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Hybrid Care Delivery: Best of Both Worlds

Hybrid Care Delivery: Best of Both Worlds

COVID-19 required many healthcare organizations to quickly launch their telemedicine services with little planning or experience. Now it's time to learn how to optimize your telemedicine services and integrate them with your in-person services in a post-distancing world with tips from expert consultant Christian Milaster.


LEA CHATHAM: Hi, everybody. Thank you so much for joining us today. I am really happy to introduce you to our topic and our speaker. My name is Lea Chatham, I'm with Solutionreach. We are sponsoring today's webinar. I'll tell you a little bit more about myself really quick too once we get through a couple of housekeeping things here. But today's webinar is Hybrid Care Delivery: The Best of Both Worlds, with Christian Milaster, and I'll tell you a little bit more about him as we get moving along here too. But first, really quick, I just want to touch on a couple of quick things. The first one being that we always encourage people to connect with us on social media. It's a great way to stay up on events like this one and other industry news related to topics around patient engagement, patient communication, marketing, all kinds of topics within that umbrella of patient relationship management. 

We put out a lot of content. We work with a lot of third parties. We do a lot of our own research and share research from others. So it's just a good place to connect and stay up on that stuff. So I'd encourage you to do that. We would love to have you ask questions. Christian is going to be taking questions when we get towards the end today. So as we're going along, please enter them in, we'll monitor questions. I see that somebody just threw something in saying that the slides aren't forwarding for them. They look okay on our audience view slide as far as I can tell. So if you are having trouble either with your sound or with your deck, I would say you might go out and come back in.

Also, one of the common questions we get is people often have trouble with audio if they're using the audio on their computer. So if you're having any trouble with your audio, I would just suggest go into the audio tab on your toolbar, switch from computer to phone, and then dial in from your phone. That often will fix those audio issues if you're having them. Other common questions, people often wonder if they can get the slide deck. It is here in the handouts, along with some handouts that Christian has provided that you can download here. If for any reason you have any trouble downloading the slides or any of the other handouts, just let us know and we'll get those to you separately. Sometimes I think depending on people's computer systems, some people are not able to download handouts out of GoToWebinar. We're not exactly sure why that is, but if you are having trouble doing that, just let us know. We'll get those to you.

The slides and the recording will be sent out later via email. So you'll have that via email as well. If you want to watch the webinar again, share it with someone else, you want to go back through the slides, you're welcome to do that. We'll make sure you get that through an email later on today. So like I said, just go ahead and enter your questions as we're going along. If you're having technical issues or you're having other problems, let us know behind the scenes and we'll try to address those behind the scenes as we're going along.

As I mentioned, our speaker today is Christian. He's the founder and president of Ingenium Digital Health Advisors. He has been doing this work in digital health and telehealth programs for quite a long time, over 15 years, and has created a lot of amazing content and does a lot of presentations like these. Obviously we're all valuing the expertise of people like Christian today, as everyone's trying to make this move into telehealth. He'll tell you a little bit more about himself as well once we get going here on the presentation.

I'll be here in the background. Again, as I said, my name is Lea Chatham. I'm the director of content marketing here, and I've been doing education for providers, patients, and staff for the last 20 odd years on topics like this one. I also speak and write for a lot of publications about patient engagement and related topics. So if I can add any additional insights in here, I certainly will. Although I'm not sure that I can stand up to Christian, he's got quite a lot of experience in this topic. I'm going to go ahead and hand it over to him here. Christian, I am going to give you control, and watch for that. There you can see Christian, we're getting his deck up. All right. I'm seeing your background. There we go. We got it. It looks great. I'm going to go on mute. I'll be monitoring for any questions anyone has, and I'll be back with you when we do our Q&A later on. It's all yours, Christian. 

CHRISTIAN MILASTER: Great, wonderful. Well, we made it through the first hurdle, which is technology, which is some of the challenges that a lot of our patients are experiencing these days with telehealth and telemedicine. I'll talk about that in my presentation. So a great pleasure to be here. Always great to talk to healthcare practitioners here, and we're actually going to have a poll here in a few minutes to see who is actually on the line. Thanks for making the time while watching this offline. As Lea set up and in this for a long time and really enjoy talking about, spreading some good information out there that's based on my consulting practice. So we've got an hour full of content here. Please send your questions to Lea, we'll have a Q&A session here towards the end of the hour, quarter to the top of the hour, and then we'll wrap it up. 

But let me start with a story. On March 18th, the day after St. Patrick's Day, I was on the ground within FQHC, and the medical director came into the meeting and said, "Our waiting room is empty. We have no patients. Our physicians don't know what to do. They're twiddling the thumbs standing in the hallways." And the CEO turns to me and said, "Christian, by when can we have telehealth and telemedicine up and running for our primary care physicians?" And I said, "By Friday." 36 hours later, we launched telehealth, telemedicine for 25 and five locations. We've we put together the workflows, the procedures, the policies, selected the technology, developed some training materials. And within a week, they were up to 200 visits a day. Within two weeks, up to 400 visits, and their pre COVID-19 volume was 600 visits a day. Combined with the in-person and virtual within two weeks, they were back up to 100%, if not even on some days to 110% of volume. 

So telehealth really, when implemented in the right way, can lead to really a great adoption. This was all live audio or predominantly live audio/video, and the satisfaction rating by the physicians, as they deemed, the clinical quality of these visits was really great. That's really the success story that I would like everyone to have. Now, a lot of people have already launched. So today's topic is about two things. It's about optimizing telehealth, and it's about to prepare for, or now move into this hybrid care environment where we are having in-person visits as well as telehealth visits. So with that, I'm going to need Lea's assistance here for a couple of polls that we want to bring in. Okay, organize a must close poll to enable screen sharing. Okay. 

LEA CHATHAM: We should be good, the polls have been pushed out and people are completing those. We'll give you guys about 30 to 45 seconds. When it looks like we've hit a threshold here on that, I'll close the poll and push out the results to everybody. 

CHRISTIAN MILASTER: Great. All right, I'll let you handle those two questions here. 

LEA CHATHAM: We are just about to 50% on the voting. So we'll just give it a couple more seconds to hit that mark, if we can. Perfect, okay. So we've kept that, we've hit 45 seconds. I'm going to go ahead and close this one and I'll just share out the results so that everybody can see those. It's nice to get a sense of that. Can you see that, Christian? 

CHRISTIAN MILASTER: I currently do not, let me hunt down the screen. No.

LEA CHATHAM: They may not pop up on your end. Can other people, somebody? Throw a comment in there just so I can make sure people are able to see the results. It looks like we're about 44% of folks say that they... Okay, great. Somebody just let me know you can there. So 44% of folks are from a health system, 24 from some type of physician office, 6% are for academic medical centers. We've got 21% from other healthcare and 6% who are other. Okay. 

CHRISTIAN MILASTER: Yes. I finally found my way in and I found the results. Thanks for doing it.

LEA CHATHAM: Okay. So I'm going to hide those and then you wanted the other poll to push out right as well. Right?


LEA CHATHAM: So what percentage of in-person? Here we go. We've launched that one. We'll do the same thing. We'll give everybody about 40 to 45 seconds to make sure we hit at least a 50% threshold of people participating, and then I'll push out those results. 

CHRISTIAN MILASTER: Yeah. I'm really wanting to know how close are you to a hybrid care environment and how strong are you interested in maintaining telehealth as a modality? So if you are 100%, that would be interesting, and less than 50%. Really gauging here so I can tailor my talking points to the audience. So health systems was great to see. 

LEA CHATHAM: Absolutely. We're at about 40% of people who have voted at about 40 seconds. We'll just give it like five more seconds, see if we get a couple more responses and then I'll go ahead and close this one.[crosstalk 00:09:48]. Got a handful more. Let's push that. So I'm going to close this one and I'll share this one out as well. Everybody, here we go, sharing that. So it looks like on this one, about our highest is 34% of people are saying 50% to 70%. Wow, that's great. 31% are 70% to 90%. 28% say less than 50, much smaller as far as 90% to 107%. And nobody's planning on being or thinking they're going to be at 100%. 

CHRISTIAN MILASTER: So it's a mixed bag. It's a third less than 50, a third, two thirds, and a third three quarters. So good to know. All right. Let's dive into the content. Thank you for taking the time to participate in the poll here. Because that's always helpful for me. Like you heard a little bit about me. I've spent 33 years in optimizing care service delivery and 20 years in healthcare. Worked that IBM and the Mayo Clinic. I am originally from Germany, although sometimes I get a little Minnesotan accent-- “youbetcha”--  in there as well. Because I spent 15 years in Minnesota. I'm working with a consortium of other experts that we are working with the clients, people that have expertise in remote patient monitoring of able health or inpatient care. That's what the Ingenium Digital Health Advisors is about, the breadth and the depth.

Our agenda for today. We're starting with telehealth defined, what everybody agreed until somebody defined it. When we talk about optimizing telehealth and then hybrid care delivery, what are really the best practices there? What is there to consider? We'll open it up for a few minutes of Q&A, and then wrap up and bonus. I am highly available for follow-up conversations, follow-up meetings. So there's multiple ways to reach me, which are in the slides here, just send a note back to the organizers. So, very happy to engage in conversations, answer your questions. I also have a running open forum session once a week that you can just drop by. So lots of ways to access the knowledge that I bring. 

Everybody agreed until somebody defined it. It's a quote I came across while I was working in way too many committee meetings at the Mayo Clinic and everybody was in agreement until somebody defined it. So telehealth, what do I mean by telehealth? It's really about delivering care to distance and the interactions that patients have without us as a health system, as a practice, as a hospital. And then telemedicine specifically is about practicing medicine at a distance, and that's really what we need to optimize here. It's about enabling the clinicians to make good care decisions by having better data and good interactions, good high quality video-based, live video-based interactions. Because what most people have been doing here over the past three months is what I would call remote care. 

It's connecting with patients at a distance, picking up the phone or speaking over a video connection that may not be as robust. A lot of my clients these days are in rural areas. So we're having a lot of connectivity problems, as I'm sure all of you have experienced at some point in all of these Zoom meetings and Team and Skype meetings that we're having these days. Putting that graphically, then you have the telehealth as the overarching umbrella telemedicine, and then telemedicine breaks down into other modalities as well, interactive patient care. So the live audio/video, that's what most people think about these days when they hear telehealth. And that's what has really helped us here in COVID-19 to keep delivering care to our patients, remote patient monitoring, and then store and forward all the different modalities.

The aim and the benefits of telehealth are really, it's about the quadruple aim. It's about improving patient satisfaction. In COVID-19, it was about still giving access to care without exposing yourself to the virus and then being affected yourself, or bring it at home to your loved ones or other people that may be at risk. It's about achieving better health outcomes. It's about connecting with your physician on a regular basis, even in times when you can come into the clinic. It's about lowering the cost of care by preventing admissions and readmissions and utilization of urgent care. Ultimately, and that's the part that I am most excited about when I work with organizations, it's about improving provider satisfaction. There's a lot of physicians, clinicians, mid-level providers right now who are not very happy with the way that they are being forced to deliver telehealth and telemedicine. They were thrown at it.

I think there's a lot of things we can do to make it better in a lot of organizations. That is really one of the joys of this work, is to really define the process that really helps physicians to practice on top of the license and focus on the clinical problem at hand when everything else is being taken care of for them. And with that, then let's jump into optimizing telehealth here. How to launch, measure, improve and repeat. Starting with the end in mind, what does a successful telehealth service actually look like? Or what does telehealth executed successfully look like? I believe it's these six items here. It's about satisfied patients that are in these days, grateful that they have access to care, but also have a good experience. It's about the clinicians being satisfied and wanting to do it. 

It's about the staff satisfaction so that staff can, who are involved in the scheduling and rescheduling, and maybe in some tech checks in other, and billing, that despite all the anxiety that COVID-19 has brought on, that they're very satisfied with their involvement and their contribution to telehealth and telemedicine. Successful telehealth looks that you can achieve pre COVID-19 volumes while keeping your patients and your staff safe. We'll get into that when we get into the hybrid care section, and then it's about 100% reimbursement. We don't want to deliver services that are not reimbursable. So staying abreast on that is important. Last but not least, but very importantly, it's about the clinical outcomes. It's about excellent clinical quality as judged by the clinicians and as experienced by the patients. 

The next six hallmarks of excellence in telehealth are all aimed at addressing those six areas of success. The first hallmark here is that telehealth is a new clinical service. Telehealth is not just rolling out a video chat program, telehealth is really a completely new clinical service, and I go into more detail, but that means their workflow has to drive technology. A lot of people did a knee jerk reaction off just buying or subscribing to some technology, or maybe you had some technology in-house. Again, a lot of your health systems. So a lot of you may have already have some pilot projects going on in your organizations, but a lot of health systems also have in gaps. So really it's the workflow that needs to drive what technology you want to select. Physician and staff training is the third one. 

The pre-visit telemedicine tech check. This is one of the key critical hallmarks. As I alluded to in that taxonomy, there's really hundreds and thousands of use cases for telehealth and telemedicine, even within that interactive live audio/video care. But direct to consumer bring your own device telemedicine is one of the top three most complicated telemedicine services that you can establish. So in order to really give the physicians and the patients a great experience and achieve the outcomes and the billability and everything, really what we're advising and training organizations on is to do pre visits telemedicine tech checks at the time of appointment scheduling, so days before the actual visit. That really has made a difference. 

It's also about metrics driving quality. We may have some quality people here on the line, meaning people who focus on clinical quality and on the metrics. So really collecting data to drive quality is incredibly important. And looking ahead here for the next two to three months, internal pre-authorization, and I'll explain in a minute what I mean by that. So let's dive in deeper here into the new clinical mindset. First and foremost, telehealth is a clinical service and it needs to be led by and shepherded by and owned by a clinical leader. It doesn't have to be somebody in the C-suite, doesn't have to be the CMO or the CMIO, the chief medical information officers. It can be any clinician who feels called for leading the organization and his peers and his colleagues through this time. But it's a clinical service and it needs to be designed as a clinical service.

You also have to designate an operational leader. I'm still shocked to see, when I talk with the clients and leads, how few have actually designated a telehealth director, telehealth manager, or even a telehealth coordinator. It seems to be just they added onto the workload of the clinical quality improvement specialists or the CEO, or within the IT department. Really what you need is an operational leader, and we'll get to that. Telemedicine, since it is a new clinical service, is really impacts the whole organization, scheduling, legal, compliance, marketing, IT, the nurses, the front desk, everybody is really has to deliver care and do their processes in a different way. That requires new workflow design. So really having this mindset that it is a new clinical service offering is absolutely key and can shift some of the thinking and get you to a more optimized telemedicine experience. So you need to define the workflows, the policies, the marketing, the training support, and focus very much on change management. 

The second hallmark then of telehealth success is that, don't put the horse behind the cart. And yes, I'm from Germany and then maybe screwing up the American idioms, but I really intentionally mean it that way. It's that most organizations go out and they buy and invest in some technology. So they buy the horse and then they try to figure out what cart they want to pull. So in my view, they put the horse behind the cart. As you can imagine, that is not as effective and efficient as it could be. And then because first, you really need to design your workflows, your clinical workflows, your operational workflows, your financial workflows, all need to be defined, and then you can fit the right technology to it. 

The beauty of that new workflow design is that you now can design those workflows so that everybody can practice on top of the license, that front desk people can do what they do best, that technical staff can do what they do best. The secret there lies in well-defined workflows that have clear handoff points between the different levels of expertise. So at the end that a physician merely sits, found clicks on a link, the patient is there, they have a conversation, they click on end call and everything is being taken care of, and they can do the clinical notes. That's the experience for the clinician, as well as for the patient that we're aiming for. After you have those workflows, the requirements, then select the technology that best fits those needs. 

Third one, physician staff training, absolutely critical. A lot of physicians do not like, and they don't say that out loud. There's some red herrings about patients don't like it, or I don't think it's as good or whatever. Because in my assessment and my experience, is because they don't have the confidence. They've not been trained, but they also are in this position that they don't want to ask for help per se. So really offering them a training. It can even be a webinar. All physicians, I train in 50 minutes, but that 50 minutes makes a difference of a lot in their satisfaction in that first story that I told. The difference between physicians that I've trained and physicians that I didn't train was one and a half points on the like at scale with regards to their assessment of the clinical quality. So it's really...

Since we have so many workflows to design, you need to also train the schedulers and the PSRs, patient service representatives. Really everybody who is involved. You can create cheat sheets, or you can create very brief videos where you record the trainings so people who are not doing that maybe on a regular basis can review that. But very critical that you do some offer, some training. And then the pre-visits, the telemedicine tech checks to really evaluate the video readiness for every new patient. If everything was well, it takes three minutes. If it doesn't go well, well, then you're glad that you called the patient because you wouldn't want to have the physician to have that experience of the technology not working for them. So you want to designate some tech savvy staff with great customer service skillset, because this is the customer service function. This is not a tech support function. You can escalate it to tech support, but it's primarily about customer service. 

You need to train and support these individuals. For example, I just trained some people, their front desk people in a mental health agency, services agency. So they're being given time by the supervisor. Okay, if we're going to man the phones, you don't have to answer emails, you can focus one and a half hours on calling patients and setting them up for the technology. You can also build a self-service page for patients of some technical checks that they can do themselves. And some of the solutions also have a technical check function as well. There're some vendors that have that built in and you can direct patients to that side. 

You want to track success of those tech check processes and audit the process. I actually have the staff submit a quick survey, "Hey, how did it go? Any problems, anything we should know to follow up with the patient?" It's very important that this is handled. This is the critical differentiator between successful direct to consumer telemedicine and not, and its investment. But again, then when we're in the in-person world, we have the investment of waiting rooms and checking people in and leading them to the room. So this is akin to that. 

Number five, metrics, driving the qualities, really collect the quantitative data around the experience from the patients, from the providers, from the clinicians, from the staff. From the staff regarding the tech check, or the scheduling from the clinicians with regards to the actual experience of the visit, and then patients either through an online survey or just to have somebody call them just to get a sample. But for the most part, these survey results are really great. Patients always indicate their willingness to do telemedicine because they see the benefits from it. It's the best way to really engage the clinicians because through the survey, they can not anonymously, but they can indirectly give feedback as to whether it's not working. So it's a great way to change management that way. You have to define the goals and predefine actions in more detail here after the Q&A on that, and then really act on that data. Because otherwise, people will stop giving you that feedback, those metrics. 

And then last but not least, but looking ahead, is that the current reimbursement is available for almost all or many telehealth services, but the reimbursement regulations will change. You don't want your schedulers or anybody else who's involved in setting up telemedicine services to become that knowledgeable person on keeping up on all the regulations across the different peer groups. So now is the time to institute, to mandate, to require that every telemedicine visit also in parallel triggers an internal pre-authorization check. That is not to say you have to have the authorization before we can schedule the visit. But that is to train them that that communication needs to happen so somebody can, when their relations change, look for alternative ways. So you don't have a whole set of visits that are not reimbursable down the road, because one of the telehealth success criteria that defined was 100% reimbursability. 

You need to establish a centralized authority to stay abreast of the legislation that's typically within the billing team, and then implement that preemptive pre-authorization for any scheduled telehealth visit now, so that when in July, August, those regulations change, you are well prepared. So with those six optimization lenses of really looking at your telemedicine service that you've established to see what aspects can you improve so that you can have the satisfied patients, physicians, and staff, and that you can achieve those other metrics with regards to financial sustainability, which a lot of organizations obviously and rightfully are concerned about these days. And with that, we'll have another set of polls and then I drive into the topic of hybrid care delivery here. So the first question is, how well is telehealth received at your organization? Just pick one of those five options here. Just want to, again, gauge the temperature. So thank you for taking the time to submitting a poll here. 

LEA CHATHAM: We've pushed that out and we'll give everybody again, about 45 seconds and try to reach at least a 50% threshold here people having voted. It looks like we're getting close. Okay. And just one or two more seconds. Okay, here we go. I'm going to go ahead and close that and we will share that out with everybody. 

CHRISTIAN MILASTER: All right. Well, a third, or was it 54% or 34%? I can't...

LEA CHATHAM: Looks like 54.

CHRISTIAN MILASTER: 54%. That's very good. Yes. So three quarters are well or okay and 9% even very well and not so well. So, very good. Definitely telehealth is here to stay. Most people understand it, and you can have good experiences. So, very great. Then we'll have some responses. And then second question was about, in your organizations, what are your biggest obstacles to hybrid care? So merging in-patient care with telemedicine. I just listed a few, if there's other reasons here, we had a limit technical limitations of five answers. So if there's any other reasons, just jot them in the chat window here. I'm going to see and hunt down if I can see that chat window, but I may not be able to, as a panelist, to...

LEA CHATHAM: I can share with you too if you can't, if you're not able to see those in your questions. And feel free to put them in the question or the chat. Whatever's easier. Folks, and we'll give you guys about another 10 seconds or so, and again, try to get to at least 50%. I know some people are saying that they're not able, I don't know why it is that certain systems don't allow people to do the polls, but occasionally that happens. So if you're wanting to provide an answer and you can't, feel free to throw it in the chat or throw it in the questions and we'll do that. Okay. All right. I'm going to go ahead and close that one and we'll share that one out as well. Here we go, and share those results. We did have some folks who couldn't do the poll, who also said technology was their main confirming issue right now. 

CHRISTIAN MILASTER: Okay. Technology and patient scientist, nobody sets personal protective equipment. That came up in a few conversations. It's interesting. Good. So yes, technology schedule its workflow and telehealth reimbursement. Yes, definitely some concerns or in some areas of the country and also some confusion around what is reimbursable and not reimbursable. Okay. Very good. Again, thank you for participating here in the polls. This is helpful. I'll focus specifically more on the on technology aspect as well. So let me rearrange my screens here.

All right. Let's move into the core section here, hybrid care delivery. How can we really leverage telehealth and in-patient care while keeping our patients as well as our staff and our clinicians safe during this COVID-19 health crisis while we're still figuring out how we can really implement and uphold safe physical distancing? So yes, obviously why hybrid care? It's primarily the continued physical distancing, whether it's mandated or not, a lot of people who are in the vulnerable population will continue to voluntarily physically distance or social distance. That also includes some staff. 

One of my clients just did an internal survey in our phase 12 clinicians. I think four of them were not quite ready yet to come into the office, and not even to come into the office, let alone see patients. So yes, we need to accommodate that and provide a telehealth aspect as well. For some it's the cost of the personal protective equipment and/or just the lack of access, although that has been relieved here. Patients are increasingly going to be expecting telehealth if they pass that experience, how convenient and how easy it is. If your clinic, if your system makes the decision to not really offer it anymore in a few months, not now, then they may take their care elsewhere. 

There's a lot of payers who are offering telehealth services that'll offer cash pay $39, $49 urgent care type of telemedicine. So there's opportunities alternatives for patients now that they've experienced telemedicine that they will be expecting that. Most physicians now are familiar with telehealth, so that provides an opening pre COVID-19. Yeah, I had a lot of conversations about physicians who have said it doesn't work and it's not good. Now a lot of people had some good experiences and your survey results, you've indicated that as well. It is indeed a very valuable clinical care delivery tool, especially in the value-based pay environment because it allows you to quickly connect with patients very easily, very conveniently. Video just provides such a more richer experience which is one of my reasons why I am on video here, is so that you don't get just the content and the voice, but you get my facial expressions, my tone of voice, me leaning it and making a point just like you would do in a regular presentation. 

That's just so much communication that we pick up as humans through the visual. So telehealth is just a much better way to provide care to distance than a phone visit or then no visit at all. It's a very valuable tool and love different areas. So the first consideration here is really how to make the most of both worlds, is to really, and a lot of organizations have done that, but I really might not make it explicit here, it's about the work location. Again, pre COVID-19, none of us could ever imagine that we would be seeing patients in their homes again, although 100 years, that's what physicians did, the house calls. Actually, I remember growing up in Germany and my pediatrician coming by my house when I felt sick at 6:30 PM, he stopped buying. 

The house calls now we can do virtually, it used to be a very good and proven practice in healthcare. So we can really empower those visits. And then to that first point here, also enable and empower and support clinicians and staff to work from home for a variety of reasons. One of them being to keep just the volume, the traffic in your clinic buildings low as well, and have a staggered approach. You could have considered a full-time remote per workforce, some staff that are at a higher risk or part-time remote work for like, again, a hybrid model here that they may be one to three days or half days a week, they're doing telemedicine from home or even administrative work from home. Like the tech checks that I've talked about, the scheduling, a lot of these systems can be easily addressed or accessed rather from home. That's what you can do.

It's important that you provide the technical support, but also the emotional support. As a lot of us have experienced, there is a degree of loneliness and isolation that can occur. My daughters who are obviously also experiencing what I would call remote teaching are experiencing that loss of having access to their the colleagues at school, the other students in the class, their friends, their classmates. So I think we also as adults are experiencing that. As the serendipitous water cooler talks are just not the same. So saying, Hey, let's quit and grab a coffee together, it does not have the same ring as, Hey, let's jump on a Zoom call together and chat a little bit. We're not quite there yet as a society. So as a leader, providing emotional support, checking in with people, Hey, how are you doing, is everything okay, beyond the regular meetings is very, very important these days to combat that isolation.

Some of the points here on the work location is that when you now think about the clinic environment and the work location there, so with work location, I didn't mean just home, is that you can convert some of the exam rooms into telehealth destination site. So telehealth where either the clinician can be, so they can sit and spend half a morning or a morning in that exam room doing telemedicine visits from that location, or obviously you can also have these exam rooms as telemedicine end points. Again, the patient is being brought in by somebody who is in PPE, who rooms patients, but the physicians actually can be in the next room doing telemedicine from their office. They can be in the next exam room doing telemedicine or they could be at home. So there's a lot of variations if we open our mind and our rigid structures that we sometimes have in healthcare to doing things a little bit differently. That's on the work location. Again, if you have more questions, put them in the chat and we'll address them in the Q&A in a few minutes. 

With scheduling, before COVID-19, a lot of the implementations that I have done, I use the Swiss Cheese Model. The telehealth visits were sprinkled in between, the physician would see a patient in person or two, and then they would switch, go back to the office, see a telemedicine patient, and then they would see patients in person again. So for some providers who were constantly running behind, we have to switch to what I call a block model, the block cheese model, the chunk cheese. That is really the recommendation here for COVID-19. Primarily because of everybody now being thrown into this and not just the early adopters, which I mostly work with, but also secondarily because of the cost and the complications around the personal protective equipment.

Seeing a patient in person and then seeing a patient over telemedicine, there's a number of physicians I've talked to who tried that Swiss Cheese Model, were really disoriented even though they left to telemedicine and found it very stressful, much more so than just spending a day at home doing telemedicine visits. That is what we really recommend that you do, is to make a schedule that keeps maybe your clinic volume at 50%, 60% so you can have a safe physical distancing, but then also you can do a lot of telemedicine visits.

Obviously from an operations perspective... for the in-person visits, you cannot necessarily schedule back to Mac again, depending on your own internal protocol for PPE. But as volume picks up, that may get increasingly more complicated and tricky. Then the other thing, this is a mixed bag slide here, is that you really want to minimize virtual waiting times, which is one of the reasons to go to a block scheduling model. But I have found across the board over the 10 years that I've been doing it, that telemedicine visits, 99.5% take less time or the same time as an in-person visit. It's really rare that physicians are running behind. Even the physicians that typically are running behind in in-person visits, there's just something about that virtual environment that really keeps people a little bit more on track.

From a patient perspective and customer service perspective, you really don't want patients to be waiting around for too long. It's one thing to sit in a waiting room and leaf through your magazines or read up on the latest news on your smartphone, but sitting at home in front of a computer, staring at your own self image is just something that you don't want to put on patients. So again, minimizing that and optimizing your workflows that you don't have the late shows for the physicians is important, and it's something that's, yeah, it's not what we traditionally or typically do in a lot of the practices. It's understood that sometimes physicians to run behind because things happen. But just keep that in mind here. So the key factors really that's hybrid care, to really do a hybrid care successfully, the in-person and the telehealth environment is primarily workflow challenge. 

You got to map all the different workflows because you have in-person scheduling and telemedicine scheduling, and you need to, how do you stagger it? How do you route patients through your organization to your open doors and into the waiting rooms? So it's a patient flow, a workflow challenge. It's also about how do you manage personal protective equipment? So all of these things really need to be mapped out in order for you to really scale well, and to get back to pre COVID-19 volumes if you add in-person and telehealth visits together. Where's my camera? There. Then the key factor is, just like in the optimization, it's training and support. If you're already developing all these work flows, is really sitting down with people or having slideshows, webinars, recorded things to really train them on their aspect of how they can contribute to creating a safe environment in which extraordinary care can be delivered either in-person or at a distance. 

It's about the training on the scheduling on the technology and just communication in general to just really let people know what's going on. If things are not going as well as they should and what's the process for that. So, a lot of that. Ultimately, with the implementation of those workflow, implementing hybrid care is about managing change. Some of you may be familiar here with this ADKAR model, and ADKAR stands for awareness, desire, knowledge, ability and reinforcement. So it's really about, if the people, the teams that you're leading have the awareness of why the change is needed, in this case hybrid care or telehealth, if they have the desire, if they have the knowledge and the ability, and you provide reinforcement as a leader, then you get to change and you get change that is sustainable.

What's interesting is when one of those things is missing. So if people are not aware, which nobody can claim a lack of awareness these days, although with hybrid care, maybe people are not as aware, but that leads to confusion that people are like, why are we doing this? If the desire is not there, then there's strong resistance with regards to wanting to do the change. So we're dealing with that for some of the clinicians that there's some resistance. Also, if patients have had a bad experience, there's some resistance on that end as well. If people are not knowledgeable, so if people really don't know how to operate the technology, or how do you do a virtual exam without vital science, so what are the best tactics here? They don't have the knowledge or about how have you built for this, then there's a reluctance to use it. 

I'd rather do the thing that I know well rather than the thing that I know very little about, which is why I've emphasized training here so much. And then the ability, and that's, again, the training. Giving physicians and opportunities. Okay, why don't we disconnect and now you initiate the call and you invite me into the waiting room. So really just giving them the training or I sit down virtually over Zoom with the people who are doing the tech checks, and I just sit there quietly for an hour or whatever they call patients to be just there to really give them the confidence on the ability to do it. And then in order to avoid backsliding, you need to provide reinforcement. That comes best by really taking a look at the data and measuring satisfaction, measuring volumes, measuring reimbursement, measuring the use of telephonic versus live audio/video telemedicine. 

So, really powerful model here to really think about how are we raising awareness? How are we creating desires, how we're providing knowledge and how are we giving people the ability? And in what way are we providing reinforcement to really make that change of hybrid care> Which will be with us in this form, I think for the next nine to 12 months, given the timing of the vaccine development. So we really have the impetus to do this right, and to make this long-term sustainable. And then with that, we're 15 minutes from the top of the hour, and I want to open it up for some Q&A here. Lea's has been keeping track of hopefully some good questions. I'm looking forward to having that. We'll take about five minutes and then I have another few slides here, where we're going to wrap it up. And I'm going to give you some bonus gifts at the end as well, in terms of some key things you can do in your organization. 

LEA CHATHAM: Awesome. Yeah. Thank you so much, Christian. That's been great information, and we do have some good questions. You did talk a little bit already about metrics, but we've had some questions from people saying, what are the metrics we need to be tracking to make sure we're doing well at this, or to be able to track quality, quality improvement? Can you talk a little bit more about that? 

CHRISTIAN MILASTER: Yes. It starts with, and I actually have that in the next section as well. So this is a great question. It's about what is important to your organization? I can give you the answers and the metrics, and I'll list some examples here, or you can just reach out to me and we can have a conversation about that, but really it boils down first to asking your leaders, is like, what is important to us? How do you measure physician satisfaction? How do you measure the staff or patient satisfaction? So for patients, the questions I ask, did you experience, or the audio quality was excellent and then strongly agree and strongly disagree the five point scale, the like at scale. 

The video was excellent. The overall experience was excellent. I felt that my privacy was respected. I felt this was as good as in-person visit. That's a question for the clinicians. And then if you're familiar with customer service, the net promoter score question is really one of the most important ones that are always ask, is how likely are you to recommend a telemedicine visit with this physician to your friends and family? And that's on a scale of zero to 10 to calculate the net promoter score. That's a set of questions I ask. With regards to the staff doing a tech check, I ask often and the clinicians and the patient as well, I ask an open-ended question. Is there anything we can do to make this a better experience for you? 

I've gotten so much great, great, great feedback by just asking that simple question. People could have emailed me that, they know I'm around, but no, they'd rather do that through the survey. So those are some of the questions I ask. When you're launching, or when you're doing telemedicine, you are having a certain set of assumptions with regards to reimbursement or technology or expertise. So one way to also arrive at what metrics you want to collect and are you willing to act on, is to really become presence to what are your assumptions that you're making? Once you know, I'm making the assumptions that patients would like it, or would use it again or of that nature, and then you develop metrics around that. 

LEA CHATHAM: That's great. Thank you. We've had a question here, which is interesting. I think you and I actually chatted about this a little bit previously, and we've developed some materials that we'll send out to folks to, and you've said some things here. This is a good question. It's about workflow for the physicians specifically. So this person is saying, "We're finding that our doctors are having to do more work to do telemedicine. How can we change the workflow so that it's not putting a bigger onus on the providers?" I know in the past I think we've chatted about, or you said things like being able to maybe have a patient or have someone do some intake with the patient ahead of time or using some other digital tools. So what are some suggestions you have there to help with that? 

CHRISTIAN MILASTER: Well, you're becoming the expert, Lea, so you’re... 

LEA CHATHAM: I've been reading all your materials. 

CHRISTIAN MILASTER: There we go, yes. I've got a lot of materials. I have a weekly newsletter where I write a lot about this. It is really, start with the end in mind. I mentioned that here a few minutes ago. Envision yourself, the physician sitting down, looking at the schedule, "Oh, I have a telemedicine visit. Oh, it's in this technology. Okay, let me click on the link." And the clicks on the link said, oh, the patient is in the waiting room. Let me allow them. So you really design it from a physician experience and then everything else that the physicians are currently doing, that they shouldn't be doing, you take away. Every system is perfectly designed to get the results it gets. So you need to change the system. Yes, at the time of scheduling, you need to maybe do a patient telemedicine tech check. And it doesn't have to be the scheduler. It could be somebody else.

At the morning of the visit, if this is a patient with chronic diseases where really having access to vital signs is important, maybe a nurse calls or even has a video call and talks about, okay, "Mrs. Smith, have you taken your blood pressure this morning, or you have a blood pressure cuff? Oh, you didn't? Okay. Well, could you take this?" So you have it available for the physician visits. So all the things that we're doing in the in-person practice, we need to think about how we can replicate that to the best of our ability in that virtual environment. Then the same for the post visits, who is going to schedule the follow-up appointment? 

Obviously the patient is not walking out and needs to pass through the gate, the toll gate at the end to check out or to be left out of the building. So how can you create that? Who's going to call the patient when the visit is done or is the patient going to call us? Or if the patient didn't call us, then call back? Again, it's about metrics, it's about workflows, it's about really designing the optimal patient experience, the optimal physician experience, and then training the staff so they can have an optimal experience as well. That syndrome, that quadruple aim, really that physician and staff satisfaction. 

LEA CHATHAM: That's great. Thank you. Yeah, I think there are a lot of ways and sometimes it comes down to maybe making some changes in the technology you're using. Those are some of the things we've been talking about, digital intake and digital bill pay and other ways of handling some of those things separately. So speaking of that technology and processes, there are several questions here about ROI and people's concerns about, is it really expensive to implement telehealth and am I going to end up losing money because it's an expensive thing to implement and we're not going to get reimbursed as much? Can you talk a little bit about more of the reality around that ROI piece around telehealth? 

CHRISTIAN MILASTER: Yeah. Right now, all the clients that I work with are in environments where there's really 100% reimbursement if you're billing and coding in the right way across both Medicare, Medicaid and private payers. There's obviously some exceptions like dental practices, or there are some other procedures that are not the traditional EMN codes, but ENM codes, behavioral health, even some dentistry services. So a lot of those are reimbursed currently at 100%. Now, that eventually will change. The investment in running telehealth and telemedicine is really, really cheap. Most licenses are between $20 and $40 per month per physician. That is really easy. The biggest investment these days is in the staff and potential, the consulting services on really designing those workflows and getting it right. 

On the other hand, it's an investment into the protection of your business model for the future. Because as I mentioned earlier, there's a lot of virtual competitors coming online and there's literally hundreds of startups right now that saw this as a great opportunity to really have consumer patient facing telemedicine services. So there's going to be a big wave of competing services. It's good business principle to just invest in that because it's not going to go away because once patients experience that they will love it.

The investments are relatively low, I mean, compared to an EMR conversion or any of the other big projects that healthcare has undergone. This is one of the cheapest one to run and it's something when done right, will really also expand your ability to generate additional revenue outside of your geographic reach taking maybe your expertise that your health system has and making it available in some rural outlying areas, thereby serving as a feeder mechanism to your specialties. 

That's one business case we developed for a hospital in Central Maine that was offering some of their expertise to the Northern Maine that was not available, leapfrogging one of the organizations that was between them just because they were better to work with and were ready to do telemedicine. So, a lot of different reasons why to make this a good ROI, but the investment is very, very modest. Reimbursement will eventually go down and it's going to be a political struggle, and we're going to have to see how the election shakes out and how Congress gets together on this topic. But I don't think we will definitely not go back to pre COVID-19 volumes here. So, very good questions. 

LEA CHATHAM: Yeah. And just a super quick add on to 30 seconds. A lot of people have asked in the past, and it's related to this, they think they need to buy new cameras or new monitors, new computers, technology like that, or that patients will need to do that. Can you just quickly speak to that? Because I think people often don't realize probably you already have the technology for the most part, that your computer cameras or phone cameras are adequate. 

CHRISTIAN MILASTER: Well, and the investment is modest. Even an external webcam and a second monitor and a speaker runs yet about $300 per physician. So really, it's such a minuscule investment considering how much you're paying for watering the plants in your building. That's-

LEA CHATHAM: That's a good example. 

CHRISTIAN MILASTER: That is really, it's a non-event. And yes, we need to think about the long-term, the viability of caring for our patients with multiple chronic diseases and how can we give them technology to make it more accessible to them? So I want to be respectful of the time. I've got some more content here. I understand that people need to drop off. But you can also then revisit the recording. So we may run here maybe five minutes over, but great questions. Again, I'm looking forward to engaging with you offline to maybe dive deeper into that. Always happy to talk about that. 

So here are the key takeaways. Killer health is about delivering care at a distance. It's a new clinical service offering that you really need to approach that way. It requires that you develop and design and implement and document and track new workflows and new policies, you need to provide the training and support and marketing and publicity just like you would for any other new clinical services launch. You need to have designated leadership and change management.

On the hybrid care side, then the key deliverable here is that you want to deliver care at a distance and in-person, and it's your new way of delivering your services. It's going to stay here. It's always going to continue in from now on to be a hybrid care environment, except for maybe some specialties. And it requires, as we've talked about, requires coordination across the whole organization, requires good communication. As we're moving into this very new mindset, you need to have a new paradigm with regard to where people are actually working, that they're working from home is okay, and new paradigms with regards to the scheduling of in-person and virtual care. Again, you need designated leadership and change management. Those are really the two bonuses that I want to leave you with here, is how you can really, with those two things dramatically, either one of those, dramatically improve the value of your telehealth services. 

If you do both, you'll reap three times the benefits than just doing one of them alone, but it's deciding who's in charge and focusing on knowing where you're going. And deciding who's in charge, first deals with identify and designate a clinical leader for your telehealth services. And it can be telehealth and primary care telehealth in behavioral health. You need to have a designated operational leader. That doesn't have to be a full-time position, or you can, as you're launching and optimizing, you can outsource that. That's the service we offer as an interim telehealth program director for the manager, but you need to have a designated operational leader. You need to have some technical leadership, as well as an executive owner for that. It is really at the highest level of the organization that somebody needs to really pay attention to telehealth and telemedicine. 

Then the second focus here, it's the DMAIC cycle, the define measure, analyze, improve, and control that is known from the call to your area. You need to define what is important. How do you set goals? Here is an example of how I collect the data. That's the Like it scale here, it's probably too small to read, but I felt my privacy best respected. I could clearly hear the provider. I could clearly see the provider. Those are some questions we're asking. You need to collect the data, and then you need to analyze them against the goals. You need to identify some trends, and then you need to improve. You need to fix the challenges, the problems, and then you need to systematize it. 

You need to then look at what changes do we need to make in the training, in the workflows, in the experience to really control that? So a lot of very, very long to-do list, just from the slide alone, just the last two slides. But the first one is easy to implement, identifying some leaders and providing them with a level of expertise that they need to be successful. So some training or access to mentors in telehealth.

With that, with just 90 seconds over, I guess I'm a German engineer, so we like to be on time. I started on time, end on time. I appreciate Solutionreach giving me the opportunity to talk to you. Thank you for being on the line here. Thank you for your good questions. Reach out to me if you want to have a follow-up conversation. I have a newsletter that I publish every Tuesday with some very pragmatic advice around implementing, and there's an archive of all my newsletters out there as well. And you can connect with me on LinkedIn and see my posts there if that's where you spend some of your time on social media. And with that, I'm handing it back to Lea. 

LEA CHATHAM: Thank you so much. That was a great presentation. We're already seeing people are giving feedback saying how helpful they found there, which is great. I just want to take one second. I know people are starting to head out and we do want to be respectful of people's time. But I wanted to mention as the sponsor here for the webinar today, a little bit more about SR Health since some of you may not be familiar with us. This is a solution developed by Solutionreach for larger enterprise. So big group practices, hospitals, health systems and those kinds of environments that really provides an end-to-end workflow that supports this hybrid care model. So with SR Health, you are able to do everything from the moment that you schedule the appointment through to that last piece of sending out that survey, including being able to deliver that telehealth visit using our telehealth solution. 

If you're interested in learning more about SR Health, you can email us at info@srhealth, or you can go to srhealth.com and schedule a consultation. We do have a lot of different promotions going on right now to support organizations as they try to ramp up quickly with better patient communication and telehealth solutions to be able to deliver that hybrid care to patients. And we're happy to walk you through that and give you a personalized consultation around how we can help you. So you will also, as a reminder for those of you who've been asking, get a follow-up email from us that will have links for you to be able to schedule a consultation if you'd like to, as well as the recording and the slides. So you are welcome to watch it again, share it with others, share the slides with others. 

We're thrilled to have been able to provide this content for you today around telehealth and we'll look forward to having Christian back again as things continue to change and develop in the telehealth and the hybrid care world. So thank you again, Christian, for being here with us today, we really appreciate all the content you provided. 

CHRISTIAN MILASTER: It was a great pleasure to be with the guys. I really enjoyed it and looking forward to getting a copy of all those questions. That was exciting to see. 

LEA CHATHAM: Yeah, absolutely. And we'll certainly take the questions and probably push out a blog post or something with the answers and any that we didn't get a chance to answer today with Christian and we'll get those taken care of too. So thank you again, everyone, have a great day. We hope to see you back here at future webinars with SR Health again down the road. Bye, everyone.