Good morning. My name is Debra Vennessy and welcome to our session. I will be your session's moderator and I am super excited to introduce you to our subject matter experts in telemedicine and remote monitoring, my friends, Dr. Todd Rowland and Ron Garbo. As I said, my role is the moderator and introducer, so let me tell you a little bit about them. Dr. Todd Rowland has more than 25 years of experience, including roles as a practicing physician and C-suite leader in multiple ventures, including digital health companies. Todd completed his PM&R training at the Ohio State University and did a fellowship in medical informatics at Harvard, MIT, before I even knew it was such a thing, and look at where we are now. Todd serves as the chair of your academy's telehealth innovation work group. Dr. Rowland is also part of a 35-member provider group, including seven physicians in the Research Triangle region of North Carolina. Outside of his clinical practice, Dr. Rowland is chief medical officer for Vital Flow Health, which provides RPM, or remote physiologic monitoring, to manage respiratory diseases such as asthma. Todd is passionate about the intersection of consumer-enabled technology, augmented decision-making, and population health. Then we also have Ron Garbo, and Ron, after 24 years of practicing polytrauma rehabilitation and integrative pain management, Dr. Ron Garbo was recently named director of cardiac and wellness integration at Virginia Commonwealth University, or VCU. At VCU, he also serves as an authority for pragmatically applying heart rate variability science using wearable technology and digital health advances for the Veterans Administration and the Department of Defense Research Consortium for Long-Term Impact of Brain Injury. A long, maybe long time ago, during his senior year in college, Dr. Garbo became Ohio State's first walk-on All-American wrestler and entered the school's Hall of Fame as the university's top male scholar athlete. After a stop at The Ohio University in Athens, Ohio, he returned to Ohio State University in Columbus for his residency in physical medicine and rehabilitation. And more recently, he's published a synopsis of his novel methodology, Autonomic Rehabilitation Adapting to Change, in the PM&R Clinics of North America Journal last year. Ron has also been awarded the Distinguished Service Award by Physicians for Peace for leading medical missions to support an Iraqi amputee clinic. Ron is passionate about integrating medical-grade wearable technology, remote monitoring pragmatically throughout health care, unbounded by geography and health disparities. So throughout their presentation, we hope that you will engage with us. Both speakers have graciously agreed to address your questions. We'll leave time after the presentation, but also in between. So you can put the questions in the chat box. So hopefully everyone is ready to dig into some telemedicine and remote monitoring. And I'm going to turn the microphone over to Todd Rowland. Wow. Thank you, Deb. That was a great introduction. I'm going to go ahead and transition to my slides here. So pretty excited to be here. Of course, all of us wish we could really be in person, but short of that, you know, the remote activity is what we're doing these days. So we're going to be talking about telemedicine, remote monitoring, and also touching on patient reported outcomes. So there's this kind of this whole intersection of stuff going on. And as Dr. Vennessy mentioned, Ron and I are the two speakers and here are our disclaimers. So let's start with kind of why we're here today. I always like to start with a why. I think everybody realizes it's been a really dramatic growth in telemedicine during the COVID crisis. And because of that crisis, a lot of things happened that hadn't been happened before. There was a really rapid reduction in the barriers, particularly the cultural ones for patients and providers at the same time. So everybody just kind of did it because they didn't have a choice. And then the insurance companies said, look, we're going to reimburse for this in a totally different way than we had before. And, you know, the crisis is continuing in this series of waves. So we're still kind of in this period where we're not back to, you know, where we had been prior to COVID. Now, you know, throughout this meeting, you're hearing a lot about post COVID patients and this really large group of patients really represents an underserved market that can benefit from PMR services. And we think the remote and telemedicine services are just as important as anything else. We're going to be touching on what's called payment parity. And what that really means is that right now physicians are being paid the same as in-person care for telemedicine. And my speculation is that will last till somewhere in 2023. Nobody really knows that for sure, but certainly the COVID crisis, the public health emergency continues. The thing that is also a driver for this is coding for remote physiologic monitoring. We'll use the term RPM throughout the talk. That's what we mean by that. And that adds revenue and supports patient reported outcome measures. So here's my other why. And I think we all have extended family that we really want to protect. And this happened to be my in-laws and I feel very fortunate that we were able to protect them in the time of COVID and telemedicine remote care ended up being extremely important in that whole process for us. So our objectives today are to really understand the growth of remote care in 2021 and speculate beyond. We're going to explore the growth opportunities in the post COVID marketplace. And then we're going to gain exposure to the whole RPM revenue and coding model. So I always like to start with current state. So right now, and as always to me, PNR physicians are the most qualified to provide care for complex neuromuscular musculoskeletal condition patients. That's always been the case. We want to make sure that we're players in the telemedicine market as well. And what I'd have to say right now is that most physicians, including our specialty, we don't really understand how to deliver efficient and profitable telemedicine services, because even though we've been doing a lot of it in the last 12 to 18 months, we're probably not as fluid with it as we'd like to be. So one of the things that Dr. Vennessy and the board of governors did really ahead of COVID was they had created a telemedicine working group. So it ended up being very insightful to do that. And we're going to be talking about the recommendations that we're making to the board of governors later in the talk. So pre-COVID, there kind of was this gradual growth of telemedicine of both products and services here. You can kind of see, we're just kind of inching along here. And then everybody thought that that gradual growth pattern would continue. Well, instead, in COVID, we had this huge spike in that first to second quarter of 2020, where so much of the outpatient care was disrupted, and the only way to really do care was telemedicine. So this is the crisis and the opportunity that we're in right now. And this is pretty unusual. Not very many of us have lived through things like this before, if at all. Now, when I think about what 2020 was like for me and for my PNR group, our group works in 21 different skilled nursing facilities. As you can see, it was a pretty rough year. And as we had COVID outbreaks in the facilities, we really had to rethink our strategy relative to how many providers we would have in the facility. So we really went down to one nurse practitioner, PA, and then did telemedicine with the physicians. And so we had to do it rapidly. And there's lots of hiccups and challenges with that, with our group, just like everybody else. So the other experience that the Academy has facilitated is the musculoskeletal working group. So at 1.55, PNR practices were providing telemedicine care for outpatient musculoskeletal patients. And the great thing about this is those groups participated with the Academy to really kind of measure and evaluate what the experience was. And that helped us figure out some of the barriers and the opportunities going forward. And this was a whole host of different size groups, including the big groups at Cleveland Clinic, Mayo Clinic, which of course have dramatically increased their use of telemedicine. So the analysis that the Academy did, which I found most interesting, was that really, if you look at body part, head to toe, it was easier to do the talking part. That was not so hard and not as hard to use the camera kind of on the head down to the waist. But then when you get down to the pelvis, low back and lower extremities, there was a lot of challenges in terms of getting people to use the camera in a way that was effective for visualization. A lot of really interesting things happened during that time, which we don't have the time to talk about, but I'll just say that the Mayo Clinic put together some really cool how-to videos that helps patients and families become more effective. So what are the opportunities for this remote physiologic monitoring and what is it? We're going to talk about how PM&R is positioned for that and how RPM and patient-reported outcomes are kind of linked together. I'm going to do that using a case, which I think is one of the easiest ways for physicians to communicate with each other. So in this case, there's an 87-year-old gentleman who's frail, has COPD. And by some of the research, he's in the old, old Medicare category above 84, 85. He happened to be in SNF rehabilitation for 21 days before going home. And during that time, he got referred to a telephysiology program, which included oximetry using the RPM, you know, the remote physiologic monitoring. And that was actually started, that referral was made while he was in the SNF. And then what's interesting is that the company that was doing that work deployed tech coaches, and they would reach out and call the adult children and the patient and kind of get the whole onboarding process started even during the SNF stay. And so by the time after discharge, the patient already had the app and the adult children had the app. They had the pulse oximetry device, and they understood that they needed to use it at least 16 times a month to be paid, to be paid by the Medicare program. So during, you know, that time, you know, that 90 day, the patient engaged in what this particular app called Game Plans, where there was a lot of virtual coaching, there's automated messaging, there is encouragement to measure. And then if the patient for whatever reason doesn't do the number of measures for the family doesn't, then there's an escalation to the care team. And I'll show you a kind of an example of a dashboard in a little bit. But one of the things that as a provider, as a physician, you see is you're going to see this dashboard, which summarizes whatever data you're measuring, whether it be oximetry, steps, whatever, you know, during the telemedicine visits. And that's a really different thing than we're used to looking at, because we're used to talking to patients and kind of getting this self-report. And here we have a data display that both of our care teams who are non-physicians and the physicians can look at. So in this particular scenario, the physician also completed six telemedicine visits using the E&M codes at parity payment. And between the combination of the RPM payment and the telemedicine payments, there was greater than $1,200 of reimbursement from Medicare for that 90-day post-SNF at-home episode. So, you know, there is a fee-for-service business model right now, as long as parity payment continues. So it's something that's feasible to do. So one of the things, and this graphic just kind of shows you an example. With RPM, there's always a device. This one happens to be a spirometer, but it could be a pulse oximeter. There's always a dashboard, which you see here in the middle. And then there's always an app. And that app usually has features of Bluetoothing to the devices. It has coaching features. It has messaging features, a variety of things. So you'll always see these kind of, this device dashboard coaching app combo for RPM right now. So, you know, pulling back a little bit and talking about the bigger picture, in terms of, you know, telehealth right now happens to be something that we're having to talk about because it's relatively new. But this is really just this progression in developing, you know, new models of care that the National Academy of Medicines were recommending for our aging population. So telehealth is something that when we learn how to do it can increase efficiency and value. I think all of us realize during the COVID crisis that we've been pushed to the limits. And even in this kind of recovering phase, we really have a workforce problem. So there's some new types of workers like that technology coach that I mentioned, that really are kind of this new medical assistant type person that can facilitate health and do a lot of things to make it easier for physicians and their patients to participate. The National Academy really also encourages promoting social engagement, and that can be through worker volunteering. The following patients as they go home in that fragile phase is really another form of social engagement from my perspective. So that's something that's important. And we all know that end of life care is very uncoordinated at this point. There are a number of hospice palliative care companies that are doing telemedicine. And so it'll be interesting to see how that works out and see if there's some improvement in the care coordination. So I always like to have kind of a bigger picture framework. And after having the opportunity to talk to experts in the field during the last 12 months, this forum framework seemed particularly relevant to how our physicians practice and are trained. And this is an initiative by the John Hartford Foundation, the Institute of Health Improvement and the American Hospital Association. And this is just really basic for us. So we always are talking to the patient about what matters to them. We're always assessing mobility. We're paying attention to medication, healthy, deep prescribing, minimizing risk. And then cognition, mentation is also extremely important. So if we can keep all of these things in mind as we do telemedicine, it can be a very powerful activity for all of us. So moving on to kind of the target state in terms of what the academy has done. And I really want to thank Dr. Vennessy and the Board of Governors for having this foresight back in 2019 to form this group. We've had a really great group of people. There's eight PM&R members with years of experience in technology, administration, and telemedicine. And they've been working diligently for the last year. And they've also agreed to work for another year because we're really getting started on this thing. And our main goal is to help members just gain a knowledge and become more efficient with their time as they decide to use telemedicine. The working products right now that we've produced is we've got a series of interviews that have been published in the Posiatris. So far we've published two of these. There's a third one coming out very soon where we're interviewing our PM&R docs who are really expert in the field of telemedicine and really out in the field doing work. The group will be producing a white paper that will be published in the PM&R Journal sometime in 2022. This paper is really kind of forward looking. It's looking out to this two to three year period to kind of look and see where we think the future is. And then we'll just like what we're doing today, we're starting to do these really more basic education modules about the how to's for this. And there'll be a series of those activities that will be forthcoming from the Academy. So I really appreciate the Board of Governors being fully on board with everything we're doing. At this point, I just wanted to really thank you for your time. And I want to see if we've got a question that we can answer. Let me kind of look here. Actually, we have a question here that I can answer before we introduce Dr. Garbo. Sure. Dr. Stephen Lewis asked, what are the risks that physiatrists do not embrace technology and home-based care? Is this our blockbuster video moment? I like, yeah, well, they know what blockbuster is. Yeah. I hope it's not our blockbuster moment because that's not good for us. Yeah. But there's always a lot of risk. And I think, you know, having been in PM&R for almost 30 years now, it's always felt like we've had a visibility problem. You know, we've had maybe a problem understanding what we do. So this is more urgent than any time, I think, in our history to really think about what our positioning is and what we can be doing. So we definitely, I think we're absolutely the most qualified to be doing this kind of work. It's telemedicine and remote physiologic monitoring are inherently team-based work. And we're really well-trained and experienced in that. So it's, if we don't step up and do it, I absolutely think that we will be at a disadvantage. So we don't wanna let that happen to ourselves. At this point, I'm really excited to hand this off to Dr. Ron Garbo. Who's a long time colleague of mine and Dr. Vennessy introduced him earlier. And I'm really excited to hear what he has to share with us about all the things he does. Thank you, Ron. Thank you both for that wonderful introduction. It's terrific to be part of this and to be introduced by both of you, former chief residents. So I'm still following you guys. And the title of this whole conference is re-imagining our future. So I'm gonna take you on a whirlwind tour, buckle up about remote monitoring. I am at Virginia Commonwealth University in Richmond, Virginia. My objectives today is how does this relate to health disparities and then two specific things, teach energy restoration remotely and teach energy modulation remotely. And I'll explain that further. I do have two disclosures and I also advise the Military and VA System Brain Injury Research Consortium on the passion, the science that I love about heart rate variability electrophysiology. Neuroelectrophysiologist has moved over into the cardiac world to a degree. So here's update, all of these are 2021. The US does rank last in access. Digital health provides a tremendous opportunity but could actually make it worse. However, just last week, there's an allocation of 65 billion towards broadband. So that's in the place of people like Todd to help solve. But the next slide is a provocative small study admitted but this is about re-imagining. Heart rate variability is noted as a whole health biomarker. And so France does not have the access issues but a six week lockdown showed that 80% had deteriorated HRV and 20% like myself had improved HRV. So my income may have dropped but I was not in any instability and was able to work. However, if I owned a small dry cleaning business or had several barriers of social determinants of health you could see how problematic that could be and what the possibilities are. I'd like to broaden the definition to talk about digital health include remote monitoring. The reason I see that is because telehealth implies synchronous communication. Remote patient monitoring can include asynchronous which means chat messages and things like that. And then the real key is how do we personalize it? And here's the history of RPM. Framingham study in the mid 90s showed that heart rate variability was this amazing cardiac risk factor, but we didn't have the digital ability to crunch this vast amount of data for a couple of decades but you'll see how important it is and how tremendously high quality studies are out there. There's a lot of junk but there are some really good studies. There's something going on at night. And remember you're most parasympathetic in slow wave non-REM deep sleep, right? What do we know about concussions and fibromyalgia, et cetera, and sleep and recovery? So remote monitoring has been driven by value. There weren't productivity RVU codes until 2018. I bring in this study. It is peer reviewed but it is a health system that's self-insured but to give you a sense of one of the drivers and how value-based it is, this is a study with over 12,000 people showing that reduced cost in care and that it is promising. So this is a driver, this value-based notion. And so we got to remember the new codes help our productivity, but the real value is in its value. So we need to become the experts. Obviously, fitness trackers are all out there and you see these massive studies with 47,000 people and there are these studies. And so I want to give you the spectrum. On one end, it's PPG, which is the light sensor. And that is not, there is artifact data with movement. So it's acceptable to track it at night. Daytime HRV is a problematic. Please don't be one of those people that quotes a company's recovery or readiness scores because they're not based on science. They do their little opaque mixture. They don't tell you exactly what it is. I'll give you a cleaner, simpler way to weed through the mess. And then on the other end, actually called per diem study where people with a cold stroke, they want to prove that rather than wearing an ECG wearable model, so there's PPG on one end and there's internal ECG on the other. And in the middle, you have single ECG or multiple ECG. And we have to figure out the comfort versus quality, what works. So they're trying to make the statement that implanting right now is not a good idea. The statement that implanting recorders for 12 months is just as cost-efficient as wearing an ECG monitor for a month. So that just gives you the spectrum on the two ends. And here are the codes you'll see. And there's a one-time setup code and then an adherence code. And it's interesting that this is actually based on the calendar month. So this will be billed probably on the first business day of every month and think of adherence to the device. Now, physiatrists, we are probably the best at bridging the impairment disability gap, but no one is good at adherence. And this is one of the promises with telehealth and with remote monitoring, that now there's actually maybe enough payment here for nurses and or physical therapists or physical therapy assistants to assist physicians. And then there's a management code for 20 minutes of time per care per month. Now, this is a big hurdle. You see these fees and quite frankly, that isn't gonna make a major impact, but if you're employed or you have a business, this could support staffing. And a couple of things to remember is you need general supervision. You should know what that is. Again, talk to your billing expert about synchronous and asynchronous, because that's still not fully articulated and cleaned up yet. And then always remember with the care management codes that no double dipping time ever. And the same thing goes, just two weeks ago, there's now remote therapeutic monitoring in 2022. Again, there's a setup code, there's an adherence code, and then there's a 20 minute management code and then an additional. So same model for, and this is subjective data, and this was specifically intended to open up to other types of practitioners can bill for this, including physical therapists and open up greater. But one of the things I want you to imagine is there's decades of cardiology nurses supporting cardiologists to prevent re-hospitalization. That was the original driver preventing these huge penalties in the cardiac world for early readmission. So can we work in tandem with physical therapists and physical therapy assistants and so forth to track certain things? So I'm gonna use COVID-19 as a model and keep quoting the consensus statement that is meant as a practical guide, and it's a fantastic starting point. But the only thing that's mentioned about smartphones and activity trackers is that they may be effective. The current state of treatment is perceived subjective energy conservation techniques. And tremendous amount of disability in long COVID is shown as well as fatigue, as well as relapses. So I call it the exercise fatigue paradox, and I've remote trained world-class athletes as well as chronic pain patients. So it's the same model, it's the same burnout exercise fatigue paradox that exercise frequently makes fatigue worse. And I agree with the consensus statement that the fatigue related from fibromyalgia, post COVID, PTSD and concussion are different sources. However, let's look at this nexus between fatigue, brain fog and orthostasis. And I do wanna offer a treatment model. If you look at the definition of chronic pain or something that is more scientific and the term chronic pain, you wanna avoid this nexus between fatigue, relapses of fatigue, mild cognitive impairment and orthostatic intolerance. I want you to start getting comfortable with the term parasympathetic dysautonomia because most times when people talk about dysautonomia, they're talking about those sympathetic, those orthostatic. But a more sensitive marker and is highly associated with mild cognitive impairment is parasympathetic dysfunction. And then one of the emerging things with a glymphatic clearance is mostly done at night. And the main driver of that is CSF flow, pulsatile CSF flow, which is driven by the cardiovascular diaphragmatic movement. So that is a premise for what I'll talk about next. So, and indeed, there's already a study that shows that heart rate variability is a outcome measure depending on severity and of the HRV markers and the severity of illness early predicts long-term. So we're now starting to see this story. We already know that HRV correlates with health longevity and that HRV is a index of the parasympathetic system. So although there may not be a unifying measure of functional capacity or fatigue or load capacity, I do believe it can be a unifying measure of recovery capacity. When you keep exercising and find out, is this five mile run gonna do you good or gonna burn you out? And to see how translational it is, you can see in the PTSD literature, one of my mentors, Dr. Ginsburg, there's a nice arts review on how it's a physiologic marker of PTSD. Couple studies that it was predictive of PTSD prior to deployment, which is an interesting thought. And then if you look at these references, if you're doing cardiac rehab, how prevalent cancer fatigue is, right? We can call it cancer fatigue, but we wouldn't wanna say somebody has chronic fatigue. So anyway, but the fatigue in medical burnout and so forth, is fatigue is a common theme. And if you look at the third reference in that is young people without any illnesses and they track their HRV and they also track their immune system and their inflammatory markers higher in young people. Anyway, so we'll keep moving forward. So the HRV response to deep breathing, if you see anybody who's diabetic, there's actually this recommendation by these two institutions that the HRV response to deep breathing should be done on every new diabetic. And again, in five years, because it's the most predictive measure of long-term diabetic morbidity prior to the diagnosis. This is really powerful data. And it's not that it's difficult to measure the sympathetic system appropriately, but billing and obtaining this can be done on your standard EMG nerve conduction study equipment and you can train staff. And there's the CPT code. And I want every primary care office, wellness clinic and so forth to be able to do that at some point. And that's one of the things I'm working towards. Here's a case that we're going to submit here. She has POTS and orthostasis associated with long COVID. The POTS is a very good model. Once you understand POTS, COVID is much more complex, many comorbidities. If you're looking at 19-year-olds who are sedentary for 10 months with palpitations and exhausted even just with eating meals, that at the end of this, from the beginning, you see a number and you see these up and down, when therapy is introduced, when there's a liter of IV fluids, et cetera. But at the end of the day, she is discharged from physical therapy in September and I'm going to reestablish care. So she's been completely on her own without medications for a couple of months. And she's exercising five days a week. So at the beginning of this, totally sedentary at the end. And so if you see three nights of poor HRV tracking in a row, you know they have lost the ability to recover, even if they're resting. So that highlights your therapy and can give you a couple of days warning before trouble. This is somebody I've managed and coached in North Carolina. It's a teacher who due to stress, just prior to COVID, retired, chronic knee pain, usual care didn't work. Couldn't walk, but could bike. So vigorous biking and less work, no work. So less stress for 10 months, still not quite there. Becomes intentional and independent with recovery. And you see over several months becoming intentional, independent with your recovery. There's no substitute for several, not days, but several months of decent sleep. So they became intentional after 10 months of biking and less stress. A couple of months later was the first time that person who at one time was suicidal, entertained returning to work. I believe the brain gets rinsed for a few months and then you can start to entertain returning to work. And they've returned to work as a school teacher again, so far quite successfully. This is my own healthcare burnout. My first bout was with atrial fibrillation in 2002, when my cardiologist said it was not related to stress. I think the answer would be different. I did not believe it. And if you believe compassion fatigue is a cursor for depersonalization and the data is most strongly around emotional exhaustion, this is a marker of that. And so I thankfully passed my board's recertification two years ago, which meant, so heart rate variability is nonspecific, but it's incredibly sensitive. So three interventions, less stress by successfully finishing my boards, less sitting around, more exercise, less alcohol. And you see, these are measured in weeks. So this is sustained improved nocturnals. So this is a number affiliated with heart rate variability. And so I'm very passionate about this talk, and I say it's a clarion call for HRV research. Before you think I'm hyperbolic, it's important that we take the high ground and understand it because it's easily misconstrued. And please read this 2017 for early researchers. Here's the other most important image I want you to see right now. It's energy conservation, and we can have this beautiful image software by this company, ECG. And you can make parasympathetic green. You can make, you see the heart rate goes up. You can make exercise blue, and then we should have dotted moments of recovery throughout the day. And this is now an objective, more objective to help energy conservation. And then lurking at these numbers as heart rate goes down, blood pressure should go down. CSF should take its place in the skull, and you should have better rinsing. And so that is a measure of restoration. Quiz time, first billionaire athlete hint. First name is Michael, bet all your Bitcoins. And I should take most of it because you probably may have said Michael Jordan. It was actually Michael Schumacher. Michael Schumacher destroyed the Formula One race circuit for about a decade and a half with left foot braking from when he grew up doing rally cars. So we are not driving a one-footed car, and we are not, you'll never hear me talk about autonomic balance. It's two levers. And when you do respiratory breathing, respiratory sinus breathing, you're engaging the left foot brake. So I started thinking about with the right foot that beta blockers, stellate ganglion blocks, and maybe acceptance commitment therapy is letting go of the gas pedal. And so you need to address both levers, engage the braking system, and disengage the throttle. And there's different ways to do that, and everything has different risks. If you get very disciplined with this, you can do amazing things. And this is someone who's supposed to get their third cardiac ablation, had chronic pain, saw me, halter monitor just before I saw him. You can see the PVCs on the first visit. Three months later, she learned the breathing techniques, eliminated one emergency room department visit at least, eliminated one cardiac ablation. The cardiologist still didn't believe me, so two and a half years later, I wrote this up with Dr. Gilman and Dr. Goldberg, and to this date, still no problems, still can mitigate PVCs. This is another, this is a gentleman, is mid-20s, brain injury after childbirth. He's fortunate, he has aggressive problems. He is fortunate enough to have a millennial 24-hour helping him with the temper. And in this particular case, it helps to have a millennial. They had two different PPG monitors, one heart rate variability biofeedback, and one of these activity trackers. And when he's triggered, instead of the conversation be constantly about the trigger, when avoiding triggers, it could be about self-regulation. So you see in the moment, opening up one app, opening up another app, doing focus breathing. Now, I believe all this can be done remotely. And so there is a pilot study. And so this is the one slide I think my disclosures are important. However, Dr. Govertz, there is renowned at heart rate variability biofeedback, and it is a peer-reviewed study. And the reason I'm so passionate is not about the advising. It's about having treated a young man that was placed on 2,000, 2,000 morphine equivalents per day for his low back pain, for his unsuccessful low back surgery. And I worked with him for a while, and he was lured away by what I'd say the marketing of the neuromodulation possibilities. And so the real power, I believe, is tracking longitudinal nocturnal HIV. And I want you to be able to prescribe, just click on your EMR and health record and HIV biofeedback focus breathing, 10 minutes BID and PRN with RPM and have that supported. And so this is the summary. If you can accept energy is finite, or you don't, I'd ask you to read that article. But here's the equation. I want to add subjective energy conservation training and improve it with nocturnal HIV for restoration remotely, modulation skills with the breathing techniques to improve conservation. And the terminology maybe goes to energy utilization. And the shortest possible way I can say is autonomic rehabilitation towards parasympathetic health. I have another case. Obviously, I don't have any time just yet for that. But unlike usually, when I talk with Todd, I go way over, I'm barely over today, I think. And now I'm at Richmond, I'm excited to implement these things. There's a bit of irony. I was born in Egypt, I'm naturalized citizen, my office is now in the Egyptian building. It's not because of the 19th century heating and cooling system there. It is based on the opportunities to create something. So with that, I'd like to hand it back to Dr. Vennessy and Dr. Rowan. Oh, thank you. Ron, can you just simplistically tell us how, you know, I'm just thinking of our conversation last year, I think you said you can just do your heart rate monitor. I don't have an Apple Watch, but I think a lot of people do. I have an old-fashioned Fitbit. Right. So yes, these will be wearable devices, ring, chest, ECG, wrist monitors, and you'll open up the app in your phone. Eventually, you know, right now I got to use three or four different companies. That's for sure going to get solved. That's inevitable. And with these payment models, it's going to happen even faster. So, you'll be able to do remote heart rate variability. So in that pilot study, we showed that we can train somebody for anxiety, how to do the breathing skills to physiologically modulate their autonomic nervous system real time with these devices. They'll become easier. It's been very cumbersome moving forward the last 10 years, but, you know, so this is reimagining the future. It's still really cumbersome, but it's coming. And so my plea is that the equity task force and the COVID task force implement and hopefully I can be part of that conversation about how remote physiological monitoring and as well, our colleagues, physical therapy colleagues, how we can work and be those translational positions with this data. There's a question from Amy that wondered whether we could have the group discuss how telehealth platforms are integrated into our electronic health records. Yeah. So there has been, you know, some degree of integration. And I think Deb in our discussions, we were discussing kind of what the Cleveland Clinic has been doing and, you know, there's movement in that space. And I think eventually most of the electronic records will definitely have a video option where you can be doing these things. The question is, is how much of the integration of this remote physiologic monitoring that will happen? Because, you know, the things that Dr. Garbo is talking about would really just not be possible without the RPM, you know, billing model. It just opens up a whole new world of kind of monitoring measurement and self-care and coaching, right? So this whole paradigm of us hoping the patients remember how they felt while they come in the office visit and not measuring anything. Well, that seems like not using a stethoscope to me, right? You know, it's kind of the old way of doing things. So I think what you're going to see is a combination of having these dashboards, which I showed you kind of graphically in my talk, that are sitting alongside. So you might be using your EMR with a telemedicine session and on an iPad, iPhone, something, be looking at the dashboard. Now, all of us in the RPM space are working towards integration with the big EMR vendors. And, you know, the companies that I'm with, we're working on that. We've done some work on that. But I would say it's a little bit of a work in progress right now. So people will have to probably be a little patient for that total integration. Yes. It's cumbersome now. It's going to be much easier. There's going to be, you know, the drivers, the value-based drivers, the productivity-based drivers. It's going to be much simpler in the future. But admittedly, it's still cumbersome. And we need to take the high ground. In the data world, there are dozens and dozens and dozens of rabbit holes. And the performance world has a great wellness model to it, but can be very sloppy with the rabbit holes. And it does require, you know, the data with these devices does need to be with HIPAA boundaries, with medical quality. They can be incredibly important because I don't use 50 of the data points. I use longitudinal nocturnal HRV. So not the recovery score, but get comfortable. And you got to dig in your app to find it. And they'll call it your stress score or something like that. Yeah. So I would comment that we're kind of in this early to early middle adoption phase. And, you know, so you're going to have to be enthusiastic about this work. And I don't think this is kind of the, we're not in the late adoption phase. This is not a Walmart technology that you can find on the shelf today. But it did take 60 years to adopt the stethoscope. So, you know, change can happen. I think one of the things that's the most encouraging thing to me is the cultural compression that happened during COVID. I've never seen 10 years of compression into one year where both providers and patients at the same time said, okay, I'll go ahead and use my smartphone in a different way. That would have taken 10 years had COVID not happened. And I've talked to so many colleagues in the space that pretty much agree. I know that the Mayo Clinic had put out a 10-year strategic plan that they said, well, we accomplished it by 2021. So they literally had a pre-COVID 10-year strategic plan for some of this stuff. And by the end of 2021, it was accomplished. So that's kind of some evidence that there was a 10-year compression of orientation. Absolutely. Yeah. And that's, I mean, I work at the Cleveland Clinic, a friendly competitor, and that was for sure. I mean, I'd done all the training and then, okay, March, we're doing it. There's a couple other questions on the chat. Betjamosi Jones wonders if we know if Medicare will continue reimbursement of telemedicine after January 2022. I know I practice in the state of Ohio and I know that it is, there is legislation through March of 2022. And I know we have some faculty, or Carolyn's on, so she might be able to help us too with that answer. Yeah. So I want to break it in that question into two parts because there's RPM and RTM. So there's remote physiologic monitoring and there's RPM. Those are approved programs. Those programs, those were not changed as a result of the COVID crisis, the public health emergency. So those are existing models that are there. Okay. We're going to get more experience with RTM because that's a relatively new thing, but it's so similar to how you code and bill for RPM. I think there's a lot of similarities. The biggest question is parity payment for the in-person synchronous telemedicine visits. And I don't think anybody knows the answer to that right now. But anybody who does, I'd like to talk to them because I keep asking everybody at the AMA and other places, and we're all speculating. I think how the AAPM and I can help. Honestly, I don't think it'll be in those codes. We will continue with physician shortages. We will continue to be risk receptacles. So I foresee a day where physical therapy assistants are reviewing the RTM subjective data and helping with the RPM physiologic data and triggering us under general supervision as those values, number of people would take care of and how value-based it is will make us more and more important. So when ACO contracts are written, if we do a tremendous job of bringing value to the table, that should bring up our value. I don't understand that world, how that transitions to resources in our pockets, but that's where I need help from you guys. Yeah, I think, Ron, I think what you're saying is absolutely correct. Because there's such an evolution in this kind of distributed team-based care situation between RPM and RTM, we need to really embrace this and make sure that we're a vital player in this market. And I can't think of a better physician specialty to be involved with physical therapists and others as they do RTM. It's kind of hard to imagine, frankly, that we wouldn't be part of that. But if we're not getting ourselves up to speed, building up the education support, really helping our members, we could be quickly less relevant. And I think that there are a lot of other medical specialties and physicians who would be happy to fill that gap for us. So there's definitely a risk, which Dr. Steve Lewis had mentioned in his question earlier. And there's, Dr. Williams wondered about CPAP treatment for sleep apnea impact on HRV. How does CPAP? Yeah, so you need sinus rhythm, number one, so if you're atrial fibrillation, you technically don't have an HRV. And yes, that can complicate things. I do want to say about, POTS is a great model. I do want to say, if you talk about what I'm talking about to a classically trained autonomic specialist, they're not going to know what I'm talking about. And again, the analogy I want to make is when that car runs off of the road, it does appear that it's too much throttle. And we see that with orthostasis and we want to do tilt table testing and measure the orthostasis. But another possibility could be the braking system has gone bad. And so the HRV response to deep breathing is a parasympathetic and I liken it to the thickness of your brake pad. So it might not be that you're going too fast. It might've been, I believe we're focusing on the wrong thing with POTS management and fibromyalgia management that has orthostasis, people who have orthostasis that we need to to look at this vast HRV data as an index of parasympathetic health. There is a question also about RPM and RTM. Absolutely. They want us to collaborate and to coordinate and to case manage and so they can be built together. And they are trying to help us, believe it or not. And then Ron goes to a question from Dr. Vargo about maybe any resources about autonomic rehab potentially differing between POTS, post-concussion, fibro, PTSD. So that's why I've published this chapter. It's just a brief synopsis. It's way too dense, but the bibliography, autonomic rehab in the archives, it's exactly why it's my opinion, but the bibliography is quite powerful about what I presented today. And even if I'm wrong, it's safe and mindful and it's breathing skills at the end of the day. So I personally believe ethics-wise before you prescribe a beta blocker for POTS or you prescribe a Steli-Ganglion block for PTSD, I would recommend you have to fully flush out heart rate variability biofeedback ethically before, or you start implanting vagal nerve stimulators post-stroke. Focus breathing. And that's one of the things we found out clearly in post-COVID, people can't tolerate exercise and breathing has to come first, but the Petrino papers talk about breathing first, but that's all subjective training. I want to tighten that up with heart rate variability biofeedback. Great. Thanks, Ron. We have just a few minutes left, so I'm going to take my moderator prerogative and ask Todd and Ron, what do you guys see as the biggest near-term opportunities for PM&R to do well in telemedicine? You've got three minutes. So I'm going to answer it from a little bit of a personal bias perspective. The case that I gave about the 87-year-old gentleman with COPD, I think is absolutely something we can do today. So the group that I'm part of, Carolina Rehab and Surgical Associates, we're really dominant in the research triangle. We cover six inpatient rehab settings. We cover 21 SNF facilities. We have over 30 PAs and MPs. We treat people till their discharge, yet people are very fragile in that seven days, 30 days, 90-day window. And there's a really great opportunity, particularly after SNF rehab, to follow people and do that really simple step-counting, remote physiologic monitoring, and telemedicine so that we actually have a view into their home, because we are absolutely the most qualified specialty to do that work. And it's just a shame not to have us be helping people when they get home, because why should we be cut off after people leave? And primary care and geriatrics is not covering that well right now. So there's a lot of opportunity for us to help our patients. So I would ask for six hours to explain what I just did in 22 minutes, but I will say, I will say, I will say. So sad for you, Ron. I know, but what I will say is the hardest thing I have is proving reduced health care utilization. And that's where I need the most help, is making that argument, because this is really value-based. And I can show HRV outcome measures. I can show fatigue measures, pain measures, all these things. But then when I go to ask, how do we… I'm always stymied. And so that's where I look for help and opportunity. Absolutely. Well, thank you so much, everyone, Ron, Todd. We are OSU wearing the red for you guys. So thank you so much. Have a great day. Enjoy the rest of the academy sessions. There are wonderful things there. So thanks a bunch. Thank you. Thank you.

telemedicine

remote monitoring

physiatry

COVID-19

underserved markets

RPM payment

HRV

fibromyalgia

telehealth platforms