<v Jordan Cooper>We are here today with David Fletcher, Associate Vice President of telemedicine at Geisinger Health System. David, thank you so much for joining us today.</v>

<v Fletcher, David>Thanks. Jordan's pleasure to be here.</v>

<v Jordan Cooper>Today we'll be speaking about telemedicine at Guy Singer. I think it's safe to assume that our listeners are well aware of, or at least would not be surprised at telemedicine, that visits spiked significantly during COVID. Geisinger is no exception. In the past four years, guy singers telemedicine program grew 200 times per previous volumes, with a half million telemedicine telehealth visits during the height of COVID between March 16th, 2020 and March 20th, 2020. That's four days. Guy Singer completed more than 784,000 telehealth visits.</v>

<v Jordan Cooper>At its peak, the health system averaged more than 3800 encounters per day. David, I'd like to ask if you could describe how you went about overcoming the challenges associated with rapidly scaling up this program to meet patient demand.</v>

<v Fletcher, David>Yeah, I was huge challenge. And you know, I'd love to claim credit for being having enormous foresight, but there was a little bit of, you know, I think we were a bit lucky in that we had just transitioned to a single platform.</v>

<v Fletcher, David>Prior to that, so in the years before I started a geisinger, it was, you know, kind of hit and miss or little pockets of programs. Some had been. We're using one system and another, we're using a different system and and so we had made the decision to really try to get all on one platform. And so we have one platform that would do video into the home, hospitals, clinics, etc.</v>

<v Fletcher, David>Etcetera. And so we had done that and it was still, you know relatively niche product. You know we have less than 1% of our visits being done via telemedicine.</v>

<v Fletcher, David>Prior to COVID.</v>

<v Fletcher, David>And we had a couple, you know, number of specialties that really focused on in neurology and and pulmonology and a little bit behavioral health and.</v>

<v Fletcher, David>UM, and then all of a sudden, you know, we just, we had to immediately scale up and we had, you know, we had to go from 20 specialties to over 70. We went from maybe a couple 100 providers to over 2000.</v>

<v Fletcher, David>And so.</v>

<v Fletcher, David>And the the fact that we kind of had the one platform we had one process to use was enormously beneficial. So we we ramped up our training, we did all that you know that kind of as you mentioned really within about a month we were able to get everybody on. And so we didn't have to rely on you know a lot of health systems they had to kind of just use zoom or FaceTime or whatever just to kind of get through. We really we stayed within our platform the entire time. And so we didn't have kind of the enabled us to more efficiently do our billing and all the back end stuff.</v>

<v Fletcher, David>Was able to just continue a pace because we were able to scale up so rapidly and so we found that, you know, I the great thing is.</v>

<v Fletcher, David>A year or two into kovid we had, you know, we're in Central PA and we had a a snow day. And so we found the same thing. We were able to really quickly pivot and reschedule some of those in person visits to video visits because we knew that the clinic was gonna be closed.</v>

<v Fletcher, David>And so we were able to show that we were able to decrease our no shows that day by well over 1000 visits just being mean that visits otherwise would have been in person. We were able to convert to video. So once we kind of got that underneath our belts, we were able to continue to use that same process going forward any time we needed a quick wrap up.</v>

<v Jordan Cooper>So speaking about unexpected challenges and adoption rollout, I'm wondering how telemedicine is role in relation to other departments has evolved within the Guy Singer health system over the past few years. And I ask because obviously if you're going from fewer than 1% of all patient visits, pre COVID telemedicine with a few 100 providers to all of a sudden this is the facto. I'm wondering if there's any politics within the organization if certain departments are protective of their turf, how are you navigating all that? How did other departments, did they just embrace it?</v>

<v Jordan Cooper>Were they hesitant where they resistant and keeping digital arms length? What happened there with Internet scene politics?</v>

<v Fletcher, David>Yeah, that's a great question. Yeah, absolutely. So, I mean it was we, we did, we had to start working with, you know, again before we it was almost kind of by definition whoever we were working with, they were doing it because they were interested in telemedicine and they had come to us and said, hey, I really wanna do telemedicine and so.</v>

<v Fletcher, David>And and it flipped after that, you know. Now it's we're we're going to everybody, people who maybe.</v>

<v Fletcher, David>Till medicine wasn't even really on the radar and we're working with them now. You know, we were very lucky. Guisinger is, you know, kind of has innovation in his DNA and. And so we had a lot of great partners on the operation side, but certainly the provider education.</v>

<v Fletcher, David>And the provider experience is key. In fact, people ask me all the time at conferences like, you know, how did you, how did you ramp it up so quickly and a lot of it is the, you know, the patient experience which gets a lot of attention, and rightly so.</v>

<v Fletcher, David>You know, but the the the key that I always tell everyone is it's equally important to have the provider experience because the providers really drive a lot of the adoption. So even in one of our specialties, I can see enormous variation from provider to provider. They're serving the exact same demographics, same target market. It's just that certain providers are really enthusiastic about it with their patients and others aren't. And so that's been really the big key is.</v>

<v Fletcher, David>Building in integrations, so our providers, they're in our electronic medical record all day. So we built in a lot of integration with the EMR, so that it's very easy for our providers and that has been key to getting uptake really throughout all these different departments.</v>

<v Jordan Cooper>And this podcast, we do have a very technical audience. Would you mind speaking about the actual technicalities of integration with your interface engines, how you were able to accomplish?</v>

<v Jordan Cooper>I I I know that guy Singer has a relationship with Intersystems but but more specifically how did you? How did you drive that provider experience that you have to rework workflows. How did you get the?</v>

<v Jordan Cooper>How did you integrate those virtual visits into the electronic health record and their general workflow?</v>

<v Fletcher, David>Yeah, absolutely. Great question. So the the the main key is we really push on our vendor partners and say, you know if if you come to us with a, hey, we got this great idea, you'll just log into the separate portal every morning. It's like that's that's basically a showstopper for me because everything has to really flow through our regular scheduling and Yammer. So in our case, when we schedule a patient for a either an in person visit or a telemedicine visit, it goes through our EMR. We happen to be an epic shop.</v>

<v Fletcher, David>And so we schedule an epic and then that automatically flows through. And so we we we've integrated with our our telemedicine vendor so that they get that information, they send out the link to the patient and it's in the providers schedule right in the EMR and. And so there's no duplicate scheduling. We don't have to say oh, this one's telemedicine doesn't go to the portal, schedule them for the telemedicine platform and as well as in the medical record. And so the same thing. And so some of the other types of integrations we have are when.</v>

<v Jordan Cooper>Would David?</v>

<v Fletcher, David>You know, when the patient has their visit provider gets done documenting, then we have a a manner of a way to automatically close that encounter at the end of every day because they don't have the front desk staff doing the normal pieces they would have. And so that gets done automatically.</v>

<v Jordan Cooper>When you did encounter provider push back, what were some of the rationales and how did you overcome those?</v>

<v Fletcher, David>Sure. So you know it's it's been a a mixed bag now some of it is is just the very legitimate of you know hey, there are elements of this exam that I can't do remotely and and and that's you know can absolutely be the case. And so the thing that we've really been doing a lot of work on is pulling the data and trying to find out OK, which visits there's there's one thing to like the snow day example or the height of the pandemic. Hey, we got to see the patients in some way. This is our only.</v>

<v Fletcher, David>Option. Now that we're it's kind of quieted down a little bit. The question is what should we do going forward and you know to what degree is it, is it a patient, just a patient convenience? Are there instances where we see we actually have better outcomes or certainly if the ones where they're worse, we won't offer it. And so we've really actually worked with a lot of our providers to say, OK, what's what can you accomplish?</v>

<v Fletcher, David>And you know, and I think it does have very just somewhat provider provider, you know some are very comfortable kind of thinking outside the box and saying you know what, I don't really have to.</v>

<v Fletcher, David>Hooked the stomach. I can ask them to do it and then, you know, tell what's going on or, you know, depending on whatever their specialty is and and. And so we really make sure that the clinician has a strong voice and deciding what is clinically appropriate.</v>

<v Jordan Cooper>Have there been any surprises associated with the rollout and massive scaling of the program?</v>

<v Fletcher, David>Umm, so I'd say you know, one big surprise is just how much our older patients really have come to rely on it. And and like it and I think you know going again pre COVID talking about telemedicine and telemedicine audiences. You know they always say yeah, this is great for like the millennials and people born with a phone in their hands, but it's not really for the older patients. And we haven't found that to be the case at all. We actually are satisfaction surveys.</v>

<v Fletcher, David>Our older patients like it almost to the same degree as our younger patients and.</v>

<v Fletcher, David>I think part of the reason is that we very consciously.</v>

<v Fletcher, David>Uh designed our workflows to be very seamless, so as I was talking about for the providers, they're not logging into a separate portal. Same thing for a patients. We don't make them go through the EMR portal. We don't make them log, create a separate ID and password if they're in our system.</v>

<v Fletcher, David>We just send them a link, you know HIPAA secure link and they click on that, they get right into the platform. And so we've had a lot of we see in our survey, you know, responses a lot of patients have said I didn't think I'd be able to do this, but I actually really loved this. This is so easy and things that I would have never thought of a patient said you know, I have a brain tumor. And so getting on an elevator in your hospital like makes me sick every time. So being able to just sit in my living room, you know, that's a godsend and.</v>

<v Fletcher, David>So I think issues like that you know and and transportation issues et cetera. So we we find that our our older patients actually really love it and it's really not a young person's tool at all.</v>

<v Jordan Cooper>I know one thing that you've spoken about is making telemedicine available to everybody, but in particular you you've actually, I mean, as you mentioned, counterintuitively, it's not just younger populations tend to be the early and more frequent users of telemedicine, but actually you're targeting a senior population and a rural population. Why? I mean, it's one thing to say we want everybody to come, but it's another thing to say we're specifically targeting seniors. Why is that?</v>

<v Fletcher, David>Yeah, so, so a lot of it is just our our demographic area. So we're we're located in central and northeast Pennsylvania.</v>

<v Fletcher, David>And it's it's not a rapidly growing area and it's and we're so we're aging and so it's kind of by necessity you know and and and in a way it's been a a good thing because it's really forced us to be very thoughtful about our processes and to be really intuitive and simple with the way that we we roll things out and so so that's why and and we also have a very rural area and same thing it doesn't make sense to hire.</v>

<v Jordan Cooper>Right.</v>

<v Fletcher, David>You know a a super subspecialist, you know, infectious disease expert to sit in a small clinic in a very, you know, a town of 3000 people. But we can get access to that specialist for everybody. And they don't necessarily have to drive. So a lot of what we do is in the home, but we also do things in the local clinics. So if you live in say, lock Haven, PA, it's not a very big city, but you don't have to drive 2 hours through the mountains to get to our main campus in Danville, PA.</v>

<v Fletcher, David>You can drive a block away to your local clinic. They've got the cart and the peripherals, like the stethoscopes and things like that, that they can hook up, and so you can have a full exam with your subspecialist in many cases.</v>

<v Jordan Cooper>Got it.</v>

<v Jordan Cooper>So.</v>

<v Jordan Cooper>How has guy Singer been addressing technical problems when the patient is unfamiliar with video conferencing technology, or if there's a lack of broadband connectivity in the patient's homes? As you mentioned, a rural small town or a general lack of availability of peripherals such as stethoscopes and otoscopes?</v>

<v Fletcher, David>Yeah. So yeah, it's it's a big challenge and I think you know, part of how we've addressed it has been a little bit like I mentioned. So. So the clinic based telemedicine is there for.</v>

<v Jordan Cooper>Got it.</v>

<v Fletcher, David>Certain types of visits where it's like, hey, we need, we need to be able to listen to the heart and lung sounds. So then, OK, home isn't appropriate, but we can get your nearest clinic. Same thing if we if they say I you know I don't have broadband in my house then we can say well can you get to we see we've got a clinic you know a mile away from your house can you get to that clinic and so we we host them there another thing is we've looked at we've gotten a grant from the FCC.</v>

<v Fletcher, David>The uh for some some to cover some broadband costs and we hope that that will help kind of spur additional investment in broadband infrastructure because it is certainly an issue and my big worry is.</v>

<v Fletcher, David>You know, for the tools you talked about and I think that is so important, it's not talked about often enough. I think honestly, but.</v>

<v Fletcher, David>Ideally, you know eventually people will have their medicine cabinets will have, you know, instead of just band aids and things. It will also have like a a digital stethoscope or something like that and we could expand the pie of what we offer in the home that way. But my worry with that is and there are companies out there who do that title care and other groups like that AMD and.</v>

<v Fletcher, David>Umm, but if my worry is that if we start to rely on that without having some tools available to to serve, you know patients with lower means, does this become kind of a niche convenience for people of greater wealth? And we really wanna make sure that we are able to serve everybody and. And so I think that's something that as an industry we've really gotta think about and you know how do we how do we either have these tools be very inexpensive.</v>

<v Fletcher, David>Do we have things like, you know, a Community Center that has them, you know, how do we make sure that that it's not just a, you know, again a niche convenience for people, it means.</v>

<v Jordan Cooper>So you're alluding to your concern about how telemedicine can potentially exacerbate disparities if there's limited access to patients with broadband, which is correlated with socioeconomic status, are there any other down signs to telemedicine?</v>

<v Fletcher, David>Yeah, you know, I I think so much of it is.</v>

<v Fletcher, David>Umm, you know, I I I think it it requires a blend and and you know and again fortunately like a geisinger that that is one thing that we can always rely on. Is that OK if you need some piece of some element of this visit that needs to be in person we've got that infrastructure in place we've already got clinics throughout our footprint and and things like that.</v>

<v Fletcher, David>And and I do worry a little bit about, you know, kind of some of the the processes or programs that are just purely virtual only. OK, then what happens when you do need?</v>

<v Fletcher, David>Some sort of service so you know you just gonna kind of dump on the existing facilities that you know have built in all this infrastructure. So. So to me like an ideal situation is.</v>

<v Fletcher, David>A platform that has has both options available because there are gonna be times you've you've gotta have a blend.</v>

<v Jordan Cooper>One has been impact on provider burnout turnover workflows in a documentation burden, especially in the past few years. You've seen the great resignation, you've seen a lot of burnout, especially in healthcare field because of the COVID pandemic. What's been the impact on on on those four elements?</v>

<v Fletcher, David>Yeah. Yeah, uh, you know, it's it's been huge. And I I think, UM, telehealth specifically, I think it has potential.</v>

<v Fletcher, David>Uh to help alleviate a lot of those issues. Now it it depends on how it's implemented. So if if someone goes in and says OK telehealth, you know maybe you can do this visible faster. Let's increase your template you know by double because ohh you'll you'll just be seeing patients over video. You know that can be a problem. But I think by and large it's it's helpful in a couple different ways. So one is obviously.</v>

<v Fletcher, David>You know, we have some behavioral health providers who who don't even have to be in a clinic for, you know, a whole days worth of visits because they're, they've got so much. I mean, they do about 80% of their visits via telemedicine. And so that additional flexibility, I think is very helpful for a lot of providers. And then also very important for us, we here in Central PA, it's a very rural area and it's it's a beautiful area. A lot of people love like to live here. But there are people who.</v>

<v Fletcher, David>Wanna live in a more urban area and very hard to recruit here?</v>

<v Jordan Cooper>Got him.</v>

<v Fletcher, David>But that becomes less of an issue because we can have them if, as, as long as they get a license in Pennsylvania, they can be anywhere in the country and and see patients. Now we have to kind of bifurcate it out and say, OK, these types of businesses go to you, these go to the in person you know. But I think it does have the ability to some of our access issues. We've really been able to help with all noticing.</v>

<v Jordan Cooper>How of payers been responding to their shift in telemedicine?</v>

<v Fletcher, David>Yeah. So that's been, I mean the biggest key to the the you know, the enormous explosion growth you talked about at the beginning was really the the dropping of some of these restrictions that we've had previously, particularly with Medicare.</v>

<v Fletcher, David>UM and uh and and really a lot of the payers have kind of followed Medicare's lead on this and so.</v>

<v Fletcher, David>The couple of the biggest things that you know were barriers before were they said OK, if you're gonna do have telemedicine be paid, it has to be extremely rural location. And by and large it has to be a clinic. There were a few exceptions for they would allow it in the home. But by and large it was in a clinic setting.</v>

<v Fletcher, David>And so they weighed that during COVID and. And so you can just see the enormous uptake that has resulted initially because of necessity with COVID. But now I think increasingly because really the patients are demanding it.</v>

<v Fletcher, David>UM and and so right now everybody is still kind of going with these waivers and and largely things are being paid kind of the the same degree as in person still remains to be seen that the Congress, you know put a 5 month extension beyond the public health emergency that they'll continue to waive the morality and the in home restrictions.</v>

<v Fletcher, David>And and then beyond that, you know, we're I I think there's so much critical mass that we're hopeful that they'll continue to to pay for it, but it's still up in the air to some degree.</v>

<v Jordan Cooper>Uh, how have how's risk sharing with accountable care organization shared saving plans contributed to affected or been affected by the influx of telemedicine?</v>

<v Fletcher, David>Yeah. So it's that's a great question. It's it's a I think a huge piece of the puzzle for telemedicine. And honestly, the number one reason I came to Geisinger about four years ago was because Geisinger has its own health plan. And so they also participate in an ACO and and I think those kinds of value based systems lend themselves extremely well to telemedicine. And I'll give you 1 great example that we've we've had here even prior to COVID actually as our was called the Geisinger at Home program.</v>

<v Fletcher, David>Whenever is funded by the health plan and the idea is.</v>

<v Fletcher, David>We would actually send nurses and community health assistants into a patients home and help coordinate services for them and and they had a concern, they would actually initially they would call a doctor. A doctor would physically drive to the patients home. Now obviously we wanna scale that up. So we've added the telemedicine element to it. So the nurses go with a tablet and the stethoscope otoscope exactly like you described.</v>

<v Fletcher, David>And beam in a doctor and so.</v>

<v Fletcher, David>That kind of model, you know, doesn't make sense in a regular fee for service makes enormous sense for our health plan because we were in the first year alone, we were able to show $2,000,000 worth of savings because those patients didn't have to go to the Ed. They didn't have to get readmitted into the hospital because enormous cost for the health system. So I think just a great example of the.</v>

<v Fletcher, David>That the that value based.</v>

<v Fletcher, David>Model lends itself really well to full population management, which telemedicine is a great tool to help enable.</v>

<v Jordan Cooper>Now David is interesting. Speaking to you, your program at Geisinger has actually been named the number one National Telehealth network at the Telehealth Innovation Forum. What differentiates your program from Myriad others across the country, what factors have contributed to the growth of telemedicine outside? I mean, what makes you so special? What's your secret sauce?</v>

<v Fletcher, David>Yeah. So, I mean, I think it's a lot of things. I think you know partially it's you know, as I mentioned, Geisinger has a long history of kind of innovation. And so we had a lot of partners that really helped us and everyone really got on board quickly. And then I think in a way some of the challenges we face forced us to do to design things in a very scalable way. So you know the older population we knew we could not rely on people to download apps and create passwords and all that kind of thing.</v>

<v Fletcher, David>And so it we we took a lot of the friction out that would you know you would normally encounter trying to stand up telemedicine.</v>

<v Fletcher, David>UM. And so I think that kind of that combination of you know, the the culture of the, of the health system and and just being thoughtful and about the design, you know really kind of came together and allowed us to to grow in a very rapid way.</v>

<v Fletcher, David>Yeah.</v>

<v Jordan Cooper>Well, David, I appreciate you answering that question. We are approaching the end of this podcast episode. I'll open it up to you. I'll suggest maybe any challenges with integrating data with integrating workflows with somehow balancing providers, satisfaction with patient satisfaction, engagement, working with the operations team. I'll leave it up to you, the challenges, the lessons learned and scaling up your program.</v>

<v Fletcher, David>Yeah, absolutely. Great question. And it's I and I'm glad for this audience because it's it's not always the most front of mind, you know, flashiest part of telemedicine. But honestly, one of the biggest challenges we've got going forward and we're working on right now is that kind of workflow integration issue. So like the way I always describe it is when you go into the clinic, what do they do? They hand you a clipboard with a stack of papers about this deep that you've and you've gotta sign an initial and do all that stuff. And a lot of that is, you know.</v>

<v Fletcher, David>Informed consent type issues and you know, sometimes maybe even signing up for a clinical trial and things like that.</v>

<v Fletcher, David>None of that was built in for a telemedicine visit. You know, we were mostly in the clinics and hospitals, frankovich. So how do we recreate that whole experience and hopefully make it a lot more simpler and convenient and tie all that stuff back to that same patient in their medical record? So a lot of that kind of work is needs to be done. And I'd say the other really big challenge.</v>

<v Fletcher, David>I kind of briefly alluded to it earlier, but it really understanding, OK, it's great. We we kind of showed what we can do with possible to do with telemedicine, but what should we do with telemedicine and that's still an open question and I work with a lot of my colleagues or else across the country and say what do you what do you finding. And so for a long time, there's real question of like it's telemedicine gonna be a + 1, are we going to do these telemedicine visits and then immediately have to follow up with an in person visit because there were pieces of it that we couldn't do via video.</v>

<v Fletcher, David>Is this gonna explode? Costs, explode, utilization? I think that's what some of the payers initially worried about and you know, so we've done a big study of that and found that that was not the case that actually you were basically just as likely to have a follow up for an in person As for video visit. So that was good. But then within specialties which visits should you target are there?</v>

<v Fletcher, David>Are there downstream effects that we don't know about? You know, if you have your first visit via telemedicine versus your second visit, you know all those kinds of things. I think there's just enormous data out there because we've had to do it for the last two years, three years.</v>

<v Fletcher, David>Umm, but now, now we gotta really sift through that and figure out what's the optimal.</v>

<v Fletcher, David>Instances to do telemedicine.</v>

<v Jordan Cooper>Well, thank you. This has been David Fletcher, the associate vice president of telemedicine at Geisinger Health System. David, again, I'd like to thank you for joining us today.</v>

<v Fletcher, David>Thank you very much, Jordan. It's been a real pleasure.</v>