Good morning, everyone. So today, for our first talk, we are going to be discussing some changes in healthcare and navigation of those changes. We will present some framework and some kind of pearls that we've learned from a telehealth initiative we've been using to collaborate with outpatient musculoskeletal care using telemedicine. So through the course of the talk, we'll have a brief introduction with some polling, and then we will let Dr. Samuel Concepcion set the stage for kind of the current healthcare environment we've been working in. Then I'm going to spend some time talking about the development and implementation of a framework, and then lastly, we'll have some clinical pearls from Dr. Melita Moore, concluding with a question and answer period afterward. So please do feel free to throw in any questions or comments in the chat that we will hopefully be able to get to there later on in the talk. So to start, I wanted to kind of get a sense of the landscape across the country, first prior to COVID, and then perhaps some related questions during and after COVID. But prior to COVID, recent changes to your local healthcare market, such as changing referral patterns, technology, direct access, affected your practice patterns and volume. Not at all, minimally, moderately, significantly, or you're not quite sure what was affecting changes over the recent past. So I'm going to give everyone a moment here to go ahead and respond to the poll here. So we found, and we'll elaborate upon this quite a bit in the near future here, but there were several different factors kind of changing the underlying environment, and some of those, of course, have been evolving over some time. But some were more recent, and so we'll talk a little bit about that. Give it just another minute or two. And so it seems to be a pretty even spread here. So as you can see, there's kind of a wide variety here of responses here. Not so much significant, but moderate to minimal, and I'd say that kind of reflects our experience here. So another poll question here for you. Prior to the COVID pandemic, how often did you use telemedicine for direct patient care? So never, occasionally, regularly, as in less than 20% of practice volume, often comprising more than 20% were several times a day. And of course, keep in mind, this is prior to the COVID pandemic, as I think we all can recognize. It's taken on a much more significant role in clinical practice over recent months. And as you might guess, we'll talk a little bit about this as well. So as you can see, this was the case for us, very, very occasional use, if any at all, as seen, and certainly nothing to the extent that's being used in many practices today. So during the COVID pandemic, how often did you use telemedicine for direct patient care? Now, I assume that this number is going to be a little bit different. Again, the same possible responses here. And I see as more responses come in, the greater you see several times daily. But there is a pretty even distribution here. So you can take a look here, you know, pretty evenly distributed with perhaps a little bit more weighted, you know, towards the often to several times daily. And I think that would reflect our current practice in our network as well. Last, prior to or during the pandemic, how often have you used telemedicine to coordinate patient care with other professionals, such as therapists, social work, advanced practice providers? So a little bit different question here. And you can really respond to this in reference to prior or during. Thank you for watching! And so I just saw Dr. Quarterbine had responded. You guys aren't seeing these, so I apologize for that. I had the impression you were able to see these numbers. So as these polling numbers come in, I'm seeing that just about 2 3rds of people never use telemedicine for coordination of care. So that other 3rd, kind of an even spread of those few options. So this is what we're really going to be discussing. Of course, all of us, I think, can acknowledge that telemedicine has taken on an increasingly important role in medical care in this day and age. But this will be the, this last context is what we're really going to be discussing today. How can we leverage tools such as telemedicine and networks to better coordinate care across the care team? So briefly, our objectives here, we're going to discuss some technological changes in market forces disrupting the role of outpatient musculoskeletal physiatrists. And then we're going to kind of facilitate collaborative care with the rehabilitation team, discuss some ways to use new technology or new systemic approaches to do that, to develop strategies to reposition musculoskeletal physiatrists as the leader of the outpatient rehabilitation team. So to reposition ourselves in the healthcare system as a whole. And then ideally to evaluate clinical characteristics, which might indicate a high likelihood of success during rehabilitation. So those are some of the things we're going to try to elaborate on here today. So I'm going to hand you over to my colleague, Dr. Semmel, to discuss our current healthcare environment. Great. Thanks, Matt. Let me see if I can get myself a little more aligned to the screen. Sorry. Wanted to set the stage for everybody just to understand a little bit of our health system. So I'm the vice president of medical affairs at MedStar National Rehab Network. The National Rehab Network spans the mid-Atlantic region. We have two inpatient rehab facilities, one in DC National Rehab Hospital and another Good Samaritan Hospital up in Baltimore, as well as 51 outpatient therapy sites and 38 physicians, which we have spread between those two campuses and nine of our regional offices. Most of them are co-located with our therapy practices. Market forces that Matt was mentioning, we have direct access to PT. As you can see, the teal-colored states are the ones that have direct access to PT without a referral or a prescription in our region. There's a high density of physical therapy practices in the region as well. And many, I think most medical directors have learned that many of the smaller PT groups do things like waiving co-pays to attract patients, which no healthcare system is going to do that for regulatory concerns. So that leads to a significant leakage of PT referrals out of our network and our urgent care location. So we have 11 hospitals in our network, including the rehab hospitals. So we are a relatively large network. The things to know are Medicare allows direct access, but once the therapist determines therapy is medically necessary, then they require a signed plan of care by a physician or APP within 30 days of the very first therapy visit. So that leads to this time crunch that the therapists very often aren't able to, the PCPs don't answer, or the patient doesn't have a primary care physician, which leads to a challenge in getting patients in a timely fashion to therapy and then taken care of. Our urgent care physicians at all of our sites across the healthcare system don't really want to see patients in follow-up after they see them in urgent care. So what that leads to is they refer to one of a variety of physicians, and then hopefully the patients make their way to one of our therapy sites, but very often don't. Very often they're given a prescription, then they can take that where they want. So the head of our therapy network came to me about two years ago and said, will you consider providing a physiatrist to support Therapy Network's direct access initiative? They wanted to give a pretty steady message to all of our urgent care sites saying, look, if it's a musculoskeletal thing, send it to us, we'll manage it. And if we need to get them to a physician, we can take that on. But what they asked in this was if our physician could oversee just the Medicare patients and sign the plan of care for those patients so that they could build a same-day referral from all of our urgent care sites to the therapy sites. And our options in doing that were one, no, we don't want to do that. And that was my gut reaction was, no, I don't think we want our physicians just to sign Medicare plans of care. Now this is before telehealth in our current era. This was two years ago. So I'm not sure that we can evaluate everything on telehealth, and I don't want to put our physicians in a role of just seeing the Medicare patients. So that was my initial reaction. And then I thought, well, in my role, we have 51 therapy sites that are having tremendous market pressure to reduce leakage out of our system. I thought, well, maybe there's other options. The other answer would be, yes. Yes, we'll just see your Medicare patients. And I thought for our physicians, that's a really non-starter. We have a big sports medicine component to our practice, big, a lot of specialists within obviously musculoskeletal care. And then the question was, is there more of a partnership that we could build? And that's where our discussion started. And that's when I called Matt one evening over dinner and said, I can see a model here where we could change the role of physiatry across certainly our region. If physicians, rather than sort of fighting direct access, if we partnered with therapy, could we then do a better job managing non-surgical musculoskeletal care? On the patient side, this would provide the access to a physician. Therapy is underwriting this. So that was our deal. This was prior to telehealth being reimbursed. So the head of our therapy network said, look, I'll pay for this. I think there's enough business that's gonna come into the therapy practice that I'll underwrite this position for the first year. And then we'll see if it builds on both sides of it. So what would the patient get? The patient would get a free physician visit basically, because it wasn't reimbursed at that time. The therapist would have the added backup of a physician if they had questions. And for us, it would get us closer to the front lines of musculoskeletal care, which very often I think in urgent care is sent to ortho and to neurology or neurosurgery. And I think we might not come in as high on the list when they're thinking about who to refer to. So I thought it could be a win-win for everyone involved. And that's how these discussions started. And so I'll turn it back over to Matt to take us down the next steps. So, you know, taking it from that point, right? We had to start to think, well, how do we develop a system and the appropriate tools to enact this type of plan and theoretically reposition ourselves at the forefront of outpatient musculoskeletal care? And so, you know, when you think about that, the word that kept coming to mind was innovative. We need to be innovative. And so I think to kind of frame this discussion today, I thought it'd be helpful to think about, well, what does that mean? You know, what is innovation? And I looked at a lot of different definitions, many of which were useless, at least in this context. But I came across this one that I thought was, I think, very relevant to our discussion today. In particular, this last part, improving efficiency, effectiveness, or competitive advantage. And when you think about it, that's really, these three things are really what we hope to achieve. So when you think about being innovative in that context, then, you know, to kind of break it down into nuts and bolts, you know, what were our kind of primary aims? Well, we wanted to, of course, improve patient satisfaction and therefore engagement, hopefully keeping them within our system and improving patient retention within the system, but ideally in our practice. As Dr. Semmel pointed out, you know, there's a tremendous pressure to improve access to care because there's a lot of competition in the area in that regard. So the closer we could be to the patients, the faster we could be there, the better. And then hopefully, we were hoping, you know, we wanted to improve the quality of care that we were able to provide, perhaps by, you know, being able to do some real-time, in-person consultation using the interdisciplinary team. And potentially do so while lowering healthcare costs. And of course, these are lofty goals. But along with those, you know, of course, there are some potential dangers that we consider pretty early on as well. You know, this is an initiative and a framework that really kind of removed us from the patient, which can be unnerving. And of course, for clinicians, there was a lot of hesitancy. And most of that, you know, kind of stems from, you know, the fear of, you know, missing an important diagnosis, you know, causing inadvertent harm, which of course I think is the last thing any of us want to do. But on top of that, you know, also, you know, almost providing a false sense of security to patients, thinking that, hey, I don't need to go see a doctor. You know, even though they might be successfully treated with, you know, four or six weeks of physical therapy in this instance, there may be some important underlying kind of chronic things that need to be addressed. So that's another kind of potential danger. And of course, you know, paradoxically wasting time and money for everyone involved. So in that context, you know, I thought back to, you know, one of my earliest patients in my own practice, and I wanted to share a story because I think it really elucidates this point quite well. And this was a sports injury, the sport being cornhole. And this quote unquote athlete, he was a little bit older, a middle-aged athlete, but nonetheless pretty active. And he presented to me after acute onset of shoulder weakness during a cornhole game. And so, you know, he thought it was a rotator cuff tear. The fellow who's working with me at the time evaluated him, concurred. He thought it was a rotator cuff tear, thought physical therapy would be an appropriate next step of treatment because he did have some weakness, but was maintaining some function and pain wasn't debilitating at that point. Lo and behold, it was a little bit more complex than that, as you might guess. Just so happened that he said, maybe therapy is appropriate, but let's get an MRI of his C-spine because there's something just doesn't seem right. And the patient ended up having a very significant infectious process with epidural abscess, osteomyelitis, was admitted to the hospital the next day as soon as the MRI was complete and underwent urgent surgical intervention among many other things, of course. So it just kind of goes to show you that seemingly innocuous diagnosis could be something very, very devastating and potentially deadly. So we had to kind of figure out, you know, how do we sort these different patients out remotely? I mean, it's a challenging endeavor. So moving forward, as we started to kind of design this process and the appropriate tools, we thought about what the resources that we had at our disposal. Of course, we have a very large integrated electronic medical record that would allow for you to access clinical notes, imaging studies, laboratory tests, all that stuff that may have been obtained at another site remotely from you. So we had that. We had the very large therapy network that Jenny alluded to earlier, which I'll elaborate on a little bit more. And then we had a nascent telemedicine program within our network so that it had been used a bit for primary care in rural areas. It was also being used increasingly for emergency physicians to kind of remotely touch base with multiple different patients very quickly. So we had that resource at our disposal and we're hoping to leverage it to our advantage. So Jenny touched on this, I won't elaborate too long, but as you can see, there's a large geographic area spanning well north of Baltimore, down south of Washington, D.C. that we were hoping to address with this type of initiative. And then in that same geographic area, we had over 50 rehabilitation sites. Those being quite, quite variable in terms of the providers they had at their disposal. For instance, some of these therapy sites had physiatrists or orthopedic surgeons or the like in clinic with them on a regular basis and others were very freestanding without any associated medical providers for miles. So highly variable in that regard. So to kind of briefly kind of give you a simple schematic of how we envisioned this working, you have the said patient here who's out running one day, hits a pothole and turns the ankle, thinks they have an ankle sprain, right? So they say, gosh, I can barely walk, I need care now. So they present to, let's say in this case, the urgent care facility, which we call MedStar Prompt Care. They undergo a medical evaluation, variable in that it could be a physician, it could be an advanced practice clinician certified nurse practitioner, the like, may or may not get imaging, may or may not get any workup. It's really to the discretion of those providers. And then after that evaluation, they would be referred on potentially to therapy as Jenny had kind of briefly mentioned, or it felt more appropriate to a specific specialist, whether that be ortho, other surgical specialties, physiatry at times. And so they would be fed into this pipeline, what we call the rapid access pipeline through this encounter. And then what would happen is a synchronous visit would be scheduled via telemedicine. And in that visit, the patient would be present with the therapist on site while consulting through telemedicine with the physiatrist. These were to be scheduled encounters. So of course you can see, or at least infer that the scheduling process could be quite complex. But nonetheless, the idea was to get all three of us in the same place at the same time virtually so that we can kind of check boxes, make sure nothing was missed, kind of sign off on that therapeutic rehab plan, and then potentially plan for further medical followup if we felt it was going to be needed down the line, as we found certainly would be the case at times. So this is a very complex coordination of care here. And with that, there's a lot of opportunities in terms of some of the stated goals, patient satisfaction and engagement. You're improving coordination through a potentially hazardous kind of coordination of care or a transition of care. And hopefully you can improve quality along with that. But there are also significant threats more related to operations than anything in that there's a very complex scheduling process that was error prone. There's potential for a high no-show rate, which we found certainly could be the case. When you think about it, these patients are often going to urgent care just kind of looking for a quick fix, a healing hand, and didn't want to put any more time or effort in. Sometimes they would schedule, but then just not follow through, or sometimes they would schedule and then eventually follow through, just not at the initially scheduled time. So of course, you can see this can result in wasted time for the clinicians on both end, as well as non-billable physician time on our end. So when you think about all of these different kind of pluses and minuses, risks and benefits, a complex coordination of care can be very disorienting, and that's kind of how we felt initially as we were trying to put this process in order. But we kind of tried to power on, power through, and we decided we needed to try to put together some metrics that would allow us to ascertain if this was a success or not. So number one, we tried to develop a tool within our electronic medical record that allowed us to capture discrete data points that we could then mine in the future. So not just kind of handwritten notes or hand-typed notes with our free text, but really mineable data points. We, of course, plan to monitor utilization of the system and no-show rates, try to evaluate exactly how much we're capturing these potential patients, and then hopefully also monitor need for follow-up afterward, the ideal system of which being difficult to really decide upon. So along those lines, starting to delve in a little bit more about what are the important things to capture, right, clinically speaking, I thought it was best to kind of frame that conversation in a way that would allow us to understand who we are and how we're going to work together to make sure that we're doing what we need to do. And I think that's what we're going to focus on you know, occult fractures or other, you know, soft tissue injuries, which really aren't acutely rehab-able or, you know, medical diagnosis that I alluded to earlier. For instance, with my example, you know, you take the runner who turned their ankle, rolled the ankle, everyone thinks it's a sprained ankle. You know, the athlete thinks it's a sprained ankle. The initial clinician thinks it's a sprained ankle. The evaluating physical therapist says, oh yeah, it's a really bad sprained ankle. And you know, there's a potential, you go back, you look at the x-rays, they thought they were negative, but then you might see this very kind of subtle lucency that was missed by that initial provider. And they didn't have the radiologist to rely on for a second look at that time. So anyway, it's just an example to kind of illustrate the potential downfalls here. Another example would be the pulled hamstring. Again, let's say you have a runner who starts to get kind of a twinge in the hamstring. They say, oh, you know, I keep on trying to run through it, but I just can't, my hamstring's tight, I can't handle it. And then lo and behold, they have a huge L5-S1 disc herniation with S1 radiculopathy. I mean, I think many of us have seen patients like that over the years. So another example of those patients that we ideally would like to capture if possible. So we thought kind of, you know, more deliberatively, a little bit more scientifically, at least I tried to, about, you know, what are good ways to identify these patients? And I thought back to that old adage from like, you know, the first year of medical school, where we learned, you know, that history is 90% of the diagnosis. So I actually went back and looked through literature a little bit to try to kind of vet that. Turns out there's not a lot in the musculoskeletal literature, it's more of the internal medicine, primary care literature. And as science would have it, it's more, you know, kind of three quarters of the diagnosis, not 90%, at least in that one study. So I thought about, you know, all of these different considerations and then the tools we had at our disposal, you know, the large network, how do we take that large network and our ability to gather data and leverage it to guide future treatment and to capture more useful data? So kind of step by step here, as we move forward with the implementation, we put together a final design for clinical data collection, which I'm gonna elaborate on. We plan for some interval data analysis over time to identify these risk factors that I'm alluding to that might predict for progression during rehab. Try to identify areas for process improvement more in terms of the logistical and administrative support side. And then identify, hopefully, some medical interventions that we might use to address these risk factors and augment rehab. So in this context, you know, what is clinically useful data? I mean, I did a fair amount of reading, you know, lit searches on this and, you know, there's not a lot out there that I could find. But I did think back onto one study that, you know, kind of, for whatever reason, left a little bit of an impression on me back in the Spine Journal a couple years back. And in this study, what they did is they looked at two cohorts of patients, one with HIPAA and one with lumbar spinal stenosis, and they said, you know, if we were to gather just an assortment of different symptoms and physical findings, what would be the most useful ones in discerning these two, you know, clinical entities in a patient whether it kind of looks like hip spine syndrome? And so, you know, of course, this is kind of beyond the scope of this presentation, but as you can see on this slide, which looks a little small for me, so I don't know how well you can see it, you know, there's an assortment of different symptoms on history, you know, of course, classically, things like groin pain or tingling distally into the leg. I mean, some of these are clearly obvious, but they clearly have this predilection that can reliably predict, you know, one diagnosis over the other. Here's another chart from that same study, but now looking at some other provocative type factors, for instance, getting in and out of the car, dying dolphin clothing, things like that, much more predictive of HIPAA. So what we tried to do was, you know, put together a system where we could gather some of these types of data points, not just these ones, but of course, many others, and then see if we can almost start to develop some predictive rules, the clinical prediction rules that could help us decide who might progress well in rehab and who might not. I also looked a little bit, you know, into, for instance, upper extremity, and it turns out that I could not find much. I looked at some meta-analyses, looking at the various different diagnostic testing, and I think anybody who's really dealt into this literature on physical exam maneuvers for the shoulder and such, I mean, you see that even the things we use regularly in clinic don't really have a lot of underlying scientific value when it comes to these types of statistics. So we created this standardized intake documentation for a provider so we could codify data for this future data analysis. And then we were planning to use interim data analysis to look at these factors and hopefully predict for prognosis. Now, of course, this isn't, you know, a really fancy-looking tool. One thing that we found was that there was a lot of data on the back end of your electronic medical record. And so along with that, you know, we were forced to use some data components that maybe aren't ideal, right? So if you look at the locations here, you know, we were forced to use some data components that maybe aren't ideal, right? So if you look at the locations here, you see many that are highly relevant to our outpatient musculoskeletal training, but many that are not. Additionally, you see here, you know, kind of some of our traditional historical components, things like quality of pain, presence or absence of radiation. And it really, I think, goes in being able to capture some of this type of data, as well as, you know, duration and onset that we're looking at. As well as, you know, duration and onset that you could perhaps better discern who might need to be seen. Those data points, you know, we also included some of those related aggravating and relieving factors as well. So, you know, now, just about one year after kind of we started implementing or designing the process, not fully implementing the logistics, but what have we learned? Sadly, you know, I hope to present more than this, but the truth is that we have not learned much. And I think that the underlying kind of driver for that is probably self-evident. You know, the COVID pandemic has certainly thrown a wrench in this initiative. But, you know, even prior to that, we were seeing some kind of challenging issues in terms of data collection and analysis. So I alluded to this earlier that the coordination was challenging. We were losing, I think, a fair number of referrals that possibly could have been scheduled. Partly due to communication issues, which we had to troubleshoot. Partly due to scheduling concerns. Having to have our clinicians available for the appropriate times was at times difficult. And the utilization just in and of itself, even just outside of those issues was quite erratic. So you would see sometimes there would be, you know, 60 referrals in a week, and then the next week there would be 10. So it was very erratic and tough to kind of wrap your head around. But then as this graph kind of shows you with the utilization and the volumes by week, you see here right in that kind of that mid to late spring, our volumes just fell off precipitously. But then beyond that, you know, we had further challenges. Because of our need to pivot toward telemedicine for a wider outpatient practice, it really started to obscure some of the data and the way that these patients were scheduled and the way that the scheduling software medical record was kind of modified to make that pivot started to obscure some of our data. So now we're kind of forced to kind of try to go back and sort the wheat from the chaff, which was not our intention from the outset. But the silver lining here is that, you know, this initiative and our kind of initial design and implementation of the process really allowed us to make that pivot very quickly. Our staff and clinicians were already very, very adept with navigating the virtual kind of healthcare environment. And I think we felt really kind of well prepared those of us who were involved to make this transition. And with it, you know, it allowed us to make a, not just the streamlined scheduling process, but to really kind of take the telemedicine tool and not just do, you know, kind of your direct patient encounters like much of us do these days, but also just kind of use it to coordinate care in an environment where that's so, so important. You know, the face-to-face encounters, whether it's us with our patients, the patients with therapists, patients with their primary care physicians, you know, there's so much more chaos in the environment these days that being able to coordinate that care was really kind of a boon to our practice. It's also allowed us to make a really seamless transition to billing indirect access. So, you know, the direct access model was present prior to COVID, but it's been even more widely utilized among patients in our area now. And with the changes to billable E&M services through telemedicine, it's enabled us to essentially bill when appropriate. Now that doesn't mean we always bill, but, you know, there are those direct access patients who need medications or really do need imaging, and we're able to order that immediately and then position ourselves really as the point person for their care. You know, kind of related to, you know, it does seem that policy shifts are in favor of continuing this. And, you know, of course, again, this is beyond the scope of this talk, but, you know, there are multiple different governing bodies that are looking at this and are encouraging a wider implementation. So I think it's here to stay. And, you know, starting to really expand this conceptual framework, I think will, you know, serve our patients well. It will enable us to communicate better with our colleagues in other specialties. And I think will really be a boon to our practice. In keeping with that theme here, we're also gonna present a brief perspective from one of our colleagues in therapy moving forward here. Then we're gonna hear from Dr. Moore on some kind of clinical pearls after that. Hi, my name is Dionne Hawkins, and I serve as one of the clinic directors for MedStar Health Physical Therapy. We began our telemedicine collaboration in February of 2020. And I must say it really has not done much to disrupt our normal workflow within the clinic. We still schedule evaluations as normal. However, if it happens to be a telemedicine evaluation, we simply leave a little space on the tail end of that evaluation to connect with the doctor via the telemedicine platform. However, I will say that it has changed our practice for the better in the fact that we are able to provide even more rapid access to care for our patients. For instance, the acute patient that is in a great deal of pain or someone who just hasn't made it to the doctor and needs that incentive to just get treatment started, we're able to get them in, evaluate them, and then at that visit connect with the physician. When I think about how this has been a positive impact on our patient care, one name in particular comes to mind. Her name is Miss Nancy. She was new to the area and had not yet established her physician care. Therefore, she had no prescription for physical therapy. However, because she'd had her low back pain treated successfully with PT in the past, she was seeking to have it again. So we made her our very first telemedicine evaluation. Now to say that it was a little bit rocky is to be mild. However, despite all of that, I was more than impressed with not only having a very thorough physical therapy evaluation, but to then have that followed up with a physician's visit right there in the clinic at the end of her evaluation. I mean, she was completely blown away. She is now a patient for life. She actually refers to us as her medical dream team and has come back to us for a couple of other issues that she was having She has such a successful first trial with us. When I think about how we might be able to make this collaboration even better, simply have more of it. The truth of the matter is patients truly value when physician and therapist are collaborating with one another, creating a tailor-made plan of care for that patient's needs and that patient's particular goals. Now, for anyone that might be interested in pursuing this type of patient care model, one of the most important things to have are good diagnosticians in your physical therapists. And besides that, having physicians who are caring, who will listen. When you have those two things, it is a winning combination. So now we'll transition onto Dr. Moore here for a little bit more perspective on that. Thank you very much, Matt. Let me move my camera just a bit here. Sorry about that. There we go. I know someone was saying we were having a bit of a technical issue and audio. I think there's a little bit of a windstorm where we are, so that might impact the Wi-Fi just a little bit. But thank you so much, Matt, for giving such detailed information on our program. I initially wanna say, this is a big thank you to Dr. Simmel for not only having the vision to go along with the therapists when they presented this to us. This was very novel when we first started talking about this. And so I really feel like the vision and the open-mindedness that she had to adopt this for our hospital system was fantastic. And then Matt has done so much of the work as far as doing all of the tech, getting all of these forms together. And so they have really been leading this initiative through our hospital system. So I just wanted to say a big thank you because it takes a lot of preparation and I certainly was just here to help do the work. So I'm sorry, my camera's moving a little bit. Sorry, guys. All right. So on to, I have no disclosures here. And so I'm just really kind of helped to round that out. And so for those of you who could hear the video from Dion, one of our physical therapists, this has really been a powerful, powerful program that we've been able to put together. And so when we talk about PM&R, that is always teamwork and it's this multidisciplinary team, this has been the true definition. And so, and even in my residency, I trained at Sinai Hospital in Baltimore and it was really put upon us the importance of a great physical therapy referral. We're physiatrists, so we should be able to write very specific details. We had a lot of time with our physical therapists at that point. So I've always had this love affair with therapy. And then during my sports medicine fellowship at UC Davis, again, it was honed in the importance of working collaboratively with physical therapy. So when this was brought to us, I was very excited to be part of one of the physicians that was going to help with this rapid access. And so, as been mentioned, it was our sports medicine trained physicians that were part of this. And so we know about teamwork in sports. This was just a great collaboration. One thing I also was excited about was, it was refreshing. It was going to be a small break in clinic of seeing patients every day. So it was an exciting project for us to take on. When we first talked to our therapist, I was a little skeptical of doing this telehealth and this rapid access. They'd already had a referral from urgent care. So I kind of, why do we need to have this? But what I was able to learn was so much more through therapy. I learned to trust our therapist much more. And so I think when you have this relationship with your physical therapy team, your occupational therapy team, you know, they do good work. It was much easier to go with this process to say, okay, this is going to work. It's going to work great because we know that they know what they're doing. I also learned a lot from our physical therapist. We have different names to some of the physical exam skills that I do as a sports medicine physician versus what physical therapy does. And it was nice to say, oh, hey, what's this exam that you're talking about? Because as they're walking through their exam, I stop and I ask questions. So it was a learning point for me. As Matt mentioned, this history taking, that's all you have. That's what you have to go on. And then of course the physical therapist or the occupational therapist, their exam. But this is when you have to really learn to trust yourself, trust your history, trust your gut. So when you are walking through and listening to their symptoms, you are watching their exam as the therapist is doing the exam, you can really say, hmm, I maybe think that there's something else going on or the referral that came from urgent care was perfectly accurate. So it really has allowed us as physicians to really hone in on those skills of history taking and trusting our gut, which is something that's great. These are just a few examples of some of the patients that I had. So Matt was saying, we started this as a rapid access and then we transitioned during COVID to what we call direct access. So where the patients didn't have their referral and this was coming in for their first visit to therapy and they were seeing a physician. Even when we did rapid access, when they had already been seen in urgent care, had the referral, the patients loved this. They loved number one, having a physician on the screen. So they were kind of getting a twofer. They were having their physical therapy visit, but also a visit with the physician. And so they were shocked that there was a physician that was on the other side of the screen that was talking to them about their visit that day, learning more about their injury or why they were there. And it really gave us as physicians a great time in a moment for education. And I am huge on educating a patient on whatever they're going through, whatever their issue may be, the medications that may have been prescribed from urgent care. You know, a lot of this is musculoskeletal and when they come from urgent care, it's usually your traditional anti-inflammatory muscle relaxer. And it's just kind of helping to educate them on, you can stop this medication. You probably don't need to do this or add more of that. So it was a great moment to educate patients when they may not be seeing a physician for the rest of their time and while they're dealing with this issue. Once we switch from rapid access to direct access where anyone could come in with a referral, or even if a patient presented with the referral from urgent care as a rapid access, we were able to convert their visit to a direct access if we needed to bill. So here are a few examples of how this program has really helped with patients, their diagnosis and their treatment. So there was a 23-year-old runner that had come from urgent care to physical therapy as a rapid access for shin pain or shin splints as they were diagnosed with. And the therapist took them through their exam. They were just talking about, you know, I got a little bit more history, you know, in urgent care sometimes it's a very quick visit. And so I was able to get more history on, you know, when did you start running? Was this just during COVID? How much were you able to ramp up? You know, all the good questions that a sports medicine physician asks about any kind of injury. And so after kind of hearing his story, I was like, hmm, this doesn't really seem like shin splints. This really seems like maybe more of a stress injury, a reaction and fracture. And so just by listening to him and watching the visit and watching the exam that day, I was able to order a cam walker for him that he went to the office right where he was in physical therapy, right beside that to get the cam walker. And I was able to order imaging and he did indeed have a stress reaction. So then we were able to treat that very differently, still keeping him in therapy, changing what we were doing for his therapeutic exercises. But this could have gone on for weeks as shin splints. So we were able to shut him down. He was able to recover. And so that was a really good point that we were able to do with having him being seen telehealth for this rapid access. There was another lady, 53-year-old female. She was Spanish speaking. And so there was a little bit of difficulty when she went to urgent care. She got in the physical therapist. The therapist just really had a hunch that this is just not knee arthritis. She had fallen and she was just having severe knee pain and she was noted to have some arthritis on her x-ray. And so I asked the physical therapist, do this exam, do that exam. And it just didn't sit right with me. So she actually, we were able to give her crutches that day. We were able to get imaging the next day and she actually had a tibial plateau fracture. So these are those small things that Matt was talking about can easily be picked up. And when they're not actually in person, but you have someone else that you trust doing a really good physical exam. A 37-year-old female came in with hip pain. She had already been seen at urgent care for a hip flexor strain. Of course, as a sports medicine physician, you really get a good history and adjusted and added up. We were able to put her on crutches that day, got imaging a few days later, and she had a femoral neck stress fracture. So all these things would have just kept going in physical therapy if they had not had this intervention on their first or second visit with us via telehealth as physicians. And so this has been really a game changer for what a lot that we have been doing. And then lastly, this is the one that kind of blows my mind. I never saw this patient, not once in person. It was a 56-year-old male who had a hamstring pain. He called one of his friends to say, hey, I want to see a sports medicine doctor. It was on a Friday afternoon. So when asked, can you add this person on? Okay, sure. I saw him. He had a huge bruising, all this pain on his hamstring. I figured he had had a hamstring tear. I saw him on that Friday, was able to prescribe medication for him. He was in a ton of pain. Able to get him crutches same day. Able to get him an MRI that following Monday. He was seen by the surgeon Monday afternoon and had surgery on Wednesday. Never saw the patient once in person, but this is the power of what this direct access, rapid access can do and how it can help to change your practice and more importantly, change for the patient experience. So overall, this has just really been a great opportunity for us to educate patients more, patients that have this capability of having a face-to-face with the physician, for us to learn more about our therapists, trust more in our therapists, and really trust more in ourselves. So it's been a great process. So we will move forward to questions and answers. And so we're going to, yep. Hey, everybody. That's been a great wrap up. Very good. So we have some questions that have come through. It's been a great talk in the chat. Yeah, Malia, thank you for bringing so many great examples. I think that really kind of summarizes a lot of kind of our experiences, you know, not just yours, but I think we've had a lot of similar cases like that. And of course this isn't everyone, right? But you know, those select cases where you have something like a femoral neck stress fracture, where if it keeps going, you know, it's a potentially devastating outcome. And these are just great examples of how we can really affect patients' lives. So let's move to a couple of questions here. A lot of great questions. I wish we had more time. I think there was a good question for Dr. Semmel in regard to kind of, you know, looking at how our patient referrals have been affected by this initiative. And Dr. Semmel, I don't know if you could kind of offer any kind of words on that. Yeah, I think that probably all of us would say everything is thrown off by COVID, right? I mean, we got this up and running October, November. I think you guys were just getting off the ground. So I don't know that we have anything that would be statistically significant. It would be nice to say in another year sort of where we're at. The one thing, at least I'm hearing anecdotally from from the therapy leadership side, is how beneficial it's been in terms of relationships between physicians and therapists. And I think that bridge, there's a lot to be said for. I think that bridge is going to continue to grow. I think when therapy sees patients, they're going to continue to think physiatry first, whereas I don't know that that was always their natural tendency. So I would say that side we've gotten. And I think the urgent care side is inevitable, that once we establish clear pathways and we're in the mix, I just think it's going to take off. But no, we don't have the numbers to show because COVID really did throw off all the volumes for everybody, certainly in our region. And then I know there was a question. Data analysis. Sorry. There was a question about what happens when a patient is seen for less than a month. Do they need it? The answer is no. If they make it to three visits and it's less than a month, no. If they're better, they don't need a physician prescription. It's just you're not going to know until it's too late. So I'll turn it back to you. Sorry, there's a little lag time. Indeed. You know, I think someone brought up a point that, you know, seeing patients virtually, there's a lot of technical issues. I could not agree with that more. And that, I think, was, if anything, amplified through this initiative, just to kind of give that point a fair a fair notice. Dr. Kordaboin asked a question. I think a really good question about PT prescription and compliance. And of course, patient compliance is an important thing. And I think that one thing that Dr. Moore really kind of highlighted is, you know, when you have a patient who's seeing the treating therapist and the physician together, and they're hearing a very consistent message at the same time. In my experience, and I've heard this from several of our colleagues in therapy, they really buy in more. And I think there's really been a certain amount of synergy we've been able to kind of capitalize on in regard to that. So I thought that was a really important question to address. One other kind of good question that I saw. Dr. Moore, would you add anything to that? Well, no, I know there was one question about the tech issue in rural America. And I think this has been also a game changer for them. So as patients are coming into physical therapy, we are doing our telehealth visits that way, while they are actually at the therapist's office. And so the tech issue doesn't come as a big, not as one of the bigger issues, because they are at one of our physical therapy facilities. Now, if you're just talking about in general telehealth in rural America, yes, it has certainly been challenging. But that's what the telephone is for. So even if you can't connect on the video, and even with a lot of our older patients, so in sports medicine, we see a ton of osteoarthritis. And depending on where I am in my clinic, my patients can be 90 plus. And so those are patients when we're doing a follow-up via telehealth, I usually will just call. If they have someone that can connect on their video, then that's great. But I don't always have to make it a video visit. But even having that phone call, they have just been over the moon thrilled with the amount of attention that they feel like they've been shown, especially when COVID first hit, and we were doing a lot of these telehealth visits, the patients were very grateful for having time, even with me, to call and doing a follow-up and see how they're doing. I said, well, we still want everyone to be well taken care of. So this telehealth has been a very challenging time. Also, I think an inspirational time, because it has helped to reinforce the importance of the work that we're doing, and that the patients have gratitude for that. Indeed. One other, I saw two separate questions or comments related to this. One being from Michelle Miller, who said, could you also use the predictive tools to decide who may need further imaging at onset? I think that's a great question, and one that we've been thinking about, and one that we hope to be able to answer. I don't know what the answer will be yet, but it's certainly something that I'm actively interested in. And then a separate question, comment from Deborah Grinnell, are these data collections available that could be used across multiple systems to improve the data? I hope that someday we have the ability to get some of the things we've learned out from this, if anything, given some of the nuances I alluded to with our data collection and analysis. But I totally agree that the more that we can pool data like this together, the greater we're going to be able to properly triage and properly direct patients through these various avenues of care and do so efficiently and hopefully with lower costs. So I think those are two great points. I think we are getting close to wrapping up here. I wanted to thank my co-speakers here especially, and I really also want to thank you all out there for your active participation and great questions. I think this has been a really interesting conversation and one that hopefully we can continue. So that being said, I think we are just about wrapped up. We are. Thank you so much, Matt. This has been a great morning. Thanks, Jenny. Yes, thank you. Nice seeing you guys.

telehealth

collaboration

outpatient care

musculoskeletal care

physical therapy

telemedicine

predictive tools

teamwork

communication