Speaker: Hello and welcome to the AMA STEPS Forward® podcast series. We'll hear from health care leaders nationwide about real-world solutions to the challenges that practices are confronting today. Solutions that help put the joy back into medicine. AMA STEPS Forward® program is open access and free to all at STEPSForward.org
Christine Sinsky, MD: I'm Dr Christine Sinsky, an internist and vice president of professional satisfaction at the AMA, and I am delighted to be here today with Dr Jim Jerzak, family physician and physician lead for team-based care at Bellin Health in Wisconsin, and Dr Kevin Hopkins, who's a family physician and the primary care medical director at the Cleveland clinic. Both doctors Jerzak and Hopkins were co-authors on a STEPS Forward® module, Team-Based Care and Telemedicine. So, welcome to each of you.
James Jerzak, MD: Thanks, Chris. Great to be here.
Kevin D. Hopkins, MD: Yeah, thank you.
Dr Sinsky: And so, I want to start by asking you, Dr Jerzak, to tell us a little bit about team-based care in the pre-telemedicine world, just very briefly. What was that model like, and what is that model like?
Dr Jerzak: Well, team-based care was developed initially to try to get at the problem of the EHR burden on the physicians, the providers. One of the main parts of our project is to get the medical assistants in the room or the LPNs that we're using to help us out with the electronic health record and all the duties associated with that. So, they'll come in the room with us and help us out with documentation, order entry, and all that type of thing. And we've spent some time in in-basket rearranging to get a team approach to that, and finally some population health work, in terms of, you know, improved quality measures with team-based care and things like that. Interestingly, one of the- when we were developing our model, we actually looked at some of Kevin's articles and it really helped us developing. That was sort of fun. So, thanks for that, Kevin.
Dr Sinsky: Great, great, and Kevin, can you tell us about your experience of translating the team-based care in in-person visits that you pioneered and translating that into telemedicine visits?
Dr Hopkins: Sure. Thanks, Chris, and thanks, Jim. So, when the COVID pandemic hit, and we had a rapid shift to telemedicine as our preferred platform or venue for evaluating patients, it quickly came to the forefront of our realization that though we'd made great strides through redeveloping and transforming the in-office encounters, we just didn't have much experience in telemedicine, and hadn't applied the same areas of innovation and practice transformation that we had done in the office. So, we sort of started afresh and anew, and took our standard workflows for telemedicine that were developed pretty rapidly and applied some of the in-office workflows that we'd utilized for years relative to team-based care. This way, the care that needs to be provided for each patient, and on each encounter, on each day, is spread across our care team rather than at all resting squarely on the shoulders of one sole provider.
Dr Sinsky: And Jim, will you go on and tell us a little bit more about what happened then, when you brought the team-based care model into the telemedicine visit?
Dr Jerzak: Well, we had to spend some time re-evaluating workflows. There's a few different key findings that we had for that. One was that the expanded rooming that our team was doing prior to seeing us had to continue in a virtual visit. So, we had to get a model and a mechanism for them to get the visit started on a device prior to the visit and set up all the different things they would do- the care-gap closure, the refill pending, and starting the documentation as well. Then, we would get them in if we tried to get the workflow developed where they would have time to come into the room with us to support. I had a visit this morning with the MA in the room with me during a visit- video visit. I was doing something else, she set up the visit for me, I came in, and she helped document and do the EHR support while I was in the room. It just really worked out great. Then, I had, I left the room, she kept on the video and set up the appointment for the next visit. Very efficient and really satisfying for patients.
With COVID, for Bellin, and I'm sure for a lot of systems, there's been some challenges with staffing, and we often don't have MAs or LPNs that come into the room with us. So, we developed a workflow, we call it asynchronous workflow, to take that into account. When you don't have somebody that can actually come into the room with a physician and provide the support, what can you do? So, some of the keys for that is, again, the expanded rooming by the MA or the LPN going through all the same things they would do in a virtual visit, or even a face-to-face visit, and if they don't have time to come to the room with us because the staffing problems, they'll still set up the note and the documentation, and then they'll turn the visit over to us, and because everything's been set up, including the documentation, it makes it much, much easier for us to manage the visit, and that's been working really well for us.
Dr Sinsky: I'm wondering, Kevin, if you can talk a little bit about scheduling and any pearls of wisdom around scheduling.
Dr Hopkins: Scheduling telemedicine visits has offered some specific challenges and opportunities that we had not fully anticipated or realized when we were doing mostly, if not all, in-office visits either. That is how do we intersperse, or stagger, or cluster virtual visits, telemedicine visits, during the course of a physician's day? Is it best to sort of cohort those virtual visits at the beginning of the day, or the end of the day, or in chunks or clusters, or is it best to spread them out throughout the day, intermixed with physical in-office face-to-face visits. Certainly, that ability to mix them in might help with physical distancing, patients coming in and out of the office, not running into each other in the hallway, things like that. However, it does create some logistical challenges for the care team. One is that you have to stay exactly on time or try to do your best to stay on time, as we have patients waiting in a virtual waiting room. For some reason, we feel a sense as providers and caregivers, that it's harder to leave a patient waiting in a virtual waiting room than it is in a physical waiting room because they're sort of not as familiar with the process and the surroundings.
Dr Jerzak: Kevin, I wonder if I could see if your experience at Cleveland has been like ours, in terms of virtual visits, telephone versus video. You know, we have some problems with technology issues with some patients, not just patients that are older, but some, sometimes people with Wi-Fi issues, and I'm wondering what you do when you can't connect with a video visit. Do you convert that to telephone visits? Because I'm finding we're doing a fair number of telephone visits yet.
Dr Hopkins: Yes. Now, I'll say Jim that since compared to March, April, and even May, our number of telephone visits has dropped dramatically, and I think there's several reasons for that. We've leveraged several different virtual visit platforms. Our preferred method now is a platform that's embedded within our patient-facing portal. However, that requires a patient to be signed up for that, and only about 55 to 60% of our patients are. So, that provides us one venue. If we have difficulty connecting with our patients, or the patients aren't signed up for MyChart, for example, we have used some other- some other third-party vendor available video chat platforms that are commonly available on electronic devices. When we are unable to leverage that or utilize that because the patient simply doesn't have the technology or the ability, or we have connectivity issues on either end, then yes, we will convert it to a phone encounter. We're starting to see the need for that come back a little bit more as we're seeing more sick patients who may not have the ability to connect with us virtually.
Dr Jerzak: Yeah, one thing that we try to do is to try to get a feel for what the patient prefers. We have actually had a fair rebound in face-to-face visits, actually, even though we're trying to encourage the use of virtual visits, but, you know, even with COVID being fairly high in this region, we're still seeing a fair number of people face-to-face. So, we really try to give the people choices.
Dr Sinsky: Any other pearls of wisdom that either of you have for other physicians and other clinicians who are involved in telemedicine visits?
Dr Jerzak: Well, I would say for me, it's been a challenge to- for the technical area has been a challenge for us at Bellin in terms of getting it an easy system for patients to hook up. I keep telling our IT people, they should really be able to do one click and connect with me, and now it's quite a process of having to go through questionnaires and things like that. So, I think aiding the technical part of it would really help us a lot, and then just giving people the choice, and eventually, I think people will migrate to this technology, especially for visits that are most appropriate for that. For example, depression follow-up. I mean, we would hardly ever do an exam for that. So, I love doing video visits or virtual visits follow-up or follow-ups for that type of thing, and I think we're going to learn more, what types of visits are appropriate for what type of venue, and I think as technology evolves, we'll be able to do more virtual visit, video in particular, with some of the technologies that are emerging. That'll be exciting,
Dr Hopkins: Right, Jim, I agree. Experience is a very valuable teacher. So, as we have more experience with utilizing telemedicine platforms, we'll better be able to identify in the future what patients might be best for that means of connecting, versus in the office. Prior to COVID, the extent of my experience with video virtual visits was college kids following up for ADD who are away at school or the occasional patient following up for mood, but now today I think we've figured out ways to address even chronic condition follow-up. So, I think that we will continue to evolve how we decide who's right for which platform. Our patients will continue to have a preference I'm sure either way, but as a lot of our culture and society has become more accustomed to working from home, and working remotely, and connecting the way that we are right now through a video visit or video platform, I think it will become a more accepted means to connect with everybody in our culture and society, including your physician.
Dr Jerzak: And I think there's been the momentum for team-based care, for recognizing that physicians need assistance in the office visit, and I just hope that that doesn't revert back now with video visits, that all the burden of the work falls back into physicians. In other words, you know, team-based care is a way to provide care, and that shouldn't change with virtual visits.
Dr Hopkins: Sometimes we really do need to be able to touch our patients, to lay hands on them, to listen to their heart and lungs, to look them in the eye. Something does get lost, the connectivity does get lost through a video screen. So, I think that we will continue to see the need and our patients will continue to have a desire for in-office face-to-face visits. It may be such a thing that we alternate back and forth. If I see somebody every three months for their chronic disease follow-up, maybe every other visit is in the office and every other is a virtual. I think there's lots of ways for us to utilize them going forward, but I don't foresee us getting to a point where all care delivered, especially in primary care, is done virtually. I just don't see how that could be done adequately with the high degree of quality and patient satisfaction and quite frankly, caregiver satisfaction, than what we can do in the office.
Dr Sinsky: So, Kevin and Jim, as you look forward to the future and think about how we might use telemedicine in a post-pandemic world, what kind of new opportunities do you think we have to deliver even better care for our patients?
Dr Hopkins: One opportunity I think we have, Chris, is the ability to connect specialty colleagues in on a patient situation in real-time. So, we do some of this through virtual connectivity with orthopedic colleagues at Cleveland Clinic, where what if I've got a patient in the office who has an orthopedic issue or concern that either I'm not sure what to do with, or I need a fairly rapid referral and help with getting them scheduled. I can connect to those orthopedic specialists at any time during my clinic and run the case by them. They can look at X-rays and imaging, other imaging studies in real-time. They'll make diagnostic and or treatment recommendations in the moment, and if needed, they will take care of scheduling that patient with one of our orthopedic colleagues within the next day or two. So, we've got just a little bit of a taste of that. I think the ability to leverage the technology we've been figuring out over the last nine months will allow us to do that on an even broader scale, and who knows, it may cut down on the number of patients that we need to refer for an office visit to some specialty colleagues, cutting down the wait time for diagnostic and therapeutic interventions, increasing patient satisfaction and caregiver satisfaction, as well. I think there's a lot of potential novel applications for how we leverage video technology with our patients, along with other caregivers.
Dr Sinsky: Any last thoughts?
Dr Hopkins: I think the virtual visit just allows us one more tool in our toolbox to be able to do panel management and population health the right way. What I mean by that is to provide the type of interaction, or encounter, or touch that's right for each individual patient at each opportunity. For a certain patient today, that might be a phone call, tomorrow it might be a video virtual visit, six months from now it might be an in-office face-to-face visit, but virtual visits allow us again, just one more tool in the toolbox to allow us to provide the right touch, for the right patient, on the right day.
Dr Sinsky: I want to thank both of you. Dr Jerzak, Dr Hopkins, thank you for writing the module, sharing your experience and your wisdom, and then thank you for this time together as well.
Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA's STEPS Forward® program is open access and free to all at STEPSForward.org. STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series, STEPSForward.org
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