Today on This Week Health.

It's more than just opening up a video visit connection. There's a lot of infrastructure that you need to think about. One is try to strive for probably a hybrid model. For myself, I still go to clinic once a week. There's a level of patients wanting to see you, things that you do need to check, I think physically in person. So try to keep a hybrid model if at all possible.

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I'm Jake Lancaster. I'm an internal medicine physician and the Chief Medical Information Officer for Baptist Memorial Healthcare out of Memphis, Tennessee. And today I'm talking with Dr. Matt Sakamoto, who is a Virtual Primary Care Physician with Sutter health, Matt, welcome to the program.

Thanks so much. Look forward to chatting.

Can you just tell the audience a little bit about your background and what you're doing.

Yeah, for

sure. I've had a little bit of a meandering background so I kind of come from the informatics class of people. So did my initial med school over at Northwestern really was interested in primary care, I think from the get go.

And we started doing a lot of population health work of quality improvement work, and that really led me down that informatics path. I ended up doing my internal medicine residency down in San Diego at Scripps Mercy hospital. And during that time, for an informatics guy, we were actually on paper charts in our hospital and halfway through my residency, we went, we went from paper to Epic. So getting to see all of that turnover, what that go live looks like, definitely solidified my strong interest in the operational informatics side of things. Ultimately led me to do the clinical informatics fellowship at UCSF. I finished that up in 2020 amidst the pandemic. With all of that, a big shift towards virtual care.

And I was always interested, I think, in care outside the hospital walls, but clearly we'd made a big jump towards a virtual care and telehealth during that time. So that really sparked and increased my interest in how can we provide care for patients at home is just simpler, easier, and I actually get to work from home as well. So happy to kind of talk through the different upsides, downsides and lessons I've learned along the way.

Yeah, no, I'm really interested in hearing more about virtual primary care in what y'all are doing, but, but first you and I met through the clinical informatics fellow network, and I'm not sure that everybody that is listening to this is as familiar with the clinical informatics fellowships. So can you give us just a little bit of background. They're, they're still relatively new. I know the first one started around 2013 and when I went through fellowship, there was only, there's about 10 or 12 in the country. I think we're up to about 40 now, but tell the audience about a little bit about clinical informatics fellowships. What's the training like and what are you able to do when you come out?

For sure. The way I like to describe it it's similar to doing a cardiology or endocrinology fellowship. It's an AC GME accredited fellowship, a structured program. Two years of work. The nice thing about it is there's actually a requirement to continue your clinical work. And I think that's what really keeps us grounded. So at least at a minimum of 20% time in your home field. So again, I'm internal medicine. I did urgent care for the two years I was there, but I've seen pathologists, general surgeons and everything in between also do the clinical aerobatics fellowship.

So it keeps you grounded, you do your clinical work. But on top of that, the rest of the time is really. Operational project based work and the field of clinical informatics. I've seen the definition change a lot, but broadly again, it's kind of the use of just data and a lot of that runs to the EHR. So I think that's kind of been the main piece is how do you help with data input, which tends to be a lot of the front end work and clinician usability.

And then how do you use that data as a kind of, what are the data analytics that you do on the back end and all of the fellows, everyone has a different phenotype, but that tends to span the gamut of the work that we do.

Yeah. That's a great way to explain it. When I was in fellowship we spent a lot of time with our CMIO and helping him or her on any of the projects that they were working on. And so got, got to see a lot of that side and a little bit different than the research biomedical informatics that people may have been more familiar with before this applied clincial informatics but let's dive in and talk a little bit more about virtual primary care. Everybody knows that the beginning of the pandemic telemedicine really exploded.

It was obviously here before then, but exploded in a, in a huge way during the pandemic. But virtual primary care is a little bit different than just your average telemedicine visit for maybe an acute problem, like urgent care tell us what you mean by virtual primary care?

Yeah, for sure. And I make a specific point to say virtual primary care and virtual care, not specifically telehealth cause I, that, to me, most people, when they hear telehealth, they tend to think of a video visit, maybe a telephone call. The virtual primary care part in the same way that primary care spans the care continuum.

Virtual care as well. So I always include in that, like kind of that asynchronous messaging, so texting kind of things that are through a patient portal. Cause I think that really does that's part of the glue that keeps it together. So for me, virtual primary care, it's the same it's, I have patients I provide for their chronic care needs as well as kind of any urgent stuff that comes up and all the care coordination that happens.

So I think that's the main thing is like it's a lot of that care coordination piece. And by virtualizing that, that one, let's you look across your panel a little bit easier. And then two, and I think this is the biggest piece, is it really helps turn the primary care team, not just on the primary care physician, but actually the whole primary care teams.

I work with the nurse practitioner and a nurse that help manage this panel. And by virtualizing, a lot of the care they can jump in and help and things can happen in parallel and you don't have to stack up eight to 25 visits in a day.

Yeah. Sure. And do you see all of your patients 100% virtual or do you have any in-person visits as well?

Right. Yep. Great question. We have a virtual first, but a hybrid model. So 80% of the time I'm doing either video visits, phone calls or messaging with the patients. I have a reserved day in clinic for patients in my region that I can see in, in person. And there are things that you don't have to be done, vaccines need to be delivered in person, certain physical exam things.

And even patients that don't necessarily a physical exam, but are pretty complex. I'll have them come in and we'll talk. So I don't think we lose that personal touch at all. And having that hybrid ability is helpful. And the other nice thing is that we can take care of a lot of the easy med refill, med reconciliation things before the visit, even days before the visits or the time spent in person in the clinic is really high yield time.

Talk about a little bit about the prep time before the visit. So I'd imagine that a lot of your patients are still going to need lab work done. How do you coordinate all of that?

Yeah, we actually, and this is specific to, we call it tara practice is kind of the name of our virtual hybrid practice within Sutter. We have standing labs for our patients. So again, most patients will need a C DC, a blood work, blood chemistries. So a lot of times a lot of the friction that happens in a traditional care is like the patient will have to come to you. You'll see them, you'll write the order and then they have to go get labs.

We flip that and just say, standing lab, let them know that you have Dr. Sakamoto's labs that are needed. They get them so by the time they come to us we've already looked at interpreted and sometimes even if there's a follow-up lab, I'll add that on and have that ordered and again, so that allows for that face-to-face time to be high yield because we're working with all the information that's collected. We're not talking waiting, and then having a follow up afterwards

And tell us a little bit about the, the reimbursement model. I don't know if it's every state or if it's a national law, but you know, some require an in-person visit first for billing. What is the case in California for how they do that?

It's all over. And it depends on if you're a private insurance, Medicaid, Medicare. The upside, and what allows our model to work we only take HMO patients. Capitated payments. Capitated payment model patients into our practice. And I think that's really the only way that I see virtual primary care truly shining is in that value based care model.

It's hard to make the economics work I think in a true fee for service thing so that we work out very well because it's HMO only. And I think that's, that's what allows for kind of these extra wraparound, the time spent by myself and my team to do all this extra prep work.

It was kinda like funded basically by the HMO model, not to buy. I have to see patients back to back on a video visit.

Okay. And talk a little bit more about your team. Who all was involved. Is it still the standard number of people you would need for a in person, a hundred percent clinic. Because it's virtual, do you have any benefits from downsizing some of that staff?

Yeah. No,

I think it's not necessarily downsizing. So it's a team of four that we work with myself, a nurse practitioner, a health coach and a LVN or, or a nurse. So I think that between the four of us, that kind of, we take care of our panel. So that's about the same amount of people you would need for in clinic thing.

I think the thing that's helpful is that we actually have flexibility that we can flex our, we have three pods currently set up across the bay area. So my pod is a team of four. There's two other pods of four, basically. So if one pod happens to be busier than the other, it's a lot easier to virtually flex somebody and then to send somebody to the clinic across town.

So I think it's, yeah, the number is about the same, but I think the flexibility and ability to support and load level again, as, as one person's group is busy or less busy has been the bigger benefit.

Okay, that makes a lot of sense. And so you mentioned the post care coordination that you need to take place. Tell us a little bit more about what's involved with that. I assume making phone calls, returning messages and, and that sort of thing. Following up with health coach. But what percentage of your time is involved with, with those sorts of activities versus seeing patients?

Yeah, no

good question. And I've kind of dubbed it interstitial care, right? It's all of these, like the little pieces that connect the big visits together. So I would say probably the nice thing is it's pretty tiered. So like our nurse takes care of how the easy stuff. And then if she has questions, it bumps up to our nurse practitioner. If our nurse practitioner has questions that bumps up to me.

So kind of with that filtering mechanism, probably maybe like 25% of my time is spent doing in between stuff, but a lot of it, we kind of have protocols in place and just a good, good communication, a good trust in the team. So that a lot of these first-line things don't bump it's way up to me.

Okay. Yeah. That makes a lot of sense. I know one of the big things that's making the rounds in the news today is just the number of messages that are coming to in baskets and message box from patients. Since the pandemic started and also with the 21st Century Cures act. It sounds like you have a pretty good system in place to manage some of that increased load?

Yeah. And I think actually a lot of it is just communicating with patients, right? Like, so what is a urgent message? Kind of letting them know. And ours, we actually do tend to have them, we encourage them to message us. And I think the only, the reason why we're most places try to avoid it. We encourage them to message us because we have a team managing the in-basket. I think in a lot of other places, it solely falls on the clinician shoulders and that's insane.

Right. So I think having a shared in-basket and again, good communications, good protocols in place has helped keep that same for, from, from our end. And it leads to a time of your patient care, right? Because a lot of times a patient's waiting on just their clinician to get to the, get to that message. Half the time it's taken care of and done by my nurse before I even check the inbox.

Yeah, no, you sound very lucky.

I recognize it. I fully recognize it's a place of privilege, but I think it's a model that is neat to keep within our clinician work.

Which is

definitely something that we're trying to recreate it here. Create here. Speaking of that, if you were to give advice to clinician or physician that wants to go and move the clinic from in-person to virtual, how would you go about standing up?

Yeah, I think a lot of it is it's more than just opening up a video visit connection. There's a lot of infrastructure that you need to think about before making the jump. Well, actually I'll say two things. One is try to strive for probably a hybrid model. Again, for myself, I still go to clinic once a week. There's a level of patients wanting to see you, things that you do need to check, I think physically in person. So try to keep a hybrid model if at all. possible But when you're building out the virtual pieces again, what is your video visit technology, all of that thing.

But the other part that I've looked at is I've kind of done the virtual back office. Things that I used to be able to just turn to my left and ask my nurse to do, you can't do because we're all sitting in our own apartment. So like opening those channels and those back channels is just as important as opening those channels with the patient. So thinking through, is it going to be secure a chat through your EHR? Are you going to be messaging securely through teams? Do you have another way to kind of have again, opening the lines of communication. So think through what that looks like in addition to the technical hardware pieces.

It makes a lot of sense. And what about panel size? Would you be able to keep your same panel size or could you ramp up or go lower? I mean, what is your sense on that?

Yeah, I

think it's, I know everyone uses panel size as a metric, but it really should be panel complexity. Right. So I think a couple of different models that have popped up the Medicare DCEs. If you have a lot of super complex patients, that total number could be lower. Right. So just to put numbers on things. So our target panel size is 2000 and maybe 2,400, I think spread across our, our team. And again, that's split between myself and the nurse practitioner, but that allows us to, again, respond to patients in a timely manner, but not sort of overwhelm us with all the requests and the, the different things that the patients are having.

So I've seen, so that's for what it's worth that's our benchmark currently is kind of somewhere in like the 22 to 2,400 range for a pod.

No, no, that

makes perfect sense. I know we're running short of time, but I have a lot more questions about care. I, I guess the main one that I would like to know is for those virtual patients that you're standing, how many of them are you doing any sort of remote patient monitoring or are they going home with blood pressure, monitors and other things and loading their vital signs into your EHR? How is that being done? Or what percentage of your patients were having that done?

Yeah, I'd say, I mean, so currently probably a good, at least 25%, we have some sort of monitoring. So look for patients with diabetes, we have some continuous glucose monitoring. We've partnered with Onduo. A lot of our stuff actually comes in through Apple health kit. So that's actually been, we'd use Epic as our EHR. So those opening, those connections and just building off of what's already, there has been really helpful. So I'd say blood pressure, weight, and glucose have been like the three things that have been the highest yield stuff that we've been kind of tracking.

Okay. Makes sense. Okay. And lastly, just what are your plans for the future? Where do you go from here?

Yeah, I think

just growing the model. So right now, like this, it's a word currently have three pods seeing like what that ability and just one state. So I think to me, like the biggest leap is going to be, how do you take something from one state and then video it across state boundaries? Even parents with kids that go to college somewhere else, like being able to continue to have that continuum of care. I think the golden ticket going forward is this to be able to have continuity of care across state lines. And we are not there yet.

Yeah, no. And I would assume the telemedicine laws and being able to practice in other states is that it's still not perfect. It's still not seamless. Any sense of where that's going in the future?

My fingers are crossed on the IMLC. I think it's, I forget what it stands for, but like interstate medical licensure compact. So if we can get that through, that might open up some doors. Barring that it's, I've known a few physicians that have gotten licensed in all 50 states and DC. But that's a long road and does not seem like a sustainable route.

Oh, Ooh. That seems bad. Well, Matt I really appreciate you joining me today to talk about virtual primary care. Certainly we'd love to talk with you more in the future.

No, for sure. Thanks so much for this time. I said, this is something I'm super passionate about and always happy to chat more.

Alright,

good luck to you.

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