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.
Jennifer Mathews: Hello, my name is Jennifer Mathews. I am the Digital Content Specialist for AMA STEPS Forward®. Today, on our podcast, we are talking about telemedicine and team-based care with our guest, Dr Kevin Hopkins, primary care medical director at Cleveland Clinic and senior physician advisor for Practice Transformation, here at the AMA. Thanks for being with us today, Dr Hopkins.
Kevin Hopkins, MD: Sure, Jennifer. It's a pleasure. Thank you.
Mathews: I thought, maybe, we could start off with you just telling the listeners a little bit about yourself.
Dr Hopkins: Sure. I'm glad to. So, I'm an Ohio native, born and raised, did my undergraduate education at the University of Toledo. Went to med school at Wright State University in Dayton, and completed my residency program in Dayton, Ohio, as well, at Miami Valley Hospital. And just out of residency, took a job, here, at Cleveland Clinic as a primary care physician in the Department of Family Medicine. And I worked at three different locations, seeing patients, over almost 20 years here. My current job, I spend 20% of my time, two days a week, seeing patients, and the bulk of my job is spent in an administrative position, as you mentioned, the Primary Care Medical Director, which gives me oversight and responsibility for day-to-day clinical operations in the Departments of Family Medicine Clinic, Internal Medicine, General Pediatrics, Express Care, Urgent Care, and Home Care. I spend a lot of time doing that administrative work. Then, I'm blessed to have this position and be part of the team for practice transformation with the AMA.
Mathews: Well, as I mentioned earlier, we're here, specifically, to talk about team-based care, and how it relates to telemedicine and can help support that process. Why don't we start there, with a little background about how those two things can work together, and what your experience has been in that area?
Dr Hopkins: So, team-based care, as a model, is something that I began pursuing a little over a decade ago. My interest in it was based on a couple articles that I had read that talked about physicians and the amount of work that's expected to take place within the context of a typical ambulatory primary care visit, and how much work and documentation there is to be done. The idea is rooted in the ability to sort of share some of that care-related work across a team. And essentially, the physician does what only the physician is uniquely trained and qualified to do, while all other tasks that can be, should be delegated and shared among the rest of the team. So, it's a care model that I implemented in my practice, here, about 11 years ago, and was very successful in a lot of ways. Then, in the last two years, really, since COVID hit, we've needed to pivot and figure out how to adapt those workflow efficiencies that we had built into the in-office practice into our telemedicine visits.
From a high-level standpoint, team-based care is really a comprehensive approach to health care delivery transformation. And it includes redesigning an office visit. What does it look like? What's typical? What are the workflows? It includes things like responsibilities and tasks being shared amongst a team and delegated, as I mentioned. It also includes individual caregivers functioning to the top of their qualifications. It includes an advanced role for empowered medical assistance and LPNs, including real-time, in-room documentation support. It really has a great ability to enhance the work that we're already doing, and spread it across a bigger team. It also includes between-visit redesign, what happens between patient/physician interactions. It utilizes that team approach, all of us working to the top of our skillset and training. And then, there's also a considered focus on population health and panel management activities, so activities that need to take place within the context of a primary care practice, today, but again, with responsibilities and tasks delegated and shared when appropriate. Team-based care helps any practice to realize improvement in team efficiency, improvement in access, gains in quality of care delivered, and also improvements in patient and caregiver experience, which is critically important today.
Mathews: And as you've had to make this transition, as most people have found themselves in the same position, particularly since March 2020, how has that foundation, that you already had in place with team-based care, helped you as you pivoted, as you mentioned, into telemedicine, and how do the two compliment and support each other?
Dr Hopkins: So, until the COVID-19 pandemic really started, telemedicine had largely been excluded from the type of team-based workflow redesign, which had taken place for in-office face-to-face care delivery. I think that was for several reasons. One, the adoption of telemedicine was certainly lagging in our own health care system. Here in Cleveland, a total of 2% of our patient interactions took place via telemedicine platforms prior to March 2020, and in primary care, it was one-half of 1%. Everybody knows the next part of the story. Right?
Dr Hopkins: In a matter of about four days, we went to about 90% of our-
Mathews: Oh, my goodness.
Dr Hopkins: ... patient interactions taking place via telemedicine. We had to pivot very quickly, but what became a stark reality, very quickly, is that we reverted to what we knew from the past. That is sort of the physician-does-it-all mentality, and that physician-does-it-all mentality is no more sustainable in a virtual visit environment than it is in a face-to-face environment. We really had to pivot, and start to apply the things that we had learned over the prior decade in face-to-face team-based care models to a telemedicine platform.
Mathews: And what were some of the steps, or strategies, that you used to do that? Was it sort of a trial and error? Did you put a structured plan, written out and in place, or how did you approach it?
Dr Hopkins: Well, not at first. Like everyone else, we were just trying to survive and remain functional.
Dr Hopkins: And so, we were conducting virtual visits across four different virtual platforms because, like everybody else, we had bandwidth and technology reliability struggles. We really didn't write the playbook until another month or two down the road when we started to think, “Hey, this could go on for a while, and so we better figure out how to optimize this. Otherwise, it's not going to be sustainable for our teams.” We really had the ability to take a step back and say, “All right. What have we done in face-to-face care delivery over the last decade from an innovation standpoint, and engaging a team? And how can we, then, translate those workflows into a telemedicine environment?” We tried to come up with a stepwise approach for how to do that. And those steps have been shared through lots of outlets.
You mentioned the word steps. I mentioned the word steps. It's a good time to call out STEPS Forward® toolkits that are available through the AMA. I was able to work on the one for telemedicine and team-based care. It helps to give listeners, and others who may utilize that tool, a stepwise approach for how to engage and build their own team-based care and telemedicine program.
Mathews: Yes, very much so. And we definitely have access to the specific toolkit focused on team-based care and telemedicine that you helped author on our homepage of our website. We're also going to have a link to that in the description section of this podcast episode, if anyone's listening right now, and wondering where they can find that. So, I'm glad you mentioned that. You mentioned that you were trying to not only streamline efficiencies, but improve the way that- physician's and patient's relationship, and just improve patient care, in general. As you guys have moved to telemedicine and using the same team-based care format, what are some of the positive changes you've seen in patient care and the physician/patient relationship?
Dr Hopkins: Very similar to the gains and improvements that we saw in a face-to-face model. I'll call out a few, specifically. One that comes to mind, right away, is from a patient safety standpoint. Having someone else perform a lot of the documentation, a lot of the navigation through the electronic health record by providing that real-time documentation support, has allowed the physician to be 100% focused on the patient. Our patients appreciate that-
Dr Hopkins: ... even in a face-to-face, in-office model, I spend a lot of my time, prior to developing this team-based care model, looking at a computer screen. I'm not the most technologically savvy person so my patients found that I was spending more time examining the computer than I was examining them. That was actually a quote that I got from a patient satisfaction survey prior to the development of the team-based care model.
So, it really encouraged me to set aside the technology that was in front of me and focus on the relationship with my patient. Leveraging a team-based care model in face-to-face care, as well as in telemedicine, even though it takes place across a technology platform, has allowed me to be better focused on the patient, which improves patient safety. It also provides an extra set of ears and eyes. So, I found my clinical support staff, whether it's a medical assistant or an LPN, over the years, to be a great advocate for my patients. Sometimes I'll get lost in conversation with my patients, and I'll forget, maybe, to listen to their heart or lungs. It was very helpful, in an in-office environment, for my clinical support staff to call that out, and say, “Dr Hopkins, did you want to listen to their lungs real quick?” I'll say, “Yeah. Of course, I want to. I was just about to do that.”
And the same types of things can happen in a telemedicine environment too, where, again, there's an extra set of eyes and ears advocating for the patient, making sure that we're completing all the work that we've set out to do in the context of that visit. Additionally, having another person more directly involved in the care of our patients builds trust.
Dr Hopkins: So certainly a trust with another caregiver, which is incredibly valuable. Right? I place a lot of value on the patient/physician relationship. In my mind, there's few other more sacred relationships in our culture, today, than exists between a physician and their patient. If I can bring in a nurse, a medical assistant, someone else to also build that kind of relationship with my patients, it goes a long way towards delivering the world-class type of care my patients deserve. I have patients that will tell my clinical staff things that they might not mention to me and so that's incredibly valuable to have someone else involved in the care. It also builds trust between caregivers, not just between patients and caregivers, but between caregivers and caregivers. So it's built my relationship with my clinical staff over a period of time where we can finish each other's sentences.
My nurses know what I'm going to order when I'm treating someone for a specific disease process because I do the same things over and over. It's repetition. And so, they can anticipate those things and start to pen orders for me, and things like that, anticipate my needs, sometimes before I even know what I need.
Then, the third thing that I'll mention is, just getting back to that, the ability to remove the physician-does-it-all mentality and approach that we've taken in health care for a long period of time. I especially think of that, now, when we're fighting things like the burnout epidemic, at the same time we're fighting an infectious disease pandemic. Utilizing a team-based approach helps to improve engagement of caregivers and patients. It helps to improve the experience of caregivers and patients, and it helps to decrease the rates of burnout in our caregivers.
Mathews: Very much so. That makes perfect sense. And I mean, especially since you had to sort of do this shift to team-based telemedicine under extreme circumstances, and I'm sure many people listening can relate to that. What were some of, maybe, the challenges, or sort of setbacks, that you encountered, and how did you course correct with them?
Dr Hopkins: So, one that comes to mind, quickly, I mentioned it, or alluded to it earlier, is technology reliability. It's certainly better, now, than it was in March 2020, because we've learned from that experience. One challenge that we had to overcome was anticipating technology failures. Thinking about, “How are we going to communicate with our patients, before we connect via the virtual platform, to have a backup means for connectivity?” At the time, relative to the pandemic, could be through some of the publicly available video chat apps, or could be just a telephone call, but making sure that we had a backup plan in place when either the patient or the caregiver team had difficulty connecting.
Dr Hopkins: That was one that really comes to mind. Another is expecting and anticipating intra-patient variability with technology use. Some patients, just like some caregivers, are very facile with technology and will have no problems. Others don't know which way to hold their phone.
Dr Hopkins: We've experienced all of those types of things. Expecting that, anticipating that, and having the ability and the patience to coach our patients-
Dr Hopkins: ... through that challenge is good. A third I'll mention is making sure that a virtual visit is scheduled for an adequate amount of time. There is a common misconception out there that virtual care is so much more efficient, and it saves so much time, that we can do so much more in less amount of time. I just don't believe that's true. Oftentimes, if we're going to provide the same type of care in a virtual visit as we would face-to-face in the office, we actually need more time to provide that care. So, thinking about how those appointments and virtual visits are scheduled, and making sure that we allow enough time for them, I think, is critical. As we gain experience and efficiency, patients become more adept at those same things, and maybe, we will become a little quicker. Ensuring that enough time is scheduled I think is key.
Mathews: Has there been any pushback from your patients about adjusting to this new model? I know, from my point of view as a patient, I think there was a lot of patience from the patients, no pun intended, at the beginning because we were all dealing with this extreme circumstance. And although COVID is still definitely prevalent, we have already made a shift out of that high, high emergency setting. And I wonder if there are patients that are now resistant to telemedicine, and how do you approach that? Do you let them choose, or do you walk them through the process and show them grace until they get there? Or, do you simply say, "This is the way we do this now?" How are you guys handling that? Have you been encountering that, at all?
Dr Hopkins: A little bit. I think, after about a year of mostly virtual, patients really wanted to come into the office, for lots of reasons. Honestly, we needed them to come into the office. I needed an actual blood pressure check. I needed a weight. We needed some blood work done on folks. And we're all experiencing, now, the complications of care that has been deferred, whether that's routine care relative to a specific chronic disease process, or it's screening, patients didn't get their colorectal cancer screening done, or their mammogram done. Now, the health care system and individual patients are dealing with the consequences of that. I think there were lots of factors that were driving our patients back to the office. From, probably, mid-March 2020 through June, I believe I saw four patients in the office. Everything else was virtual.
Dr Hopkins: It's certainly different, now. That pendulum has swung back and forth a couple of times. In our system, where it's tending to balance out is at about 85% of patient encounters taking place in-office, face-to-face, and about 15% virtual. That's highly variable based on the practice, the demographic of a specific physician's panel, and certainly other factors. There are some patients that really prefer virtual care, and there are some providers that really prefer virtual care.
Dr Hopkins: So, I think we need to continue to iron out the best use-case scenarios for virtual versus in-office care, and make sure that we're providing the type of care that is optimal for our patients, not just based on their demographics, but also based on their chronic disease conditions and acute complaints. Because there just are certain things that are very challenging to adequately assess in a virtual setting.
Mathews: How do you think telemedicine is going to evolve if you had access to a crystal ball? COVID, one of the things that it definitely did, across multiple platforms, is it accelerated the process. Telemedicine probably wouldn't have made the leaps and bounds that it has if it hadn't been forced to. Now, as we start to move, eventually, hopefully, light at the end of the tunnel, out of this public emergency crisis, do you think telemedicine is here to stay? How do you think that will play a role in medicine?
Dr Hopkins: Yes. I definitely think telemedicine is here to stay, in some form, and in some measure. I think it remains to be seen what that will look like. I know that health care systems are looking at even building things such as all virtual practices. I think that's great. I think there is a place for something like that. I don't know that the entirety of health care will ever be moved to a virtual platform. I don't think that's realistic, but I think telemedicine will continue to exist in some form and in some measure. As I mentioned, I think it remains to be seen what the best use cases are. Probably before March 2020, I had, probably, done maybe two virtual visits, myself. But there are so many use cases where it is great, like patient encounters where the bulk of the interaction is a conversation and is history gathering.
And yet, I don't want to undersell the importance of touching a patient, and putting your hands on them, and listening to their heart and lungs with a stethoscope. Once in a while, you find that patient with atrial fibrillation, or some other physical exam finding that you wouldn't have figured out otherwise. Patients that are following up on mood medications, or my 20-year-old patients, away at college, following up on their ADD medicine. There are great use cases for virtual care. I think we need to continue to optimize use of them in those types of settings.
Mathews: When you brought up the 20-year-old college student, it made me think. How do you think telemedicine could play a role in potentially obliterating, or at least limiting, certain roadblocks that people have found in the past to getting care? For example, it's ironic that you work at the Cleveland Clinic. My mom has had a chronic case of hives for almost 10 years, and we've gone to every single possible expert that you could ever imagine. She lives in a very rural area in Indiana. Cleveland Clinic was one of the places that were suggested that we take her to, but it's a seven-hour drive. And I thought about telemedicine, and how that could play a role in someone like that when it was first being implemented, and I was experiencing it as a patient. Has there been any discussion about that, or any thought about that, especially for people who have trouble getting transportation to a doctor's visit, getting childcare to cover when they go to a doctor's visit, all of that?
Dr Hopkins: Yes. Absolutely. I think there's going to be a huge groundswell of demand for those types of services. Some health care systems, including ours, provide them, now, things like virtual second opinions, things like virtual consults. The great limiting step in that will be sort of the legal barriers to that, as far as scope of practice, licensure, being able to see patients across state lines, particularly new patients.
For existing patients, we're able to do that, now. I love that I can see my patients who go to Florida for the winter, virtually, through a telemedicine platform, for six months of the year. Then, I see them face-to-face when they're here, in the Cleveland area. Leveraging virtual visit technology for things like virtual consults, even among primary care and specialty physicians, I think we're right on the cusp of making that mainstream, where I'd be able to bring in a Cleveland Clinic specialist, or a specialist from some other health system, directly into the exam room, or into a virtual visit, with a patient of mine that's located remotely. I think the demand for that will continue to increase.
As I mentioned, we're doing a lot of that, now. We piloted our first tele-neurologist program for inpatients at one of our community hospitals that's in a rural setting, where the neurologist is located remotely, and evaluates the patient virtually. Then, determines if a higher level of acuity of care is necessary, that that patient needs to be transferred. I think there are a lot of use cases like that, in addition to some of the ones that you mentioned.
Mathews: This has been awesome. Thank you so much for sharing your time with us. I know we mentioned the toolkit earlier. I want to mention it again, specifically the Team-based Care and Telemedicine toolkit. You can find that on our homepage, at stepsforward.org.
As we wrap up, is there any quick tips, or advice, that come to mind if someone is looking to marry team-based care and telemedicine, and move forward with that in their practice?
Dr Hopkins: Yes. A couple things come to mind just as I was listening to you talk, Jennifer. One of the things that popped into my head is to make use of the current state, and the future utility, of telemedicine. We're in a great position, actually, to demonstrate, “Look, this is what's happened over the last two years with telemedicine, and all evidence points to the fact that it's not going away. What is it going to look like in the future? Let's actually try to build that ideal state, now, rather than waiting for the next epidemic, or pandemic, to strike, and doing it as a result of that." Looking for opportunities to engage key internal stakeholders within your own practice or organization, whether it's from information technology, nursing leadership, clerical support teams, and their leadership, administrative partners, especially those who have to do with clinical operations, continuous improvement. There's just so many folks that we could leverage to help us build and implement this type of model, or improve on what we've already developed.
And then, thinking about how you might benefit, or your system might benefit, from engaging external experts, whether it is the American Medical Association Practice Transformation Initiative team, or it's the STEPS Forward® toolkits, or it's some other organization that can help you with it, thinking about how you might engage them.
I guess the best tip, or recommendation, though, that I could give is don't get easily frustrated and give up because this is not an all-or-nothing proposition. Take what you can get, what your practice, or your organization, is willing to move forward with. Then, if you're not happy with the way things are going in your practice, whether it's telemedicine, virtual visits, or something else, you can choose to try something different.
Start with one small, but impactful, workflow change that you could make today, or tomorrow, and see how it goes. Then iterate, improve on the process, mix it up, change it up. The last thing you want to do when things don't seem to be working very well is continue to do it the same way. Right? It's not going to give you a different outcome.
Mathews: Very true. Very, very true. Good advice across all aspects of life. Well, thank you so much, Dr Hopkins, for joining us today. It's been a real pleasure talking with you, and I appreciate you sharing all of your wisdom with us.
Dr Hopkins: Well, thank you so much. It's been enjoyable.
Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA 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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