 Thank you, Mary. Good morning, everyone. A little more enthusiasm. Come on. Good morning, everyone. So our panel is Patients and Clinicians on the Frontline of Telehealth. I think it's an exciting opportunity for this audience to hear directly from the people that matter most in the delivery of telehealth, and that's patients. But also from the people who are obviously key to that delivery, and that's the clinicians. We are fortunate today to have a great panel. The panelists are all associated with integrated delivery systems, though, which is a slice of life of the applicability of telemedicine, and so we'll try to draw that out. Our objectives this morning are numerous, but one of them is to give you those real-world examples of telehealth from the perspective of both patients and clinicians. You also want to hear very importantly from patients about what works in telehealth for them, and why, and what may not work. And then finally, we want to understand the amplified benefits of telehealth in integrated delivery systems, especially when they're connected by an integrated electronic medical record. To help me today in discussing these topics, a great panel first I'd like to recognize immediately to my left is Dr. Neal Evans from the Department of, sorry, got to get your bio out here. Dr. Neal Evans from the U.S. Department of Veterans Affairs, the Office of Connected Care for the Veterans Health Administration. He's board in both internal medicine and clinical informatics. Within VHA, Dr. Evans is an active clinician. He manages a panel of internal medicine patients in the primary care clinic right here in Washington, D.C. But importantly, the Office of Connected Care manages the VA's expansive telehealth program and the VA's patient portal, MyHealthVet, the VA mobile program, and VHA's innovations initiative. And Dr. Evans is key in all of those. He oversees the development and implementation of enterprise-wide veteran digital health strategies, transforming care delivery across the care continuum, and importantly, geography and facilitating alignment of health information technologies within the VHA. Just as a way of a little praise see on his academic background, he's trained as a chemical engineer. You're a blue hand, right? Isn't that a blue hand University of Delaware? An attendant medical school at Johns Hopkins where he also did his medical residency. To his last left is Dr. Dennis Trong. Dennis has the title of Director of Mobility Technology for the Mid-Atlantic Region of Kaiser Permanente. He is an emergency medicine physician boarded, and he joined us in 2010. He earned his BA in molecular biology at UC Santa Cruz, and I think you guys are the banana slugs. Is that not correct? That is the mascot for UC Santa Cruz. Attendant medical school at Michigan State and did his residency at William Beaumont in Detroit. It's also a proud U.S. Air Force veteran. And one important thing about him that I want you to remember for later on in this conversation is that only as he board certified in emergency medicine, I need the glasses for this, but he is licensed in Virginia, Washington D.C., Maryland, Florida, West Virginia, Pennsylvania, North Carolina, and California. And that multiple state licensure issue has come to life in Dennis' own credentials because he heads our House Calls Urgent Care Telemedicine Program. And hopefully we'll talk a little bit more about one of the barriers. That's what I alluded to this morning about state licensure requirements for telemedicine. Finally, to his left, we have Ms. Brenda Truhart, one of our esteemed Kaiser Permanente members who will give you the skinny on being a patient in the system and using the telemedicine faculties and capabilities that we have, what works and what doesn't work. Dennis will introduce her more fully later. Now, just by way of a little bit of summary overview first about telemedicine, and we want to make sure we're all grounded in the basic modalities of telemedicine. Often it's thought of as video medicine and personally, yeah, I think I understand that, but I want to make sure that people understand that telemedicine has other aspects. And we, at least in Kaiser Permanente, and I'm pretty sure in the VA, try to exploit all of those modalities. They each have their own unique niche, and you're going to see some of that today. First of all, there are pre-scheduled telephone appointments, real interactive evaluative appointments that occur by telephone. That's telehealth. There is remote monitoring, usually with an interactive or bidirectional information exchange component. That's telehealth. We would go so far as to say that secure texting between clinicians is a form of telehealth. And speaking of sort of efficiency factors that were alluded to this morning, we feel that inter-clinician secure texting is one of the most effective increases of our physician's efficiency, and is one of the most popular things that we've introduced in the world of telehealth in Kaiser Permanente. We also believe in secure email in a structured format with interactive interrogatories that too can supplant a face-to-face visit. Not all secure emails can do that, but some can. And then finally there's video-based, or I would say imaging-based, telemedicine. Usually we think of that as video-synchronous interactive, but it's also been alluded to this morning. There is store and forward asynchronous telemedicine. Very, very important in fields like dermatology, where there is a dearth of specialists who want to practice medical dermatology. There's plenty that want to practice cosmetic dermatology, but real medical or surgical dermatology. There's fewer of those specialists, and something like asynchronous store and forward dermatology is very, very useful in expanding and maintaining and distributing access. With that kind of overview, many praise see of the modalities of telemedicine. I would like to turn it over with just one minute to spare to our first panelist, Dr. Neal Evans. Thank you, Bernadette. And thank you very much. I'm happy to be here and to share a little bit about telemedicine, telehealth, or what we call connected care within the Veterans Health Administration. And I did not expect to be on a panel with another person with the banana slugs. Who knew the banana slugs? The banana slugs and the blue hens. Two mascots that start with the letter B. Here we go. Let's talk about the Veterans Health Administration. We are a large integrated healthcare system. And I think we've heard some discussion over the course of this morning about how we have seen a significant implementation of telehealth in some of our country's larger integrated healthcare systems, two of which are represented here on the stage today. We take care of nine million, six million plus veterans a year, and we do so. We have 326,000 employees, 177,000, which are clinical employees. And we do so at over 1,200 physical sites of care. But we have a unique challenge in the VA. We are the only healthcare system that I know of that has, well, that we are a healthcare system. There are others within the government healthcare space, but where we are required to deliver healthcare to eligible veterans, regardless of where they are in the country, even in places where we don't have a physical presence. And that has been one of the big drivers of our early adoption of telehealth. But first, some of the speakers this morning gave disclaimers, including Helen, who gave a disclaimer that her one experience in telehealth was answering text messages from relatives about health issues. And I actually think that is relevant because I think it talks about the expectations that consumers are going to have as we move forward into the future for the convenience factor of accessing healthcare. We've heard about the theme of both access and convenience today. So I wanted to provide a little bit of an example of what this actually looks like. This is my son. He's now 11. This was two years ago. He was nine years old at the time. He's a little bit embarrassed that I continue to use this slide with his spelling mistake in improper use of the plural for the word tooth. One of my tooth really hurts. This was me, I believe, at the time I was at a conference and about to present. So I could have been doing this right here a minute ago. I had taken him to the dentist earlier that day. His mom was home with him. I don't know why he chose to text me instead of my wife when she was just downstairs. But nevertheless, what I love about this is that this shows asynchronous telehealth. And it happens spontaneously in a nine-year-old that he sent me the image to help me understand exactly what he was talking about. And this is closed-loop telehealth. So I went over and texted my wife who was downstairs and said, Henry's tooth hurts. Maybe we should give him some medication. He was reminding me. I got a little reminder that it really hurts. And then I got follow-up that this encounter had been completed. That mom got him the acetaminophen all was well. This is the customer. These are the consumers of our future healthcare system. We need to be prepared to serve these customers. But in the VA, and I think oftentimes the population that benefits the most from telehealth and where there probably is a stronger business case, since we've been talking about the finances behind this, is in the elderly population. And we certainly have with complex chronic illness and multiple needs and multiple needs to interact with the healthcare system. And we certainly have that situation within the VA. You can see here the number of living veterans per age group. And if you look in 2017, our population is heavily shifted towards the population that is 65 years and older. So when we think about telemedicine in VA, we think about telemedicine. This is our mission statement. We think about it from, and these two themes have come up already several times this morning. It's about access and it's about, in our case, the veteran's experience. You could translate veteran's experience perhaps into convenience, if you wished, since we have heard that theme today. But it's not just, it's about how do we leverage technologies to provide access to care and improve the veteran's experience, but to do so in a way that makes sense and is effectively integrated into the daily lives of both veterans and our clinical teams. We think about things in three categories. How do we use technology to connect patients with the providers that are part of their care teams? How do we leverage what we offer in healthcare, which is access to trusted relationships to improve health? How do we connect patients to their health information and allow them to share health information with us to better have an exchange? And how do we improve the care experience? We do this, our technology set, as Bernadette mentioned, includes our portal, mobile applications, connected devices, Internet of Things. I don't think the technology matters all that much. What matters is how this improves care delivery. Where did we start in VA? I think this surprises everyone. Our first telehealth encounter. I could take a show of hands as to when you think that might have happened, but I'm looking at the clock. So I'm going to tell you that it was in 1959. In 1959, we did our first telemedicine visit. It was a group therapy, telemental health, by two-way television between the University of Nebraska and the Omaha, Lincoln and Grand Island VA hospitals. Now, there was a pretty large gap between 1959 and a broader implementation of telehealth, but where are we today? It was mentioned earlier by Helen that we last year did more than 2.1 million episodes of telehealth care. And there's a definition issue. We define telehealth a little bit differently than Kaiser in these numbers that we report, although I'm advocating to adopt the way you measure telehealth to include, for example, scheduled telephone visits and secure email encounters. These visits are either a full month of remote home monitoring, a video visit, or a store and forward telehealth encounter, where some images sent back and forth in an interpretation occurs. That's what the 2.1 million visits are. And 12 percent of our veterans received at least a portion of their care through one of those modalities last year. And approximately 45 percent of them lived in highly rural areas. If you add in telephone care, that number increases significantly. And so I want to spend just one minute going through this slide here, which sort of gives you the landscape of how we think about telehealth and implement it in the VA. It's a pretty broad implementation of telehealth. And Bernadette mentioned the modalities. That's an important way we think about it. What are the technologies we use? And we also think about this in two other frameworks. One, where does telehealth occur? And we think about this in three locations. I think you've heard this earlier today. In the home, how are we delivering care into the home? And we are doing that through our portal, through secure email, through scheduled telephone visits, through mobile apps that are allowing veterans to share their data back with their health care team, through remote home monitoring through our home telehealth program, where we last year, for example, monitored 147,000 patients over the course of the year in their home and saw a 31 percent reduction in admissions and a 57 percent reduction in bed days of care. We deliver telehealth in the clinic environment, connecting our remote clinics often in rural areas where there isn't a distribution of specialists to our main medical centers. And we also do store and forward telehealth there. And at the hospital, tele-ICU and tele-stroke you heard mentioned. We also think about this as how we implement it. We implement it locally. This is about access. We implement telehealth regionally. We have multiple telehealth hubs across the country, which is all about building capacity or efficiency. And we implement it at the national level, thinking about matching patients with the unique clinician who can help deliver the care that they need, increasing quality across the health care system. This is a high priority for our organization. Many of you may have seen us announce our Anywhere to Anywhere health care initiative. And during the questions, I'd be happy to talk a little bit more about what that is. And that was also announcing our video solution, which we can also talk about and you'll see demonstrated in a video in a little bit. So with that, I am going to hand things over to Dennis, who is going to share a little bit about the Kaiser experience. Good morning. Good. All right, I'm Dennis Trong. I'm the telemedicine mobility director for Kaiser Permanente, a medical group here in the D.C. area. First of all, I have a disclaimer. I actually grew up with a huge fan crush on Kaiser Permanente. I grew up in that way in the sense that I grew up in Northern California, where one of every two members or population are members. I grew up thinking that health care was like this everywhere. So when I started my medical school and residency, I was in Detroit, and quickly I figured out health care not like this everywhere. So after that, I joined into the Air Force, and I was a medical doctor in the Air Force. And once again, life was a little normal again because it was more standardized. It was a camaraderie, and that's where we first started using telehealth. My first experience with telehealth was using WebEx as a night doctor in order to speak to my colleagues in the states who were surgeons to get some consultation. And that's my first experience with telehealth. And then after that, I actually worked for the VA for a little bit. And I was a fork in the road where I was in a ward with the VA system also. It was a great system, and I was at the fork in the road. You joined Kaiser, you joined the VA. I think either way, my choice has been amazing. I followed Dr. Loftus here over to Mid-Atlantic because, interestingly, a small fact is that I grew up about a mile away from one of the most darling medical centers of Northern California, Kaiser, Santa Clara. So that heavily influenced my decision to come here, and I'm actually just very honored to be in front of you today talking about this. Now, what is a sweet sauce? What is the secret sauce that we have at Kaiser from Nante? It's not about the telehealth, not about the technology. It's about the foundation of our system. We value integration, and everything that we do here, all this whole Web is about the integration of our system. It's not the horizontal integration. It's a vertical integration. I think of it like a DNA helix. It's like this DNA helix. At the center, the spine, it's a patient. And everything we do revolves around that patient. So whether it's technology, whether it's a new department, whether it's a new workflow, it really evolves around how do we deliver patient care better? It's like this relentless pursuit of bettering care. And that's what the culture at Kaiser from Nante that I've learned and still carry out to this day. Now, knowing all the pieces via Legos, that's how we start thinking about telehealth, which I think, hey, how do I improve the system? We have innovation opportunities throughout Kaiser, throughout our eight regions. We have 21,000 physicians and countless other nurses. They all have an opportunity to give input into innovation, including telehealth. With their input, there's a due diligence that happens. It's like you're sifting for gold. You're filtering. You're trying to sift through it and you figure out, what are the good pieces that actually fit into our organization? Not the shimmery, not the shiny, but what fits into bettering patient care? Within all that, like in Mid-Atlantic, we have the opportunity to do that. When you're sitting at your desk, you have a great idea. You've got a aha moment. And what I used to do is write on a little sticky note. You put it on your monitor. Then those sticky notes are accumulating and it forms a nice little flower around your monitor. Here at Mid-Atlantic, we have a little light bulb right in Health Connect in your EMR system. So when you're sitting there, I have an aha idea. You click that light bulb right away and just put your idea in there. It submits directly to someone from one of our teams. Then we evaluate due diligence from there. So that way the idea didn't get lost. And then we bring that physician or that nurse or whoever submits the idea back into being the champion of the idea. Because obviously there's some passion. Something drove them to submit that idea. There are many ideas around telehealth right now in our organization that's how it occurred. And luckily for us, we have, being an integrated care delivery system across the country, our eight regions coordinate and share best practices and meet and have committees in order to take these ideas and make sure that we're doing what's best for the whole system, not just one individual region. That's one thing I really love about the opportunity of Kaiser Permanente is to be able to share best practices with colleagues and learn from them from the other regions. It really makes your learning curve much easier. And one of the ideas that we had was video visits and I'm going to go ahead and talk about that in a little bit. I know Neil's going to talk about remote monitoring. I'll just talk about video visits in a second here. Before you move forward, you got to look at your history and you look at the trends and what is in your system already? Where are you moving toward? Kaiser Permanente has been doing telehealth for about more than 20 years now in the sense that we started out as thinking as we need patients to have a portal to be able to access the medical records. An idea that wasn't very cool at the time but it's very cool now. They thought about this well before it became a cool factor. And after that we were like, well what if a patient can refill their prescription online? What if they can check their lab results online? What if they can email their doctor directly? My dad's a Kaiser member, he loves the emailing part. But then other than that, what if the patients in 2012, what if the patients have a smartphone in their pocket that they can do everything from their phone? All these ideas continue to progress and then in 2014 that's when we were like, well what if a patient can see a doctor by video and that doctor have all the electronic medical records in front of them? So Dr. Loff has talked a little bit about some of the dimensions of telehealth. I was going to mention briefly what we do here at Kaiser Permanente. We talked about store and forward, that's like PAC system, tele-radiology. We do tele-dermatology here. We talked about mHealth, the patient portal. Our physicians also have Haiku, which they can check patient medical records and take some action from their phones. Over 50% of our physicians in Kaiser Permanente and all the medical groups have a KP issued iPhone. We talked about remote patient monitoring. We had the ability to monitor patients with remote glucometers, remote CHF monitoring, blood pressure monitoring, and that's some other projects we have here. But let's talk about video. So with video, it's about two-way interaction between a person, a caregiver, patient or provider, and then the provider by using audio-visual communication. This is live, not asynchronous like we talked about with store and forward. A couple of ways we do this within Kaiser Permanente is with urgent care, primary care, mental health, a patient can basically go on their portal or go into their handy-dandy app and book an appointment directly. They can also call the call center. The call center can also book it directly. As far as chronic disease management, our patients can be followed up by their primary care physician or their specialist for follow-up appointments by video. Basically, saving the patient time and money when they don't have to really come into the clinic on time. Other innovations we've had here at Facility to Facility, our piece of specialists here in the Mid-Atlantic, especially, if you bring your child into your pediatrician and there's some diagnosis, maybe they think they have a pediatric neurological disorder. It's a parent you'd be concerned. If you're in the outside world, outside of an integrated system, it might take two months to get a specialist appointment for a pediatric neurologist. What we're able to do is using telehealth, using site-to-site technology with video, we're able to get your appointment the same day, usually the same hour, to the piece of specialist that's in a remote location. Just to get things started, actually as a parent, that really kind of calms you down, knowing that we have a plan in place right now from a diagnosis. We also, some parts of Kaiser Permanente, we have telestroke where a member may show up to an ER with choke-like symptoms, and I'm an ER physician, and it's good to know that a neurologist can be on a video with me, kind of my wingman, just to try to help me out, wingwoman, help me out when, in that moment where it's a little stressful, this person may be having a stroke, you want to make sure you're not going to get that TPA in the wrong cases. So these are great innovations that we've had here at Kaiser Permanente. So, we talked about these sticky note idea. I just want to walk through our sticky note idea when we first started thinking about video visits, was we think about more what-ifs. You always got to think about the what-if. What if you had a patient who was sick at home and, you know, they didn't need to come in or they didn't want to come in, and then they went to a handy-dandy app, what they call the call center, and then that patient can get an appointment for a video visit. And here at Kaiser Permanente, there's no copay. So, when they get this video visit, they have a technological support, and what if that technological support can just give them a call, courtesy call, and say, hey, you know, are you able to get on, okay, just make sure that's that red, kind of like that warm hand off to get on. Permanente physician, a physician that knows the medical record and is able to access a record and actionable data, they're able to prescribe order labs, order radiology, use proactive care if a patient comes on with me and they do for their mammogram, I can order the mammogram right from a video visit. And that prescribed medicine to any of the Kaiser Permanente facilities or outside. And then follow-up, they can always email us back if they're not getting better. A closed loop of care. That idea is what kind of spurred where we are today with video visit part of our telemedicine at Kaiser Permanente. So, without further ado, I would like to speak with Ms. Trueheart about her experience with video visits here at Kaiser Permanente. You okay? Hello, my name is Brenda Trueheart. I'm a Washingtonian. I was with KP, Kaiser Permanente in the 90s when my kids were young. And they were, I thought it was great because I had been, I'd had the others, you know, at Blue Cross Blue Shield and when I got to Kaiser it was all in one soup, you know, fell swoop. You know, with boys, you go in often, they're bleeding here or there. I just go and get taken care of. So, I left Permanente KP when I changed employers and then I came back in 2000. And it's the different, it's very much different now. It is all inclusive. It's very easy. It's life changing really because I'm not one that has a lot of medical problems. But when I do have them, it's very easy and everything I need is right there in one place. Great, thanks for that. Can you tell us how have you used technology or telehealth within your experience, Kaiser Permanente's for? Telehealth, well, I've used emails to secure emails. I've made appointments online. I've talked to my physicians on the phone. I've used a portal. I order my medicine through use of the portal or the KP Medicine app if they have their own. I also used the remote monitoring. I have a device and every month I have an appointment that's set up which I don't have to use because the doctor I can talk to him during that time if I choose. But most of the time I have no need because he monitors not only my use of the device and how I'm doing but he also monitors my device to make sure it's in working order. So that is very convenient because I never have to go in. I've used a 24-hour call center to set up and this is where I met Dr. Traum about three weeks ago. Awesome. So he tells a little bit about yourself as far as you're a busy professional woman and why do you use the modalities rather than go in and see a physician? Well, actually I really don't going to the doctor is not a favorite thing for me since I think my kids got me out of that. But it saves time. It saves I don't have to go anywhere. I can do it anyway. As long as I have a phone or a computer I take full advantage of it. It's time saving. I talk to a doctor that knows me. My records are there when I talk to them. In any way, any way that I contact them, my records are there. It's a KP doctor. It saves money. There's no copay. If I were to go someplace else say if I would just went to a regular urgent care I'd have to pay them and then I would have to go if I wasn't with KP then I would probably more than likely have to go to another doctor afterwards. So it's all the way around. It's time saving and it makes life easy. Awesome. Would you mind sharing your experience when you had that that condition and you went to the usual call center and do those things and then how we met. Can you go through that whole experience to how it was from your end? I sure will. It was three Saturdays ago. Well on Friday I had hurt my wrist. Went to bed. It wasn't a big deal. Sometimes things get worse. When I woke up about 7 o'clock and it was really stiff. It was hurting. I said I better go have this looked at. So I called the 24 hour call center and I asked the lady I said which I wanted to know which center closest to me was open nearest to me was open. So it wasn't far. It was right down in Manassas. And I made an appointment I think I had scheduled it. She gave me a choice of times to go in so I think I said 2 o'clock. So the morning went on and my of course the risk got better. It's like I don't need to go. I don't need to go to the doctor. I'll go and I'll cancel. So when I called her I told her that my wrist felt better and I wanted to cancel. So she said hmm I had a video conference and I had never done that. I said a video conference and she told me she said it's very easy you know you either go on your app or your computer I'll send you a detailed email on how to check your computer to make sure you have everything and then you just sign on early and then I'll have the doctor call you and he'll call you and you'll have it. I said that sounds great. I chose a time and I think that one was new one o'clock or so and so I got an email and it said sign on now so I signed on I had signed on previously just to make sure I could get on and everything was working correctly on my computer because I didn't use my phone because I needed the use of my hand I'm sure he wanted to see that so when he came on he came on Dr. Tron came on early and I was logged on and it was great because it was face to face it was that you know he has great bedside manner and so and I mean he told me that you know he completely you know he examined my hand the same thing that he would do in the office if I had gone to see him he did and he was very he could tell and he diagnosed it as a bad sprain it was just a sprain and he directed me what to do he told me he was updating my records my medical record and that was it and if I had any problems the police just you know be sure to call him or email him it didn't matter so it was great it was great so I am a fan I'm a fan do you remember during the exam I mean for some folks in the room you might be well how can you do an exam over a video what was the sign that we did oh he said just do my do the bye bye sign they didn't move a wrist all around all around it was great he could see everything awesome so with your experience you know you're kind of in the IT industry too you do a lot of program management work in the technology industry what kind of advice can you give us as far as what would you improve on or would you really like about the whole experience about getting on for a video visit it was very easy to get on they even have an app on site that will check my computer for me to make sure everything's there that's needed for the conference very easy anyone can walk through it but just in case you haven't that's why you get on early and a technician was going to call but I told her you know that's okay I'm sure it would be fine as improvements maybe a way to maybe upload documentation that may be necessary or you would feel necessary or I would feel necessary we can do that I'll show you how to do that after oh you can do that okay I think it's true I brought up a lot of good points about many things that our speaker spoke about today it's really about for integration especially for me for our system and Neil and Dr. Loptis here it's integrated and it's important because telehealth becomes a complement of your system it becomes it extends your reach and patients reach to you also and also she was talking about how the technical systems and not just make the technology and you know it's going to run with it you know our population still needs a little hand-hold at the beginning just like any talking technology it's like riding a bike once you get used to it it's really easy right I mean I like to open the floor for questions or Dr. are this for Neil first in question Dr. I'm just going to briefly introduce this first of all Mr. Truar thank you so much for coming I think meetings are always better always better when we have the patient's voice as part of the discussion and so it's really great that you spent the time and I was going to bring a patient as well and I went down my list and I was aiming to bring a patient who is on our home telehealth program we target high risk highly complex patients and as I started to work down my list of people that are on the remote monitoring program one is in dialysis at the moment the other is it would be a major transportation problem getting here etc and so instead of bringing a patient since the panel is about patients and clinicians on the front line of telehealth we're going to show a little video that shows a little just taste of what telehealth and what connected care virtual care can look like in a healthcare system so you can just get a picture of it to help support the discussions that we're having today during this great meeting and there's a couple actually I think interesting themes in the video that come that key off of some of what we've been talking about one is about training how do we actually help support patients in using technology you're going to see that one is about is there value sometimes found in virtual visits that may not be as easy to tease out in a face to face visit and then the third is about innovations and how an integrated healthcare system when there's a commitment to virtual care you can start to get some really interesting ideas coming to the forefront so let's go ahead with the video I got hit twice in the head and in the legs and stuff I was relatively normal just with epilepsy and then I started having too many seizures and they cut out a section of my brain and I used to be an electrical engineer and now I'm not this next chapter Navy Veteran Emerson Beach has become an important volunteer in Charleston, South Carolina among his key duties assisting fellow veterans as they sign up for MyHealtheVet the platform empowers veterans to become active participants in their own healthcare from refilling prescriptions online to securely messaging providers MyHealtheVet is one of several offerings provided by VA's office of connected care along with VA telehealth services the VHA innovation program and VA mobile all are working to extend access to care beyond the traditional office visit I'd like to say that the VA has saved my life I would not be alive for sure if it were not for the VA I think that MyHealtheVet had a tremendously large part of that because joining in MyHealtheVet got me to realize that I can be successful he got on board he registered for account we got him authenticated and then he was able to use all the features so then he could talk on his experience using it to fellow veterans so they can really see how it does work and how it can help what I use all the time is my prescription refills you also have the ability to look at the results of tests the secure messaging feature is incredibly easy to use it's a point and click it's just like sending an email to another user it took me a while but I realized that I'm providing added value to veterans and that gives me a positive feeling inside more than just being an engineer did VA telehealth services continues to offer valuable solutions as well and with the work of mental health providers like Dr. Kim Gilroy and Judy Morris, VA is now able to provide telehealth care to veterans from the comfort and convenience of their own homes when I think about the future of telehealth in the VA it reminds me of one of my first experiences in the VA when someone said you know we don't just try to find answers we try to find solutions I think that telehealth has that potential to be a solution if I'm going to have a session I turn on my computer and I wait for the veteran to call me and I click the green button I accept and there he is I see it being beneficial for a few reasons there are veterans that live in outlying areas that can't get in a patient having a surgical or a dermatological issue needing to see a specialist at Mather can come into where I work at McClellan see me that day I can photograph their dermatology issue get it uploaded to our secure server and have a doctor look at it within a few days one of the differences is that I can access them in their daily life so if I'm talking with a veteran about how he feels about Memorial Day and he lights up a cigarette I pause for a minute and I'll ask him what just happened for you right there and so I kind of see them in these really subtle nonverbal ways one of my veterans actually had said to me your therapy has been the most effective for me and what he attributed to really is that he's not as anxious he is at his best when he was at home VHA's innovation program continues to work on the cutting edge of that technology platforms like Revamp were constructed, incubated and tested in innovation's safe harbor environment with the intent of rolling out for veterans use around the country. Revamp is a new web based care pathway that we're working on to allow improved access to care for veterans for their sleep apnea management and diagnosis we are really excited about Revamp because this is the first web based platform that really takes patient information validated standardized information and pap adherence in one single place it enables them to get diagnostic sleep testing and to have ongoing long term management of their sleep apnea in the comfort of their own home. I think there's also a trend towards patients wanting to feel more empowered and be more engaged in self management so while Revamp isn't a wearable technology like a Fitbit is it still allows them to engage in looking at their own data that's generated by their pat machine it allows them to watch videos about the diagnostic testing equipment to understand how the process works and Revamp does offer a secure messaging feature so Revamp is very exciting from a veteran perspective it offers them a number of new opportunities to engage in their healthcare the success of Revamp has really depended on the concept of team work from partnering with other physicians innovators at other sites all the way to working with the information security officer and privacy officer we've been very fortunate to have had an outstanding team that has worked so well together together these technologies are expanding access and care to veterans across the country and by integrating these technologies VA continues to find ways to connect veterans their caregivers and their care teams ensuring they have access to personalized care when and where they need it thank you for sharing that video Dr. Evans we have about 15 minutes for questions at this point in time and while you're organizing your thoughts about what you'd like to query our panel but I want to point out one thing that I don't believe has been addressed this morning is that it's a communication to telehealth and that's our point of view that it also is an amazing population health tool in the sense that we find that in terms of outreach to our populations to get care for chronic conditions to be monitored for chronic conditions far more responsiveness to texts than to old fashioned text messages that are two to four full difference in the responsiveness of patients to come in for to obtain some of the screening that they need when we've texted them versus when we've sent them the old fashioned letter or when we've even made an outreach call in fact texting far superior to secure messaging for that same application we send a lot of messages out for population health reminders and the most responsive thing that we get is texting just wanted to point that out the other thing I would say is probably common to the VA and to Kaiser Permanente is when we're in an encounter of any kind whether that's scheduled telephone or whether it's a synchronous video one of the things that our providers are always doing because they're connected to that EMR is scanning that record for hey what else does this patient need for a problem with a sprained wrist but I notice that she also needs a mammogram and I'm going to reflect that to her in this visit and order that and get that set up for her so this connection and the ability to in every encounter whether it be face to face or virtual to push forward our agenda around population health I think is a hallmark of integrated delivery systems and I think one of the main reasons why we're doing this is because we have a lot of information in our integrated delivery systems one of the things that I'll do is get a starter with some questions and I would like to ask Dennis and Neil to provide us any reflections you may have on the ability of telehealth modalities to at least partially address provider health. So we're talking about very little joy in medicine no there's very little joy in medicine right now and is this modality a different way of seeing our patients perhaps maybe a small bit of an answer or is it just another task we have to accomplish in our days? So we talk about physician burnout we're talking about that quadruple aim right we're talking about the triple aim I think for us at Kaiser Permanente it's been very helpful in the sense that we always have this underlying culture that our physician providers are trying to provide the right care, right time, right place when you match those up pretty well then your physicians in the clinic can have more time to deal with more complex patients more complex cases. We found that our physicians that do use telehealth in that manner the patients that are doing telehealth are very happy because they get more time on the screen we're kind of cutting out some of the waste and then the patients that are being seen in clinic have more complex cases are getting more time and more tension the physicians are less stressed about trying to get room to room, right so that's one way that we found that it's helping physician well being and many of our physicians are you know our patients carry around smartphones so do our physicians now and we do have a pilot where we do have physicians that are able to deliver care from home or from whatever clinic they're at so you think about that mobile solution for them it makes them much more efficient and more flexible they can control their time better those are just a couple aspects that we found our physicians that do telehealth are happier and the patients that use telehealth they actually have like a 10% higher satisfaction score using telehealth in office visits you know it's really good in office visits already but I think it's this is a very important question and I think it's a mixed bag and a lot of this depends on how telehealth is implemented and the incentives around it I think most providers recognize the value proposition most providers want to have a better connection with their patient, want to deliver more responsive care, want to deliver higher quality of care but they're frustrated with the volume of work and the danger of telehealth is that it becomes just yet another inbox that one has to manage and so I think there are three themes that I like to think about that help with this question number one is that telehealth initiatives are best implemented in a team based environment and want us to be really careful to think about who on the team should be doing what action, not all secure messages need to go to the physician, not all you heard a lot about the technical check before video visit that's a way that we can make this better for the patient, the second is to recognize this as value, Kaiser and VA have both made a significant commitment to saying this is something that we do and we're going to recognize the delivery of care via these virtual means as equivalent to face to face care we're going to give you workload credit for it the parallel for that in the private sector is reimbursement which is why this topic of reimbursement comes up so often it's how do you help me with this? I think it needs to be customized and have the provider team's voice in it otherwise there's not buy in and it just leads to more burnout. We have some questions from the floor now I don't know who came up to the mic first over here to my left go ahead. Hi my name is Melissa Williams and I'm with the national patient advocate foundation first I just want to thank Kaiser for being so timely. I just want to start off by saying a little bit what national patient advocate foundation does in case some of you are not familiar with it but we are our tagline is the patient voice and so I'm so glad to see that being reflected in this panel but we're the advocacy affiliate to the patient advocate foundation and it's a national nonprofit that provides direct case services to patients who need assistance dealing with billing errors, needing help to get to their appointments, insurance snafus, you name it, our case managers will be there to assist these people. It seems as if telehealth could really be a great solution to a lot of the issues that they face for instance one of the things that patients call about is transportation. They can't get to their appointments. They have to take time off work to get to their appointments or they have to rely on a caregiver to take them to their appointments and I just want to add that a lot of the patients that we serve their income level is the majority of them is 23,000 dollars and below and so telehealth sounds like a really great solution but there is this digital divide and so how is the VA and Kaiser Permanente how do you all deal with that or what are your suggestions so that these services are accessible to everyone? This is a very important question as well about the digital divide and I think in our healthcare system in the VA we take care of because of the eligibility criteria within the VA our population is shifted towards lower socioeconomic status there is an income cut off for which veterans are eligible for care within the VA and so we face this challenge because of access to technology simply because from an affordability perspective or broadband internet but also because of the challenges of accessing broadband internet for these services in rural America and this is one of the advantages that an integrated healthcare system brings to the table if we have a patient who we know has a significant chronic condition and is going to benefit from regular virtual care in the home we provide the equipment with cellular services and there is a strong business case for us to do that we save tremendous money by doing so many of these patients we actually pay to pay their travel cost back and forth to the medical center we deliver them more responsive care and so some of it is providing technology but I would say I would take a step back earlier this is also where there is some value in thinking about telehealth doesn't happen magically and it's not just having the technology it's knowing how to use it and so doing training during face-to-face care optimizing the time that you have in person with patients but also helping them leverage your digital tools is another way that you can reduce that divide yeah I totally agree with Neal a lot of things we call kind of a shamelessly stealing is one of the things we're trying to copy from the VA is the fact that we recognize there are patients that will not be able to afford to get into the clinic and also can afford a digital device to connect by telehealth so some of the projects we have going on are a KP issued device where they can connect to their provider and most of these are more chronic conditions just like you guys are doing so I'm a great admirer of your system and how you guys have went with that so we're definitely copying that strategy too over here well thanks for answering that digital divide question I did have a quick follow-up on that and the general question the follow-up on the digital divide question was technology do you then provide services to support that patient with the functioning of that technology as well yes we have a help desk that's available to them and for some patients we'll do an in-person visit to help them get set up with the technology in the home so my general question was can non-integrated or even integrated organizations adopt the practices of such successful organizations like yours or do they really have to start thinking about a more fuller adoption of the way you approach it I think absolutely the answer is that organizations can adopt these technologies piecemeal and again it's not about the technology it's identify a problem this is a clinical problem that we have this is a problem that our patients are having it's an issue a point of stress for both patients in our healthcare system and then think about what solution solves that problem often times what I think happens is healthcare system somebody goes to a conference they see some technology they say this is kind of exciting and they think about how do I apply this technology to my healthcare system as opposed to thinking about what is the problem where are the pain points in healthcare delivery where are we having outcomes that we're not so happy with and now let's think about sort of a holistic approach that involves both face to face care and virtual care that may involve it's not all video care that may involve monitoring that may involve web based portal something simple it's funny that we say that's simple it didn't used to be simple but now it's pretty simple some of these technologies that in my mind is the approach and allows you to then bring programs that make sense for your organization I have a similar question on the technology and where the state of the art is for the technology given the experience of physicians with EHRs and you know the promise of transforming practice through EHRs and then the practical reality for physicians where is the technology the state of the technology for virtual visits and for remote patient monitoring I have this question is because I look at all of this new technology development and quite a bit of it has to do with aspects of remote patient monitoring and people pouring millions of dollars into these solutions are there good solutions satisfactory solutions out there now or is there a need to continue to improve the technology available I believe there's always opportunity to improve technology but I think the big part is integrating it we have so many pieces of technology out there that it causes more fragmentation in the technology world if you're a clinician and you're a patient and you're trying to use five apps for five different devices I think of it like home automation back in the days we had one clicker for your shades one clicker for your lights one clicker for TV whatever it is now you say Alexa sleep time and everything goes off I kind of think this should be almost as seamless and everything needs to be integrated as you're going to get a great experience for the patient and for the clinician so it's not about shiny and shimmery in my mind I love seeing technology but I think about how does that really fit into our model and what we're trying to do the solution we're trying to provide I think that sums it up so we are unfortunately out of time I did want to especially thank Ms. Brenda Truhart for sharing her story with us we know that this was actually a long commute for you this morning perhaps a little bit daunting and we really appreciate you being here to be that voice of the patient please let us know ping him ping me if we're falling down on the job now okay so you've got to be that voice of the patient as we continue to deploy more technology to my panelist Dr. Dennis Trong Dr. Neal Evans thank you very very much for a stimulating fascinating panel this morning and to our audience you're now invited to lunch it's back where we had breakfast this morning back in the mission room want to bring you back here around 1250 because we have another video we'd like to share with you this morning one more round of applause for all of our panels