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Scaling Up to a Telehealth Future (10:17)

“[In 2016], NewYork-Presbyterian, Columbia doctors, and Weill Cornell Medicine set forth on a path to be the national leaders in telemedicine and artificial intelligences,” says Peter Fleischut, Senior Vice President and Chief Transformation Officer for NewYork-Presbyterian (NYP). “We have a lot to still accomplish. That being said, we’ve created a pretty comprehensive framework.”

NYP is working with key stakeholders to replicate that framework throughout the United States. In early 2017, the health system created over 50 telehealth programs that were scaled to about 100,000 visits by the end of 2018. “This is about providing the same level and standards of care throughout the country and throughout the communities and the patients we serve,” says Fleischut.

For example, if a patient in any of 46 U.S. states wants a second opinion, they can do so online and connect directly to one of the 400 board-certified specialists in over 80 specialties from Weill Cornell or Columbia and in a couple of days receive that second opinion. “It’s not just doing the opinion or providing the technology — we need to provide a higher quality,” he says. “Twenty percent of the time the diagnosis of the patient is changing, and some 40 to 60% of the time that provider is recommending a new and a different treatment option.”

In emergency care, by offering telehealth services in its ED — video visits with doctors — NYP has reduced a typical 2 ½-hour visit, from admission to discharge, down to 30 minutes. “But we don’t want to stop there,” says Fleischut. “We want to provide that same capability in their home, on their phone, or going to a kiosk.”

When it comes to specialty consults, such as psychiatry, there aren’t enough specialists to provide the same level of expertise across NYP hospitals. The health system used to provide consults within 24 hours but with telehealth can now do so within 1 hour, anywhere in New York City.

“A lot of people associate telehealth with urgent care, and it’s not at all,” says Fleischut. It’s specialty care and other services, too.

Fleischut mentions the mobile stroke unit: saving a patient’s life by saving 50 to 60 minutes of ischemia time —over 100 million brain cells — by bringing an ambulance to the patient’s driveway and doing a CAT scan and treatment right there at the patient’s home. “While it’s a hard model to scale, it’s our opportunity to use telehealth. Now we have a fleet of mobile stroke ambulances that can provide that care in Queens, Brooklyn, and Manhattan, and we will go farther and put more ambulances out there to share this life-saving treatment.”

“I could [continue to] talk about those siloed services, but it’s really about a coordinated care model. It’s all about the patient,” he adds.

Ron, a 37-year-old Queens resident, hadn’t seen a doctor for the past 9 years. Walking to work one day, Ron felt a little short of breath. He didn’t know what to do, so he walked into a Walgreens and went to the nearest NYP OnDemand kiosk. He followed the kiosk’s simple instructions to get his blood pressure, heart rate, and oxygen level, and within seconds was connected to Rahul Sharma, the Chairman of Emergency Medicine at Weill Cornell.

“Just think about that for a minute,” says Fleischut. “Ron, in moments, was connected to a world-class expert and able to get care instantaneously by just walking into a Walgreens.”

Unfortunately, Ron’s blood pressure was 230 over 120, and he was short of breath. After a quick virtual examination, Sharma transferred Ron to a local hospital in lower Manhattan, where he was diagnosed new onset heart failure, diabetes, and hypertension. “Frankly, Ron ran the risk of dying at any moment with that critical blood pressure, and because of Rahul, he saved his life,” Fleischut says. Days later, Ron left the hospital with no heart failure and his health has since improved, including the loss of 40 pounds.

“He calls Dr. Rahul Sharma ‘Dr. Kiosk,’” Fleischut notes, “and he says Dr. Kiosk saved his life.”

“The days of brick-and-mortar urgent care are going to go away. The capital expense is too much, and digital medicine is here, and it’s here to stay. And it’s not just about that one transaction that Rahul did for Ron. It’s about the ability for Ron to go back onto maybe his Walgreens app when he’s refilling his meds and follow up and do another video visit with Rahul in any one of four states,” explains Fleischut.

“Or maybe he wants to go through his Epic portal to be able to do that video visit. I don’t know. It’s really up to Ron. Or maybe Ron does online scheduling through something like Zocdoc and is ready to do an in-person visit and then all of a sudden he realizes, ‘Wow, I can do a telemedicine visit within minutes just like I did in Walgreens.’”

Ron’s hypertension didn’t go away — NYP still needed to send him a blood pressure cuff and scale to remotely monitor and keep him out of the hospital on a long-term basis. “That’s the type of care that Laura was talking about when she was saying about the quality we need to provide,” Fleischut explains.

“I would be the first to say this sounds easy, but it’s not. It’s our responsibility as providers to be indispensable to our patients, to be able to take care of them, and we have to overcome these challenges,” Fleischut says. The challenges range from reimbursement to regulations, provider workflow, and work-life balance.

“We can’t wait for the reimbursement to come along, to be able to provide this type of care. We need to go beyond, and we need to be able to provide these services now, so we can do it in a highly efficient way,” he says. Leaders also also need to measure total cost of care so that they’re not just investing in bright, shiny objects.

“We need to be the leaders that are going to drive the regulatory change to take these life-saving conditions and drive them to patients’ homes so they’re available,” he adds.

As for work-life balance, leaders need to be conscious of “work-life synergy.” Fleischut prefers the term “work-life synergy” to “work-life balance” because some providers may choose to work 80 hours while others choose to work 40, and “if they are happy and they are engaged in their work, they’re going to be happy and engaged home, and it’s their decision of choosing that balance, because it’s not really a balance, it’s synergy. And that synergy is what will thrive.”

“Steve Corwin [President and CEO, NYP] constantly pushes us to not think of as ourselves as provider systems, but to think of ourselves as technology companies. Meaning it’s about speed and scale,” says Fleischut. What he has described is just a segment of the telehealth services that NYP aims to provide. They’re also working on virtual primary care; fall monitoring in hospitals; teleparamedics for high-risk patients who leave the hospital, where teleparamedics are scheduled to go into patients’ homes to adjust medications and video back to the hospital team; remote monitoring for high-risk pregnancy patients; telelactation consultants; telenutritionists; and telepharmacists throughout the enterprise.

“It’s about scale, and we need to scale quickly.” In 2016, NYP did 1,000 telehealth visits. In 2017, the health system scaled up to 10,000 visits and in 2018 reached 100,000, with a goal of 250,000 visits in 2019.

Fleischut says health care systems can apply this framework to artificial intelligence to reduce back-office costs and to robotics to improve hospital logistics, leaving the audience with two key points:

“Daniel Barchi, our Chief Information Officer, commonly says its 80% people, 15% process, 5% technology. And it’s true. There are a lot of technology advances that have been around for years, and it’s how we transform care with them.”

“The second is a point that Dr. Corwin commonly makes: Technology is not our future, technology is not our destiny, and technology is not value-neutral. It is up to us as leaders how we use these tools to really transform care, to drive down the cost, to provide high-quality access and high-quality care.”

From the NEJM Catalyst event Disrupting the Health Care Landscape: New Roles for Familiar Players, held at NewYork-Presbyterian, October 25, 2018.

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