So, welcome everyone to our March call. I've got a brief agenda up on this slide. We are going to shuffle around our order just a little bit. One of our panelists has to leave a little early, so we're going to have our panel discussion pretty much at the beginning of the meeting. Or at least we're going to have one of our presenters at the very beginning of the meeting. We'll see if everybody else is ready. And then I do have some information on our check-in survey. We're going to go over those responses just very briefly. And then I'm going to check in with the rest of you on the call just to make sure we're really understanding where you all are at and what you need to complete the project. We have three speakers for our panel discussion. And that focus is going to be on platforms, scheduling, workflows, all of the things that are kind of the nuts and bolts of setting up the telehealth practice and making it function properly. We are going to try to do some open Q&A and collaborative sharing. So if something that one of our presenters says prompts some thoughts that you have, feel free to unmute yourself during our open Q&A and ask questions or share on your behalf. I also want to spend a little time going over how to track your progress with your goals. We're going to look through a couple of different examples and talk through whatever resources you all feel like you might need to make sure you're tracking your goal completion properly. As I mentioned in the FYS forum post earlier today, we're going to do a little physical exam work as well. I have some breakouts that we'll go into towards the end of the call, but I also want to review that resource that I posted to FYS forum earlier today. And then we'll conclude with some next steps. I do have several polls during this presentation as well. So definitely engage when you can. Just as a reminder, this statement, we actually posted a similar version of this statement on our FYS forum following our last call. So I'm just going to read it out to you. The MSK telehealth practice collaborative is designed for member dialogue and exchange. The purpose is to allow all members to share their experiences, successes, and failures so that the full group can learn together in a respectful, collegial, and inclusive community. So like I said, this statement's also posted to FYS forum. It applies to discussions here and to that FYS forum community as well. So we're hoping for collegial sharing and being as inclusive as possible. So I have shared this slide since December. This is kind of our inching along on the timeline of the project. We're now in the middle of our second collaborative call. There are just two steps left. In April, you're going to receive an exit survey. And then data is going to be submitted to ABPM&R on a rolling basis. So I'll talk through this a little bit more later in the session. But we're not going to give a hard deadline on that. We do want to give you all time to complete your project as needed. So we'll go ahead and talk through that a little bit more. And if everyone can mute their lines for now, at least. Obviously we'll want to unmute later. So I think actually I'm going to break here just to make sure that we have time for our first speaker to get through his presentation since he has to leave a little early. And then I'll check in with the second two presenters just to see if they want to continue the discussion after him or if we want to break for a little bit and go back to some of this content. Dr. Bruzek, are you available? Great. So I'm going to stop sharing. And you just let me know when you want me to share that resource that you provided. Okay? Great. Thank you very much. So I've been involved in telemedicine for about three years now. There was an established company that I was interested in in Seattle and came on board with them. My goal initially was to determine whether telemedicine would be appropriate to try and keep people out of nursing homes, extended care facilities, provide them with help. The other reason was because geographically we're such a huge state, territorial, we're looking at servicing people who couldn't drive to the doctors. This past month was quite revealing as far as our project, because both paths to get to eastern Washington were closed for about two weeks, off and on, so we could see the value of telehealth when snow breaks up our paths and we can't travel from east to west as we should. I was asked to talk about what our successes have been. Successes have been very good, but that involved a lot of planning and a lot of rehearsal as far as seeing our patients, working with the staff, making sure that our computer systems were equitable to the task, and staying on time for office visits, because I think it's very important to be on time and allow the amount of time that the staff feels this particular patient may need. I've given you a folder with some articles, including an article on musculoskeletal examination by family physicians. I happen to be currently working as the regional dean for a medical school, and a few of our students, not all, do rotations through our telehealth office. Successes have been very good as far as dealing with patients who have difficulties with transportation. As far as challenges, there have been some challenges. For example, some patients we discovered didn't have the right equipment, so we worked with a little company out of Seattle and got them to use computers to provide to the patient. You may be able to do that in your own area. If not, we can maybe look at the possibility of giving your patients the computers they need. The problem we ran into, though, which we didn't get a big break on, is the cost of cable for them. So they still have to come with the cost. Luckily, we found a donor who was willing to pay for these patients who couldn't afford it. We've got about 120 patients who this particular individual underwrites for the cable every month. As far as scheduling, we don't really find that to be a problem with scheduling. I'm not sure if you all have participated in telemed yet. But I think as long as you stick to a very tight schedule, like I said, you rehearse with the patients. Let's put up that little outline that I gave you. Can you share the screen with the outline? There we go. This is something we borrowed from a medical student rotation course that the armed services put together. You can see the checkoff list that we use for our patients as well. This is not a thing that's quoted. This is freely given out to everyone, so you can certainly use this. But the biggest thing that we learned is that we have to rehearse. We have to rehearse how patients can access the computer, who's helping them out, et cetera. And even rehearse with the physicians. We find some great physicians that adapt. As far as the logistics are concerned, again, we run into problems with some logistics. But because of the fact that we work with certain companies, we've been able to solve that problem. Other problems. Reimbursement. I'm sure people have had some challenges with reimbursement. Many years ago, I learned that a lot of my problems could be solved if I knew the medical directors of each of our payers in the state of Washington. And then got to know the insurance commissioner. In fact, helped me get the insurance commissioner to go into the office. He's been there for a while. He's a former optometrist, so he had some knowledge of medical problems as against other insurances. I'm pretty sure he had no knowledge of medical practice or medical problems. So I would really encourage you to find out who your medical directors are of your various payers. Get to know them. It's easier now than when I learned how to do that. You have Zoom. You have other products that you can use. Get to know them. And then you get to know the medical person who is your insurance commissioner. That's a very powerful office if you're not aware of that. Bluetooth technology. We're currently working with just some oxygen monitors, et cetera. But there's ‑‑ I can't tell you what the new equipment is yet. We're working with two firms in Seattle. But they're going to open the door for a lot of other monitoring at home with the Bluetooth equipment that's coming out. Any questions for me at all? And I will go ahead and share the files that you shared with me on the FIS forum community so everyone can download those. Including this one. Thank you very much. Any questions for Dr. Brzezak now? He has to leave in 15 minutes. So before we move on, I just wanted to make sure we give everyone an opportunity to ask any questions if they have them. Thank you so much for sharing. So Dr. Martinez, I know we had talked about you presenting a little later. But are you comfortable presenting now? Yes. I can present now. Okay. So this is the slide that I have. And basically what we found is about 53 patients, percent of the patients that we saw that were still being seen in the office, about 45% were telemedicine. From those, about 64% were phone visits. And about 36% of the telemedicine total were video. And about 60% were phone, 40% video. 17% include from all the total of the patients that we actually saw in the clinic. And we were actually to drop significantly that no-show rate to about, from all the telemedicine appointments, about 4.8%, which will be about 2% of all the patients we saw. In disclaimer, I don't have the no-show rate of the patients that were seen in the office. But with that said, because they implemented the same routine for the outpatient patients seen in the office, the no-show rate of the patients that came to the office also improved. So overall, I'm just going to stop sharing if I can figure out how to do that. So overall, I think that it was a great opportunity of trying to improve the show rate and, of course, the productivity. I know that there's some states that, unfortunately, they're not getting paid for phone telemedicine. We are getting a nominal fee in Massachusetts. So we're not earning as much as we would with video visits or with face-to-face visits. So that definitely is an option. And if you had the same situation that I had, I think that just trying to find a patient and be able to coordinate with them and be sure they will be available for the time that they're scheduled will be very helpful and productive for your office. Any questions? So what did you do to improve the no-show rate? I guess I missed the key point of that. So I actually had, so what the staff were doing, they were just calling the patient and telling them, you have an appointment with Dr. Martinez at 8 and he will call you to your cell phone. And that was it. And they were just maybe leaving a message on their voicemail. What I encouraged them was for them to keep calling until they were able to talk to someone. If I can make a comment on that, one of the things that I'm dealing with in terms of my own dad is there are any number of people who don't accept unknown phone calls or else repeat and recurrent phone calls can even be blocked because of spammers and fraudulent activities. So I would suggest that that's something that might be counterproductive to have repeat recurrent calls so much as sending a letter or giving out something or a text or an email saying these are the numbers we'll be calling from. Please put these into your contacts list so that you know when we're calling you that we are doing so to accept a call from us so that we can help with reminders. What's your preferred way of being reminded for upcoming appointments? That way you get the patient to be giving permission for contact also to be participating in their ability to be motivated to remember and to participate more actively than in the care program starting from before the visit all the way through. That's definitely a good intervention. In our case in our institution the patient are calling and make their appointment so they will know that they will be getting a call. They're just not picking up the phone when we call them. So it's not we're not we're not getting spammed or we're not getting blocked by spam filters. So it depends on the institution of course and we are doing the intervention after we know that the patient will be expecting our call. Yeah not everyone is coming from a place like Bay State which is a well described organizational phone network. So especially in private practice you want to make sure that the patients understand and have agreed to contact because for HIPAA reasons as well we want to maintain confidentiality. We want to make sure it's safe and OK to leave messages for them on whatever the message services. So if it's even voicemail to make sure that it's safe and OK because not everyone wants to have a doctor's appointment message on even their home message. I agree 100 percent not only that but it is sometimes we do have people that put their phone number instead of their cell phone. And when you're traveling trying calling them they may not get the message. So then that's why also sometimes it's helpful to have a family member or someone else specifically for geriatric patient that may not understand that and know you very well. But again that's that's that's a little bit above and beyond my my project. Yeah. And the last thing to just suggest then is to keep track of how many contacts it takes because that can be significant also for your staff to know for staff resource allocations in terms of a larger scale. How much time and effort does it take one call versus seven and then being able to just generate a postcard for people who take more than five to say we have tried repeatedly to contact you. We're reminding you of your appointment and you know in the no show policy of your office. But that way at least show also that you have documented and demonstrated well-intentioned effort. And that often gets back to being able to show when you're able to bill for no show services because time one time or another there's going to be needing to cover for your resources or someone else on your team. And to show that the person didn't respond to even reminders is a sign of no show or else of not being participatory in their care. And one thing I'm glad that you mentioned that because one of the things that I observe as well is that from the total of the telemedicine visits that I had during that month. I only had two no shows and one of the patients was on a day they were unable to reach the patient and I don't know really what happened to the other patient because it was not documented. So we lost that data point. We know that the patient didn't show but we don't know if we reach him or not. But I know that at least 50% of the no shows were not found. So you know for sure that if you didn't find someone it's possible that you may not be able to contact them when you call. And depending on your infrastructure maybe you like to maybe overbook that slot thinking that maybe you may not be able to reach that patient. Again it depends a lot on your style of practice. But maybe a good backup to keep that in mind in case that you cannot reach someone to confirm the appointment. We contact the patient three times automatically through our computers. We do it by text and by email. We don't use the phone. One week before, three days before and the day of the appointment. We get three reminders. It's like a marketing program. Marketing tells you you have to contact your client three times before you make the sale. So we use that concept. Nice. Does anyone else have strategies for reducing no shows that they want to share with the group? It's obviously a great topic and one that increases practice costs significantly. Yeah I have one comment. This is Rich Ramos and I'm sorry using a computer that doesn't have a webcam. I personally would not and I'm not saying everyone needs to do what they want to do but I would not charge a no show visit for a missed telemedicine appointment. The technology is not where it needs to be like a telephone where if I call someone's phone number I'll either get an answering machine or that I called the wrong number etc. But the computers, the internet, the patients being able to use this, I just personally would not recommend or I would not charge a no show fee for not being able to reach someone. But my biggest comment to Dr. Martinez because I have found this similar thing is that if I would attempt to do a video and that's unsuccessful because my patient doesn't know how to use their smartphone or something doesn't work. What is amazing is I have 100% ability to just hang up or get them off the computer, their cell phone and just call on the phone and I can complete my visit. Now again as I discussed with my small group in the past I still primarily would only do telemedicine visits for established kind of chronic patients. I just am still, and I guess we're going to talk about this tonight, still not sure how reliable a physical exam is on the video. I know it can be done but it's just not the same thing. It's never going to be the same thing and I understand that as seeing patients in the office, touching them, seeing how they walk in etc. But I just wanted to say that I do have 100% conversion if I use the telephone. But just like Dr. Martinez said, Medicare does have telephone only visits which are charged, I mean I think we can get reimbursed like $10, $15. It's better than nothing. So what I do with my schedule is if I'm going to do a telemedicine with the video and it fails, I just make sure that all of my telemedicine visits that are scheduled, that if they were to be converted to a telephone visit only that I still get paid the video portion. But I'm not doing as many telemedicine visits as everyone in this group appears. I mean I'm doing like one a day if that, but that's just some of the observations I've had with my own clinic. That's great. Any other suggestions before we move on to the next topic? Okay, Dr. Quirrell, I'm sorry if I'm butchering your name. Are you comfortable presenting now? Yeah, I'm here. Let me see if I can. So this is, you know, I may not have given this kind of lecture before because, I don't know, this will be hopefully a three to five minute presentation on multidisciplinary care in a virtual world. So I don't know how many this applies to and basically this will be a quick overview. And I think Carolyn thought about doing a doodle poll to see how many people this applies to because if you don't have a multidisciplinary clinic, this can be a five minutes you're going to snooze on. So I'll show you what we've done here. I don't know if I can share my screen. and my little thing doesn't want to show me on there. Here you go. Do you have the, do you have permission or? I think I have it, my little, there you go, do you have this? Okay, so you're seeing this and I'm gonna do this and swap, which one are y'all seeing? Let's see this swap, y'all see the main screen here? So this is a virtual integrated practice unit at UT Health Austin. So I'm at UT Health Austin, Dell Medical School. And the idea in a quick summary, we have an integrated practice unit. And what that means is we have multiple specialists working together. So we have surgeons, non-surgeons, physical therapists, chiropractors, nutritionists, the whole need learners, all in one room, seeing the same patient while they stay in their room. So it's the idea of integrating care around the patient. And this is our actual place where we work. Then highlighted is the bullpen is where all of us crowd around. So the bullpen, all the providers that live there, there's a huddle room or a library where we have a pre-clinic review of patients for the day, look at their imaging, look at their previous records. And all around, we're surrounded by 10 patient rooms. And so this is what this kind of bullpen looks like. It can be more crowded than that. These are patient rooms. This is that huddle room where we discuss patients pre-clinic, another pre-clinic huddle. So what you know what happens with COVID, when that hit, all of us had to pivot quickly to telemedicine, but we had this multidisciplinary clinic that we tried to convert to telemedicine. And so what we did is we created a virtual bullpen. All the rooms were created virtually. So all of us are at home as you are. We all hook up to the internet and we all get moved in this virtual bullpen. We use the normal Zoom functions, the basic Zoom functions and use the breakout rooms and we've renamed them. So you can see out here, I'm in patient room one, the bullpen's there, there's patient room two, three, four, five, all the way till 10. And you just, as a provider with Zoom co-host functions, you can move yourself through all of your patient room like you want to, you can go to the bullpen freely. These patients are given only guest functions. Once they're placed in a room, they are essentially stuck in the room and can't leave. They can't communicate with other patients. So all the HIPAA is acknowledged and taken accounted for. This is how we all look in the huddle. In this bullpen, the curious thing is that we actually thought of some anthropologists who said having these virtual representations is very soothing to humans to have us all in the same room. Even though we're in our homes, we feel like we're in our clinic because we see the same patient room one through 10. And we go to patient room 10 for our virtual room. And we go back to the huddle room, we go back to the library. And so we kind of feel like we're there. So it was very, it's kind of some sort of odd virtual comfort. So what the patients would have looked like, they get, they make a phone call, they get an appointment, they get sent their PROs. On the day of the appointment, they hook up to their internet at home. And one by one, they put in a virtual queue. They cannot see one another. They're admitted one by one. The virtual rooms one through 10 are already there. The MAs come in, we're all sitting in the bullpen waiting. The MA comes in, rooms them individually. And the cool part is this, as a provider, we can all go in at the same time or independently. We can go out, bring somebody else back in, talk to say, hey, we go back to this bullpen, talk to the physical therapist and say, hey, I want you to go in and see this person. You can go in together and talk to the surgeon. They can go in and talk to them. And everybody can go back and forth. Physical therapists can go in by themselves. They can go back out and talk to you again. You can bring in a social worker if you have, you can bring in a nutritionist. And this can continue back and forth all day long, and it does. And so we continue to run our clinic in this kind of virtual world, exactly the way it was in the real world. And this is all again with basic Zoom functions. So that's it. So I do have a poll I wanted to see, and obviously we can have time for questions now as well, but we can set up a 30-minute, 45-minute webinar specifically on this topic and have time for practices that are sort of set up more along these lines to talk through how this would work for them. So I am gonna poll whether or not you'd be interested in that. And that can give us a sense of if there's a need to set something up. Can I ask a question while you're doing the polling? I think it's very, I don't have a multidisciplinary clinic, but what I like about what you were able to do was room the patient virtually, and then I come in when I'm able to. Interestingly, I've used several platforms. One of the first I used was DoxyME, and I know that they had a, and I even paid, I did the paid version, the upgraded one, not the free one. And in the beginning, I would call all these people, and again, no one ever, just like someone made a comment, it's a cell phone, how did they not answer it? But that's neither here nor there. But I had like several people, and I would just see the first one that responded. And then I would see that there was another patient in the waiting room, but one of the frustrations I had is evidently that patient would wait like one minute and then leave. And then I was back to sending them another message through DoxyME. So the question I have, number one, is the Zoom, I assume, is HIPAA compliant, but I also, again, like the ability to room a patient on the Zoom while I'm still seeing a live patient, and then I come out and do my Zoom. So can you make a comment on, is it HIPAA compliant, and how long will a patient, but your practice is different because it sounds like they could be there for hours, but how long would a patient be willing to sit in the Zoom room, and how does the staff or myself, I mean, I wouldn't make a patient wait an hour, but it may be 15 minutes, 15, 20 minutes. The key is this replicates your exact practice. So this isn't, this is, if you have one MA that works for you, they live in the main host room, the patient comes in, they just have to remember to put them in one at a time. Because when you come in, you say they're in the queue. So when, like this meeting today, it said the host will let you in. So you have to wait for the host to let you in. So you can have, if you have two patients at 10 o'clock, there's only one at a time, that MA greets them, hey, thanks for coming. They place them into a patient room. You're waiting in the bullpen, you can see them whenever you feel like. And they let in the next patient. It's your schedule, just in the virtual world. If you run 15 minutes late with real patients, you're gonna run 15 minutes late with these patients. You can pop in yourself and you have the MA pop in and say, hey, he's running late. Just like a real world practice. There's absolutely no difference. If you're in a practice, you have five patients in five rooms and you're late, what do you do with your patient when they're 20 minutes late? You can go in yourself and say, I'm running 20 minutes late. Or you can have your MA look at you and see. When you have the breakout room up, your MA, whoever else is in there, can see where you're at. Oh, he's in room three. He's been in room three for 20 minutes. I know that patient in room three is gonna be another 20 minutes. So he or she can go to the room and say, hey, he's running late. It's your practice in a virtual world, no changes. Dr. Cianca, you had your hand up for a second. Did you have a question? Just a comment. It actually is fascinating the way you're doing that group practice. It just seems kind of chaotic. I don't know how everybody keeps track of what they're doing if they're kind of involved with five or six patients all at once. Again, there's no more chaos than in your real world. You go out, the huddle room is the bullpen where we all live. You can see where everybody is. It's even better if someone's, if you left and went to the bathroom, they go, where did he go? Where's Cianca? And he's the master. Here we know exactly where you are. You're in room three with a patient or you're in the bullpen or you're in the library. We had this library, because if you're in the bullpen, it's like people tell me jokes sometimes, you can talk about patients. So if you have a patient which you want to talk to about to a specific provider, I'd say, let's go to room 10. Let's talk to her privately. But we kept this library where you can kind of be quiet, do your documentation, but I can still find you. If I need you, you're in the library, you're muted, your screen's black, you're doing your work, but I'd go in there and say, hey, PT, can you wake up? I need a physical therapist. Can you turn on and flip on the screen? Hey, what's up, what do you need? So it's no more, it's actually less chaotic than the real world, because we know where everybody is all the time. Now, we have dedicated telemedicine clinics. So it's in that morning and morning and afternoon, you know, the team is there. Hope we don't have like random person, we don't have a clinic, real world clinic, and then have a tele. We do have off, one-offs like that, but for the majority, we have clinic teams always in these blocks. So again, it is our real world, completely to the T in a virtual world, better in the sense that we know where everybody is at all times. Dr. Robinson- Is there anything you have to do to configure on the Zoom? So again, I mean, obviously look at me, you can only see my name because I'm on the wrong computer without a video. I'm no computer expert. So I can sign up for a Zoom account. How do I, I'm not gonna need five patient rooms. I may need two at the max. How does that, do you have to configure something or is that self-explanatory if I just practice with Zoom? That's why we're doing this separate thing. It probably takes 15 minutes, 20 minutes to show. You have to check some boxes, uncheck some other boxes. You can make two patient rooms, you can make 20 patient rooms, you can make whatever you want. But it's just a matter of going through, open this thing, check this box, check this box, uncheck this box. And when someone comes in, you make a provider co-host, you make patients not, you get a guest. So there's just things to do. I have a Word document of how we trained our staff to do it. It can be done and learned pretty easily, even if you're not very tech savvy. Dr. Robbins, I think you had your hand raised first. Yes, thanks. Nice presentation, Dr. Corald. The questions that I have, first off, for HIPAA reasons, thinking, especially if you have, if you're at your own desk, it's one thing, but even so just, it's great to be able to see all the people, but do you have a way to only show, are you going back and forth to doing only that one person at a time of you also, and the two of you, or are you keeping it all like, I think very much like Queen's Gambit of everyone playing the same chess boards and going around the room? Which is how, Dr. Scianco, I think about it, is it's just compartmentalizing. And as long as you're going from one to the next sequentially you're just thinking of it in a different way in your mind to go to the next room. So I don't see it any different. So I do have one other question just to ask up front. How do you do it with family conferences? Are you able to patch in more than one person at a time to the room? Well, we don't do family conferences commonly in this thing, but yes, of course you can bring more people in the room. However, it may be, as long as the patient agrees to it, of course, those HIPAA compliant things. With HIPAA compliant, it's UT and the University of Texas and with all the medical legal people going over this thing, it's compliant. There can be a disaster if the host accidentally closed the rooms and everybody was shunned to the main area. That would be a disaster. If someone pushed the wrong, if they do not push close all rooms, that would throw everybody in the main lobby. So that could be a disaster. Someone push that button, yes. Just like if someone went through your clinic and opened all the patient doors and threw all the patients, that could happen. But knock on wood, it has not happened. Dr. Dhalakia, did you? Yeah, Dr. Karol, great presentation. This is interesting. It's the first time I've ever heard anything like this. You know, I just wanna know, how long is a patient visit? And if you could give us like a little scenario on your, like give an example on how you treat, how you interact with the patient with this type of virtual setting. So like, let's just say, the MA puts that patient into a room. And then what happens after that? You mentioned you have a physical therapist, nutritionist, so on and so forth. How long is a visit? If I came in, how long is a new patient visit? How long is a follow-up visit? I mean, the challenges that I have with tele-visits, and I do outpatient physical medicine rehabilitation and pain management, and I do tele-visits with patients, physical medicine, rehabilitation, pain management, and mainly I'm utilizing tele-health for mainly status post injections and medication refill. And I think most of us are. So can you just give us a, you know, paint a picture for us on- Yeah, so- Typical picture. So this is gonna be, we're gonna go into, I guess this is the right, you know, platform for how we do an exam. So we did do a lot of new patient exams when we started, because there was no option that within March or in April of last year, there was just not an option. So we, I have a, we created these videos of myself, actually, going through and bending and going. So we did the full exam for me, and I would, I had a video pulled up where I could share a screen and say, this is where I've been, and go back and forth. So I had that exam. My rehab expert has her camera set up with her, you know, I have this behind me, and I don't feel like doing it in real time. But she has to, well, she'll get on the ground and do rehab, but she'll, let's watch me, and she will have a mat on the ground. So the key is before you do this, prepping as part of the things the patient gets sent, we want you to have either a camera, I mean, if you have a laptop, make sure that the screen goes to the ground. We want to see this backdrop. We want to see your whole body. So we send this to them, and again, about 50 to 70% of people actually do it and have the laptop and are ready to go. We have some people who are just not tech savvy, and we'll say, if we don't feel, it's the chronic pain. If we can feel comfortable, if not, we have to, now we have the privilege of, I mean, the opportunity to bring them to the office, because we're at a different stage. But I think this, I'm not sure this is the setting to say how we do it, but so we do do a physical exam. For the low back, I do single-legged squats. We do walk on heels, walk on, you know, do toe raises. So we know that L2, 3, 4, one is covered or not. Upper extremity, I find a little more struggle, because you just do it against gravity, so that's a much more difficult thing. So in the exam, what would happen in real life is I would say, okay, if they need rehab as part of this, and my rehab person's for you, I will say, hold on one second. I go out to the bullpen. I talk to my physical therapist. I say, hey, this person's dumped in. They have two weeks of acute back pain. It sounds discogenic or extension bias. And they go in there and they will do that part of it. They'll do the rehab section of it. And if they need to come back out and tell me, I can go back in or come in together and we'll say, hey, I'm free. Two of us will be in the room with them and they'll say, this is what I found. For behavioral health, so we use a social worker's behavioral health for cognitive behavioral therapy, and that's actually gone really well on telehealth, telemedicine, and actually they have been at home this entire year until this week or two weeks ago is the first time they're back. So they've been doing all telemedicine with their, we do cognitive behavioral therapy for chronic pain, the manual. And it's been, they say it's been very successful. I mean, it seems the patients that engage have done really well. So that would happen. They would do the same thing. We'd leave. It's sometimes, it's more difficult to bring them in in real time, in real life. We'd get there, we'd grab them and do something called a meet and greet where they just introduce themselves. That has not always worked as easily with telemedicine because they're seeing other clients and it gets, that's been more of a challenge. Well, you know, just a couple of questions. How long is a new patient visit for you with this type of setup? And how long is a follow-up visit with this type of setup for a typical, let's just say complaint of neck pain or low back pain? Again, I want to make sure I respect everybody else because we're going into the UT Dell IPU. So this is a academic center. Yeah. Remember that. Okay. The academic center has worked on something called value-based medicines. They're trying to prove outcomes. And so there's a high cost up front with expected to be better outcomes at the end. And so we end up, the value is cooped up over a one year as opposed to this first visit. So the first visit can be longer. So we typically have, and with two patients, we're running simultaneously an hour each one for new patients, but there's two in one hour. And then the follow-ups are 30 minutes, essentially. But there's not many follow-ups. A lot of that's put in that first hour and the follow-ups are essentially trying to be, or it's trying to prove the value, which is a totally different mindset than the current fee-for-service. Now, how's the patient experience? Do people, the patients get fatigued from, this is great, this is a great setup, but like, do patients get fatigued from this or what's your, you know, have you had a setup? You know, again, so we're, I don't wanna, I feel like I'm dominating this thing on IP, so, but the, what I'm seeing is that patients have a preference as it opened up, as the world's opened up and patients have the same option to see in office versus telemedicine, the large majority are choosing to go in office. So most telemedicine over the year has changed to follow-ups. Tomorrow we have one with two or three new patients, which is unusual in the morning. So that's the trend I'm seeing, even though patients are offered both. New patients tend to wanna be, I don't know, my theory is that they wanna be touched, they wanna, they don't feel like they're fully examined without being in the office. That's my take because that's the only way I can explain them having both options, the in-person being full and the telemedicine being hit and miss. Great. So based on group feedback, I think a separate call on this topic definitely is something the group is interested in. So we're gonna go ahead and base that call time just on Dr. Kuralt's availability and we'll get an invitation out to the full group. I'm assuming we'll try to aim for something in late March or early April. So more to come on that. Thank you to all three of our presenters. This was a great discussion. I'm gonna move on to sharing. All right. So I know we went a little bit out of order. So I just wanted to remind everyone of where we were. We were just doing a little overview of our program. So we did get a couple of questions on our check-in survey that was sent out in February, just about sort of some of the logistics of the program. So I wanted to give you some more details on that in this slide deck. If you are participating for MOC credit, some people are not, but certainly that was one of the main impetuses of this program. So we wanna make sure that everyone is doing what they need to do to make sure that they can earn that credit. We are gonna launch an exit survey starting in early April. The deliverables for this project are gonna be that baseline survey that you completed towards the end of last year. The project selection survey that was completed in January, and then the exit survey that you'll complete in April or later. Those pieces of information we're gonna be submitting to ABPMR to document that you've completed the improvement project. So just to clarify, those are the only deliverables. We're not looking for you to submit anything else to us. It is important that all three of those surveys are completed to earn credit. So if you have any suspicion that you might not have completed one of the first two surveys, please let me know. I also have PDF versions of your completed information for those surveys, and I'm happy to send those to you. So email me for a survey link if you need it, or email me for a survey PDF if you need it. As I mentioned earlier in this meeting, we have not established a formal deadline for the exit survey. We know that some of you may need a little additional time to complete and meet your goals. So we're not trying to rush you to complete the project, but we do wanna make the survey available ASAP for those of you who have completed your goals and wanna move forward with getting your credit. So we'll try to submit data to ABPMR on a rolling basis so that as people are submitting their survey, we're making sure that ABPMR knows they've completed the project. So I wanted to direct your attention to a few different resources that we have on FYS forum to help you meet your project goals. The first resource is really a healthy-sized playbook that the AMA put together. I believe it was published earlier last year. I wanna say that it's published since COVID, and it's a couple hundred pages of really great information about how to launch a program. So several of you did indicate that your project goal was to actually create a telemedicine program. If you don't already have a program, this playbook is a great resource for you. If you already do have a program, it's got a lot of appendices that may be applicable to some of the work that you're doing in your current program. We also posted some reimbursement resources, including our toolkit, which is on our Academy website, and then the ATA webinars, which include also some webinars on how to set up a telehealth practice. We have a post about telehealth waivers. So these are waivers that were issued by the Department of Health and Human Services during the pandemic. So if you have any questions about what's okay to do now that sort of isn't typical, but is okay because of COVID, all of those waivers are outlined in that post. We also have a state telehealth laws post from last week. And then today I posted an article, as well as a link to a presentation by a group of PM&R physicians published in the PM&R Journal, which is a great resource. The presentation is from, I believe it was May of 2020 from the different providers talking about setting up a telehealth exam. And it's an excellent presentation. I attended that in May and would highly recommend that you download it, that you view it. It's available in our online learning platform for free if you're a member. And the link is in that FIS forum post. So we've only had a couple of members participate via FIS forum so far. I'd really encourage you to at least take a look at these resources. And also you can join the conversation by asking questions or you can share resources of your own. So the resources that Dr. Bruzak presented earlier today and referred to in his presentation, I'll be posting those tomorrow so that you have access to those as well. All right. So I wanted to do a little check-in reminder about the check-in survey. So this data is, we got data from 24 participants. And this question which was asked, I think the last survey respondents we got were earlier this week. I wanna say potentially Friday was the last time we got some contributions. So we do have one person who's completed the project. Most people are sort of hovering in the middle, but people are definitely at various stages of completion on this. And then we also asked how confident people are that they will be able to meet at least one of their goals in the next one to three months. So thankfully, most of the respondents said that they're very confident. I did actually wanna check in with all of the attendees on this call. So I know some of you may have completed the survey, but if you didn't, or even if you did, I'd love to hear today if you're feeling confident about your ability to complete the survey. Or not complete the survey, complete the project. Sorry. Okay, I'll go ahead and stop there. So we did have most people still in the same categories of feeling very confident or somewhat confident. We do have someone who indicated unsure. If you're comfortable and want to unmute yourself and share any hesitations or anyone who's maybe in the somewhat confident category, what could help you become more confident in your ability? Okay, no need to share. I have a couple, another slide with another poll. We did have a few people identify some barriers to completion. There were a few themes. Time was one of them, so I'm really hoping that the assurance that you don't need to complete by April 1st is helpful in terms of time. Some people indicated time, and I think they really meant having the time in their schedules to actually dedicate to focusing on the project. So I absolutely understand that that may be a barrier as well. We also had a number of people who had exam goals note that they had limited patience with the specific condition that they had identified. So for example, people who identified a shoulder exam as being something they wanted to improve on not having patients with shoulder issues. So obviously, that potentially could be something that given a little bit more time, you'd be able to complete the project. Decreased utilization of telehealth was a major theme among the survey completers, and I think obviously as things become more open, there is the chance that some people may phase out telehealth in their practices. So I am curious if anyone wants to share on that topic. And then technology issues were also a big problem with just people not being able to connect properly to platforms or technology limitations on the part of the provider. I noticed, Dr. Cianca, do you want to unmute? Did you have something to share? Well, regarding decreased utilization, the first pillar of my project was polling patients to see what their interest was, and the way I posed the question is if you had your choice between telehealth or in-person visit, which would you prefer? And not one person yet has said telehealth. Wow. And I can understand that, of course, and perhaps it was the way I worded the question. In my mind, the only way I'm really going to utilize this is if somebody requests it because it's not an advantage over an in-person visit for almost all things that I do, with the exception of maybe follow-ups for medication or something that Dr. Ramos had referred to earlier. So I'm not all that surprised, but it is going to make the project a little bit more challenging to complete. Absolutely. I think that that's likely a similar scenario for a few people, at least. I'm wondering if anyone else from the participants on the call tonight has had thoughts about telehealth long-term, a year from now or even six months from now, depending on expansion of vaccinations. Hi. Hi. This is Kiran Vedada. I'm calling in from Hawaii. I'm actually settled over here in Honolulu. Thank you, everybody, for everything you've contributed. It's been very interesting. I just wanted to mention, for me, with telehealth and some of the things that it's brought into the practice, especially here where we treat Outer Island patients who often have to take short flights over, which becomes sometimes a burden to the insurance carriers because they do pay for the flights over because of a lack of access. So it's really opened up our ability to access these patients and provide them with ongoing support about conditions, education, and they love these visits. It's been a little bit overwhelming in terms of patients who have said, where has this been? They've been really kind of missing this kind of option with physicians. So it's interesting to hear that because there's definitely the ones who always want the hands-on and a lot of people, I think you can never really replace the value of seeing somebody in person, even just to watch their cadence and demeanor. But for locations that have issues of access, it's become a true game changer. And so for us, we hope that this continues to be something that is covered. And we've already seen some insurances starting to kind of backpedal a little bit in terms of reimbursement. But as an institution, I work part of a hospital, I mean, I'm a hospital employee and outpatient private practitioner, basically. And so we are receiving a lot of positive support from administration in terms of figuring out a model that will allow us to continue offering this to our patients. And so for me, the message has been pretty much across the board, patients who felt like this is something that we should have been doing a long time ago, and they're thrilled that it's here now. So it's kind of just to show the other side of it, I thought I'd chime in there. Karen, I can see where that would be the absolute ideal scenario. You should be able to use this going forward. Why should you have to take a flight to see your doctor? You know, I've been to Hawaii a number of times, and I can imagine that, you know, people from every island might be going to Honolulu for the majority of their care. So I would think this would be ideal for you or anybody else that has that kind of catchment area. Absolutely. Another thing I just want to point out, in my practice, I do a lot of musculoskeletal ultrasound and a fair amount of fluoroscopy as well. And so with the MSK ultrasound stuff, you know, there's a lot of times where the new patient kind of wants the procedure on the same day, and you can't always anticipate for that. And usually we try to get that done. You know, that's how it always is. When you have a telehealth appointment ahead of time, where even though the consult might be for a specific procedure, when you get all the education out of the way, and you get into depth about the consent form that they sign and the details of the corticosteroids and all the kind of like the pros and cons and talking about COVID and potential immunosuppression, it's really hard to jam-pack all of that in an in-person visit and then have them decide on an injection and then perform it on that same day. So I'm finding that it's been a true game-changer in that sense as well, because when they come and see me for an injection that I've already set up after having a telehealth visit, during that visit, the wrap-up of the message is also that like, you know, any questions come up, let's talk about it now, because the visit's going to be quick. And they tend to kind of be primed to respect the fact that I'm squeezing them into my schedule, and they know that they're there for the injection. And that's kind of, it's kind of taken away one of my frustrations from the past, because in the past, you just squeeze somebody in for what's supposed to be a quick thing, and then it ends up being a by-the-way, my left foot also, you know, it just, those kind of personalities I've found that this has allowed me to kind of optimize my practice in terms of the time I have in-person. So yeah, truly, for me, it's been nothing but positive, actually, despite all the inability to communicate with patients sometimes, and calls being dropped, and video issues, truly, truly been positive. Thanks so much for sharing that, that's a great perspective. I wanted to share another poll, just to check if you're feeling like the barriers that you're encountering with completing the project are similar to what's on the screen here. Great. So we did have a couple of people who had some different barriers they were encountering. And I guess I'm really interested in knowing what barriers you're facing. But also, if there are things specifically that the Academy can do to help you cross those barriers, we obviously want everyone to succeed with this project. And if there are individual things that you want to reach out to me about, obviously please do. And we can certainly see if there are resources we can provide. Additionally, obviously the FIS forum is something that I'd encourage you to take a look at. And if there are questions that you're encountering that potentially your colleagues could help with, that's a great way to sort of start some discussions. All right. So this was when we were going to do the panel discussion, so we're going to move past that. I wanted to take some time to talk through tracking your goals. We did have a couple of people who reached out just with questions about how to make sure they were tracking, that they were meeting their goals. You know, did they have to do some chart review, for example? Questions like that. So as I mentioned, I do have copies of all your goal surveys. So if you need a copy to remind yourself of what it is you sort of agreed to work on for this project, please let me know. I can send you those. Whatever you decide to do in terms of tracking, any mechanism you use, that's really just for your personal use. Just as a reminder, you don't need to submit any chart review or any spreadsheet, anything like that, as a part of this project, but it is something where that could be very helpful to you as you hit that exit survey. Chart review may not necessarily be a required element of this project. It really just depends on what goal you set. So it may be appropriate for your project. And I'll show you a couple of examples of that. And then the other thing is if you have not been tracking your progress, you may need to go back and do some evaluation since January just to see how your progress has been. So I pulled three different examples of goals for us to talk through today. I do have a little survey at the end just to check in with you about additional potential resources. So this goal was from one of our attendees who wanted to increase the number of televisits they were conducting. They identified their current level as being five visits per week, and they wanted to move that up to a desired level of 10 visits per week. They identified a couple of different steps to meet those goals, really specifically discussing with the front desk and established patients. So what I've built here is a very generic template pulling a couple of weeks from January into February to track how many visits were done by telehealth, how many times you proposed telehealth to established patients, and then whether or not you discussed identifying telehealth patients with staff. So obviously I filled this in with some mock data, but the idea would be that you would potentially do some chart review if this is weeks past just to see how you could answer these questions. Another sample goal here was to improve communication skills during the telehealth visit. The metric that this person identified was personal rating of success. They felt that they were at a current level of three out of five, and they wanted to bump that up to five. So they identified three goals to meet, document communication, or three steps to meeting the goals. Document your communication level for in-person visits, identify areas of improvement with telehealth visits, and then reassess each month regarding my progress in implementing changes. So this one was a little bit more complex, though not a ton more complex, but it's a little bit more complex just because they've identified a couple of different steps that they really want to achieve. So what I built was a small chart for tracking. I selected two charts per month. I think in reality this person's going to want to check a few more just because that it's just not enough per month to really make sure that the growth is happening. I built in a little space here for notes about areas of improvement. And then I did a monthly assessment rating that is an average of those per-chart ratings. Okay? And then I just have one more of these to review, and then we can kind of talk through them. This is the last goal I selected, improve ability to perform effective exam of the lumbar hip region. The metric for this person, it was a completely different person, but they chose personal success rating. The current level of success is three, and the desired level is five, similar to the last person. So the goal here was the steps identified here was integrate use of family member into exam, and then consult with PT and colleagues to identify measures they're taking to improve their exam. So similarly, I built a chart based on chart review here. So personal success rating, whether or not the family member was integrated, and then I assumed that this person would do a consultation with their colleague or PT maybe once a month, and then made some notes here. So these are entirely templates, and I would be very happy to, These are entirely templates, and I would be very happy to talk with any of you who want to talk about how to potentially track your goals. I can share these via this forum if that would be at all helpful to you. But the idea here is really that simplicity is okay, and really it's encouraged. The bottom line is, are you working towards your goal and taking the steps you need to take to meet it, and then documenting appropriately that you are meeting it? So I do have a poll associated with this. So the question is, based on the information just shared, do you feel confident that you can create a tracker for your own project? Yes, no, unsure, or you already have something in place? All right, we're just going to collect a couple more votes. All right. So it looks like most people are feeling pretty confident in this, but we do have a couple of people who are unsure and one who does not feel confident at all. So a couple of options. Obviously, if you're comfortable and want to discuss in this setting, we can start discussing that now. Alternatively, you have my email address and I'd be very happy to work with you individually on setting something up. As I said, I've got all of your goals saved in my files. So does anyone want to discuss this now as maybe more of a personal individual thing? All right, so just a reminder, this information will be free to collect. I would recommend just holding onto it in case we need any additional documentation. I'll go over this a little bit more just in the next steps at the very end of the presentation, but just as a reminder, this is a pilot program, so we're working with ABPMR. We've been in communication with ABPMR since the inception of this program, but all of the review and approval and actual doling out of MOC for credit is on the side of ABPMR, so everything's gonna be subject to their review, and obviously, we can't absolutely guarantee that they'll approve everything, but that is the intention and how we set up the program. All right, so I'm gonna move pretty quickly through a couple more slides because I do wanna give us some time to do breakouts. We wanted to focus again on physical exams just briefly during this presentation because we know it's a big part of a lot of the goals of the collaborative participants. We wanna make sure you have the resources to do that. This was the article. I know I sent it out on FIS Forum pretty late today, so I just wanted to make sure everyone was aware of it. This is the article that I was referencing earlier in the presentation, how to conduct an outpatient telemedicine rehabilitation or prehabilitation visit. Like I said, there is a really excellent hour-long webinar associated with this paper and featuring several of the key authors on this paper, so again, highly recommend you listen to that. The article was released quite early in the pandemic and it reflects the fast-paced turnover into telehealth visits. This article was accepted, I believe it was even in April, so this really was a quick-moving group. It emphasizes tips for how to make the visit feel similar to in-person while also leveraging the additional benefits of telehealth technology, so I think it's a really nice balance of trying to make the patient feel like they're in person in some ways while still using the technology in an innovative way. It also features two extremely detailed tables about performing and documenting physical exams, so I think that does still feel like a bit of a barrier for some of the participants, so I really recommend taking a look. This is a part of one of the tables. This is the second table, and it shows lists of potential exams that can be conducted without assistance and then performed with assistance from a non-clinician, so you can see sort of the expanded ability to conduct exams if you are using a family member or caregiver, so obviously not going to review this in detail, but wanted to make sure you understood that this is what was in that paper. Okay, so we are going to break out into some groups of three or four. The idea for this breakout, and we're going to give you probably 15 or 20 minutes in the breakout sessions, we're not going to do a formal report back like we have in the past, but we are going to open up for discussion about any challenges or successes from your experience. We'd love for you to do sort of a mock exam, so if you have three people in your group or four people in your group, it's going to depend. You can do a couple of exams depending on how long they are, and we'd love for you to sort of focus on the exams that are part of your goals or exams that you're having current challenges with if exam isn't one of your goals, and I know in our January call, we talked about a variety of workarounds, a variety of ways to set up cameras, et cetera, so definitely think about that, but really the goal here is just to give you some more experience. That was one of the things we took away from the check-in survey. People are just looking for more opportunities to try some of this stuff out, so I'm going to stop sharing my screen. Our team is going to start splitting you into rooms pretty soon, and like I said, we'll have about 20 minutes to do this breakout, okay, and I'm just going to walk you through some reminders about next steps, so if you haven't already, please do set up a system to track your progress with your goals. Please be sure to save whatever tracking mechanism you build, at least until we know that you've received credit. It's just a good thing to have on your files just to make sure that you've documented your completion of the project, and like I said, I am very happy to help guide anyone who needs some help with building a tracking tool, so reach out to me directly. The exit survey will be distributed in April. Complete it when you're ready, so when you feel like you've completed your project, please do complete it. If we start to feel like we need to set a deadline, we will do so, and we will give you ample time to make sure you can finish, but for now, we don't have a formal deadline. Just to give you a sense of what that exit survey is going to look like, it's going to be pretty similar to your baseline survey that you did at the end of last year. We asked a lot of detailed questions about your comfort level with different types of encounters. The only addition for this survey is really going to be that we are going to have some questions specific to your goals. Our idea is that we're going to try to have some of that data pre-populated for you so that it will sort of ask you, you know, here's your goal. Did you complete it? That's the ideal. We hope we can set that up for you, but as I mentioned, I do have a record of your submission, so we'll make sure you have access to what you said you were going to be working on. Again, just a stress that we do want you to engage via FYS forum, especially since this is our last collaborative call. That's really your avenue to collaborate with each other. We don't have an end date on that FYS forum group. We might keep it going for several months after that exit survey launches, just so you guys can connect. And the last thing is I did want to put out a poll just to see if you all would find it helpful to have a meeting. And actually, Jose, can you make me co-host? There we go. Okay. So just let us know if you feel like an April check-in would be helpful. We would not have a two-hour meeting. It would probably be more like an hour. It would be a time for you to ask questions as opposed to me presenting information or us having formal presenters. It would really be just a touch point. So again, this wouldn't be required. Okay. So most of you did not really feel like that was necessary. We'll sort of see where we're at and we might make just an informal call available. Again, absolutely not mandatory and there wouldn't be any formal information sharing. It would just be a connect. So you would not have to feel obligated to attend if you don't feel like it would be helpful for you. So that's the extent of the information that I have prepared for today. Does anyone have any questions before we close? All right. Well, thank you all. Thank you so much to our presenters today. Thanks for taking the time in the breakout groups and feel free to email me if you need anything. Okay. Thank you guys so much. Have a great night.

virtual integrated practice unit

virtual clinic

Zoom

HIPAA regulations

integrated care

telemedicine exams

new patient exams

in-person visits

behavioral health appointments

cognitive behavioral therapy

patient visits

follow-up appointments