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This is Laura Deda with the Becker's Healthcare Podcast.
I'm thrilled today to be joined by Dr. Ethan Booker,
chief Medical Officer of Telehealth and Medical director of MedStar Telehealth
Innovation Center at MedStar Health. Dr.
Booker is a pleasure to have you on the podcast today.
Thank you, Laura. Thanks for having me.
Now, I know we have a lot to talk about,
and I'm excited to get into the meat of our discussion because I know Telehealth
and virtual care is something that is on the top of so many minds in healthcare
today, and really making sure doing it right is a top priority.
But before we dive into that larger discussion,
could you tell us a little bit more about yourself and your background? Sure.
I think it's,
it's useful to kind of set me within the context of my health system, I think.
So as you mentioned,
I'm the Chief Medical Officer for Telehealth at MedStar Health,
which is kind of an interesting role, not a,
not a role we needed a few years ago,
and one that I've grown into as our health system's capabilities in telehealth,
uh, have come along. So, um,
MedStar Health is the largest healthcare provider in the Maryland and Washington
DC region. Um, spread out over more than 300 locations in 10 hospitals,
uh, urgent care clinics, ambulatory care centers,
really all of the features of a regional, uh, health system,
including a focus on, on the academics that we produce and research,
education and training. Uh, and our, uh,
when you sort of flagship academic hospital, MedStar,
Georgetown University Hospital,
the journey that I have had myself as I'm,
I'm an emergency physician and I've been working clinically at MedStar MedStar
Washington Hospital Center in DC for, uh, this will make 18 years,
uh, now,
and have had the opportunity to work in a variety of areas around innovation and
improvement, um, air medical transport, uh, that kind of thing.
And starting in 2015 began to have the opportunity to use telehealth to
improve operations in our emergency departments. Uh,
and so in 2017 when the MedStar Institute for Innovation,
where I sit now, uh, chartered the MedStar Telehealth Innovation Center,
uh, I came on board in partnership with Bill Sheehan, my boss,
the Chief Innovation Officer, uh, now of MedStar Health. Uh,
and we began to build the capabilities, uh, of,
of telehealth that really prepared us for, uh, the moment, uh,
in March of 2020 when much of what we built, uh, came to fruition.
And I think we'll probably spend some time talking about the journey from,
from that date onward and, and where we're at now.
Absolutely. I think that's such a great point because for so many,
that inflection point of the pandemic beginning really put them down, uh,
a very fast paced journey towards virtual care and telehealth,
and one that they weren't necessarily prepared for at the beginning,
but you know, now are really able to lean into and become, uh,
advanced within that technology in that space. So based on your experience,
and especially the last two years,
what are you seeing as some of the big opportunities as well as headwinds that
you have your eye on?
Yeah, I think there continues to be, um, you know, a lot of excitement, uh,
about the opportunities that are in front of us in telehealth and,
and using those tools really to expand the envelope of,
of the way that we care for folks. You know, we're really excited that,
you know, just recently in, in March of 2023,
we surpassed 2 million telehealth encounters over the,
that three year increment that I, that I mentioned starting in March of 2020.
And as an, an academic health center, we're, um,
excited about the opportunities to develop better learning in that space,
including research that,
that I co-lead with partners in the MedStar Health Research Institute,
as well as partners at Stanford and Intermountain in the,
the Connected Care Access Research Equity and Safety Consortium, the,
the Connected Care and Safety Consortium for short, um, that,
that is supported by grant work from A H R Q that we're just really excited
about the opportunities to focus on safety and quality in the
delivery of telehealth. I think those are some of the opportunities that we're,
that we're really excited about. Lets kind of demonstrate, um, the,
the success that one can have and really changing the care model for,
for the way we, we care for patients. And I think that's really, you know,
the big opportunities here are, are about creating continuity with patients,
really creating an experience that that is,
is or can be ubiquitous without being invasive, uh,
to really change the, the model of care delivery and think, uh,
really about the care delivery as opposed to the location per se. Um,
so those are the, some of the opportunities kind of in a,
in a global sense that we're excited about. Um,
I think that the headwinds, as you mentioned, um, are kind of,
they're kind of twofold in some ways, um, or at least how i,
I am experiencing them myself in, in, in our organization.
The major one that's external is really the evolving telehealth policy
landscape. Um,
and that is a really complicated one because it's not just sort of one set of
rules. It is the rules that are determined at the federal level,
um, by acts of Congress, by the regulatory environment, uh, of the,
the many agencies that are involved, whether that's hhs, um,
and Medicare rules,
or how it is that they guide states and Medicaid implementation, uh,
as well as other regulatory agencies like DEA regarding controlled
substances, and then each of the states individually, uh,
having their own, uh, rules and regulations and reimbursement landscapes,
which really does create a significant headwind for how it is that we move
forward. Now, the thing that's really very positive is that,
um, the federal legislation, uh,
that came out towards the end of the calendar year last year,
ongoing guidance from those regulatory agencies is very positive
as a whole, um, as is the state environment as a whole.
Um,
but the complexity of the interaction between the two kind of creates this
circumstance of, of some uncertainty, um, about,
you know, for any individual provider thinking, well,
for the things that I do, what does that mean for me?
And what does that mean for me in the way that I approach my patients
cohesively? Right? Because it's not as if, particularly around telehealth,
you're dealing only with one state jurisdiction,
or you're da dealing only with one payer. You really have to approach,
you know, a kind of all jurisdiction, all payer model, you know,
in a place like, like, uh, MedStar Health spread out over dc, Maryland,
and Virginia.
That can create the kind of complexity that creates the second headwind,
which is one that's internal. And this is true for all health systems,
that complexity and uncertainty creates a,
a sense of a conservative approach. Um,
and so the challenge or headwind that,
that is created by those external features comes in the internal environment
by trying to help us, you know,
we try to be clear with our organization what's permissible,
what's reimbursable, uh, what's kind of safe and high quality,
what's equitable, uh, that kind of guidance.
And we really have to be consistent in that messaging,
both understanding it from those external, um, parties,
but also being able to communicate it effectively to our own people so that we
can remove that uncertainty and that bit of hesitancy, um,
that that can prevent us from leading as,
as much into these opportunities as we'd really love to. Um, so I,
I think those are the two things that kind of contribute both that regulatory
framework that then creates the uncertainty internally that in
some circumstances, not all,
but some circumstances just kind of creates a hesitancy, uh,
that is the job of our innovation institute, uh,
to often innovate around and overcome.
Absolutely. I, I think that's such a, a great point. And, you know, definitely,
um, with video, that uncertainty, whether it's the regulatory,
the telehealth or, or anything else, um, that that's happening,
I know change is happening so quickly, and so it,
it's great to have that kind of outline of, you know,
how do you approach that with your team and,
and really keep moving forward even though you know that, you know,
there are certain things that aren't set in stone. So I,
I really appreciate you doing that. Has the team been pretty responsive?
Yeah, I mean, I think it's, it's a question of, of consistency, um,
and also kind of, you know,
the ability to get in with the team themselves and do the work. Um,
as I mentioned, I, I've,
I've been an emergency physician in my health system for, uh,
for getting close to 18 years now, and I work clinically every week,
and so experience, uh, what it is to deliver care. Uh,
and so I think I have the,
the great fortune of being able to engage with service line leaders and
frontline clinicians and, and kind of say like, listen, I know this is hard. Um,
uh, but this is, this is an opportunity for us to do, um,
a better job of, of providing access to our patients, to,
to connect to our patients, um, to be, uh,
innovative and flexible about our workforce, um,
addressing not only the demands, uh, of a really changing environment for,
for hiring and, and retaining workforce, but making sure that that,
that they're sort of operating efficiently and effectively and,
and doing sort of well in the work that they're doing.
And I think those are the things that, you know, approach that way.
This is a way to, to improve the access to your patients.
This is a way to improve the efficiency of our practices. Um,
this is high quality care consistently, I do have,
have positive results from folks,
and we've had just terrific partnership within our system on, on,
and not just kind of pivoting, you know,
things we used to do in person to now we can do through a different
modality, but really rethinking the model of how we're delivering care.
Absolutely. I, I think that makes a lot of sense,
and definitely it's inspiring to hear that, you know,
you're able to really keep your eye on that goal of better patient care. Now,
from your vantage point,
and especially what you're doing with the telehealth Innovation Center,
how would you really see that adding value to the organization overall?
Where do you see big opportunities for growth and how are you measuring that?
Sure. I, I mean, I think they come along the same lines that I just described.
And so I'll, I'll give you an example of, of, again,
not just replacing one thing with another, but really pivoting the model.
So we are working with our clinical service lines on a model called
Connected Care. Um,
the implementation of this most in its most mature firm is in primary care.
So in our connected primary care model, we have, um,
a workforce and workflow transformation in which we've added
new workforce, uh,
including nurse practitioners and medical assistants who work a hundred percent
remotely, uh,
and focus on a handful of activities that we know are gonna be high impact.
Um, those activities include same day and next day telehealth, uh,
appointments with established patients, because as I pointed out,
access is a critical issue. Uh,
and so we've been able to improve access to our primary care footprint,
um, as measured by third next available appointment. Uh, in those, um,
practices in which we've implemented,
we're about two thirds of the way through scaling through this implementation,
uh,
at which point all 360 of our employee and primary care providers
will be supported in this model. Now,
what was important about the change was not just inserting telehealth
to, to drive this change,
but we protect nearly 50% of the time of those nurse practitioners
to do the kind of asynchronous work, um, that's really important for access,
but also, um,
was sometimes preventing our primary care physicians from focusing on the
face-to-face encounters that they really wanted to be doing.
So those activities include things like prescription refills,
uh, portal message management, lab follow up,
and also opportunities to be the,
the supervising clinician for remote patient monitoring for folks with chronic
illnesses that are appropriate for that, for that, um, type of service.
So, um,
the prescription refill in particular is worth pointing out as a, as a way of,
of leveraging a remote workforce and asynchronous type of work.
And we've also, um,
inserted some automations into that process to make it as efficient as possible.
And the,
the 12 nurse practitioners who are currently in support of our primary care
footprint have supported more than 270,000
prescription refills that would've previously been done by primary care
physicians, either after hours or,
or squeezed in between the appointments where they were seeing patients.
So in addition to the,
the nearly 20,000 telehealth visits that we've done, um,
which were access to our established patients,
we were able to take the load of those prescription refills off of,
of the primary care physicians.
And we've measured the impact of that through a couple of different ways.
One of them is about our cycle time to refill these prescriptions,
which has improved significantly,
but another one is actually after hours EHR time by the
supported physicians.
So we've been able to demonstrate in some of the practices that have really
leaned into this somewhere in the neighborhood of 30% reduction and after hours
EHR time for providers.
So that's that 6:00 PM to 8:00 PM or 9:00 PM time that most primary
care doctors will tell you was, um,
every day something that they were doing, uh, and what really was,
was not the most fun thing they could do in their practice. And so by,
by taking that and being thoughtful about how we manage it, uh,
we've been able to allow those primary care physicians to actually have some
increased capacity in their day to see new patients or more
complex patients. And so in addition to generating the,
the novel revenue of those telehealth visits for the nurse practitioners,
the productivity of the supported physicians has also gone up.
This is a model that is entirely additive.
It's not just moving fingers around from one to another. Um,
and the impact of patients has really been significant. We,
like a lot of health systems use press gainy to understand the experience of our
patients, uh,
and we've seen some really significant improvements in percentile rankings,
particularly along the lines of access, uh,
of our patient experience scores as we've scaled this model through our primary
care footprint. Um, right now we're also using this model,
not an exact replication,
but really a framework of how we think about using these technologies, uh,
in cardiology. Uh,
and also we're thinking about the opportunities to use this not just as a sort
of service line transformation,
but to think cohesively about a disease condition or a patient population.
So we're also applying this model to diabetes, um, as a,
as an approach where we're looking at the opportunities to, uh,
engage patients with a chatbot remote patient monitoring, uh,
grouped sessions for diabetes education. And again,
kind of leaning into the model of how it is we can optimize our resources,
which we're a big health system. We have, we have,
we are well resourced in many ways, but we,
like other health systems are constrained and how do we become very efficient,
uh, while also improving the quality of care we deliver? And that's a,
a kind of way of thinking about how we use these tools, uh,
to really to move forward and not just in a, um,
incremental replacement, but really in a, a transformational way.
I love that. I, I think it makes so much sense to, um, you know,
think through how you can leverage that technology, um,
to make things easier for the clinicians as well as patients and, and, uh,
become more efficient as an organization.
And I really appreciate the detailed way that you went through how you track and
measure and think about, you know,
what that return on investment for these changes and these technologies are.
And speaking of that, I know that, um, you know, um,
right now is a particularly challenging time for many industries,
but healthcare in particular dealing with inflation and in short staffing from
many organizations. And so from your perspective,
what do you see as being an important investment or a risk that's still worth
taking, taking, um, even as healthcare resources and dollars are precious?
Yeah, it's a, it's a great question. I,
I think what I laid out for you in our connected care models was focused on the
ambulatory environment, you know, um, the, the clinic, the office,
the patient's home. Um, but obviously we're a, we're a hospital system. Um,
and so, um,
there is a significant amount of opportunity in, um,
in making smart investments in our inpatient footprint. Um, and,
uh, we also have a, a very large, uh, nursing workforce,
which is one of the areas that like other health systems,
uh, is a risk. Um, and,
and our ability to recruit and re and retain nursing staff,
uh,
is really an important part of where we see value for ourselves going forward.
So, um, we think that the inpatient environment,
starting at the patient and thinking about the patient's, um,
autonomy and control of their environment through technology is an important
place to be making an investment,
but also one that we can effectively leverage to make ourselves more efficient.
Uh, meaning, um,
getting more technology at the bedside for the patient to
feel connected, um, to their care team,
to the services that we provide to their family members, um,
as a way of staying connected to them while they're in the hospital,
whether they happen to be, you know, just across town or across the country,
that digital connection's really important at the bedside,
but it also allows us to bring services to the patients such as our palliative
care team, uh, which has a really robust capability, uh,
and is really leaned into telehealth as a way to deliver those services. Um,
our acute pain service, uh, is rounding on patients fairly routinely.
Uh,
and we're working on ways in which to deliver things like chaplain services and
music therapy, uh,
and case management to the bedside in a way that is efficient and effective,
standardized and centralized throughout our system.
So that introduction of technology at the patient bedside in the inpatient
setting is a place where we think it's worth making an investment,
but it has a set of risks as well. Um,
the introduction of new technology to a workflow always comes with the risk of
friction.
And so kind of an additional part of the investment we've made is a group of,
of of our associates that called Telehealth technology coordinators or TTCs,
uh, that really grew out of a,
a kind of redeployment and volunteer program that started during covid,
but it's matured and formalized to be a group of people,
non-clinical people, um,
who can be quickly dispatched with appropriate technology to a patient's bed ti
bedside to kind of proactively prevent that friction from
occurring either from the patient side.
And really importantly from the nursing side,
we want our nurses to be focused on clinical care of patients and not doing
these things that are, that are not clinical care, that are,
that are not within where they should be spending their time and energy. And,
and so the TTC gets to the bedside and facilitates that encounter to make sure
it's, it's seamless for the patient, that it's comfortable for the patient,
and that if you're a palliative care physician who needs to be engaged with the
patient and the patient's family members,
you have certainty that that connection's gonna happen.
And you yourself don't have to do the troubleshooting as a clinician to
make sure that it happens, but it's really all queued up for you.
So we think there's great opportunity for an improved experience
for patients and their families, uh,
in the inpatient setting through greater control of their environment,
some autonomy, more connection, more information,
more ability to deliver education, a more seamless, um,
transition back into the, their home in the ambulatory setting, uh,
but also for us to be more efficient as a business to distribute
services more effectively. But, and,
and that may come at, you know,
we wanna make sure it doesn't come at the cost of distracting
clinicians from doing the work they should be focused on.
And so we've made that investment for someone who's really proactively there to
make sure it doesn't become an environmental full of friction.
That's such a great point. Dr. Booker, thank you so much for, um,
jumping in and talking through all of that. Now I know we're, um,
ha have had a great conversation. And before we wrap up, I just wanted to know,
is there anything else you see as great opportunities for growth in the future
or anything else you wanted to leave us with?
Yeah, I mean, I think that, you know,
I started by talking about opportunities for continuity. You know,
I mentioned this connected care environment I mentioned, um,
talking about the inpatient environment and,
and some more patient technology there that allows a more seamless
transition back home, back to the ambulatory environment. And I, I,
I think, you know, just sort of again, globally strategically,
the opportunities to really create continuity, um,
and what I would describe as, as a,
a ubiquitous experience without being invasive is really
where the opportunities are for growth. Um, and what I mean by that,
ubiquitous but non-invasive experience would include things like remote patient
monitoring,
partnering with patients to understand their own consumer wearables.
Um,
really thinking about a cohesive approach to partnership with patients
about the data they are collecting in many ways themselves, uh,
and how we can create for them a climate of care, um,
that is less dependent upon the locations where they happen to
be for care. Um, meaning not just at home,
but at work and in transition and as they go to visit family and friends
and, and really being available to our patients in a way that is
really continuous and comprehensive. Uh,
and to do that in a way that also meets the needs, um,
that they're likely gonna have proactively, uh,
and rather rather than waiting reactively for an encounter to occur.
Um, and I think there's gonna be lots of different pieces and parts, uh,
to do that effectively. That means thoughtful change about our ehr, um,
which is still encounter based. Uh, it means thoughtful, um,
changes about data, data security, um,
how we collaborate with patients on the data they're collecting themselves and
how we visualize it, how we manage the noise of all of that.
Um, so I think there are definitely challenges in there,
but I see great opportunity, um,
for application in that space of really thinking about ubiquity, um,
and continuity.
Absolutely. Dr. Booker, thank you so much for joining us on the podcast today.
This has been such a fun and interesting conversation,
and I look forward to connecting with you again soon.
Great. My pleasure. Laura.
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