Welcome to Can You See Me Now? Optimizing Telehealth in Sports Medicine. This is a three-part webinar series from AOSSM. You can enter questions throughout the webinar by using the questions tab. Questions will be viewed by faculty and answered during the panel sections of the webinar. With that, I'll turn it over to our moderator. Thank you again for joining us. Well, I'd like to welcome everyone back for our third and final session on telehealth in sports medicine. And today is really, you know, an exciting portion. We'll be talking about the innovations and where we go from here. How do we make telehealth better? And how can we use it to make our practice more efficient and really expand our practices? Our first speaker today is Dr. Chad Mather from Duke University, who's been the vice chairman of our practice transformation unit at Duke. And that unit really focuses on ways to provide health care differently. And really, this telehealth fits right into that and as a new practice model and a new way to reach our patients. And Dr. Mather has been leading this telehealth initiative way before COVID-19 and has years of experience. And he's going to teach us today a little bit about making a transition from just using a telehealth visit into how to make it a telehealth clinic. And so, Chad, why don't you take it away and give us some lessons. It's good to be back for this third night of the webinar series. And I'm excited to present to you our work from transitioning from video visits to full virtual clinics. We know that COVID has massively accelerated our exposure to and the opportunity for video visits. And it hasn't always been smooth. There are some technology disruptions and challenges as well as efficient use of this opportunity and technology. And that's to be expected. I wanted to start this talk by talking a little bit about technology implementation and some insight on that. And the technology adoption life cycle illustrates our challenge as well. This is a well-known phenomenon that describes how technologies grow over time to have better support, better structure around them, that allow that early, late majority, and then the laggards to use them effectively. Prior to COVID, video visits and telehealth were largely in that innovator, early adopter area. It had not crossed the chasm as this well-known book describes. And so COVID kind of jammed all this upstream. And that's why most of us have had experiences with some of these challenges where the technology may not fully support it and we don't have the support around it to make it highly efficient. And if you've had that experience, you should. But that's not necessarily a reason to stop using video visits and telehealth, but it does give you some insight on how to move forward. Another important part of technology implementation, and this is true in any sector, is that it is most successful when it builds off of successful human processes. So technology can't come in and solve a problem. Technology can only come in and make a successful human process more efficient, more distributable, more accessible, et cetera. And so when you think about how we move telehealth forward, we need to think about how we do this already successfully in the clinic. You may also be thinking, you know, let's just go back to the way it was. It was much simpler. The shutdown is over, so I only needed to do video visits when I couldn't see patients in person. And I would definitely underscore that that would be a mistake, too. We'd be missing, again, that opportunity that has been presented. We know that video really matters. You know, Eric Strauss showed us a couple weeks ago how superior it is to telephone calls in a randomized controlled trial. And then the Rothman Group has shown us that there's a markedly increased patient preference for future use of telehealth after experiencing it. We know that it can improve patient experience primarily through improving access, time from injury to surgery, for example. It can improve the quality and also often frame it to patients as an augment in-person visits, not a substitute. And it certainly can be cost-saving, most importantly to the patient. Also, markedly saving to the employer when a patient doesn't have to take off half a day or more for a visit. And also for us, in the form of capacity considerations and overhead. Also, we know that the outcomes are great. This is from our cohort. This is a pre-COVID cohort. And looking at some of the outcomes, 93% satisfied with their experience, 90% connecting easily. This is the big one here. The 57% said this was just as good as a face-to-face visit. And then we also noted a 50% overhead cost reduction. So excellent results and high levels of acceptability. We also looked at miles saved and time saved for the patient. So the median miles saved was 125 miles with two and a half hours of reduced commuting time. And we didn't see any difference in no-show rates. And yet, barriers remain. As I mentioned earlier, to video visits. And I think one of the ways we, again, we said let's solve this by going to our effective human processes, our established successful way of seeing patients in person, and try to adapt that to a virtual clinic. And some of the questions need to be answered there. Who, when, and how do we do this? Well, who we primarily utilize them for, post-operative patients. They're already in a value-based model, and we usually see them at their three or six-month follow-ups, and more routine follow-ups. The non-operative imaging follow-ups, these are low-acuity visits. It allows us to show the images to the patient. And they previously were done by phone, so you're adding value here. The remote or busy patients, there's a huge value for the patients here, saving them lots of time. And we still do see new patients, ones that have been seen within our system. You typically have imaging or detailed notes, including physical exam. But also ones that are seen by outside colleagues. This is an excellent service to them by speeding access. And I've definitely seen this speeds the time to ultimate treatment. And, again, the key going forward for the success of video visits is going to be identifying this group, this 57% who is likely to say that it's just as good as a face-to-face visit. And that's some work undergoing right now. Those of us participating in this webinar and viewing can also do in your system, just to create predictive models to identify those patients at the time of scheduling. When do we do it? Well, I would, you know, at least at Duke, a lot of people had tried doing them during their physical clinics. We do them in a dedicated time, just like in mimicking a clinic. There's less efficient use of your physical clinic resources when you do them during a physical clinic. So I would recommend optimizing your physical clinic separately from the video clinics. We do them when the physical clinic space is either inconvenient or unavailable. So if there's capacity constraints or, say, before the operating room, where you may not be in the clinic evening or weekends. And then maybe when you are not available for a physical clinic either, when you're either on vacations or at meetings. How do we do them? We have Zoom integrated with Epic. That has been a huge step forward. We used to use Cisco WebEx, and it was very inconsistent. Here you can go in and out of a virtual room. So you can have your CMA or support staff come in, say, to schedule surgery or to do an intake. We also, I do these off-site. So I've shown that you can do this off-site without being on a dedicated professional network. I utilize one ATC and one trainee, which is decreasing staff, front desk staff. And then there's one or two fewer staff members for this. And then we utilize Microsoft Teams. This is an excerpt from our schedule here. You can see a nice full schedule, video visits. And then we use Microsoft Teams to talk back and forth about patients. We can then also open up a video if it's easier to talk in person. And through about a couple months of doing this, we have demonstrated that we are at 120% of physical clinic capacity. So I know there's a lot of concerns about video visits being less efficient. And when you utilize a more of a virtual clinic model, it can be just as efficient or more efficient. So in summary, the virtual clinic is the natural evolution of video visits. You've probably experienced them being inefficient and convenient. And they should have been because that's where it was in the technology adoption lifecycle. But that can be improved by relying on your existing successful clinic processes to create successful virtual clinics. We've shown that efficiency is easily attainable. And importantly, video adds value. And I would close by saying that we need to find a way to identify these 57% of patients and deliver them a video visit because of the significant time and convenience savings that comes along with a video visit. And thanks for the opportunity. Well, thanks, Chad, for that insight on how to move forward with a virtual clinic. Next, I'd like to introduce Thomas DeBardino, who is one of my co-chairs, coming from TSAOG Orthopedics and San Antonio Orthopedic Group. He's a West Point product and a colonel in the U.S. Army, as well as Executive Director for the Krokar Research Institute. And he'll be speaking on the importance of your staff, in particular the MAs and ATCs, and optimizing that clinic workflow for telehealth. Good evening. I'd like to thank AOSSM for sponsoring this great academic activity in telehealth. I am Thomas DeBardino, currently from San Antonio, Texas, where I've been for the last four years. My task is to discuss how I optimize clinical flow and why the MA and ATC becomes an integral and important player in this activity. I have no disclosures. I have no pertinent disclosures related to this talk. So my platform components, we've all talked about EMRs for this being our third night in a row. We have the electronic medical record. Everything has to tie into the medical record. We have an interface, oftentimes. I use a particular app called Mobius that interfaces with my cell phone, and I can walk around and interface with that app, and it flows directly into our electronic medical record, using the Dragon backbone for speech recognition. There's certainly a PACS system in all our lives. We use the GE PACS currently, and remotely I use a software application called My Medical Images. It's a way that patients and healthcare providers around the country and other radiology groups can upload to my personal secure website. So teleconference platform, the crux to the telehealth presence. I currently use the Zoom platform as I'm a clinical professor through Baylor College of Medicine, so I plug in through that backbone, which is very robust. And there's so many others out there, and there's a new one every week. The technique video site I incorporate, whether I'm in clinic, in live patient visits, or in a telehealth visit. I either direct patients to the URL, or I sit there and I go through the video with them, especially if they have specific technical questions. I can zoom in to the right minute or two of the video at play and discuss with them the peculiarities of their planned procedure. Etiquette, I think it's good to look into the camera. Patients want to feel that you're present and have eye contact with you. I say dress as per clinic. It might be in scrubs and a white jacket, or it might be in scrubs. I currently am in scrubs routinely during this pandemic period because we're wearing hats and gloves, and we look like we're doing procedures all the time anyway. Auto-mute patients upon entry. I think that's key because they don't want any surprises. You don't want any surprises. And ask to turn on video so that there's no, obviously, any surprise video visits. Park patients in a digital waiting room. I think that's important. Just like we park them after they check into our front desk, into our real waiting room, a digital waiting room with most platforms. Send an e-mail invite. I think that's critical. The whole process starts with the e-mail invite. In there, there has to be a greeting, a time, a very specific time, and a link for them to click on that's hopefully very straightforward. Here's a typical Zoom video platform type invite. It's got the start time. There's a little greeting, and it gives them the link in multiple platforms to link directly into the video. Here's what it looks like, the Zoom conference. You can see there's a participant area. That's myself and maybe if I'm in the clinic setting or even remotely. We've done this many times on off hours or on the weekend, an important VIP visit. Assistant, my coordinator, my MA, or one of my other extended providers can help getting patients into the waiting room. Here we see three patients. They're in the waiting room, numbered fictitiously, patient one, two, and three. Only upon entry do they hear anything and see anything, so that's what's nice. Then we've got the obvious share screen keys that we're all used to now. The MA and the ATC, they virtually room the patients when I'm in clinic mixing up telehealth with real patient visits. They are the IT logisticians. They teach the patients how to mute their video and turn on all the different gadgets. They confirm the logistics, and they say Dr. DiBerardino is in the middle of an unusually very busy clinic, and they confirm the focus nature of this telehealth visit, whether it's going to be to review an MRI, discuss a postoperative wound, or whatnot. And then they open the appropriate images, just like they would in our room on the big screen. They can open up MRIs, the reports, the actual visit on the EMR. All that's prepared just as it would be in real person. And they obtain the basic screen capture of pertinent range of motion and maybe a picture of a wound, just like they would come out and say, hey, Dr. Di, there's a problem wound in room two. Now they have a picture of it, and they can capture it through our many apps that secure a screen capture or a video capture even for motion. They park the patient back in the waiting room until I'm ready to see them, and that might be, well, a couple of new patients have come in, and they're over an X-ray waiting to get X-rayed, maybe some long-length films to look for something involved with varus or valgus. And then I, in between patients, will go and unpark them and see them during the telehealth visit. I entered this preassembled visit, if you will, and it greatly limits my time, and it's a very useful corpuscle of about three to five minutes only, and the patients have been engaged since they checked in. So it's really a multimedia visit. It's real-time review of MRI scans via the share screen, and it's as good or better than an in-office review because I get to capture the exact films that I want them to focus on instead of having the myriad of films up in the room. I pre-select the images, or my MA and ATC or clinical coordinators do. I can look at specific series. I can already have annotated them the night before if I have a lot of time on my hands, which is not usually the case. It's easy with a multi-screen setup because I'm going to have this all slaved to different screens and then share them appropriately. Here we're doing a patient-directed exam for abduction pain and weakness. This is just like I would do it in a real visit. It's a legitimate post-operative review of functional gains or range of motion and resistive activities, in this case a rotator cuff. So the keys to efficiency and success for all. I think make clinical assistant or the MA the telemed co-host, and that's possible in most of the platforms. Those people contact the patients. They troubleshoot the mute and video technical issues, and that's critical because you don't want to waste precious physician time trying to figure out how their speakers need to be unmuted or they're on their headset versus their computer-based speaker and whatnot. And then they park the patient in the virtual waiting room once they're completely ready for the physician encounter. I interact with the patient only after they're ready, just as it was a real clinic visit. This keeps the MD contact time to a very valuable five minutes or less, just as it would or should be in a routine follow-up or even a new patient visit in a real brick-and-mortar setting. So in conclusion, disasters and pandemics pose unique challenges to healthcare delivery, and we are up to the task. Through telehealth, although telehealth will not solve all of these issues and challenges, it's well-suited for scenarios in which infrastructure remains intact and clinicians are available to see patients. Health systems that have already invested in telemedicine are well-positioned to ensure that patients with COVID-19 receive the care they need in a timely fashion. Your usual clinic team must be integrated into these electronic telehealth visits to maximize patient satisfaction and overall efficiency of clinic flow. Thank you. I look forward to taking some questions in the group session. Thanks, Tom, for that talk. I'd like now to introduce Dr. Christian Latterman, who is a chief of sports medicine at Brigham and Women's Hospital and serves as the director of the College Research Institute there. He's a leading expert in college research, but today he'll be speaking on, as serving as a chief of sports medicine, how he has organized a group's effort in implementing telehealth. In particular, how to get those land adopters to adopt it to help expand not just an individual's practice, but a group's practice and footprint in the region. So take it away for us, Christian. Good evening. My name is Christian Latterman. I am talking today about how to organize a group's practice telehealth efforts. I have seven minutes to give you an outline of that. I do have some disclosures. Telehealth and sports medicine in 2019 was at best really an afterthought. It was generally an awkward setup, required specific computer setups, a lack of streamlined sign-ons for patients. And at the end of a regular clinic day, this was really not what anybody was looking forward towards. And it was often met with uneasiness by the faculty. They considered it a waste of time, rather preferred regular phone calls from the car on the way home or things like that. There were also technical issues with connectivity, no real space to set it up, and specifically in rural areas, difficulty with the Internet connections. In addition to that, there were legal and reimbursement issues, issues with practicing across state lines, and then also no reimbursement for the pediatric patient visits. So it was generally not considered to be an option. Then COVID happened, as we all know. And in our particular situation on March 7, that resulted in a complete close down of our practice. All visits were canceled for the next four weeks. Seven days later, there was an emergency order that was passed down from the state government. And that really changed the game because suddenly telehealth visits were reimbursed, video or phone calls, at the level of regular outpatient visits. It was allowed and tolerated across state lines, and there was some legal protection in general during that time. At the same time, in our institution, this led to an extremely rapid ramp up of initially an EPIC-embedded virtual visit system that later on, within about a couple of weeks, failed and was switched to Zoom. And then as an alternative, we also had Doximity Video Dialer as an alternative that was allowed. This whole process took a week or two. Nothing happens in a week or two in an academic medical center, but this actually did happen. FaceTime in general was discouraged, but could be documented as a telehealth visit rather than a video visit. So how do you teach an old dog new tricks? How do we convince particular colleagues who are really not that familiar necessarily with computers how to do this? Well, there was a necessity. Patient care came to a halt. In-person visits were disallowed unless there were emergencies. No surgeries really happened, and there was a significant urge to connect and take care of our patients, obviously, and all of us. Plus, suddenly, a lot of the faculty had time at their hands to actually try to work these things out. So there were no clinical duties and a strong encouragement by our leadership to learn telehealth. They made webinars available, educational emails, one-on-one Zoom sessions, which really I believe made a difference. Things that had to happen in order to make the virtual visit platforms actually work for us all did fall into place. First thing, we needed to create a front-end registration system that admits patients through a web portal. You can see an example of this right here. That is followed up with emails, instructions, personal phone calls, or one-on-one help if needed. It's fairly time and personnel intense, but once it's set up, it works. We needed to have IT access for faculty and staff. That means Zoom accounts had to be set up. Some people needed actually PCs or laptops at home, which they didn't have. The admins had to have adequate access at home in order to do these top steps here in order to get the registration set up. The internet connectivity had to be improved in some people's households. Then other things like PDF scanners, for example, needed to be bought for individual admins, particularly, but also physicians in order to be able to take care of the actual paperwork. The other thing that was important were frequent exchanges between the faculty on tips and tricks, how to time visit, set up to deal with dropped calls, learn multitasking, and then also the use of smart phrases and macros because our little wishbone microphones that we like to use really had to be moved over to either smartphone dictations or smart phrases during the visits. These are our actual numbers. If you look at this, basically, before in sports medicine here, before March, we didn't do any telehealth visits at all. Spine in our department did a few because they were trying to trial this. Then suddenly within a couple of months, we ramped up to close to 500 visits a month because this was a time where we basically didn't have any other access to our patients. It has since slightly gone down, but you can see we're still doing about 120 visits a month in telehealth in sports medicine to a grand total of over 2,000 visits over the last six months. If you look specifically into sports and you look at MDs and PAs and new versus established visits, obviously, during the time where we were shut down, there were a lot of visits, particularly established patient visits, not so much new until later in May and June, the numbers of new visits went up and it has come down since then again. Most of the visits that have been done now are established patient visits. I'll show you in a little bit why. PAs generally fewer visits overall, but pretty much the same distribution. How does it really break down by physician-relevant factors and satisfaction? In part of our MDP institution, Adam 1040 from the Spalding Institute looked at that very carefully and he found, for example, that telehealth use prior to the crisis was very low. The numbers of visits until physicians were comfortable using it was typically it was typically somewhere between a one and four range and then most of them were using Zoom. Obviously, there were barriers initially, reimbursement concerns, lack of knowledge, and then time. However, those were overcome. Would they use it in the future? Pretty much everybody says yes. The majority of visits were really follow-up visits, follow-up for imaging and maybe test results. Interesting is that the overall satisfaction rate of our patients was generally very high. One of the concerns when you're doing these virtual visits, obviously, is that it may not be accurate. To be honest, I think that may not be true. Bradley, for example, looked at this carefully and looked at shoulder exams and he really showed that the overall diagnostic accuracy, both for in-person as well as for virtual visits, is equally poor to moderate. I'm not sure that that is really so much of a determining factor, particularly in the days of better imaging. I think what it has taught me, for example, is to listen more to my patients. Many of the exam findings such as range of motion, for example, can fairly easily be demonstrated on video. A couple of tips and tricks. 15 or 20-minute visit times seem to be working best. Stay up front to the patient that we have 10 to 15 minutes and end the visits two minutes early. Why? You see here a timeline over a 15-minute visit. You start up, you set up the computer screen, the patient file is pulled up with the demographics and the phone number and the Zoom call is enabled. You wait for the patient to sign on. Enter the phone number into the Doximity dialer at the same time. Wait for the patient to connect. If at two minutes there's no connection, then call the patient with the Doximity dialer with the number that you already entered. If the patient answers, ask if they have a smartphone. If so, send the video link text from Doximity and start the visit. If not, you just do it as a phone visit. Then pull up the wrap-up or text entry. Populate the virtual visit template while you talk with the patient. Structure your conversation according to your template. Now if you can't do that, then you just have the conversation and you don't fill the template at the same time, but that typically means you need to add that time at the end of the visit. If you dictate, then you have to do that. If not, then you try to finish that note while you're talking with the patient. And at the end of the visit, you text your admin or PA for special needs, i.e. difficult order entries, special appointments, etc. If you do not connect with your patient after minute five, cancel the visit and reschedule. Other things is build in a fake visit every other hour. That allows you to catch up or do a bathroom break. Determine with which visits you want to virtualize. For me, for example, that is mostly post-ops, simple cases within global period or six-month, 12-month follow-up where I don't expect any significant issues. If there are, then ask the patients who come in for an in-person visit. Patients with OA, most of the time they are not properly treated, partially treated. A lot of things can be done, not particularly on the non-operative side for which you really don't need to see the patient, to be honest. Outside referrals that may need additional imaging, have unrealistic expectations, etc., second opinions. Those are things that I like to pre-screen in a virtual visit to make sure that when they come in, typically from longer distances, this is not a wasted visit. MRI CT follow-ups, I think that's a no-brainer. And patients that have two pages of questions, one family members involved, etc., sometimes it's better even after you've seen them in person to then schedule a virtual visit later as a follow-up visit to answer other questions if necessary. How do we do this today? Most board faculty do virtual visits one half or full day a week. The timing is for some after the in-person clinic, for others they use a separate day and combine it with an admin day, that's what I do. Either from home or from the office, that's dealer's choice. The access has generally improved despite limited inpatient visits per day. And that's interesting and I think that is one of the things that we have seen with the virtual visits, that even though our overall inpatient numbers are lower, the virtual visits can make that up and our volume at this point is almost back up to near normal. How do we plan to use telehealth going forward? Somewhat dependent on reimbursement, of course, but if it stays this way, then we plan to create a virtual urgent care concept, a 12 to 18-7 concept, where APPs are the first contact and then physician contact is done once imaging and initial assessment is done. The integrative part of our access improvement strategy is tightly linked to telehealth. It improves patient satisfaction rates and I do believe it is here to stay. The caveat is that, of course, not all geographical areas are able to accommodate the necessary connectivity. Thank you. Well, thanks Christian for giving us your experience on how to organize a group's effort. Now I'd like to introduce Dr. Jeffrey Dugas as well as Glenn Dortch from the Andrew Sports Medicine Institute. They'll be talking about how to implement telehealth into your training programs. Dr. Dugas serves as the ASSM Fellowship Committee Chair and Glenn serves as the Director of Education at the Andrews Institute. So go ahead and take it away guys and teach us how to teach. Good evening. I'd like to introduce my co-speaker, Mr. Glenn Dortch. He's the DIO for the American Sports Medicine Institute here in Birmingham, Alabama. I'm Jeff Dugas, the Program Director for ASMI's Orthopedic Sports Medicine Fellowship and we're going to talk to you about incorporating telehealth into training programs. Here you see our disclosures. As we all know, the ACGME accelerated their implementation of telemedicine as a response to COVID-19 and with most, as with most things ACGME, the key aspect is the supervision of the fellows and they have definitions of direct supervision as you can see here on this slide and then we'll have another definition on the next slide. Dr. Dugas will walk us through. So the new common program requirements that came out permit faculty members to provide direct supervision through technology, through virtual patient visits. How this is done is made at the program level so we have to decide that and how we use it. They're not going to mandate it or even and script it but we're going to have to decide those things. It's not a mandatory thing but it is allowed. It's also possible for them, the residents and fellows, to conduct these things on their own and then discuss it later with faculty or it's possible to do this jointly with a trainee and faculty together. We found in our program with fellows, we don't have residents in our program, we found with fellows, that in most cases the fellows were capable of doing most of the visits themselves and we shared the work with them. We divided and conquered and we found this was a good way not only to teach and interact virtually and review clinical situations but also to give them some autonomy to practice, make decisions, and evaluate things independently. So one of the important things is how to know where do you start and obviously you have to start with a technology platform. We chose to use a platform called Doxy.Me. What we liked about Doxy.Me was that it created a virtual waiting room and basically in doing so our staff was able to send an email to the patient and create an appointment at a specific time with an email link to a virtual waiting room and they logged in and we logged in and I was able to click on their time with their name and do a virtual visit with them. It was video and audio, obviously relies on Wi-Fi and a digital connection which is important and so you have to get your technology, your IT people involved because they have to be able to set these things up as well as make sure that your hardware can handle these kind of things. It's a communication channel so there has to be the ability to interact virtually so video, audio, texting, things like that. You may even have the ability to share diagnostic images and so performing a clinical assessment requires a history taking. Obviously there's some discussion, there's some interaction. You may ask the patient to show you some things virtually in terms of physical exam but there are limitations and you have to know those limitations. It's also important to document how much time you spent, that the visit was virtual, that it was video, how many minutes it was and what the nature of the visit was and that there was a consent on both parts to do this virtually. Other things to consider is the alternative between in-person and virtual and allow, if you're going to do in-person visits, allow the staff time to disinfect rooms, distance your patients and facilitate efficient scheduling so you don't have too many people in a building when there are restrictions on those kind of things. It's very important to provide clear communication to your patients with regards to the timing of visits and surgery and all those kind of things and so we found at Andrew Sports Medicine that the more clear we were with patients and the more definitive we were with their time commitments, what was expected of them, what the process was, how frequently we were disinfecting, what are what our measures we were taking to keep them safe if they were going to be in our building were taken, we found that to be very important. The patients told us in feedback scenarios how important that was to them and that that was one of the more important things they felt in certain deciding to do an inpatient visit. Virtual appointments are helpful in a multitude of ways in underserved populations, people who can't get out, people who choose not to get out, people who choose to stay home, they're afraid of contracting the virus, we have to respond to those people and make it possible for them to. All right, so some of the pros and cons, most of these are pretty obvious, but obviously the ability to provide care without exposing the patient or the provider to COVID risk, that goes without saying, but there are also some direct cost savings as far as personnel materials, travel for the patient, some other things like that. The cons, in general, the patient has to be physically located in the state where you're licensed. That's not an always or never thing, but in general, that's the thought process. It definitely changes your workflow in clinics, so that needs to be thought about, and the possibility of increased medical legal exposure due to making diagnoses, recommending surgical treatment, and following up with the patient without the ability to perform a regular physical examination, and then obviously technology limitations for both the patients and the provider. It's important to know that COVID-19 was not the genesis of telemedicine. We've done telemedicine with patients from a distance for a long time, but it is important to note that the reimbursement for these things is different from payer to payer, state to state, and you'll need to know what those limitations and rules are before you start this. In a lot of places, if you're not in the same state, you will not get reimbursed for your time, and so you have to decide if it's worthwhile to see those patients at that time virtually. Our experience has been different than a lot of places and similar to others. At the height of our stay-at-home order, which was back in March and April, about 90% of the care that was delivered by our clinic was done by telehealth. The faculty and the fellows had to be trained in the technology. We all went through a training, and we had to rely heavily on our IT people to make those things happen. When there were problems with Wi-Fi, when we had problems at home, we had to rely on people with IT experience to make those things happen. It completely changed our workflow. We went from a certain number of patients and surgeries to virtually nothing. I can tell you personally, I did not go to the office for six weeks. Now we're in October, and we're basically back to normal. I would say we're conducting less than 5% of our patient care via telehealth. We're back to full surgical volume, and Alabama has been open for business for a little bit. Things are fairly normal here at this point. Here's a screen that shows the FAQ questions we have on our website for patients to get acquainted with everything before they come for their virtual visit, questions that they're able to ask otherwise that we don't have to get on the phone or try to walk them through. Again, on the right side of the screen is a tutorial on how to use the DocSeeMe app for them when they actually come on for their virtual visit. It's important to know that with these type of virtual visits, you may require more than one technology platform or more than one computer or more than one screen. When I did these, I did them with a laptop or a tablet for the visit, and I had a computer open with our electronic medical records so I could access patient records. You could do it all in one and switch back from tab to tab, but it's important to be able to access EMR so you have a full set of information when you're doing these kind of visits. In summary, I think telemedicine has been and will continue to be here to stay. It's important to train the people that are in our fellowships and residencies how to use these technologies and how it's appropriate to use and what the rules and regulations are that govern these things. It was required as part of ACGME during the pandemic. I think it'll remain a part of our everyday lives going forward, and it's important to understand the technology and have support for the technological side with IT people. The flexibility and workflow changes that it allows and creates may be important down the road, and I think its place in our future is uncertain except to say that it's likely here to stay. These are our references that you've seen throughout the presentation, and Dr. Douglas and I would like to thank Dr. Brian Boscone for his help in sharing some of his slides about telemedicine for us to use in this presentation. Thanks, Bri. Thanks, Jeff and Glenn, for giving that talk on how to teach our trainees about telehealth. We'll move now from the optimizing telehealth into the innovation section of this webinar. So I'd like to introduce Dr. Ronald Navarro from Kaiser Permanente in Southern California, where he's a director of perioperative services. Kaiser is one of the largest HMOs in the country, and has a very unique delivery care model, and during this telehealth and COVID-19 period, they've come up with a pretty innovative way in providing care, and they've really flipped our traditional model. And so, Dr. Navarro, provide us some insight on the Kaiser experience. Thanks. Flipping the preoperative workup with telehealth. Hi, I'm Ron Navarro. I'd like to thank the AOSSM for this webinar series, and inviting me to kindly fill in for Dr. Tejuani, who could not make this webinar. I'd like to especially thank Dr. Lau for his kind invitation. Many of the presenters have had insightful comments, so apologies for that. But I'd like to thank Dr. Lau for his kind Many of the presenters have had insightful comments, so apologies for any redundancy. I'm not a futurist per se, and I hope my slides provide some food for thought. Let's get going. I have no conflicts pertinent to this presentation. Thank you. Brief moment to explain the Southern California Kaiser Permanente Orthopedic Book of Business, which I help to oversee with 13 medical center chiefs. There are over 4.7 million patients covering over 56,000 square miles in Southern California, from just south of Santa Barbara to the Mexican border, and from the Pacific Ocean all the way to the Inland Empire. Those 13 orthopedic departments and chiefs then comprise over 210 orthopedic docs, over 130 orthopedic PAs, not counting spine and podiatry, which also work in tandem with us. For an understanding of our size, we did over 14,000 hip and knee arthroplasty cases last year. It's important to understand that the COVID altered world has changed the way we think about everything. So maybe it is not the post-COVID world, but the COVID altered world, as things won't entirely go back to normal as this learning from COVID-19 has changed the thinking as it relates to our health, health care, economy, and maybe even national security. For us in Southern California Kaiser Permanente, you see a classic COVID-19 virtual or telemedicine story. You see our daily volumes on top, the percentage of face-to-face in the middle, and the percentage of tele and video on the bottom. Next you see the change in the total volume as well as the percentage face-to-face and tele flipping at the time of the California stay-at-home policy. Then you see at the end of the first surge an increasing volume and changes in face-to-face and virtual with face-to-face becoming more once again but a larger percentage of virtual or tally and video at that time. I do want to point out though that our PAs never became more virtual as you see here and their volumes dropping and then rising but the face-to-face and virtual components never crossing one another as you saw in the total grouping. It's important to note that. I do want to mention contextually because it's important for this general topic that I'm speaking on today that we saw that there was a silver lining of innovative care out of the back end of the COVID-19 pandemic. We took this opportunity to innovate and look at the possibility of different thinking to virtualize lean care that was condition focused based on the ability to create capacity and give good patient value in the process. One example of this is the condition for knee pain that you can see here where there are multiple inputs by patients into a system that deals with this condition and then multiple eventual outputs after diagnostic imaging such as x-ray is performed. We believe that for this condition of knee pain they will patients will be able to earlier see a specialist, have more of their visits be virtual, have less wasted visits and ultimately end up being a happier patient as they speed to eventual full determination of what the problem specifically is with true diagnostics and full-fledged treatment regimens. Why the move to telephone or video pre-op? Let me give you some examples. Patients like avoiding returning to the clinic for more than one visit. The virtual push predated COVID-19 and this pandemic. The move to more telemedicine has certainly been accelerated due to COVID-19. We believe that condition based care redesign and one touch or less touches surgical episodes of care as I showed in the busy slide earlier are part of the future at Kaiser Permanente and the tele pre-op is a virtual piece is just complimentary and supplemental and additive to that grouping. Further, loosening of regulatory rules at state and federal levels provides an opportunity for us to explore these new ways of thought specifically to telephone or video pre-op. Will these rules tighten back up in the future? It's hard to say. The informed consent is just as effective over phone in our belief and to many it's a copy and paste session in the pre-op session for many anyway. Will the revenue opportunity of billing for pre-op be on the cutting block as the federal government tries to find ways to save money and the cost of care of health care delivery? It's hard to say as well. There are some potential limitations of a telephone pre-op. Some of the can'ts and this is just a partial list include you can't do a consent at the same time, you can't give crutches or a brace in advance so that training may have to occur at another time and the patient cannot pick up their postment operative meds simultaneously so a visit to the pharmacy might have to be done at another time. As well there can't be a sign off on the work note and this has to be done asynchronously but we know that in this time of electronic medical records and emails of the patients into the medical record environment via this electronic means that can be passed from one to another in a asynchronous and simplistic way. Some other potential limitations include especially from my system and other integrated systems you can lose out on care gap closure meaning telling the patient at the orthopedic visit that they might require a mammogram or hemoglobin A1c and for chronic disease coding the acuity of the population at per this chronic disease coding can help in determination of payment for the next year in a prepay environment like ours so you lose opportunities for that. It's likely that there's less revenue opportunity in a telephone pre-op and it's a PA's issue for some practices as PA's or physician's assistants perform the pre-op and so maybe it's a non-issue for this webinar series we could maybe discuss this later. Here you see our track as more telephone pre-ops are being done in orthopedics and the next slide shows the differential uptake by different medical centers within our system. I was able to get regional data and here you see OBGYN, orthopedics and urology are the biggest adopters at this time and trending larger. As many of you know the CMS has proposed changes including the elimination of the inpatient only list over a period of time and with complete phase-out by end of year 2024. This is going to provide good opportunity for ambulatory surgery centers and there is a comment period but it seems like this is theta complete as it comes forward. There are other changes including the virtual elimination of a full-fledged physical and instead a focused assessment that's coming. I don't think we should be sleeping on these changes because they also have implications for things like a telephone pre-op. So in conclusion virtual medicine is poised to dominate care delivery in some way shape or form. COVID-19 pandemic has sped that transition. We are trying to transform care in KP and there are many reasons for that transition. There are some limitations and I think that telephone pre-ops are a piece of that activity. We keep value in mind while transforming care delivery. We measure our results and iterate over time and my prediction is that telephone pre-op is here to stay. We are still learning, trying to earn customer business and survive just as everyone else is. Thank you very much for your time and attention. Thanks Ronald for that talk and teaching us about the Kaiser experience. Next I'd like to introduce Dr. Lee Kaplan who is the chief of sports medicine at the University of Miami as well as the medical director of the University of Miami sports and a team physician for the Miami Marlins. So like many of us he is on the sidelines a lot and he's developed this app called SirenMD which provides sideline consultations for sports medicine injuries and so he's gonna be speaking today about that app and his experience on utilizing telehealth on the sidelines. So take it away Lee. This is Lee Kaplan at the University of Miami. Today I'm talking about managing athlete health on the sidelines. My disclosure is that we will mention SirenMD and I'm a founder and shareholder in SirenMD. Sideline health. Currently the medical treatment teams rely on insecure and ineffective communication channels. Most caregivers coordinate through text, email, phone calls, and consumer apps. These aren't secure. This process is wildly disorganized, inefficient, and creates bottlenecks in patient care. We've learned is to take care of patients on the sideline and when they're in practice and we're in our clinics is communication is critical. To me health care is communication. Timely communication drives patient-athlete safety so it's critical to give and deliver health care efficiently. If you don't do that there's a high cost both time off from the field in the court and the doctor-patient relationship as well as the coaches relationship with the physicians. I have a situation similar to many of us in the AOSSM. I take care of a college athletic program. I'll practice within the university health system as well as our professional baseball team in town in Miami-Morelands. So how do you take care of multiple people at once? A lot of it is just good communication. What we've used and you can use many things. There are other consumer apps you use text messaging etc. We use SirenMD and to do that we have the ability to have multiple teams in one place. So whether you're using this technology or others organization and then making sure that whoever you're talking to is limited to the need-to-know basis as required by HIPAA. And then tailoring your care team so that they're really understanding exactly what you're up to and at what time a patient is injured. Part of this is advantageous because you can continue to increase the caregiver specialties. So for instance we have concussion involved and radiology involved on every one of our teams. I have found that coordination drives better outcomes. The more you can communicate not complicate things by passing messages through or the old game of telephone and the communication where you have to repeat yourself or have multiple phone calls. It's really helpful if everybody is doing it around the case. So we've tried to do is improve patient outcomes and increase the efficiency of care and the quality of care through doing this. Remember quality is defined as efficiency but also effectiveness. So how you do it and making sure you don't have to repeat yourself is important. So for instance a player is injured we can utilize this technology or you can utilize others but let everybody know there's injured. Once that happens and the patient is notified and the doctor is notified you can go on and respond. So this is an example when the team was on the practice field as well as you could have an example when they're on the actual pitch or actually on the game field or court. And then once the MRI is ordered you want to make sure that you have the ability to get that back and review the MRI in real time. The other advantage of using this system or a system like this is everybody can review the same information at the same time and the ability to have the imaging in a cloud allows you to do this. We have found that centralizing primarily around the individual case for the individual athlete rather than around the communication between everybody is important. What that does is it allows communication to go back and forth and move forward. And as long as the patient care is being facilitated along the timeline their care will be good. So this we're going to now move into a video. This video is showing the technology that we've used. You can see that SIREN is a platform on the phone. It's also a platform in other ways. It can be utilized both on a hard drive or a desktop as well as on a mobile. You have the ability to have people in red or really prioritize. And the back and forth communication that is done can go through. So this is an injury to a knee. The picture was taken. It goes directly to the cloud so it's not on the phone or HIPAA non-compliant. You can actually have an uploading of the scans. It's been very helpful and I have multiple teams in multiple places to be able to look at the scans in real time. These obviously are the scout views and then we can go into the regular views as well. It's important that you have a high quality scan. You can visualize whether on mobile or on a desktop. But we can go through this knee MRI and evaluate exactly what's going on and communicate with the people that are actually in that location. I like to use voice messaging to talk back to the other caregivers and everybody will receive the information at the same time and it's all documented. This documentation of information and when it goes through also democratizes the data. So whatever system you use, allowing everybody involved, the assistant trainers, the trainers, etc. to know the other physicians is very helpful. We found this extremely helpful in a concussion environment where a concussion specialist may not be on the sidelines but he or she can get involved by not only sending back tests such as impact so that we know what the baseline is, as well as do video conferencing and telehealth directly. So we have the ability and we'll show you to do telehealth on this system or you can use it on other systems as well. And this will allow you to have media contact. We have found that especially in the college athlete where the parents are often involved or the grandparents knowing that the concussion specialist has seen or talked about the case has been very valuable. This is an example of a hand fracture. We have the x-ray and then after the x-ray we can actually use telehealth to have the trainer show us the hand, go through it, speak to the patient. We can look at the x-ray. The x-rays can easily be uploaded or you can take a picture of the x-ray. But then just by tapping the face, this is Vinnie Scavo, our head trainer at the University of Miami, we have the ability to voice or video call. So we use this functionality from the trainer, especially nights and weekends, so that the physicians can actually see and speak to the trainer and the athlete. We found that it's very important for the athlete to know that we're involved. So here in the example, the athlete can show their hand, you can see the dorsal swelling, but they're able to move everything and we can rule out a fracture without having to be there. This has been very accommodating to everybody involved. And you can leave a message on either this or whatever technology you use that can be downloaded at a later date into the EMR or whatever system you're using. It's great once these are posted or everybody is communicated to know that everybody's on the same timeline. So one of the importance in sideline health is to make them feel as if if you're not there, you're there. Or if you are there, you're doing the things that are our basic principles of, you know, bringing no harm and making sure that you have a high level of communication to get the athletes back to the condition that they can be in. We've used it with COVID. With COVID, it's been very important to let everybody know in real time who has or has not had any illness. And by knowing what their testing results are, we have the ability to immediately start contact tracing and move forward from there. We also have a list of all COVID positive patients. We know what date they were positive. And so it really has been helpful organizationally to use technology as part of sideline health within COVID. Obviously, the faster you can quarantine somebody or bring them away from the masses of the rest of the team will help you get the best level of care. We've also included not only the physicians and the athletic trainers, but the athletic administration in COVID care because of their level of importance from an administrative standpoint, a conference standpoint. Thank you for looking at our way of handling siren health and sideline health and siren MD at the University of Miami. You can utilize any technology that's out there and available. This was our choice. We look forward to the discussion that follows. And with that, I'd like to invite our panelists for this evening to turn on their webcams and mics for the panel discussion. Well, thank you, everyone, for those great talks learning a lot. There's a lot of things that questions that have come up. I want to make sure I get to at least most of them. Let's see. Chad there. Yep. So the first one was was for Chad, but I think others can answer this as well was kind of, you know, how is this virtual clinic capacity affected your quality of life, or maybe your PA's quality of life? And that question was directed toward Chad, but I think, you know, Christian can answer that in terms of, you know, promoting that amongst your faculty, whether that's an incentive or not to use it more, and then the other faculty, how they feel like it's changed their quality of life using some more of the virtual stuff. So we'll start with Chad. Yeah, I mean, I've, I really enjoy it. I enjoy being off site. And every now and then allows you to help out a little more with kids there, because you can, they can be home with your home. And, you know, I mean, it's just a nice change. You have a cup of coffee, there's just a different pace. And I think for me, you know, I like to change it up. I don't like doing the same thing all the time. And I think that, you know, that's a nice thing about it. I have not gone like way, way off site. Although, you know, I have some, you know, my dad lives out in the mountains. And so I plan to plan to try to roll this into working out there and here and there to do some clinics. And I do think, you know, it also is an opportunity to engage the staff, you know, we have a lot of us have younger staff, and the more talented they are, the more unique things they want to be doing and more stimulated they want to be. And so, you know, it's a way to keep, you know, I think higher performing staff happy and as part of the team. Yeah, I mean, for us, it's kind of similar, we were in a fairly unique situation, because we had a very hard shutdown. I mean, we were literally closed for three months completely. And, you know, what the telehealth approach here allowed us to do is essentially pick up the shambles, if you want. So and start putting stuff together, it requires a lot of communication up front, I kind of, you know, pointed that out in my talk. But the interesting thing is, is we have basically two different kinds of adopters, we have people who say, you know what I use, I don't really like it, I didn't like it much. And they are back to pretty much full operations clinically. But we also have probably two thirds of our faculty in sports who are still doing the video visits, I do one half day a week, where I basically do anywhere around between 15 and 20 of these visits up front, my PA has a virtual visit clinic open every day of the week, and several of my colleagues do it that way. The other thing which I think we haven't really talked about, which is really important to understand is we have several faculty with young children. And they have significant issues with childcare. And for them, that allows them to continue their practice and allow their spouses to actually continue whatever they are doing in terms of work, and still, you know, do productive work, but from home. Yeah, I think that's, that's a really important part, especially with all the changes that are happening. Another question for Christian that came up was kind of, are you guys advertising this to the community? Like, how are you advertising it as part of your practice? And that's a that's a little bit of a of a sensitive question right now, because we are in the middle of a complete revamp of our entire sports operation. And so right now, we are not doing any advertisement whatsoever. But this will be a very large part of our overall advertisement strategy. In fact, actually, we are right now, kind of a little bit along the lines of what Ron was talking about, we are essentially standing up almost a virtual hospital that where sports is going to be a large part of and we are basically creating a virtual urgent care clinic for sports that will be covered mostly through APPs and allow us for direct access to, to MD physician care within 24 to 48 hours. Yeah, I mean, I think we have a virtual, not virtual, we have our in person urgent care, which has been very useful in capturing patients, I think the virtual aspect could make a change the ballgame even more. So I think that's a really interesting kind of piggyback on that, or Ron, you know, your model that you kind of described was pretty unique. It's, I just wanted to confirm it, it sounds like the patients are all being seen virtually by you pre op, and you're basically meeting them on the day of surgery. Is that kind of right? You know, we were designing currently three work streams. And certainly the one touch deal is specific to some of our hand swim lane, the knee minisectomy, we picked just the biggest volume cases. So we did total knee, knee minisectomy and hand and carpal tunnel. And so hand is first time you see him, the hand surgeon sees him is on the day of surgery, but they've been seen and dealt with before that we believe that patient reported outcomes and some of these things like CT6 is a sports thing, but that can tell people that they have a carpal tunnel when you just gotta answer the six questions. So clearly we do that one touch. Knee arthroscopy, minisectomy, really high volume case. That's maybe one touch, one visual by the surgeon before, but we can probably do that one touch same day of surgery because the PA will talk to them on the phone. If the MRI shows the tear and somebody touches them one time, the surgeon can certainly see them the one time and never follow up with them again. Maybe a phone call post-op after the minisectomy and maybe one visual by the PA at one week out for wound checks. Total knees a little bit more, we're leaning out every single episode of care to kind of remove wasted visits. We're basically a big cost center, so maybe some of you who wanna see people more because you're putting the ducats in your pocket, that's just not my deal. And so we just gotta lean it out as much as possible, but keeping patients happy and they can always jump back into face-to-face if they need to, but that's kind of the general approach. Yeah, so you have a unique model that all your referring docs are in the same network. You've probably worked with them before and you can trust their exams and everything. But a question I have is how are patients feeling about it? Are there patients who are hesitant about anyone that changes, hey, I actually wanna see you before and like what's the process of allowing them to do that? Yeah, they can call back in to clinic if they need to be seen face-to-face. And so we always have exit strategies for them to come back into face-to-face visits, certainly. Okay, one of the other questions that came up was for Tom. Now you had talked about using your MAs and ATCs to kind of help set up the patients, but as a director of research out there, how are you doing PROs or everything? Is that part of the virtual visit? So we do a lot of SOS for the PROs virtually and we've been doing that since I got here from 2016. So this just kind of made it simpler. We have that as part of our template and part of our kind of invite is to, hey, make sure you've, if you're waiting for Dr. D in the waiting room virtually, make sure you've caught up with your SOS PRO. So we actually, and that's part of the visit. So it goes into that crucible of five minutes that I spend with them feels like a half hour because we've engaged them the minute they logged on to the minute we let them go. We still have them virtually. They're not taking up a piece of leather seat in the hallway. They're not taking up room and radiology and we don't have to clean up the room and turn it over in this COVID pandemic era. But there's a lot of value added cost savings and efficiencies built in, but we've got our hand on it virtually. So we can have our research assistant come in. She can scour the templates electronically and she can say, oh, I'm gonna pick off this one today. This one's recalcitrant. This one needs a phone call. We've got them right there electronically. And we just send them a message and a link saying, please take care of your six month follow-up or your three month, whatever it is that they need to answer on the PRO piece. Yes, I would think that people who are using virtual are probably more technology savvy and probably can do that easily. So it sounds like it's probably helpful for that part of it. Thank you. I'd ask the group doesn't, for every 10 people, one person who thinks they want to be seen face to face, there's 10 who don't have to find parking, come in and waste time. So a lot of people like this, especially like some were showing with video. It's amazing. Yeah. And then I kind of want to pull the fact because we've had throughout the different talks, some people are saying that they dedicate a separate timeframe for the telehealth visit, where some people are saying they're kind of weaving it in between patients. And Jeff, maybe how are you doing your trainees? Are they kind of simultaneously doing a virtual visit while you're doing an in-person visit? Are you giving them dedicated time to see their own patients virtually? Like how are you guys doing it there? You know, in Alabama, we're kind of back to normal. I saw a regular clinic today. I saw 60 patients and I had one telehealth visit from somebody who was 10 hours away that didn't want to drive back for a post-op visit, which I would have done by Skype anyway. So what we see, our practice is very different from many other practices. And I would caution anybody to equate the practice that we have with anybody else. But our patients don't want to do telehealth. They're not in for that. And we've heard that over and over, we've offered it and offered and offered it. And they want to come in. Yeah, they don't love the parking, but we've managed to keep people distanced and create some efficiencies where there's not as many people in the space. The fellows are doing some telehealth visits, especially for the first post-op visits. They've been able to do those things. But, you know, the patients in Alabama and the patients that come to us, they want to be seen. So I would say it's a different patient population maybe that just doesn't want to do telehealth. And anybody that wants to, we're happy to do it, but we're not pushing it. We're not pushing in-person visits, but the patient population is very much pushing it. Well, Tom, maybe you're kind of an advocate for kind of squeezing in the patients between other in-person visits. Do you find that's hard to have three MAs and ATCs keep up kind of doing both simultaneously? No, it actually, it gives them a little break because they're digitally doing things anyway on the computer, getting EMRs ready, putting images up in the big room on the big screen. Now they just put it up on my laptop. If I'm in a room talking to someone who needs an extra special talk, it's their fifth surgery or whatever, they know they go, oh, they've got time. They go over on my laptop and they key up the next couple. They pull the images up on the slave monitors. They put them in the virtual room and say, Dr. D's five minutes out. And they queue them up like it's, you know, an airport sort of. They're like the air traffic control ATC is what I call them. They're really running the ship and it really empowers them. They have a little bit of ownership. They're helping make it efficient. So they get a little lunch. Maybe we get out on time in the evening for a change. And actually we just let them stack them in as they come. I don't have slots for news, slots for follow-ups, slots for post-ops. We just stack them in. I never want a patient to call and say, I want to be seen at 11. Dr. D doesn't have a new at 11. He has one at one. I'm like, I don't care. It doesn't matter to me. A news is as simple as a follow-up, a virtual follow-up, looking at a wound on a screen. I'm color-bind. I see it better on the screen because I can change the brightness sometimes. So there's a lot of different ways to do it. And I like to be, the young fellows have taught me this. They're like, hey, just open it up. Just see what happens. And when we did that, patients were happy and it didn't overburden us. And we actually became, we were playing reverse Jenga. We could stuff in telehealth in between big visits and little visits. People go off to get x-ray land and you're like, where'd they go? And they're like, hands in clinic today. It's backed up a lot. Everyone gets an x-ray. So to us, it really worked symbiotically. So for my clinic, I have a lot of big patients, big high volume, they bring in a box of paperwork and op notes, and then the new ones, they just want to get an MRI and be seen for their cuff tear. So we really figured it out that it kind of takes care of itself. The volumes have dipped, kind of gone up and down. Now they're starting to go back up again for whatever reason. People like it because we tell them preemptively, hey, here's the menu of what we're gonna do. We're gonna see you preemptively, that's today. And then, hey, you have an option for telehealth for this visit and this visit, because you live in Del Rio, which is five hours away, still in Texas. And they're like, well, that sounds good. That's a long drive. That's like 20 bucks in gas. And so they look at it a little bit differently in the big state of Texas from that standpoint. And I would say that's true for us too. The follow-up visits, especially the first post-op visit or two, I think people are much more receptive to that. The complex problems, the athletes, the high-level athletes, they're not gonna do telehealth with you. They need to see you and test you out and kick the tires and all that stuff. We haven't found those guys willing to do that. Lee, what's been your experience with higher-level athletes in terms of telehealth? Yeah, we've done a couple of follow-up visits. We've actually used it to talk to the teams and the agents. We've had to discuss things, but there's not anybody that I can think of a first initial visit that we used it. And it's just what you said. There's so many people involved and oftentimes things are acute and you wanna put your hands on them anyway, and they're showing up already teed up. We've used it a lot in the situations that were described previously. We've used it with a big geographical area and horrible traffic, similar to what Ron probably has, although I have to tell you, Birmingham has some of the worst traffic I've seen. And in terms of dealing with those patients, I think it's been really fruitful. And then we use, very similar to what Chad said, we use Zoom Embedded and Epic. So we're in a situation where we have moved more and more as much as possible to showing people MRIs over it. We found it actually to be, they seem to drill it in more almost than they do in clinic. I was fortunate. I was on our initial kind of test pilot. It was myself and three psychiatrists for 1300 doctors. And I could tell you, we did not use Zoom. It was not embedded. It was really painful. So Tom's points regarding technology, I think are really key. And then Christian made a good point, which is not all the physicians are the same. So I really jumped in because, I was on the phone with Douglas when this thing first hit and we were like, what are we supposed to do for the next six weeks? So we jumped in really early and had the experience because of a siren of using it with the athletics department. And we've used it a lot around COVID. We found that we were the epicenter, the Marlins 18 of 40 got stuck in Philadelphia with it. So we didn't have to use Rothman's group, the Phillies doctors, great guys, but we didn't have to use them. And we were able to do telehealth the whole time. Now, Glenn or somebody else may comment that that was illegal based on the telehealth rules. Actually during that period of time, it was legal. So we've found that with COVID, especially with our primary cares and we take care of a lot of those ourselves, it's been really helpful. Yeah, I'll say that I think the siren platform has been great. We've used it for a long time and it's very usable and user-friendly. We use it across multiple different avenues of sports and sports medicine. It's been a terrific platform. And we had a question about the siren MD. Now that all of us have Zoom embedded into Epic or other EMRs, is siren MD, were there any troubles in getting people to use it now being as it is a redundant, is there medical legal issues of having imaging put into a separate platform or anything that you've had to, anything you've experienced using that platform? We could talk offline about the attorneys I've had to hire, but no, they're having legal issues. Chad and I probably talked about this a couple of years ago. It's all, it's HIPAA compliant and everything else. It's actually different, right? So what you're using in Zoom is you're using a telehealth platform embedded into an EMR, which is really a repository and you're making it, you're kind of giving it life a little bit. Siren's really a care collaboration platform. So you have everybody commenting on it. It embeds the text messages, but also the phone calls, the activations. It's great for us to use Zoom and it's great to talk to patients, but at least in our health system, which is a pretty big health system, we don't really have ease of access. I know Tom mentioned that people were just uploading their MRIs. It's getting better, but it's not great. So for instance, with our teams, we have the ability to share, we have the ability to go back and forth. We have the ability to do something called limited access. So you have access to that one case, but for instance, you don't have access. That actually came because of your organization, because we had an athlete hurt at Duke on one of our other teams. How do we get to see all this stuff in real time? So Siren's a little different in that it's care collaboration. It can download the information into Epic through the media platform. Epic has a really nice sandbox and we're currently involved with, I don't know, another system called Athlete RMS, which I'm not sure if you guys know about, but Athlete RMS is what we use for Major League Baseball. The NHL uses it, NBA just signed. So embedding into the EMR so that you have those kinds of platforms. In no way is Siren gonna be the only thing doing this. I mean, it's exploding so quickly. There won't be one winner. It really is amazing that we've all used Zoom. Even GoToMeeting is now using different aspects of it. So this is here to stay. I would say, based on something Glenn said earlier, the ability to even listen to Tom talk about the multiple platforms and the different ways to use it, we are right at the beginning of this thing. I mean, I had a conversation with the guys at NYU and they were really interested in why can't we embed? Now, we were talking about Siren, but we could easily be talking about Zoom. Why can't we embed goniometers and other things that we can do even a more advanced exam? So the cardiologists are doing that. So I would think that somebody around orthopedics, some of the innovation stuff Chad's doing at Duke, you'll be able to put in some things that can give a real objective kind of evaluation. So I think we're really at the beginning of this. I think it's remarkable that so many people have picked it up so quickly, obviously in this situation, but we're not gonna go backwards. I do agree with Jeff. Our clinics will become what they are, but we're looking at some innovative ways to add clinics, do some things like it sounds like you're doing at Duke and really try to expand the, not really for a marketplace niche from a competitive standpoint, but to be better for our patients and more easily accessible. Because the number one thing people complain about is navigating the system and access to care with any of us. And so if we can improve that, that'd be great. Yeah, I think that's a good transition to ask Chad a question about the virtual clinic. And one thing we're talking about access, but what about costs? You talked a little bit decrease in overhead and are there tangible numbers that say you do a half day of virtual clinic compared to an in-person clinic? How that difference is? Yeah, I think that's something we're working on and it certainly is. The overhead is definitely lower, although for our time is about the same and we're the most expensive input. So one thing I would say about the overhead is that it's lower, but it's not so much lower that it should go back to the old reimbursement levels. I think that's an important thing to say, right? And hopefully we can inform them that. Yeah, it is lower, but it's not that much lower. In addition though, there's such a savings for the patient and for the employer and other stakeholders that there's probably value in incentivizing that. So that's where I think between the two of those factors, I think parity probably should stay beyond COVID. So hopefully we can advocate for that, certainly. Brian, can I ask Chad a question? So I've been in conversations, we built a pretty big center that sports medicine is in here and we're gonna build two more and they're almost on hold right now. And part of it is because one of the questions is, do we need so much space with people doing telehealth? Are you guys starting to look at anybody else on the call? I'm sure Kaiser is in terms of downsizing your actual physical space. I think we are starting to look at it. We still need to get more people at that, maybe 20% level. I think it's probably about the magic number of video visits, but then you can, then that does affect your growth strategy. There's no question. It allows you to expand your physical facilities more and maybe hire more people easier that way. And so there's no question. And I think that's what will really be the spark is when we change our overhead, our bottom line, our P&L statements, for somebody that hits that maybe whatever target that is and then sees an impact on their bottom line, that will really get people utilizing these different telehealth options more and more. Yeah, you're direct. We've had that option or that problem actually, because several of our providers have essentially moved their entire offices to their private home offices. And so now we have an entire section in the main hospital where we have office space where nobody has been in for months. Yeah, yeah, yeah. I think that's gonna be the same way for our offices as well, the office space itself, yeah. Ron, how's the Kaiser experience with that? Are you guys finding more space? Well, to a couple of points. No, it's a great, great question. And to a couple of points, we're expecting our providers, our surgeons and other allied providers. Some of my surgeons don't like being called providers, so I correct myself, at about 30% virtual. And we always build out in a deficit fashion in our system. So two or three years after a building is built, it's maxed out. So this has really given us breathing room and space. So a lot of our surgeons are doing four 10s. Some of you probably think that's an anathema to think about like 40 hour weeks, but instead of doing five day weeks, they're doing four day weeks. So then we can move around and we have to do less of that now be given this move to virtual. But I think it also begs the other question, if people are using their homes as a space and they're in a integrated system like mine, is the system getting benefit out of them because they're using their own phone lines and stuff like that? Where's the rub or where's the balance for the surgeon in using home stuff when they should be using Brigham and Women's or University of Miami's or Duke stuff to that thinking, but probably a completely tangential issue. But I think we got to think about how that looks in the future as well. That's actually a really fun one, right? Because many businesses are going through this. Friday night, I'm actually gonna be up in the research triangle. We play NC State, where there's a large statue of Dr. Dugas when we pull into the stadium. I'll be back. But I've been thinking about this more and more, how many businesses are affected, right? It's the opposite of WeWork almost. And so, and I could tell you in South Florida, many places people are investing, I'm sure in California, a ton more in their homes because of these things. I mean, so it may not be anything we can handle. It may be cultural and environmental and we're gonna have to evolve with it a little bit. It's actually an exciting time. Yeah. Well, we're getting close to our time here. So I just wanna see if anyone else has any questions on the panelists. I think there were a couple here, but I just wanna make sure the panelists have any other comments they wanna add or any questions they wanna ask. Yeah, I just wanted to make one quick comment on the VIP patient or the athlete, the high touch. I think video visits can be used for that too. And that gets back to my point about being an augment and increasing the touch points. Now you'll see somebody that is technically a new patient physically, but you feel like you've known them before, you've seen them before. So yeah, I think they can really be a great augment to increase touch points and build a relationship with people too. So it may be different than exclusively indicating someone for surgery remotely. You know, I don't get to spend a ton of time with Dr. Andrews. He's not often in Birmingham as much as he used to be, but one of the pillars of his career and one of the things that he built his career on were the 10 commandments that he so to speak puts out. And one of them is availability. You know, he gives his cell phone to everybody. We all do that. So the whole idea of these virtual visits is not a very foreign concept in the sports world. I mean, that's something that Andrews has taught us from the time I was a fellow. So he's been communicating with these people by phone and by Skype and by, you know, things like that forever. And, you know, you ask him about it and he's like, it's kind of situation normal. I'm already doing it. I've been doing it for 20 years, you know? So I think in the sports world with the athletes who work with them, probably already used to delivering that level of service. And it's probably not that much of a different role for most of us. I think another thing is, one thing I've noticed is that people are used to seeing people at their houses now, wherever they're back or not. You don't have to be in a clinic. People are comfortable with that now. So it's kind of a, you know, a nice little benefit. So it's not a surprise to see a kid running around or a cat running in the background anymore. Yeah. Or a dog. Or a dog. Yeah. You'll always be in the hall later on. Well, I want to thank all the panelists for coming out and also, you know, putting the presentation before and having this very engaging conversation. So it's a lot to learn, a lot of exciting things to go and what things we can do with this new technology. So thank you everyone. Thank you. See all you guys. All right. Bye-bye. Good to see you guys. In person soon.

telehealth

sports medicine

virtual clinics

technological challenges

medical assistants

athletic trainers

group practice

training programs

patient care

HIPAA compliance

pre-operative assessments

post-operative follow-ups