April 30, 2020: We’ve grown accustomed to seeing hockey stick charts as telehealth usage continues to skyrocket. During these unprecedented times, there have been some extraordinary solutions to problems, many of which we hope will endure after the crisis has subsided. Today’s guest, Lyle Berkowitz, a primary care physician, IT practitioner, and telehealth expert, joins us to talk about what telehealth solutions will look like moving out of the crisis. While it is important for healthcare organizations to respond to the here and now, it’s equally as essential to be future-minded to ensure lasting solutions. In this episode, Lyle dives into some of the challenges with the initial surge in telehealth utilization. He stresses that the hurdles were far less about the technology and more physician shortage. While the solution of telehealth has been around for ages, the problem it was trying to solve was misguided. Instead, by reframing the issue to be about optimally using physician resources in conjunction with providing low-cost, high-quality care to patients, then we have a plethora of new solutions. It was never that there was not appropriate infrastructure for this type of care to be deployed, but rather, that cultural inertia was the main obstacle. Now that patients and doctors have seen the benefits of telehealth, it’s about having the right governmental and organizational support to support the gains made. We also discuss how healthcare can take a page out of other industries’ book in terms of automation, why fraud and abuse aren’t reasons to stop telehealth and patient responses to virtual care. Be sure to tune in today!
Key Points From This Episode:
COVID Series: Telehealth’s Tipping Point
Episode 238: Transcript – April 30, 2020
This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.
[0:00:04.5] BR: Welcome to This Week in Health IT news where we look at the news which will impact health IT. This is another field report where we talk to leaders in health systems on the front lines. My name is Bill Russell, healthcare CIO coach and creator of This Week in Health IT a set of podcasts, videos and collaboration events dedicated to developing the next generation of health leaders.
Are you ready for this? We’re going to do something a little different for our Tuesday news day show next week, we’re going to go live at noon Eastern, nine AM Pacific, we will be live on our YouTube channel with myself, Drex DeFord, Sue Schade and David Muntz with StarBridge Advisors to discuss the new normal for health IT. With you supplying the questions with live chat. Also, you can send in your questions ahead of time at [email protected] I’m so excited to do this and I hope you will join us. Mark your calendar.
Noon Eastern, nine AM Pacific on April 28th. If you want to send the questions, feel free to do that and you can get to the show by going to thisweekhealth.com/live. This episode and every episode since we started the COVID-19 series have been sponsored by Sirius Healthcare.
They reached out to me to see how we might partner during this time and that is how we’ve been able to support producing daily shows. Special thanks to Sirius for supporting the show’s efforts during the crisis. Now, on to today’s show.
[0:01:25.4] BR: All right, today’s conversation is with Dr. Lyle Berkowitz, a primary care physician for over 25 years, IT practitioner for Northwestern for many years, innovation champion and telehealth expert as former CMO and EVB for product strategy for MDLive. Also, chairman for healthfinch and automation platform workflow, automation platform for healthcare. Good morning, Lyle and welcome to the show.
[0:01:48.2] LB: Thanks for having me, Bill.
[0:01:49.7] BR: Yeah, I’m looking forward to this conversation. I’m sure you have seen these curves, I mean, the hockey sticks are now pretty prevalent. I’ve talked to a lot of health systems and they talk about going from 40 telehealth visits a day to 400 or even thousands of telehealth visits a day. These really are extraordinary times and we were going to focus in on telehealth for the next 15, 20, 25 minutes. And specifically, we’re going to try to figure out what it looks like moving out of COVID-19, post COVID-19.
You know, I’m curious, let’s just start with the basic question. We’ve introduced entire country even the world to telehealth many for the first time. Do you think this is going to be a tipping point for virtual care in our industry?
[0:02:43.6] LB: Absolutely. Yeah, it has been a huge tipping point. I mean, this is something that many of us have been arguing and pushing for, for decades. I mean, think back on it, the very first phone call with a telehealth visit. Alexander Graham Bell called his assistant because he burnt himself. “Help me. Come over here Watson,” right?
We’ve been using virtual means of communicating with patients in various ways for a long time. And certainly, with the technology that has advanced over the past few years, becoming easier and easier to do. It’s really been a combination of reimbursement and perhaps regulatory changes and just social and cultural issues that have prevented us from moving further. This has become an inflection point. And this is as I say, don’t let a good price go to waste.
This is showing us that there was never acknowledging or in trust or need, it’s been very much an inertia to not do things and reimbursement issues that overcome. It’s a little like Dorothy in Oz. We had the ability all along. We just had to click our heels.
[0:03:55.3] BR: Yeah. Absolutely. We did have some technology hiccups early on. I guess we didn’t anticipate going from 40 to 400 a day and having to really ramp up that many physicians. It was pretty rapid. Some of the larger telehealth practitioners – Actually, our telehealth organizations actually stumbled a little bit coming out of the gate in terms of that scale.
What are your thoughts on being able to scale that quickly? Did we just not anticipate the infrastructure that was going to be necessary or just anticipate that kind of growth that quickly?
[0:04:35.8] LB: Yeah, for the independent telehealth vendors, the issue is all about supply, demand and time. No one predicted or could be prepared to essentially, double volume overnight or within the matter of weeks because the issue, I don’t believe in any of the cases of the technology as much as it was having enough physicians. Being prepared for the volume. There’s no clinic in America or anywhere that can just deal with doubling overnight patient request. That’s essentially that’s what they had to do.
The health system level, what’s interesting is that have patients scheduled already, so they – all patients contact them and explain to them, “Do your visit online now.” That could be a phone visit, could be a video visit, I do think that the health systems probably stumbled a bit if they were trying to do video visits because that implies a technical ability of patients that often isn’t there and requires a level of support. So, we know that EMR vendors and the telehealth vendors in the technology space and the health systems themselves did probably struggle with the technology side of video.
A number of folks I talked to in health systems, I just did phone. The issue at that point became, what and how will they be reimbursed? And a phone visit being reimbursed, the same as the video visit, the change that came on the parity pipe laws where that they definitely a video visit, could be reimbursed similar to an office visit. There’s still I think questions as to whether phone visits can be some are interpreting the new rules, regulations and can culture from both CMS and commercial pairs that, “Yes, phone visits are acceptable,” and they can bill at an office visit levels.
Others are using the phone-based codes, but those are incredibly less financially viable just compared to the office visits.
[0:06:37.5] BR: All right, you took us in the reimbursement direction. I’ll take us in the government response, sort of setting up how we sustain this. Over the weekend, just some stuff that pulled out a story. The quote goes, “’I think the genie’s out of the bottle on this one,’ says Seema Verma, CMS administrator. I think it’s fair to say that the advent of telehealth has just completely accelerated and it’s taken this crisis to push us to a new frontier,” which is essentially what you’re saying.
“There’s absolutely no going back. Law makers might worry that permanently easing access could increase spending and that affect will no doubt need to be evaluated. ‘But this to me,’ Ms. Verma says, ‘is the most clear example of untapped innovation.’”
All right, what should – if you were coaching Seema Verma at this point, what are some things they need to put in place in order to sustain the gains that we’ve gotten from a telehealth perspective and then access and then ease of access to care that we didn’t have prior to this?
[0:07:43.5] LB: First, big credit to Semma Verma. This is not new. She has been advocating, a fan of telehealth, virtual care for the past couple of years. I’ve been in meetings with her. She has been a fantastic champion for this. I’d love to hear that type of vote.
The number one thing that has to happen is that the reimbursement changes need to continue and they need to be more clear. Essentially, we have to make sure that we are paying doctors appropriately for their time and their intellect in taking care of patients whether it’s the office or online, whether that’s phone, video, asynchronous care, et cetera.
With that said, it’s still a fee for service world in many cases. And so, that implies a more volume and that’s always what the [inaudible 0:08:36]. The government can only set the CMS right. The commercial payers need to follow that. So, no matter what Seema Verma says applies to CMS but the commercial payers. need to follow suit and that’s what we certainly hope they do.
And in fact, if they do that, the good news is, there’s still documentation standards that have to be done, we’re not going to – Doctors aren’t going to bill for a simple one-minute phone call that isn’t documented. It’s got to have some actionability. What we found also that be live and the other telehealth vendors that found is substantial savings and care because if you provide fast and easy, convenient access to people, they’re going to decrease the need to be in the urgent care and emergency room.
That saves a lot of money and frees up the system to take your people who really need to be there. And it’s both being able to do it in a quick, easy way but it’s also quicker access. Now you don’t have someone waiting until they’re super sick and need to go in and see the doctor, go the emergency room. If we can catch them a little earlier, manage them better, it does save money.
[0:09:50.6] BR: Yeah, the thing about the government is they’re worried about –I assume they’re worried about fraud and increased cost. You know, how do you address those two things, how do you address the fraud aspect and how do you address the concern that there’s not going to be enough money to pay for something like this?
[0:10:09.0] LB: Yeah, fraud and abuse is an issue, whether it’s office space or virtual space. What’s good is that they’ve gotten better at rooting this stuff out and there’s certain areas that have been probably more right for fraud in terms of medical devices, compounding meds that they have gone after successfully.
I think these days with computers, artificial intelligence, et cetera will probably be easier to find the outliers. As usual, it’s a couple of bad apples. You don’t want to preverbally throw the baby out with the bath water. The vast majority of doctors are wonderful, kind caring humans, who going to do this appropriately. And I think it’s going to be easier because of technology to find the doctors that would abuse. But they would abuse in the office as well virtually. It’s silly to just say we can’t support virtual care just because it’s virtual when it’s really the individual that we have to work out.
[0:11:14.7] BR: All right, you know what? A crisis hits, a few things happen: We react, we sort of stabilize that environment and then we reimagine it. We reacted with a bunch of makeshift solutions and we scaled some of the industry leading solutions that have been out there.
One of the questions I’m getting from a lot of people is, “Okay, we threw things at it. We threw FaceTime at it. We threw Zoom at it.” Some of the more advanced health systems already had MDLive, American Well and others and they scale those up.
But the ones who put things in place, they’re now saying, “Okay, is this the new norm? If this is the new norm, how do we transition from this makeshift – What does a well-designed telehealth or at least virtual visit platform look like for a health system?”
[0:12:10.9] LB: This is where in the innovation world, we talk about rethinking the problem, understand what problems you’re solving and this is – I think been a fundamental issue or flaw that I’ve been arguing for years in the telehealth industry, needs to think is, “What problem are we solving?”
We have to move away from that the problem that has traditionally been, “How do we replace a 15-minute office with a 15-minute video?” That’s an important problem, it has its place, it is beneficial but it in the end is not reimagining care and it’s not something that can scale.
What we really need to think is rethink the problem. If the problem is, “How do we take care of someone, with a routine, repeatable type of issue in as safe and effective, high-quality, low-cost way as possible?” That problem opens up a whole new world for us, that involves not just video, but any type of virtual care and automation. And it’s a combination of automation and virtual care that will allow us to scale and manage many more people in that really high-quality cost- effective way.
What we’re starting to see for example is the use of front-end chat bots, the triage and collect information on them. By the time you get to the doctor, most of your note and most of your process is complete. [inaudible 0:13:47] is an example of a company that has been very successful at doing something like that. And most of it be telehealth companies and EMR companies have some level that are the ones who do that really well will succeed the most.
Second is asynchronous care. Not everything has to be live and or video. If the goal – the goal is taken care of someone; the goal shouldn’t be doing a video with someone. The truth is a lot of patients don’t like video. In fact, have a lot of it, telehealth experiences out there, you’ll find much more phone care than video care, combination of convenience and comfort level and asynchronous allows or even better scale of use of physician resources, where the patient will fill something out online and then the doctor will be able to review it and ideally you will have some level of technology that reviews how that works. So that the bottom line is the patient can do the care on their timeframe. The physician can do it efficiently and the result is that you have a very efficient visit. It’s high quality and eventually I would imagine you don’t need a doctor for much of the routine care that we do, it can and should be automated.
This is where we talk about the next level of government’s FDA approval for simple stuff, sinus infection, UTI’s, etcetera. These are pretty routine, evidence-based, algorithmically-based problems that can be solves probably without necessarily having a doctor involved, unless there is an issue that needs a doctor’s review. Similar to other industries, you don’t escalate to the highest paid person, unless there is something abnormal going on there.
[0:15:37.6] BR: And you are a primary care physician for 25 years and it is interesting to hear you talk this way because it essentially really changes that game. You gave a talk at I think the health catalyst summit where you talked about reimagining the number of visits that a primary care physician could handle. And I think it was from 2,500 to 25,000 or am I getting those numbers, right?
[0:16:07.4] LB: Yeah, so what if we 10X healthcare? But the goal is not to increase the number of visits a doctor sees. It’s the number of patients that they can manage. So how can I – a typical primary care doctor manages a panel of 500 patients. What if they can manage a panel of 25,000 patients? What would it take?
And what I talk about is my ‘sad and fat philosophy.’ It is a combination of simplified automated delegate with team repeatable error. And then use financial incentives, automation, AI, teamwork and telehealth to operationalized more here.
And two of the key things there are teamwork, so delegation of more of the care to team members that are unpowered by technology like healthfinch, does that by telling staff how to reach them and using protocols and rules appropriate for the patients. So, you don’t have to bother the physician. In fact, we saved a million minutes a week of physician time by helping to automate and delegate that care.
And then I think we’ll even move more to pure automation for a lot of routine care. If you think about the pyramids of patients, 80% of patients have routine repeatable type of issues that we could probably automate, similar to how the other industries have used an online self-service automation. So that you have hypertension, diabetes, if you have a sinus infection, as long as you are staying within the lines, we should automate it, you know?
This is probably going to save the healthcare system. Because we currently don’t have enough doctors to take care of all the patients in our current paradigm, which is a blockbuster like “bring everyone into the office.” And taking those visits and just putting them online isn’t enough. We have to automate it further so that the typical doctor can take care of more patients in the panel with his team but actually only needs to see a smaller number of patients.
Another way to think about it is taking the doctors and converting some doctors into complexologists, where they were doing the care online and overseeing computers and other staff in complexologists, who are taking care of the really, really sick people. And therefore, you have a much smaller number of people that are managing who really need their care. You have to be seen whether to divide those outer, the same doctor can manage all of that.
But the bottom line is we have to do what every other industry has done in this in using IT automation to manage more of routine type of care because that is how we get to the part where we have enough doctors to take care of everyone. I will often say we don’t have a shortage of doctors. We have a shortage of using them efficiently. The more that we can use technology to enable automation, the easier and quicker we’ll get to the point where everyone is going to get the care that they need in a cost-effective way.
[0:19:20.5] BR: All right, so last set of thoughts here and it is really around – The healthcare environment has been hit pretty dramatically, right? We know that a lot of health systems right now are losing money, a fair amount. I mean they are not doing the elective surgeries and those kinds, there is a lot of things they normally do that they’re not doing. The surge really hasn’t hit in a lot of places and so there is a lot of empty beds, quite frankly. So, the financials have been hit.
If you were consulting with the health care organization right now, not necessarily the payers, but the providers, is there an opportunity to rethink this coming out of it or is it going to be more of a – they are going to still be in a react mode because they are going to be reacting to a whole bunch of lost revenue that they have to figure out how to plug holes at this point?
[0:20:16.9] LB: Yeah and right now I think most health systems are understandably focusing on the here and now, how are we going to take care of everybody in a safe way? Stay in business, etcetera and that is appropriate. But they also need to start thinking about creating a team to think about in the future. In three, six, 12, 18 months where are we going to be and how are they going to be prepared?
I think that the way I am working with health systems to start thinking about future scenarios. Where might the future be? I think the biggest issues if I am going to look at it is one, you know where are we going to be with COVID? Are we going to be past COVID or are we still going to be dealing with it in a lot of ways?
And I would say on the other axis I look at are we reimbursing for virtual care? Has that happened that we have continued reimbursement at a parity level. And then those create four quadrants and for health systems to start understanding, for each of those quadrants what is my strategy for each of those and what are the milestones that I need to start looking out for to understand which quadrant is more likely? And in any quadrant, you are still going to be re-imagining here.
This is also where value-base care becomes incredibly important. If you are in a value-base environment and you’re getting paid per member per month, you are a much better situation. And in fact, a really good situation because you are still getting paid, but doing less of the care.
I also think there is going to be a big push and need for consolidation is doctor’s offices, particularly private doctors are going to go bankrupt without the support of the larger health systems. We are going to see what type of money the government is going to need to bail out. I mean they bailed out the banks in the past, they’d better damn well bail out the hospital systems, you know who are a true backbone of America as well as medical groups to stay afloat.
And then long-term we have to rethink, either we have to really rethink how again we automate and virtualize care and then rethink how we pay for care. And then those are surfacing discussions that are made at a local level, certain they will be done at the government level that need to be followed really closely. And the hospitals and health systems need to advocate for themselves.
[0:22:38.7] BR: Yeah, so Lyle this has been a great conversation. I really appreciate it. But my last question is just around the consumer, right? The consumer of healthcare. How have they changed? I mean I assume there is some expectations that have changed and I assume their is also they behaviors are going to change. I know that you can’t go for even two months and tell people no visitors in the hospital and you created this environment where people are a little concerned about not practicing social distancing and going into the hospital. How are we framing – how are we thinking about the changes that is going on in terms of the consumer and what their expectation is going to be coming out of this?
[0:23:23.7] LB: Well interestingly, I think consumers have been looking for this for a long time. When we saw some of the comments at MDLive from patients about their satisfaction with the system, one of the common threads that I always see is people saying, “I really love this service. It is fast, easy,” etcetera, “But I hate going to the doctor’s office. There is all those sick people there and I don’t like being in a room with sick people.”
This is well before COVID. They knew that the current system wasn’t great. Don Berwick, the famous doctor in equality called it “the tyranny of the office visit.” It is inconvenient, it is health risk, risk for your health has been around for a long time. We, as primary care doctors, knew that if someone came in for a checkup and they’re in a waiting room with sick people, they’d be back in a few weeks. Not a good situation.
So, I think consumers have been looking and asking for this. They just were not sure how it is getting paid for, who is doing it? They want to do it with their doctor if possible but for minor things they may do it with anybody that could do it. So, I think that we have broken the barrier and we have shown both doctors and patients, this is easy and feasible. Most doctors I talk to they’re like, “You know what? This isn’t as hard as I thought and my patients will love it.”
Think about every other industry. I often use Blockbuster and Netflix as an example. Blockbuster insisted that people love coming into the office, into their offices, into their buildings, claim with the DVD’s, talking to staff. No. What problem should have they been solving is people want some type of media. Netflix figured out how to do it, easier and cheaper, more conveniently and it worked very well. Healthcare industry needs to take a lesson learned from that just like, Bill, when we were young, we used to have to go to bank and talk to someone to get money right? That doesn’t happen anymore and in the same way, healthcare has to learn from that.
On the inpatient side, I’m on the board with a company called Oneview that does inpatient software in the patient room and they quickly had rolled out software that helps with virtual rounds with your doctors and nurses and virtual visits with – between the patient and their loved ones, which came out as there wasn’t a ton of interest in before but became very important very quickly. Virtual interpreters too. That type of software in the hospital setting will just become standard as people need to get isolated. We are live in a different world now. But we have the technology to do it. We just have to get over some of the cultural inertia in healthcare that takes time to change but we have done it now.
[0:26:09.1] BR: Absolutely. Lyle, thank you for your time. I really appreciate it. You are sheltered in place, where are you located out of?
[0:26:15.6] LB: I am in Chicago.
[0:26:17.4] BR: You’re in Chicago. What is the situation like in Chicago these days?
[0:26:20.4] LB: You know it is quiet, it is beautiful out. People are still out walking, being active. You know as the weather gets nicer, Chicago is the type of town where everyone loves to go out. So, I think they are going to struggle a lot as we get into May and the weather gets better. But everyone is being very respectful of each other, keeping their distance. The studies show it is very hard to spread in outdoor space and you know, this is a tourism town though.
It is hurting. There is a lot of people in the hotel and restaurant and convention industry and they are suffering right now. So, we are hoping the right balance comes along. The hospitals here have been amazing. They have prepared excellently. They have expanded their ICU ability. We have opened up at our convention center at McCormick. They have opened up a contrary hospital if needed.
So, we are over-prepared but we’d much rather be that than – It’s like my family. We always have more food than you need at a holiday celebration, so it is the same thing here. We are really prepared for potential onslaught. We – our ICU’s would have been overfilled if we didn’t expand. But every hospital I talked to is prepared well and because of our relatively quick and aggressive move and stay at home, we have seemed to flatten the curve. I think the angst is over, the extending into the end of May, the Governor is pushing through that.
Business people are getting pretty worried about that and trying to figure out what is the right compromise is. And we’ll be watching I think everywhere from Sweden to Georgia to see how that works out and see if there’ll be some balance that lets us get back a little more normalcy and let people get back to work.
[0:28:09.8] BR: Yeah, absolutely. Lyle again, thank you for your time. I really appreciate it.
[0:28:13.4] LB: Okay, thanks Bill.
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