Good morning, good afternoon, whoever you are listening to us virtually, welcome to our new world. I'm thrilled to be here today with Ginger and we are going to be talking about telehealth and our new normal world. Before we introduce ourselves, let's take a look at a couple of the objectives that we hope to accomplish over the next 45 minutes with you as you participate with us. Susan, can you pop up that? Thank you. So number one is we're just going to sort of define what we're talking about. Probably nothing during the COVID pandemic has been more, both meaningful and transformative to us than telehealth services, but yet it's probably still fairly poorly understood. So we want to talk about what that actually is, sort of the rules of the road, so to speak, how that fits in with some of our NCDR registries and certainly how it fits in with our whole quality component. And then more importantly, identify some of the best practices from my day job as it looks at both patient care, patient access, and a bit of revenue generation, because obviously we've all been in a very traumatic economic whirlwind since March. So with that, I think you have gorgeous pictures of Ginger and I on the next slide. And those of you that don't know me, I'm Kathy Bega. My day job is with 80 cardiologists, 90, I think, cardiologists and vascular surgeons across the 14 acute care hospital system and a service line. And with me is Ginger, who is really the queen of all of this stuff. So she's really going to give you the best tool. So Ginger, you want to tell us a little bit about yourself? Thank you, Kathy. You're always so kind. So I'm Ginger Beesbrock. I'm with MedAxium. I'm the Executive Vice President of Care Transformations, and we've been working really hard the last months on getting you the things you need to do to really roll out and execute on telemedicine successfully. I would say, though, this isn't new. We've all had some ability to do this, but as you'll find, related to the pandemic and hopefully moving forward, we've got a lot of opportunity here from a revenue cycle perspective to make these things stick and to be able to build them into our delivery models. So we're excited to share some of those things with you today. We're hoping to see you all live, but right now we're learning how to do this all virtual. So Susan is our slide navigator. She will take us through our disclosures, which from a telehealth perspective, this is not much. But on the next slide, we do have a disclaimer. So disclaimers are very important for Ginger and I. My law license has been lost in the mail for a very long time. We have exceptional people on the Medaxeum team and the ACC team that help us with coding and documentation. So what this says to you basically is we will give you the very best of our knowledge and expertise, but of the one thing that we have become very confident of, change is with us and change will continue. And this specifically in the world of telehealth is something that will change very, very rapidly. So with that, let's get started and take a look at what we're planning to do. As I mentioned to you at the top, we're going to try to define telehealth services because it's really broad. It's not just audio and video, there's a whole lot more to it. We're going to talk about how I have used it in my practices and what Ginger is seeing across the country as she does an incredible job in helping people implement both telehealth services, setting up the programs, how we really can help our patients because it's a whole different world for telehealth. And then at the end, kind of bringing it all together because we're here as part of the quality summit, we're very fortunate to be part of a hot breaking topic because of course with the rules coming out, telehealth continues to be very, very important. And as you'll see on our next slide, the one, and I love these, we have a person at MedAxium that does some great graphics. And this one I think is pretty indicative of what we have lived through since March. I think the one thing that we have learned is we can really change on a dime. And when the world is right with us, or even when it's very wrong with us, that we really can execute things very quickly, such as shutting our practices down and changing on a dime over to telehealth services. But that being said, it also has said how quickly we can retrench. Ginger and I were talking about this, and it's amazing to me that I had a practice of probably in April and May, about 70% was on telehealth. And now I'm about a half a percent. So as we learn to do this, and one of our challenges to all of you out there is what are you doing in your practices to truly look at how we deliver healthcare and how telehealth really should be part of that. So let's start at the basics. When we sort of look across this whole continuum, you'll notice that we use telehealth an awful lot. But telehealth is a small subset of telemedicine. So right off the bat, and especially when you start talking to your insurers and Medicare, we need to understand exactly what those different definitions are. So telemedicine is the entire broad component of telehealth. The one that we have been using, obviously, through the pandemic, is that verbiage of telehealth, which is the real-time audio and video. And this is the one that probably caused the most confusion in late March as we were sort of talking through this, because honestly, trying to get a hold of our 80 and 85 and 90-year-old patients, their grandkids weren't around to help them try to get on the video comportion. And so many of us were using just the phone. But let's be very clear that telehealth is real-time audio and video. There's also an element that we had that is called the virtual check-in. That can be used for a couple of different things. You'll notice the different codes on there. We used that early on. And again, I'm not going to bore you with what we did and hiccuped and started and stopped. I'm going to try to help us just get through to where we are today. So the virtual check-ins have actually been a code with us for quite some time. We actually have been able to use that with this one little itty-bitty problem, is it wasn't paid for. So it was a code that looked good on the shelf, but we didn't really use it in real-life practice up until the pandemic. Then you'll see the next one is our audio-only or our telephone visits. This became very useful to us. Also, didn't carry payment until the pandemic hit. We'll talk about that. You'll notice it's a time-based code, so very important. We're not going to talk too much about e-visits via your portal, EMR, those types of things. There's lots of different codes. You'll notice the codes are pretty similar. So be careful that you don't get confused with them. We'll tell you just a little bit about portal use, but I don't think there's really a whole lot we need to cover today. And then we'll talk a little bit about the remote monitoring systems, because I know Ginger and I both believe that that will be an area that we just are not going to get away from. The tasami of data that we are getting from our patients is something that we need to deal with. So if we take a look then and try on the next slide to evaluate exactly what this looks like, the asynchronous component, the synchronous component, supervision requirements have changed as part of this whole thing. So we want to make sure that we speak the same language and talk that same language. And when we are billing for a telehealth audio and video, that's what we need to do. So documenting, whoops, we tried video, but it didn't work. But we're really meant to do it, but it just didn't happen. Then you can't charge the video. So it is very important that you are live audio and video elements and synchronous as we go through this. So on our next slide, now that we understand all of our definitions, why would we use telehealth? But one thing, especially during the pandemic, obviously safety, not only from our patient perspective, but also from our clinicians and our staff perspective. We really didn't know what we were dealing with. We didn't really know how we were going to deal with it. We also needed to make sure, at least in my world, that we had a continued workforce. We tried to protect our workforce during the early days of the pandemic. We had payroll protection in place. It was best if we could keep them actually working. And this was a great way that we could actually do that. We were actually able to redefine our workflow, and we could do some of this work from home. So even as we were having child care issues on top of our patient access, it was a way that we could continue to provide care and not bring us to a standstill. And not insignificant is financial loss. I mean, obviously we know that our health care systems, our independent providers have all suffered significantly during this pandemic. And not that money is the infrastructure, but it is important to keep our practices as afloat as we possibly can and to get the insurance companies to pay us appropriately. And then the real big key, I think, and one of the ones that ACC via the COVID hub was very active in, was ensuring that we could reach our patients specifically in our rural locations and our patients that were socioeconomically depressed, those that don't have internet. How could we connect with them, which obviously is via phone? So how did we do that? As we kind of go along and look at our next slide, we'll see that one of the main reasons of how we can improve care comes from both our provider and our patient perspective. I think the other important thing to remember as we go through this is prior to the pandemic, the amount of telehealth was negligible. We are now in the millions of telehealth codes post-pandemic and as we live in this public health emergency, or as we call it, the PHE. We'll go through some of those rules, but the one thing that we have identified specifically for our providers is it does reduce that no-show. Although I will say our patients are feeling much more comfortable coming into the offices today, and we're taping this in mid-September, so that has gotten a little bit better. But we still have some of our immunocompromised patients that really need to stay at home. We can increase our clinic capacity because our issue was really space. We couldn't have 20 people in our waiting room. We have things marked off like everybody else does. So we really use telehealth as a mechanism to expand our capacity and such and take advantage of our physician flexibilities. And for our patients, it is amazing to me where they take these calls from. We are no doubt doing telehealth visits in their offices. Of course, we started at home, but now I think patients have come pretty used to being able to communicate with their provider via telehealth. Ginger, my guess is you're seeing some of these same things in your day-to-day work with some of our practices. Is there anything else that you'd want to highlight as we talk about improving access for our patients via telehealth? Yeah, I think one of the things you comment on that I think is important is the physician flexibility piece. So if you have scenarios where you need a physician in an imaging area and maybe don't have a full day worth of images for them to read, their ability to be doing some virtual visits or telehealth visits from that space now is an option. So when you think about where you have capacity within your workforce and where their typical roles and responsibilities, you may be able to meet some of your demand. A lot of that access and how we get patients in, this has increased our ability potentially to manage our capacity a bit better. Yeah, and I think the other thing that we have found from our providers that has truly been amazing to me is the connection with our patients again. It has actually brought some of the joy back to practicing healthcare, is what my physicians have said to me, because they're meeting their patients one-on-one. It's probably not too dissimilar from our kids that are in the e-learning and all of a sudden the dog comes bouncing through or the baby starts crying and you just pop them on your lap as you're doing your e-learning. The ability to see our patients in their normal setting, I think has done an awful lot both to help us diagnose as well as to treat our patients. So let's take a look at the rules and how telehealth has changed since March. It's really so hard for me to believe that it's only been since March. So number one, it was regulated by geographical areas. Telehealth was something we could never do in Chicago. You had to meet certain rules and requirements in order to do that. We couldn't do it from home. Neither the provider couldn't be home nor the patient could be home. We had to do it in HIPAA compliant. Now I think we have learned even though we don't need HIPAA compliant, you can use Zoom, you can use FaceTime. Most of us via our systems have sort of pushed us back into that HIPAA world. We do try to use secure communication just because we are talking about healthcare and I think we've all seen the issues with some of the taking over at some of the Zoom meetings, not ours today, so don't worry about it. We're very safe here. We couldn't cross state lines. For some of us that are really close to Wisconsin and Indiana, that was a problem. You had a bill with certain codes and modifiers and all kinds of stuff. We couldn't use it for new patients. We had to do phone and video. So that was just a few short months ago. Let's take a look and see what's actually happened since then, how quickly those rules could change. So Susan, if you can give us the next slide, it will really sort of tell you where we're at and I'm going to take you just through pretty quickly some of the evolution just so you can see how fast it changed. So early on, we had some rules that came out in March and April. They added 80 codes for us that included the ED. The big one was we could do it for new patients and such. We could also do it in the hospital setting. We eliminated some of the rules that you could only use it once out of every three visits. In our SNFs, we have a very active cardiology SNF presence because of our bundled payment and some of our alternative payment models. So that has helped us an awful lot. The point of service, that's what that POS stands for. Don't want to lose people with acronyms and such, although I do tend to use them. I try very hard not to, but I do tend to use them. Those have changed dramatically. Let's just say you need to understand the rule. So those of you out there who are listening to us, this is where you run and you're and find your Nicole or our billing person from MedAxium to give you those rules, because we're not going to bother trying to tell you that today. There's many webcasts that will help you with that. And be careful with your private payers, because their rules are very different. And remember, too, that the Aetnas and the Blue Cross and the Unites of the world have Medicare Advantage plans. So a private payer United and a Medicare Advantage United may have totally different rules. Not logical, but it's very true. So on our next slide, let's take a look and see what happened in early March. This was probably the very largest change that happened pretty quickly. It went back to the early part of March. The big issue was that they would pay providers the same as if it wasn't in person. So that payment parity, very, very important for payment parity. Some of the patients weren't so sure about that. They weren't so sure that they should be charged the same amount if they didn't see the physician in person. So there was some of that. We did some of those discussions with our patients. The other big change is that instead of using for our physicians that might be listening in or our APTs that might be listening in, we didn't have to use the 95 and 97 coding guidelines. This was a pretty big change that came like right in the middle of COVID. And instead, we could use medical decision making or total time periods. Now, why is that important? Well, it's important, even though this talk isn't about that. But since you're going to be listening to this in October, the new rule is out. And starting January 1st, how we code our E&M visits and our office setting will be changing to mirror this. So my opinion is this is sort of getting us ready for some of the new rules. But your coding and documentation could follow just medical decision making and time. And of course, the issue of crossing state lines became much easier because we were allowed to do that. One of the things the private payers did that was most helpful was they did reduce and waive cost sharing. So that was very helpful to our patients. So it's not to incur that. So those were what we call the interim final rule. On the next slide, we'll take a look and see what that virtual check. And we'll kind of go through a few of those other ones. We've talked a lot about the telehealth, which is the audio and visual. This is an example of the virtual check-in. There's some rules to that. Again, this isn't a talk about all the rules. But just so that you know that there are rules that have to be applied. Because we sort of got used to, I heard a lot of physicians say, as long as I document this service was provided during the pandemic of 2020, that they didn't have to meet the rules. And that's not necessarily the case. And I will give you one of my favorite things from one of my ACC colleagues. And that is just because you get paid doesn't mean you get to keep it. So please be careful with how you use your codes. Please be careful how you document. And you'll see here, one of the big issues with some of these codes is that you had to get patient consent ahead of time. You couldn't have an E&M visit, you know, before or after. So you do have to run some audits and edits on this. So 2012 is an important, and it's an important code. We don't use it because we use the telephone codes. But it's there for you in case you want to look at it. So let's take a look at the next code that we're going to talk about. So that next code is the phone only code. This is probably the one that generates the most discussion. So let's just get it out of the way, because I know I have it in another slide. But as of today, or tomorrow, depending on when you're listening to this, the phone only code payment parity appears to be going away January 1st of 21. So if you have been using phone only and expect to get paid as if it's a video phone or an in-person, know that that is one of the things in the proposed rule, proposed rule, that we do think probably will change. But the important thing about the phone only, you can see the 41, 42, and 43 codes, they're done by time. So very important to document your time. You can't just say 10 minutes, you need to actually document in your EMR component. And then the same rule as we had with that G2012 code in the prior slide, no E&M visit seven days before this particular code usage. So it is important to know that we're using it specifically for taking care of our patients. But you can use it for new patients, that is very helpful if you've got a new patient that may be immunocompromised or can't really come in, it is important to know that you can use that particular code. So on our next slide, we'll take a look at the e-visits. Again, I promised you we weren't gonna spend too much time on those. Ginger, I don't know, are you seeing a lot of this being used with our APPs at all? Because if not, I think we'll just leave this here for educational purposes. Any comments you wanna make on the e-visit code? Yeah, this is an area I don't think we do a great job using our portal capability. So it's really not a widespread, common practice at this point. Yeah, and I think that says to us, we need to get our portals more user friendly. They need to be able, and again, many portals do have the audio and video capability. So I think as the pandemic winds down and we sort of look at delivering healthcare in this new world, that is something that we'll come back to. So let's head on to our next slide and take a look at the remote monitoring. RPMs is what we call it. It is just amazing to me between Apple Watches and CardioMEMS and AliveCore, which I think is called something else now, how much data patients want to give to us and expect us to manage. On the next slide, you'll see that we did put some elements in here for people to understand what RPM really is. You should identify it as if it's an E&M service because you're really rendering a opinion, a medical opinion. You need to make sure you're documented. This is another one of those that requires patient consent. That's a very important waiver that we have received during the public health emergency is how we get those waivers. But once those waivers are done, this is really important. We have to kind of go back to those rules and making sure we have an established relationship. So we don't have Ginger sending me her Apple Watch and expecting me to render a medical decision on it. The other issue of both acute and chronic care is very important as we talk about our remote monitoring capabilities. And I think as more and more of our patients have this, the key is going to be whether or not they want to pay for this service because that's a key. We have our worried well that could be at the gym and every time their interloop recorder has something, they're sending us all this information. So it's very important in your practices that when you have a patient with a live core Apple Watches or remote device checks or a interloop recorder, cardio mems, that you explain to them when you need their data, that you explain to them that it should be symptomatic. So very important. And the proposed rule, what I have on here is what the proposed rule is, but we'll need to take a look at that as we go along. So I'm gonna speed this up just a little bit so we make sure we give Ginger enough time. So our next slide, I think, starts to wrap us up on some of this. And actually, I think it's the next two slides. I put these really in here for educational purposes so that you can print them out because people always say, what are you talking about? What does this really look like? So I think this is a great slide that was put together that has our vendors across the top, tells you what kind of capacities and capabilities it has. And I do think that this is an area that vendors will be very active in. Our ACC Innovation Center is also very active in this particular world because I think virtual care will continue to be with us even more so than it even is through the pandemic. So if we take our next area is the big kind of concerns that we've had as we've gone through this. Physical exam was probably one of the big ones. How do you do a no-touch exam? So we have identified the no-touch exam, how that can really happen. ACC has it on their COVID website. MedAxium has it on its COVID website. It's something that we were able to educate to. It's also amazing to me with telehealth how quick our patients got used to this. Man, they're right there ready with their weight and their blood pressure and their pulse. So we can't underestimate making our patients part of this process and shared decision-making. So very, very important. Technical issues, the grandkids have done a good job educating us. We'd like to thank them for that, but I'm not sure that that's quite over yet. Use your staff wisely. We always tee our patients up with our MAs and stuff. So make sure that we use them wisely so the physician isn't stumbling around trying to get them hooked up. And then make sure you treat it as an office visit. It needs to be treated as an office visit. And the one thing that we learned early on is we didn't do a really good job in our follow-up. The telehealth visit stopped and we just sort of stopped. So that scheduling, the image scheduling, the follow-up visit scheduling, we did sort of fall on that one until about May. We realized that in May and we came back. Did you find that also, Ginger? Yes, absolutely. It just kind of, because the process changed, it's like we lost our muscle memory and all these things started falling through the cracks because we forgot. So I'll talk a little bit in the next section about really putting some structure on this so that that doesn't happen. Yeah, I think that's really important. So our next slide, I think I've got a couple more before I turn this over to Ginger, is just how we're using telehealth. I think there's no doubt about it. You'll see the big question mark there for cardiac rehab. You will find different opinions on this. I think it's also very important as we talk about our registries because that's something that CDR, we do try to make sure our patients not only are referred to rehab, but actually go to rehab. Pulmonary rehab, personally, I find it's gonna be very, very important as we're getting into this post-COVID. Here's the issue. The codes are specifically not on the telehealth code list. So this is gonna depend on your compliance and legal department. I'm not gonna give you any of that disclaimer that we said at the very beginning. I'm not gonna give you any advice or recommendation. This is something that you're gonna have to work through in your own world. But I think using telehealth, the one thing that is a little sad to me is that we did learn how to move very quickly in COVID. I think we've retrenched a little bit into our normal, let's take four months to implement something. And I also think we've not using telehealth as much as we could. So I think that's a lesson to be learned. Next slide is, this is an important one for onsite because when you're in the hospital, at the beginning, many of us felt that if I was outside the room, that I would need to charge a telehealth visit. And that's not true. So CMS has come through very clearly that if you're in the hospital and you are communicating with the patient, even if it's via audio and visual, that it does not have to count as a telehealth. It actually can count as in-person. So an important fact. Next slide, Susan, takes a look at the time-based as I mentioned to you. Here's a critical thing to keep in mind for both this, as well as in the future, when we get to January for our new codes, is making sure you include all of your time. Ginger is great at helping us organize our schedules and making sure that as we're doing preliminary chart prep, calling the physicians, calling referring docs, looking at labs, looking at images, the post-visit time, all that can be counted, but it has to be documented. So making sure that you use all the time possible. Next slide just kind of quickly takes us through what those times look like. As you can see, if I visit at 67 minutes, most of us don't have, Ginger would never let us do that. She makes us do 15 and 20 minute schedules. So we would never be able to do time. So it's important for you to really make sure you understand both the CPT identification of time, as well as the CMS identification of time. So just a good thing to keep in mind. Our next slide takes a look at what those codes look like in the final schedule. So again, you can see that the level five code in the proposed rule does do 55 minutes. Again, 55 minutes is not 15, 20 or 30 minutes. So very different, but these are the ones in the proposed rule. The prior slide gave you where we're currently at. These are the proposed rule slides. Also, you'll notice there's some big changes in work RBU. So we'll just leave that as a little teaser for you, because I know we have our MedAxium meeting right after the quality summit. And we also have our ACC summit meeting coming up, and we'll be talking a lot about these new codes at both of those venues. So taking on our next slide, it looks at our COVID. As we go through these slides, you'll see the ones in red are where our waivers were. We thought this would be a good take-home slide for you, so that if you're still a little bit confused about what we're allowed to do during the waivers. The other important thing to remember is that our waivers now, if they end the public health emergency tomorrow, it'd be very hard to pull our practices back. So one of the nice things that's in the proposed rule is that we will go to the end of the calendar year following the end of the public health emergency. So that will give us some time to go back to how we might need to do things as it relates to our different codes. Next slide, please. It looks again at some of the enforcement decisions, how many audits. As you may know, CMS stopped their audit process during COVID. They didn't stop the law on their back. And they have identified that some of these rules are really legislative in nature and very difficult to change. So we need to keep that in mind as we're sort of looking at our waivers. And you'll also know one of the big waivers, of course, was using a phone only. So very, very important as we watch how those codes come out. That final rule will be out in late November. So something important for us. So remember, the red is where our waivers came from. The other colors are where the original rule was at. Our next slide takes us to where we're going. So where are we going? As we identified at the top of this, one of the comments, you can sort of see the yin and yang on this. You'll see that Seema Verma, who's head of CMS, came out with this comment that nothing can replace the gold standard of in-person care. This is a really interesting component to where we're at. We need some studies. We need some research. Is in-person really that gold standard of care? Or can we do equally as well with telehealth? So the left side of your screen says telehealth was really a lifeline, but what is really the best way to deliver care to our patients? Where is it that we really wanna go? And then take a look at that right-hand numbers that we're looking at. The absolute change, the amount of dollars spent is very, very important. So if we talk about payment parity, we have to talk about whether or not we're gonna see an escalation in use. We have to keep in mind medical necessity is critically important, no matter if we're using in-person visits or telehealth visits. But you can see that the predictions are that we could almost eliminate 20% of our office visits and use telehealth. That's really significant. We could reduce healthcare costs doing this alone. However, can we have payment parity with that? If we're not doing it in the office, we don't have all that overhead, should we still be paid the same amount? So big efficacy issues, big economic issues, no easy answer, but you can see the dollar tag. 3 billion pre-COVID, 250 billion post-COVID. So where's that crystal ball? I think when Ginger's done, we'll talk a little bit about that crystal ball. Next slide, Susan, please. So here's your proposed rule. Remember, there is a proposed rule and an executive order. They came out neck and neck. One came out in the morning, one came out in the evening. The president was bound and determined that we were gonna know where he wanted to go as it related to telehealth. There's probably a whole lot more questions that have been raised as opposed to real solutions, but we will get to the solutions as we get to the final rule. We've talked about whether or not there'll be parity, so we don't know. We also know new patient visits will probably be pulled back because they aren't at least on the proposed telehealth rule. An important one is direct supervision. So direct supervision, as a reminder, for any of our stress imaging, cardiac rehab, those all require direct supervision. You can do that with audio and video. So that is current now in our pandemic world, and the proposed rule has that also coming up to us. Next slide. All right, so these are the two releases. I won't reiterate them for you, but you will know that Congress has to modify the Social Security Act before the pandemic ends because the telehealth rules are embedded in the Social Security Act. So just because we want to change it doesn't necessarily mean we can change it. So very important that we're gonna have to have Congress help us decide what that future of telehealth really is going to look like. Next slide. These are just some technical things. I won't go over them for you because they'll be here that you can give to your billing people, and I wanna get to Ginger's components. So next slide. Talked about payment parity, also talked about direct supervision just in case you didn't catch them on the other slides, there they are for you just as we wrap up. Ginger, you wanna take us through how to make this work in the real world? Yes, I'm gonna add some operational insights here. Again, another primer, Kathy did a nice job on the front end of this, I won't read through all of this, but just know that telehealth, telemedicine, there's a lot of virtual options these days of what can be provided and different ways of doing that clinician to clinician through e-consults, clinician to patient, which is what we talked a lot about today, and then patient to mobile health technology. So, so many options and just really having an understanding of what those are and what's required is important. As we go into the next slide, really why? And again, we kind of get through to some of the operational things, Kathy touched on a lot of these, but that care close to home, for those of you that might have a large outreach or maybe have a large transfer population that are coming from community hospitals, this is a great opportunity for follow-up and managing them while they get to stay in their own locations and developing these relationships. And then the very last one is the one I wanna make a point of more than anything, and this is looking into our, for me, it's looking into my glass ball of what I would like to see happen, but right now it's been an alternative delivery mode because of the pandemic. It really is, as Kathy pointed out with some great statistics, it's a value care delivery model. It's a way we can add additional resources or maybe better cost effective resources that can still provide good quality and the high quality we're looking for. We need some more research on this and we need to watch it closely, but I think we don't want this thing to go away as the pandemic goes away. There's significant opportunities here. So a couple of pearls, if we move to the next slide, I have, Kathy mentioned early on about how some of her physicians really got that joy of medicine back. I've gone into other programs where they're like, if you have me do one more telehealth visit, I'm not sure what I'm gonna do. There's a difference. And the difference is how we roll this out, how we operationalize it and the structure that we put around it and whether it's tele visits, whether it's phone visits, whether it's how we're gonna manage the remote patient monitoring and the information coming in. I'm not gonna read all this, but you need to go through an exercise like this. You need to get the right people in the room, including the providers, representative from the clinical team, revenue cycle team, IT, and start to talk about and what are all those components that are required. I loved when Kathy mentioned this needs to be treated like a regular visit. This can't be something that somebody's doing off the side of their desk. Now I mentioned earlier, you've got a doctor in the imaging room, he's got some time, but it's still structured. The processes are there, the processes are followed. Otherwise you get to the end of this and orders maybe did or didn't get put in, follow-up care maybe did or didn't go where it needs to go. And we have patients calling us back saying, I had this phone call and they told me to do this, but I didn't hear anything. And the difference between having everything teed up so that this is an encounter that your provider team can do with joy versus an encounter that your provider team is very frustrated because they can't get the technology to work. It's the homework on the front end and as operational leaders, that's what we're responsible for. So you can read through this as you have access to the slides, but the goal is to create enough structure that those surprises don't happen and it's embedded in your operational flow. If you look at the next slide, just a few, I mentioned these already, but from a provider standpoint, making sure the patient can hear and see you. So now make sure your physicians and APPs are educated on how to do these effectively. We do, and even now I know of some programs that still have some of these, from doing these from home and having good lighting and all those things just to help, just as we do on our Zoom calls, make sure that everything is there. And then for the patient, Kathy mentioned already, we've done a good job of conditioning them to get that information teed up. Many programs that I advocate for this will do a patient check in the day before or earlier in the day or even as part of the visit with the MA to get all that information and get everybody teed up. In addition to that, using even your check-in or your clerical staff that now to help teach the patient and maybe do a mock Zoom call and get that technology set up so they're comfortable. Our patients, many times they're nervous to see the physicians and the providers anyway. You add technology onto it and that first visit can be a very anxiety provoking visit. Doing some homework on the front end again can be really helpful. Next slide, as we've kind of look at just different patient engagement strategies. I think, I mean, many of these I've touched on. The one I want to point your attention to and Kathy mentioned it is transparency around insurance coverage and co-pays. The biggest issue that I've seen people run into on the, with patient satisfaction on the back end is where our expectations are mismatched. If I know going into this, but this particular service is going to have a co-pay or going to have a 20% sharing and I'm going to have, you know, it's patients need to understand what this looks like financially. So that there, you don't get that, but I only talked to him on the phone. Really? You billed me. Well, you knew that before the visit is part of your consent and some of those other education pieces. So really aligning those expectations can go a long way from any issues on the back end. And the other one on here, one of our programs developed an actual how-to video. It was a YouTube. They send it out to their patients ahead of time. They could watch it and really see how that all looked and what it was going to feel like and look like and how to set that up. Wow. A couple other things. If you go to the next slide. So I talked earlier about this being an alternate, not being an alternative, but really beginning to embed it into your clinical workflow and the way we deliver the care. And so what I've done is I've broken this up and, you know, start to thinking about your clinical strategy. We've got procedural care that includes pre-procedure and post-procedure management. And then we've got chronic disease management. This is actually one of the things I love about cardiology is we do both, which is a, which is unique to most, most specialties and you've got urgent needs. So when you start to think about these different patient populations and where we deliver the care and how we deliver the care, to me, the goal would be to think about this and where would some of these virtual telemedicine options fit. And so as you, I kind of started to walk you through a framework around that and these next slides, and I won't go into all of these in detail because I know we're getting towards the end of time, but this is the idea. So think about the care pathway, the different touch points that need to happen and is there opportunity for some virtual care, some video care, some telemedicine care. In some cases there will be get your revenue cycle people and what you need. There will be opportunity for some, some revenue generation related to these or reimbursement. In other cases, especially in the procedural area, it may be part of the global, but you're meeting an objective that historically you would have to bring that patient in, or maybe you're just engaging a patient, educating a patient so they're better prepared when they show up for that visit or for that procedure. Same thing with your, if you go to the next slide, same thing with your chronic disease management. So thinking about these patients that we're seeing every three, six, 12 months, and it's just routine secondary prevention, medication management, monitoring is in every other visit is a once a year. One of those visits, if you think about the cadence that we're monitoring them could be transitioned that one over to a virtual visit. And I kind of gave you some potential examples of things that could happen there. We go to the next slide. I want to touch briefly on e-consult. So this is the in-hospital. I'm at the tertiary care. I've got my remote regional community hospital, my critical access hospital. Many of you are maybe doing these already. But if you're not, these are really great opportunities for managing these patients. In some cases, you can keep the care close to home and you can manage the patient there and bring them in as a, send them home. And I'll see them as an outpatient. If it's a low to intermediate risk chest pain patient. In other cases, you can quickly identify the fact this patient needs to be transferred for the higher level, higher acuity care. So this is a great process to set up, but it requires infrastructure and requires processes. So again, get all those right people in the room as you begin to build this out and figure out what all needs to be included. If we go to the next slide, it kind of walked you through what those, you know, how they keep that care close to home. And then the final slide just looks at some of the benefits. If you go to the next slide, both for a patient experience perspective, you know, reduce travel burden for family, reduce cost of care. And then finally, the benefits to the health system. Again, so many of us in the larger organizations, we don't have a lot of beds. If that patient doesn't really need to come, it's better to keep them at home. It also engage, it allows us to engage with them. And I think get them in the system from a follow-up perspective. So many times we bring these patients into our larger centers and we send them back and things kind of fall out related to follow-up care. And if we can get them within the provider, you know, physician sees them, we get them into the bigger system. We build that relationship. Now we can continue to follow them after they go back to their community. So lots of different, you know, you can kind of have these for a resource as you look to develop something like this. So same thing with this slide, again, just talking about, if you go to the next slide, some of the opportunities or benefits for the hospital health system. It can actually support, reduce your door to door to door balloon time when you have those transfer patients coming in. And some of the other things I talked about related to maybe you don't even need to bring the patient in and we can manage them in their own community location. If we go to the next slide. And then there, again, I talked about needing structure, but there's lots of opportunity around getting it all the right people in the room to really build this out. But when it's done, it works well. And there's a lot of benefit to these, these e-consults. And if we go to the next slide, I want to kind of bring this back to talk about where there's opportunity in utilizing your quality, your registry data, the MCDR, your e-reports, where you're getting good information and really see where there might be opportunity in your care pathway. You know, as you look at these in your ability to kind of watch your trends, your ability to see, are we beginning to fall out and find out what that problem is before there's enough, before it really becomes an issue. It's looking for those missed care opportunities. And I'll be honest, my experience, and if you go to the next slide, many times where I start to see fallout is not so much what's happening during the procedure, but it's what's happening on the front end around the pre-procedure planning, the support, the education, the assurance that the I's are dotted, the T's are crossed on the front end. And then the follow-up again on the back end and ability to get these patients back in the clinic quickly or just plugged in for good follow-up care. So when you start to think about on the original outline for this, I think I had actually put telehealth services, and then I put procedural opportunities. Well, we're not doing procedures in a telehealth way, but the idea here is when you look at the care path for that patient and all the different objectives of care that need to be provided, and then you utilize your quality data to show you where maybe I've got a missed opportunity or go back and see where is that care being provided? Where are we meeting that objective? And if we're not, there may be opportunity where some of these virtual services can help fill some of that void. And I think this is just good ways to manage your quality information anyways and really make it actionable, but identify that area of opportunity through your metric review that's happening on a routine basis by the right people. Identify where the care objective takes place. So if I'm sitting in the hospital and I'm part of the hospital team and I look at, we've got acute care and kidney injury, which may be some procedural, but it may be because we should be holding the ace and hinder in the morning and we're not, you know, we're not adjusting to that on the front end. You know, think about where we touch these patients and what affects that. Identify a current process and owner. Evaluate an option to optimize that delivery through, there may be an opportunity to do some telehealth through that. And then process improvement structure to really build and implement that strategy. So if we go to the last slide, I think we're going to bring this home with just some of those things that, but if I would say the one take home for me and the information that I shared with you today is the structure. Planning for it on the front end. Don't do this off the side of your desk. Get all the right people in the room that need to contribute to the right process, the right flow, the right standards and the tools and the resources that your providers and your patients need in order for this to be successful. You know, Ginger, we're waiting for Susan to join us. You have an excellent point. If I look at my cath PCI and my ICD registries and I identify medications, that's always an issue that we think we have so well tackled and yet we don't. How great a telehealth visit could be to try to capture that data. And I bet Susan would be thrilled if we could get that data a little bit better captured in our registry. So Susan, how are you? I'm good. That was wonderful. Thank you both. Ginger and Kathy, you've added so much to this summit so far. The information that you shared and the opportunity for our participants to be able to download the slides and continue to spread this information is so important. I think we have time for a couple of questions. Are you ready? Got your crystal ball? Okay. So in your thought, in your experiences, what do you think, where do you think that telehealth will look like three to five years from now? Ginger, do you want to take that one first? Sure. I think there's a couple things. I think one, for the most part, as a consumer and from a patient perspective, we've appreciated it. And many of us have had really great experience with it. And I think we're going to be pushing to say we want to continue to be able to get at least a portion of our care that way. So I think that the healthcare organizations that have a very high, what I'll call consumeristic markets, you're going to have some pressure around continuing to provide. In addition to that, though, I think there's big opportunity for, especially in cardiology, around those chronic disease management patients and our ability to track them, manage them, manage some of the things that early on that would have gotten them into trouble where we'd have to urgently get them in the clinic or urgently get them back into the hospital. But through some of these more often checkpoints that are more cost-effective or through, we didn't talk a lot today about things like chronic care management or principal care management, but ways that we can use our teams to really stay close to these patients and provide some direct touch points with some of our more, our higher community or more fragile patients. I think it's a significant opportunity for us to I think it's a significant opportunity and I'd like to see it built into our delivery models. I'd like to have us identify on the front end, who are the patients? What type of the visits? Where does it fall in their care pathways? And so that it becomes just the way we do business, not an alternative when we get ourselves into a pandemic. And the only thing I would add to that excellent summary is that I think we need to get out of our comfort zone. I think what I saw us do was pivot because we needed to, but then we came right back into our comfort zone of face-to-face visits. And I think Ginger's absolutely right. I think our patients will demand it, but more importantly for our chronically ill patients, what better way is there going to be to really keep tabs and have them part of that decision process? So I think it's a challenge to all of us out here in the world with our boots on the ground. Healthcare is local. I challenge us to use and figure out where telehealth fits into our continuum of care. I think it's really important. So how do we help our practices and our health systems prepare for this future world? How do we help them further? Well, maybe I'll take that one first. I think things like the quality summit, things like the ACC summit, the MedEx meetings, that sharing of best practices is critical because we are so busy. I mean, the one thing that I just, it just amazes me is how busy we are. And we have to realize that last I checked, McDonald's is still very much in business and the gyms aren't necessarily overflowing. And so the need for solid healthcare delivery hasn't changed and we need to help each other with best practices. I think some of the things we learned through telehealth, through some of the COVID webcasts and the MedAxium webcasts was really learning from each other how to do that. The stuff that Ginger gives us that helps us figure out just from an operational perspective, how to make that work in our practice is so important. If you don't listen to anything else we said here, go to that one slide that Ginger had that puts everything together. It will give you a roadmap for doing what you need to do. Ginger, what do you think? I will add two things to that. And it's more of what we're doing on the back end to try to get you better solutions or get our organizations better solutions on the front end. And that's the advocacy. You know, there's been a lot of movement and some of these things are going to stick, but not everything. And so we've got a very strong advocacy team that's working through that. The second one is the way we work with some of the industry. So the reality is some of these tools are not that good and we need better and we deserve better. Our patients deserve better. And there's a lot of startups and a lot of technology that's there. And so our ability as the ACC and MedAxium, and even all of you as our community to engage with, this is what we need as those things are being built. Because a lot of this is that technology platform can really make or break. So not to be a commercial, but to say we're doing a lot of work in the background that you don't necessarily see and helping to build some of these things that hopefully will be much more user-friendly and can allow us to do the work that we need to do. The crystal ball is still pretty fuzzy though, Susan. So as we wrap up our time together, any last words that you'd like to share with our participants? Ginger? I guess I would just say it's if there's a lot of opportunity here to really round out or add some additional tools to better manage some of your patients or maybe all your patients. But as you think about, I can line up a hundred procedural patients or a hundred chronic disease management patients and their needs are going to be different. And some of them may not need this type of connectivity and some of them may very well need it. And we don't have the ability to provide it right now. So I think it's all of our responsibility to understand what's available, what's required, and then thinking about those specific patients and how we can best meet their needs and where these things plug in, where it makes sense. And so if you haven't been doing that already, I would urge you to learn more, go out to some more of those webinars and figure out what your capabilities really are internally because there's some really good opportunities here. Yeah, and I guess I would like to leave us with a challenge exactly as Ginger has said. And that challenge is don't forget the lessons we've learned. Don't forget how quickly we can pivot if we really need to. So treat each of our decisions that way and don't be afraid to do things differently. I think using telehealth, identifying quality, the quality summit has always been about our accreditation processes and our registries and how we can truly benchmark each other so that we keep that bar rising throughout the country as it relates to cardiovascular care. Use the tools that become available to us from technology or from rules and regulations from Washington. Sometimes they are our friends and can actually help us deliver care in a less cost effective cost, no cost efficient, more effective environment. Very, very important. And I think to continue to use vehicles such as you offer us, Susan, and the college offers us to truly have those experts at our fingertips that are helping us take care of our patients on a day-to-day basis. Well, again, thank you both for sharing your expertise. You have contributed to making this 2020 virtual first time ever summit a success and we very much appreciate that. Thank you. Thank you.

telehealth

COVID-19 pandemic

patient care

reimbursement

access to care

healthcare costs

patient satisfaction

implementation

chronic disease management