely be doing diagnostic testing for chronic urticaria.

We know that this testing is not necessarily appropriate to be doing all these other aspects. And what's important is our history and the majority of the visit is really about that history taking and counseling. And when patients are taking a while to get in to see the allergist, they're instead going to the ER, getting courses of oral prednisone, seeing the urgent care, having frequent touchpoints with these more higher use situations, higher use of the ER, higher costs, instead of, you could get them in faster with the allergist and just do a quick assessment history give them the understanding of using oral antihistamines and you can get that assessment done faster without necessarily having to bring them in or have them accidentally stop all their antihistamines in anticipation of skin testing when they don't need to.

Just three more quick, deep dives into each of these diseases, and then I'll be done. So, we with drug allergy. History is what's relevant. Patients aren't coming in with anything you need to see right then and there. You need to know the history of what happened.

We can also do much more directed penicillin allergy history assessments by the allergist, and you can do faster ones in a row through telemedicine. And then that visit, when they get the skin testing for penicillin and an oral challenge, if you do that back-to-back, that's about two hours. So, a patient can have a quick 15, 20-minute visit with the physician, assessment of what's appropriate, whether they need skin testing in an oral challenge. And then they can schedule, much more easily, not on the doctor's schedule, but the nurses that runs in parallel when the doctor is in clinic, all of their testing to be done and it's much more flexible for them. All the staff is working at the top of their license and we're getting much more efficient and effective care.

Food allergy. I think that one particular area here that I have not seen as much discussion around has been that, you know, adolescents and young adults in food allergy are almost a lost population. There's minimal follow up at a time of when they're transitioning to college, heightened risk. They're finally managing food allergies on their own and not without parental support. They're making their own meals.

They're navigating University dining systems. A lot of these, you know, adolescents don't know how to use an EpiPen because their parent was always the one taught. And now that they're coming into adulthood, this is very much a lost population in our specialty. And many of these patients are so fluid and comfortable with using technology. So, if we want to meet them where they're at, get them in for a faster visit, a quick visit, education. This, again, this doesn't have to be with a physician that can be with a nurse educator, but also maybe reassessing where they're at before they go to college. What are their true food allergies? Making sure they know how to use an EpiPen is incredibly important, and telehealth can really facilitate that access to that population.

And then I just think when we're thinking about utilizing telehealth in the long run beyond the pandemic, our immune deficient patients are we're always struggling with having increased infections, potentially in the winter during viral season and coming in and sitting in a waiting room with other sick patients around them. And if we can then tailor, you know, our immune deficiency check ins, you know, maybe during the wintertime, it's always telemedicine in the summer when there might be less exposures, that's when they can come in person.

If we feel like we need to balance that, that's something in the long-term where I think that we can take advantage of the patient's perspective of their own immune deficiency and their fears and anxiety around coming into a medical provider's office. This is also, immunodeficiencies are rare or rarer than allergies. And so especially on an academic institution, patients travel from far away coming to us and we can take advantage of the access to patients who are further away, specifically within immune deficiency and really giving our specialty, our expertise to these patients who may not have someone nearby to be able to help manage that.

So, the last thing I just wanted to say is, you know, these are examples from my experience from a small practice. But we also really need a lot more data, evidence, research on the value of virtual care from allergist immunologist. We're a small field, but this telehealth is so particularly important for allergy and immunology. We are so unique in that. And I think all of us would say we need more data, we need everyone to help us to figure out what is the most appropriate disease to be seen on telehealth? Are we still getting the same outcomes? Is this actually financially advantageous or effective? And how do we implement this in the best way within allergy? Because as I'm just a quick mention on what we did, you know, none of this is measured yet. So that's really where I'm done. So, I'll pass that peck over to you, Bernadette. And I know I went through that very briefly, there.

Lim: Thank you so much, Dr. Volertas. Just really appreciate you doing some of the deep dives there into the specialty use case is really, really helpful. I know I can't, every time this happens it's a can't believe 90 minutes of just flown by, and I not an easy feat to try and touch on all of this in an hour and a half session.

But I just wanted to wrap up here. Thank you all for participating in the telehealth use survey that we conducted at the end of last year. I just wanted to mention that we are finalizing some of our data analysis on this and plan to publish this here in the next coming weeks. And then we'll host a webinar event to walk through these findings on March 31. So, we hope you all can join us. Next slide.

I think the next slide might be our contact information. If you have any questions for Dr. Volertas or Dr. Elliott in follow up, please feel free to send it to us. We'd be happy to relay that and just wanted to, again, extend a huge thank you to our speakers today. We just really appreciate you sharing your insights from both an organization perspective and also from a practicing perspective. It's been incredibly helpful and thank you again, Jennifer, for your support in co-hosting today's event. In follow up here, my colleagues will be typing in the chat a link to a short survey. We thank you in advance for just taking that and thank you all again for participating. We hope you have a great day.

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Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.