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Carrie Nelson (2): (INTRO) we went back to the usual way of doing things once the pandemic settled down. And I realized that healthcare systems are very burdened from so many different forces and that they were going to need really strong external partners in order to truly transform care.

My name is Bill Russell. I'm a former CIO for a 16 hospital system and creator of This Week Health.

Where we are dedicated to transforming healthcare, one connection at a time. Our town hall show is designed to bring insights from practitioners and leaders. on the front lines of healthcare.

Bill Russell (2): Today's episode is sponsored by Meditech and Doctor First .

Alright, let's jump right into today's episode.

Sarah Richardson (2): Welcome to Town Hall with This Week Health. I have the pleasure of interviewing Dr. Carrie Nelson, who is the Chief Medical Officer at T Care. T Care is a local company that partners with hospitals and health systems to deliver primary care and behavioral health services via telehealth.

And Carrie, you've been a leader in healthcare [00:01:00] transformation for several years. You focus on quality, patient safety, population health programs, And your background in technology enabled care models is really impressive, especially to those that are listening today, because recognizing that need for innovative approaches to how we're improving the delivery of healthcare education outcomes is key.

So thank you for being on the show.

Carrie Nelson (2): Thank you for having me, Sarah.

Sarah Richardson (2): Absolutely, and I want to ask you more than anything is what inspired you to transition from traditional healthcare roles into leadership position in virtual care and what you're doing with telehealth at vCARE?

Carrie Nelson (2): Yes, been working in leadership roles within the traditional healthcare system for 20 some years.

And and really have had a passion for health care transformation over that time. And that's led me on these various trajectories around quality, safety and population health. When we went through the pandemic, I observed this speed of change that had never happened before. And when I first started leading change, I went and read everything there was to bring change.

learn about [00:02:00] leading change, and I found that it's really about patience and persistence. And all the patients over those years seemed to not be needed in the course of the pandemic when we found we had to just really turn on a dime, adapt new protocols for care, change the staffing model, change how we were using our facilities in a whole range of ways.

And I thought we learned a new competency. I was excited to see what was possible when we really put our mind to it. And I thought, Maybe I'm not going to have to be so patient going forward. Maybe we'll actually accelerate the pace of change in healthcare transformation as it's been needed for so many years.

And then I found we went back to the usual way of doing things once the pandemic settled down. And I realized that healthcare systems are very burdened from so many different forces and that they were going to need really strong external partners in order to truly transform care.

And that's when I decided to try. To help transform care from the other side of the walls on the outside of the health care system [00:03:00] and focused on digitally enabled care models especially as an access solution, which is such at the root of so many ills in our health care environments.

Sarah Richardson (2): One of the things that you have shared in some of your interviews and previous information you put out there is the fact that it can take up to 38 days. For someone to get a primary care appointment, let alone the specialty referral that may come with that. And then in addition, this massive shortage of providers that we're going to have, especially as this,

the boomer generation

hits its apex in the next 10 plus years.

When you think about those two things combined. Why do you get a sense, potentially, that there are fewer people utilizing telehealth during the pandemic? Because it's actually a huge win. If you didn't immediately want to go for it. All those factors being part of the equation, what do you see happening in the next few years?

Carrie Nelson (2): So patients absolutely love telehealth. That has shown itself in survey after survey. And so it's not patients that have [00:04:00] wanted to go back to more of in person care, the old model of, how we always delivered care prior to the pandemic. It's really the healthcare providers, and I understand it.

It's hard to switch between brick and mortar in a telehealth appointment. So they've, health systems have tried a variety of different things to try and make that more feasible. But frankly there's just not everybody is willing and interested in being a telehealth provider.

virtual provider. And so we've started to think about it as, there's officeologists and then there's virtualists. And so we're building out a medical group, a true medical group that is focused on excellent at being The challenge in terms of the primary care access that you described with, 38 days, actually that's a, that's across specialties.

That study was done by ECG consulting and it showed that 3, 000 some practices they tried to contact. About 20 percent of them, they couldn't even get through. And for the others, they actually got through, but they found it was 38 days getting a, reasonable [00:05:00] appointment. That problem is only getting worse, as you point out.

And so don't see a world where telehealth part of that solution. And it does cross disciplines. It's primary care and specialty. And as you point out, people, the aging population, more and more chronic disease, there's just more of a demand for services. And some specialties are already at terrible low rates of access.

So we can provide, for example, at KeyCare, we provide rheumatology services, we're building out a neurology service program, and we do have behavioral health in addition to our primary care that helps to remove some of those barriers and just continuing to grow across those disciplines.

Sarah Richardson (2): I love that you've shared that you've got the people who like to be in the office and those that have that digital specialty.

How is the training and delivery different, especially from an entropy and connection to patient perspective? For a physician who is now well garnered in the ability to deliver digital care versus the in person, how does that transition of training or that approach to the patient change?

Carrie Nelson (2): So there's, it's really important to be able to establish a good rapport over [00:06:00] the video interface, and it requires, what we call website manner in a way that, you're really making eye contact and you make sure your background looks professional and you're aware of how you're appearing on camera.

All of those things are things you don't have to think about in the office. And over years and years of work life, providers have done. Honed those skills in person and it just takes a slightly different skill set over the video. But it absolutely can be done. And in fact, some patients feel like in some ways they're getting your undivided attention when you're doing a video visit because you aren't getting that knock on the door.

In my own practice, I would get a knock on the door, The doctor's on the phone from the emergency room, or you've got to give orders to this particular, lab that is requesting information. And, all those things are just part of the chaos of in person care in a primary care practice that doesn't exist in a virtual environment.

Sarah Richardson (2): What are some of the most significant wins or successes that you've achieved at eCare so far with the approach that you've shared with me thus [00:07:00] far?

Carrie Nelson (2): You bet. Yeah, so we've been really very fortunate to grow quickly. We have, right now 17 health systems signed, and working towards 27 in contracting total, a total number of 27 based on those that are in contracting.

That's a pretty remarkable growth company that's only been in market for a year. So it speaks to a real need to have the telemedicine resources beyond what a traditional healthcare system can provide on their own. Many of them have their own telemedicine programs, but their resources are outstripped and they need extra help.

After hours, weekends, holidays. And they're going to be used during the winter surge, all of those things. And so the advantage we bring is

the care is fully integrated because

we are

on the most common electronic health record that health systems are

on, and that's

Epic. And so we can see the medical conditions, we can

recent labs that a

patient may have had.

So we can make medical decisions based on that good information maybe it may [00:08:00] result in a change in a dosage of a medication or, a shift in the differential diagnosis based on all that information. And then similarly, the health system providers can see the care that we've delivered.

And so there's full transparency across that divide, which is really something that health systems have been hungry for.

Sarah Richardson (2): you think about some of the challenges you face in promoting telehealth as a mainstream option, how are you working with the health systems to address those?

Carrie Nelson (2): To make it mainstream?

That's a great question. There is no question. We still have change management challenges. We are really focused on making sure we have not only leadership support, but we need frontline support. So we need to make sure that if, for example we're building a program that is going to support an obesity medicine clinic because they can't get

All of their

get all of their follow up

and, they can

their follow up patients in, but that would mean not getting any new patients in, and they've got a waiting list that goes till February of next year.

We can help them with their follow up appointments so that they can, [00:09:00] provide better access to all the people that are wanting those services. What that means then is we work closely with those providers in that clinic, we know what their clinical protocols are, we know how to escalate to the team at the site, and we have an ability to really do warm handoffs and, streamlined communications and orders and referrals on that basis.

So really working closely with the people that are feeling the pinch of the access problems and building that trust is essential in overcoming some of those barriers.

Sarah Richardson (2): When you think about things like some of the chronic conditions that come up, and not only is it hard to get an appointment, there may be multiple appointments that are required, and one of the things that you've shared in some of your interviews in the past is how hard it can be just to get to your appointment.

So when you think about equity and access and getting people to their appointments, when you think about what telemedicine and what virtual visits can do, You've got an extensive background in patient safety and quality. What measures is SheCare implementing to ensure the high standards in virtual care that make people more comfortable with that as a [00:10:00] method of receiving care?

Carrie Nelson (2): Yeah I would say we're in early days as it relates to measuring effectiveness and quality as it relates to telehealth. so we have an opportunity to be creative and use all the data at our disposal to make sure we're doing that in a robust fashion and we're building that at KeyCare. So we have some very traditional measures that you might see in brick and mortar, such as antibiotic stewardship for kinds of, respiratory conditions and making sure we're not over prescribing antibiotics.

But we're also looking at reasons people come to see us and some of those reasons are frankly not the low acuity. There are folks that have behavioral health conditions or people that have something more serious going on that really requires, they want to weigh in with somebody, some clinical professional to say, yes, you really do have to go to the emergency room or you have to go to the urgent care or you need to make sure you're seeing your primary care doctor regularly because the access problems are just so much of an issue [00:11:00] that sometimes they don't even want to pick up the phone or try to go to the emergency room unless they know they really have to. And so we are able to look at the reasons people are coming to see us and based on the relationship that we have with our health systems, we can do warm handoffs.

And we have patients, for example, that might come to see us three times in a month for a migraine. We're not solving their problem. We're only putting Band Aids on it, but there are people who back in their community Providers that can actually take more of a continuity mindset and be able to put them on a preventive medication.

So able to do those handoffs. We had another patient just recently who called because she was having a lot of bleeding. And there was a big concern from the provider that she really needed to go to the emergency room. We then did a follow up call with her later in the day. She had gone there.

She had been admitted to the hospital. So we're able to do, those kinds of Care coordination functions in a way that helps keep people safe and gets them better connected to their local health system as well.

Sarah Richardson (2): When you think about that, whether [00:12:00] it could be something that's immediately acute, when you think about really the role of fellow health planning and managing chronic conditions, how do you approach that aspect of care?

Carrie Nelson (2): I love that question. I think that's an opportunity that we are Going to be embarking on soon. We have evidence that chronic conditions take far too long to get under control. If you look at a hypertension as an example, it's over two and a half years from the time of a diagnosis of hypertension to the time that a patient might get control, if they get it at all. And that's data that is well known from the American Heart Association. And for that reason, there've been some initiatives to try and improve hypertensive care. With the American Medical Association, they have a particular program where they've worked with groups, but you still have the access problem.

So in my own practice, I would see a patient with hypertension and I'd say, I'd like you to come back in three weeks and let's see how this new medication is working or the dosage adjustment. And then my front desk person would come back and say, you don't have anything available for two months.

And so that, that is [00:13:00] one way those things get prolonged. We are building a program to where some of those folks can be sent over to key care. For very close monitoring and dose titration a lot of self management support, counseling on diet and lifestyle, and then sent back to their primary care doctor when we've got them in control.

And that way it relieves the primary care doctor of, that burden of those frequent appointments, which, would likely be happening in an ideal world so that they can take care of people that really do need to be seen in person.

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Sarah Richardson (2): When you think about that true aspect of care coordination, how often does the key care physician work with either the PCC or the specialist in different conversations?

The patient, sometimes when you have these chronic conditions, you actually want your doctor to talk to each other. So you're sharing the medical record behind the scenes. How have you seen telehealth become a bridge in the ability for the care coordination to actually be happening between two humans when there's truly something that's been recognized in the patient for their needs?

Carrie Nelson (2): Absolutely. I think that's absolutely critical that relationship gets developed and it's also part of the trust right? It's funny because you have, I think, in the previous days before telemedicine was really mainstream and it may continue to exist today, there's this, who are those doctors feeling, from people in the community that are seeing patients in their practices, who are those [00:15:00] doctors that are going and doing care online and they're for a couple of different provider groups, and there can be a mystique about whether or not they're actually good doctors.

And so creating that relationship, especially within virtual primary care, for a practice that needs that extra help is critical. So you have scenarios where you have a practice that has they may be down a doctor, right? So a doctor went on maternity leave or left the area, and now the rest of the doctor, the providers in that practice have met with the onslaught of the patients that still require care.

So we can put a patient and put a provider as a partner with that particular practice in a way that yes, there's a relationship that gets developed so that the handoffs are easy. There's a common agreement on how the workflows will happen. And there's a respect for all of us adhering to Best practice clinical guidelines in a way that really is necessary for a virtual primary care scenario.

Sarah Richardson (2): think about telehealth better addressing the needs of the underserved population, do you think about the [00:16:00] issues like the broadband access, technology disparities? There often is the concern that seniors don't want to use technology. They absolutely do. We've got some of the social barriers. How has P Care been addressing those challenges?

Carrie Nelson (2): Those are, yeah, I'm glad you circled back to this disparity issue and folks that have trouble with access for a variety of reasons. Some of it might be transportation, some of it might be broadband, and some of it might be, a disability that really requires, extra help to get to a brick and mortar facility.

For one, we are active participants in the advocacy world around making sure that broadband access is it is becoming it's creating health disparities today for the reasons that we're talking about. And so with American Telemedicine Association and other advocacy bodies, we are very much a part of that conversation to move legislation in a way that allows more equal access to broadband.

As it relates to other inequities, we certainly recommend, we, we use language translation services. We are [00:17:00] also advocates for making sure that phone remains an option when the video can't work or when, the broadband isn't supporting it, or somebody just has some technical, challenges in, in working with the equipment.

So sometimes you just have to. try to deliver the care over phone. And sometimes that works and sometimes it doesn't, but it should be an access point that remains available. And then finally, as it relates to elderly people, we did our own survey around this to find out because we do annual wellness visits for seniors.

And there is a belief that seniors aren't tech savvy, but when we looked at the data, it was very equivalent between seniors and other age groups, about two thirds of them are. very comfortable with doing virtual visit. And so I think that's a misconception we should really put aside.

Sarah Richardson (2): I'm glad you mentioned that it's really a misconception. I think about the amount of quote unquote seniors that I see, and I'm on the road all the time. They're all on, they're all on Facebook, they're all on Instagram, they're keeping up with their grandkids, they're keeping up with their families, and they're not, it's not an [00:18:00] unapproachable space.

to mention having come from Trinity most recently, We call the aging population of people that are over 50. And I'm like, dang, that's me and my husband now. I think we'll be absolutely fine with telemedicine. In fact, we use it pretty often because if you're on the road and you get sick what are your options?

You'd want to be able to connect with a telemedicine provider. It's come so far and yet for something that's been out there for quite a while, it was hard to get implemented prior to the pandemic. When you think about a leadership insight and about advice you give to healthcare leaders really looking to innovate and drive change in their organizations, whether that's a virtual program or otherwise, what are some of the things that you've learned on your journey?

Carrie Nelson (2): Back to patience and persistence, right? I do have conversations with leaders in different health systems that will tell me, oh, our providers really aren't in favor of letting the care for our patients go to a third party, And yet they are, at the same time, burned out and not able to deliver the care that It is really about continuing to [00:19:00] push past those, that resistance and to build relationships with a company like ours, with the people that are actually creating these solutions, where people just like the people that are delivering care in these physical sites and those points of resistance can be overcome.

But there's sometimes I think people give up a little easily and I think that's where the persistence comes in and just making sure that you're continuing to, build the case on a whole variety of levels. What's in it for them? What, that's ultimately what it comes down to.

What's in it for those providers? Get a small little, wedge somewhere with a few willing people and build from there. That's a really important way to go. This always worked for me in the past. I remember I started my healthcare leadership journey back when I was in my own practice, and I was having trouble getting my own colleagues to make some changes.

And I remember thinking, but these people are my friends. If I can't get my friends to change, what am I going to do for the rest? And I started to realize it's just a human phenomenon. You're faced with a [00:20:00] change. It creates a little bit of fear. You want to, you have a lot of questions and you really need to know what's in it for you and then give it a try and then start to, get a story around that in a way that influences others.

Sarah Richardson (2): I love that about a story that can influence others. To your point, you start to build that slow momentum by showing that the art of the possible is really there. So when you think about that with FHIR, what is most rewarding about the work that you're doing there now, and how do you stay motivated, for lack of a better term, in a field that is rapidly changing so quickly?

It can be hard to treat those small pockets of influence at times. So what are you most proud of right now?

Carrie Nelson (2): What I'm really proud of is that we're here. to augment this really precious resource of our healthcare system in this country. It's a strained resource. There are so many burdens on it, legislative burdens, many other, just the burden of caring for the volume of people, the financial situations that these health systems are in.

So what excites me is the ability to prop them up in a [00:21:00] way that helps relieve a burden and helps them, find continued success. Cause communities very much need our health systems to be successful and to thrive.

Sarah Richardson (2): You have a crystal ball. What does the one and perhaps three year horizon look like?

If you were to literally create a path for telehealth and the things you want to see happen next, what would it be?

Carrie Nelson (2): I get really excited about everybody having a kit in their own home to where they can do a strep test, they can do a urine, they can do a flu and a COVID, and they can Put on a device that allows us to listen to their heart and lungs or see their ears and throat and everybody should have something like that.

The technology is there and we can do so much more. It's an efficient avenue of care, not just for patients, but also for providers. They actually did a study that showed that Providers that were incorporating telemedicine into their practices opened up, at least an hour of extra, in their day.

And so we need that time because our population it has more and more clinical needs. And so being able to create an efficient model of [00:22:00] care that's also extremely high quality by having that special kit in everybody's home would just expand the application for these things.

Sarah Richardson (2): about the career path for a physician, is it probable that there may be doctors who go straight into digital medicine as part of their practice, or do you see it as something that's more mid or end career as an option to help avoid some of the burnout that we hear about today?

Carrie Nelson (2): Oh my, that's a really fabulous question.

So I do believe, for us, we do require several years of experience, at least three to five years of clinical experience in a brick and mortar setting. And the reason for that there may be two reasons. One, maybe it's just too soon to open up that door that you're describing until we have more training specific telemedicine in the future.

Carrie Nelson: training environment.

Carrie Nelson (2): Secondly, I recall in my own practice, working alongside my colleagues. In that first year of practice, how much you learn and how much you ask your colleagues, their opinion about things. If you're sitting You [00:23:00] know, oftentimes in your home, in front of your computer delivering care, you don't have that community of colleagues to help you grow as a clinician.

So I do believe, my belief today is that it is something for people who've had more experience in the brick and mortar setting. They've examined a lot of patients, they've got a clinical judgment acumen that has been honed through those experiences that can really be used to its best advantage. In the telemedicine setting.

And I think coming in too early skips some of that, which could be a little more risky.

Sarah Richardson (2): How does TPHIR treat that physician community in a digital environment?

Carrie Nelson (2): Yeah, we're really working to develop a true primary care group. And so it's important for us to have that feeling of a shared set of values and, shared commitment to quality in partnership with our health system colleagues.

So I've worked very closely with our providers. I'm on, texting with them on a regular basis. We have at least one provider forum a month where we have open discussion about [00:24:00] things that are changing. things that are getting their input on different things. That's another important thing that we're doing is making sure that , our providers voices are actually being heard and used to make the technology support them to their best advantage.

That's a really important thing. Our, I'm a job, I'm a physician and so is our CEO Lyle Barkowitz is also a physician. So it's a physician led organization and that brings that perspective of how important it is that our own providers. they feel that we're setting them up for success in the way we're designing our technologies and other resources.

The other thing I would say is we really like to work with people approaching at least 20 hours a week. We have some that are less than that, but when you get that, amount of time with them , there becomes more of a bond and a relationship that, that can be established than if they're just popping in, five hours a week or something along those lines.

I think that makes a difference as well.

Sarah Richardson (2): And what I love so much about the telemedicine aspect and virtual care is that It can be [00:25:00] 24 hours a day. You can't have that acute need to get you dressed immediately. One of the things I remember reading about you as well is, sometimes there's a stigma of going in to talk to a physician.

You might run into your neighbors there, and you might run into somebody who's going to

you questions

you are uncomfortable answering

and yet sometimes you

establish that before

virtually. A way, especially with the mental health

that we have today and there's actually so much

time

spent

either in isolation or online.

and

you realize I can create this relationship

physician

that makes me So it's stepping into that desire for that type of care, not something that has anything attached to it other than wellness for yourself.

Carrie Nelson (2): It's interesting.

I, I think there's a number of forces that have affected the comfort level we have now, today, and talking about behavioral health conditions that didn't exist before. And so more people are accessing it and the ease of access through telemedicine is just making it that much better for that movement to continue to take hold.

It's absolutely true. And it's not only true with behavioral health, it's true with general [00:26:00] medical health, because I was trained as a family physician and. Back in the 60s, the family doctors said, you know what, we think medicine needs to be based on a bio psycho social model, meaning your biology interacts with your psychology and your social circumstances.

So it's not all disconnected. That's now gone mainstream. It wasn't so mainstream in the 60s when the family doctors declared that, but that just tells you that when people are coming to us, with a particular concern, it's that whole package that is coming to us. It's not just their physical bodies.

And, the conversations that we have with people, cover that ground.

Sarah Richardson (2): The fact that, you think about your longevity is attached to your ability to live longer, healthier, happier, independent life, because you're taking care of yourself, you've had access to care, you're not isolated.

And all of the abilities for people to stay in their homes and actually get the care they need is something that continues to be innovative and delivered through telemedicine. I love what you all are doing at Q Care. And thank you for providing that, that [00:27:00] capability for physicians and for patients.

Because it is a two way street, they have to meet truly in the middle for it to work out well for both. What about Q Care have we not covered today that's important to you, or do you want to make sure that our audience understands about the mission that you're on today?

Carrie Nelson (2): Yeah, thanks for that question, Sarah.

So I think it's really about let's not think small about the applications that we can help deliver. So I think many of us are very comfortable with an urgent care model around telemedicine, but really expanding upon the virtual primary care and even Coordinated care between behavioral health and primary care can be very much enabled through this kind of an approach.

It's not just a carve out over there somewhere. There's some doctors that are taking care of people so I can have my Christmas off or whatnot. It's really a, it's really a A true partner with my practice and with my health system in a way that helps us both deliver the best care to people across a broad spectrum of [00:28:00] conditions.

That's really what we're striving for.

Sarah Richardson (2): That's a bit of a tough question because it came up this week twice in conversations I've been having. The first one is the report was put out about the hospitals with the highest and lowest margins. And then an interview I listened to this morning on our news day show with Dr.

Zafir Chowdhury from Seattle Children's, stating hospitals are more and more being asked to do less with their budgets, less with the ability to deliver what's really necessary to them. Never before have we been in such a strife of We have to do all the glass all of the time. Telemedicine can help to solve that.

When you think about the impact of what that really means, what is most encouraging to you in the ability of how telemedicine can contribute to margin and also give people back that feeling that they're not having to sacrifice something in their ecosystem to give back to their patients.

Carrie Nelson (2): Sure, so a couple things. One, we get our providers credentials with our health system partners, so we become a profit center for them. And so they're not just referring out and losing that revenue. We can [00:29:00] actually make sure that they capture some of that revenue. That's one way. The other that I haven't touched on and \that we're not doing today but some of the virtual care that can be delivered.

to hospitalized patients. So there's such a nursing shortage and they're trying to do more with less in particular on nursing. And you've got many nurses that have left the profession or are leaving there, variety of reasons, much of it from the pandemic, but some of it is just an aging workforce.

And it's hard doing that. It's hard, heavy lifting work at the bedside. So many times, a hospital system can work with a nurse that's remote, can do a variety of things. They can collect a bunch of history. They can gather a lot of history for admission. They can teach the patient discharge instructions.

They can also coach a young nurse at the bedside who might be doing a procedure for one of her first few times in a way that it doesn't take. away from somebody down the hall who's got other pressing needs with other patients, it's really somebody there to be on video with them that's seasoned and can really [00:30:00] help them make sure that procedure goes well.

And so those are other ways that we can start to help help health systems cope with these financial strains.

Sarah Richardson (2): I love that. Bringing revenue back into the facility. So at the end, the caregiver can still spend time with the patient face to face. So it's really the equilibrium that gets created, especially when you're in the inpatient setting.

And it's augmented by the innovation and the acceleration of the telemedicine programs. It's a good balance to have. Dr. Carrie Nelson is the Chief Medical Officer at KeyCare. Thank you so much for spending time with us today. I look forward to watching your organization grow and for the proliferation of all of the amazing things that we covered today.

Carrie Nelson (2): Thank you, Sarah. I'm really grateful for the opportunity to chat.

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