 And now, without further ado, it's my absolute pleasure to introduce our morning keynote speaker, Dr. Helen Burston. Many of you know Helen in her role as Chief Scientific Officer of the National Quality Forum. You may know her from her previous role as the Director of the Center for Primary Care Prevention and Clinical Partnerships at AHRQ. She is now, I guess, now sort of officially at the beginning of January, assuming the role of Executive Vice President and Chief Executive Officer of the Council of Medical Specialty Societies, CMSS and its 43 member societies represent almost 800,000 physician members in the United States. Dr. Burston is the author of more than 90 articles and book chapters on quality, safety, and disparities. She is a professorial lecturer in the Department of Health Policy at George Washington University School of Public Health and a clinical associate professor of medicine at George Washington University. Immediately following Dr. Burston's presentation, we will jump to a reaction panel facilitated by my colleague, Keveney Klein, and then Dr. Burston will come up and be able to answer questions at the end of her presentation. So thank you all, and Helen. Good morning, everybody. It's a pleasure to be here with you today, and thank you to Kaiser for inviting me to join you. I'm really thrilled you've pulled this meeting together. There are so many unanswered questions in telehealth. And I think the policy implications are really important, and there's an opportunity here to hopefully move the field forward. Interestingly, I have one disclosure, and it's not financial. The disclosure is I'm not an expert in telehealth. I actually don't deliver telehealth services. I've never delivered telehealth services unless you count the constant rashes and things my family members put on text messages to me, which I'm sure many of the clinicians in the rooms have certainly seen. I don't think that really counts. And I have actually never received them myself. So important disclosure. So I guess the next logical question is, why me then? Why am I standing here today as your keynote? And I think part of this is, I think, the opportunity to tie the issue of telehealth into the broader context. What's the broader context around health system reform? How does this tie into our bigger thinking around how we improve access, improve quality, and really help try to bend the cost curve? Because obviously that's a critical issue for us today. So my task for the next bit of time here with you today is to help try to raise some of these questions. And at times I'm going to be intentionally provocative because we've got much smarter people than me who will follow and try to answer some of these questions. First, how can we really leverage the potential for telehealth? And I think in many instances, including the work we did at NQF, we just kept hearing over and over again. This phenomenal potential, and I think we need to tie that to evidence. When has telehealth lived up to its potential? What lessons can we learn from where that potential has been realized? And what's unique and different about the examples where telehealth successes have been found versus where maybe not so much? Where are the measurable demonstrated benefits and improvements? How can it reach its full potential? And really, I think at the end, challenging, I think, very much the next panel. There are potential challenges to really thinking about how to get wider adoption because we've seen lots of great examples of where this works beautifully in integrated systems like Kaiser and the VA. How does it move to practice like where I see patients with my residents at a local academic health center? There's no space for it. There's no system for it. There's no technology for it. I'm not even sure there's an appetite for it on the part of clinicians or patients. We need to understand what sort of the secret sauce we can learn from the places that have done it successfully that can be translated over into a broader view. And really importantly, I think, like any other innovation, and we've had many of them in health care, some successful, some not successful, we really need to do it in a way where we can demonstrate those benefits. Like with any other technology that we add to health care, I don't think we can really assume that technology improves care anymore. I think there was a lot of excitement early on that the latest widget that came forward, the latest technology would always drive improvement. And I don't know that we've seen evidence of that always. One of my favorite movies is Monty Python's The Meaning of Life for anybody who's seen it. And there's just this wonderful scene where the swimman comes in and she's giving birth. And she looks up and she goes, well, what should I do? And the doctor goes, oh, shut up. You're not qualified. And they all turn and the parade of administrators walk into the delivery suite and they're all excited as he turns on the new machine. And the administrator goes, well, what does this machine do? And the doctor goes, it goes, beep. And they, oh my goodness, oh my goodness. So I think the challenge for us all here is we can't just have the latest shiny new toy without being able to, in fact, demonstrate that it's really rigorously evaluated, has demonstrated improvements, and can get us where we want to go. And the issue of cost, of course, cannot be left out. I think an assessment of the current evidence to date is really pretty mixed. It's been pretty limited. And adoption certainly remains a significant challenge. Lots of news about it, though, as I think Barry pointed out. It is all over the place. Every day there's some new exciting piece about how telehealth is moving forward. You may have seen a piece just a couple weeks ago on CNBC about the Etna CVS merger, as well as Apple's engagement with American Well. And the opening line to that was telemedicine is the next big thing in health care for more than a decade. So how do we make it not be the next big thing for the next decade, but in fact, think about when and where it's most appropriate to deliver the right care to the right patient at the right time and actually help us achieve the goals that we have. And there have been great examples of great successes from places like Kaiser and the VA, but we need to understand what will it take to make that reality and take those opportunities and drive them into real health care. I want to begin with a story of my father-in-law. So my father-in-law lives at home in Cleveland, Ohio with my mother-in-law. He's got epilepsy lifelong and has pretty moderate to severe dementia. Recently, he's somewhat communicative. He woke up one morning, and my mother-in-law noticed that his jaw was swollen. And so she got a little anxious. He seemed OK, didn't have a fever, but a little more out of it, perhaps than usual, though hard to tell. So she called the practice that they have gone to for a long time, and the nurse practitioner listened and said, oh, he should go to the emergency department. And so she dutifully very difficult to package my father-in-law up to leave the house, get in the car, get help, get him to the hospital, get him to the emergency department. And of course, she was listening to the advice they gave her. And logically, as she appeared there, they did an evaluation, and they ultimately decided that he actually had an abscess tooth. But because it took so long to get anybody to actually evaluate his tooth in a hospital setting, they admitted him to observation because he had already been there so long. He got far more confused at night, far more combative overnight. And then the next day was sent to go get a tooth surgery done. So the good news is it was he did fine in the end. But my mother-in-law was then faced with this substantial bill for Medicare who refused the services because the ED visit and the overnight stay, in fact, was then deemed dental care. She was simply following the advice she had been given. She didn't, as a consumer, had no idea what this was. She was just anxious about her husband's health. Now imagine a scenario where she could have, in fact, had a telephonic consultation with a clinician. It was pretty obvious, as we heard the story, that this was logically an infected molar. But you couldn't tell that on the telephone. I don't blame the nurse practitioner at all. She was simply listening to the story without being able to see him and making that assessment. So I think what an opportunity that would have been to have saved her a trip to the hospital, to have saved her substantial savings, but more importantly, to have actually gotten him the right care when he needed it. And in an environment where you could even get access to specialty care, could he have actually had, very quickly, a dental provider being able to figure out what he needed, get him into oral surgery and get that taken care of? So let's take a step back. Let's think about when and where telehealth could be most valuable. We continue to have a very uneven distribution of providers across the United States, particularly in some specialty areas where it's very difficult to still access some specialists, in particular, mental health services. And we still have urban and rural areas, in particular, that have substantial deficits and access. We also know that poor access, we've known this for years, can lead to delays and diagnosis, which can ultimately lead to greater expense and poor outcomes for the patient. So getting people in the door when they need it to the right level of service, I know something Kaiser has spent a lot of time working on, is really an opportunity for us. A piece of this, as we think about where it could be most valuable also, I think returns to where we have the greatest morbidity, as well as potential costs, which is the aging population with multiple chronic conditions. This isn't always about the healthy person going in for sore throat examination. It's really how do we think about what services can be provided to patients where you can really maintain and evaluate what's happening with their often multiple chronic conditions through remote patient monitoring, as well as virtual visits as needed. Also, I think sometimes people immediately begin thinking of telehealth as just that potential video conference. And there is so much more to telehealth, as I think we learned as part of the work Jason and I did at NQF. And in fact, some of the evidence of the provider to provider telehealth is even more striking when you can actually provide the expertise to a clinician from somebody more skilled than yourself, is very striking in terms of that expertise. But also, examples like Project ECHO, which I was very proud to have given him his very first grant when I was at ARC, to begin that work of not only providing those specialist services, but also providing an opportunity for teaching and training. So the next time a patient with hepatitis C comes into your office, you actually know what to do. Those are transformational opportunities that go way beyond, I think, what is often the hype about what is or is not telehealth. I think the opportunity to think about where you can provide those asynchronous services, the store and forward services, what kinds of things can be collected and then people in a different time could take a look at them. Great examples of how you can look at eye screening for patients with diabetes, examples where radiographs can be looked at off cycle, as well as evaluation of skin lesions. So teladerm, telomental health, certainly, at the top of those lists, with some pretty good evidence in that space. Distance consultations have probably had some of the strongest evidence, tele-ICU, tele-stroke. Again, outside the usual thinking of telehealth, much more inpatient focused, but dramatic improvements and a place also where the business model seems a bit more clear at times or contractual arrangements that make that financial piece of this more clear. There's also the issue of remote monitoring and I think that's really, as a primary care clinician, the place where I can see the potential. I can see the challenges and the barriers, but the ability to really see somebody's ongoing, for example, glucose, blood pressure and weights for a patient with congestive heart failure can dramatically impact disease management, hopefully prevent an ED visit, prevent a hospitalization. An interesting recent review I just saw from two years ago said, some of these remote patient monitoring have also have some evidence that they improve patient engagement, something we desperately want and need as well. You know, it's when patients bring in their glucometers or their blood pressure cuffs, it's very different to have looking at the readings of what happened over the last month and seeing some days that were really bad that we didn't know about or we could have intervened if in fact that information was available to us in real time. So what factors actually can lead us to have more adoption and results from telehealth? So in looking at the literature, talking to a lot of people and much more skilled in this certainly than me, I think with almost any other healthcare system intervention, a lot of the same factors are the same. You need a local champion. You need somebody who really sees the value of this and pushes it through in your health system. I think we need education and training of the entire team. This isn't just about docs. This is about doctors and nurses and actually as somebody who teaches residents, my residents have never encountered telehealth. They have never had any interaction with it. Many of them at GW may wind up working for Kaiser. They have never had that experience. How do we make sure we weave that into the way we teach nursing students, medical students, also pharmacy students who are increasingly doing a lot of this work telephonically and remote as well? How do we get providers engaged? And I think some of the provider engagement piece here is a sense from them by engaging in telehealth, it will not only improve patient outcomes, but it'll improve their quality of life as clinicians. And I think we have all seen pretty strong evidence right now that there's a lot of burden on clinicians that clinicians feel very overworked. There's not a lot of joy in practice at the moment. And I think what is potential here is can some of these interventions increase some of that joy in work by seeing you're doing better for your patients in a way that may not be quite so overwhelming? But you also need tech support for telehealth, right? You've got to have people who can come help you when the technology is not working. As somebody on Monday who had to live with the update to our EHR as I was entering notes and had four phone calls to get somebody to allow me to get in and approve my notes, it makes me anxious to think about how many local practices not part of an integrated delivery system are gonna be able to get that tech support when they need it in real time. And also actually Mark and I were at a recent meeting about innovation and technology and there was an interesting discussion about telehealth and also this question of how can most clinicians both carve out time and space in their practices to begin to incorporate this. And from one of the health plans who was there with us said they're not seeing a lot of appetite at least in this region for pushing that forward even though they've begun to experiment with payment in that way. And last but not least and something you'll talk a lot more about today and very relevant from the policy context is and then what do we do about reimbursement? In many instances I think it is considered the rate limiting step, whether that's actual or perceived. I think at times payment has in fact improved in many states in many areas. There's much more flexibility built into MACA for example to allow for that but if the perception on the part of clinicians is it's not reimbursed there's not gonna be a great appetite to do it either. But the opportunity to think the way the whole healthcare system is moving towards paying for value and allowing people to get more bundled payments or payment over an episode of care provides the flexibility that places like Kaiser have had for a long time to say I'll just provide care however it makes the most sense. Most patients we bring in for post-op checks for example do not need to take the time it takes to come into care. Much of that is a visual inspection of the wound and can probably be done via telemedicine and save the patient a lot of opportunity costs there for their job, for their family and just the cost of the visit. The other question is how do we take more of that long view also? How do we, the reimbursement may be the issue we think of in the short term in terms of payment for this particular service but oftentimes we don't have that longer view to say telehealth may not improve the, may not lower the cost for that immediate effect but perhaps over time we'll start to see a decrease in some of the bigger ticket items like emergency department use, hospitalizations, re-hospitalizations where actually a lot of the money is but if we don't take that longer view of care it's gonna be difficult to see. So why have we seen greater success at places like the VA and Kaiser? I mean if you look at the literature and I've spent the last couple of weeks spending a fair amount of time reading a lot of these papers repeatedly it is the integrated delivery systems that have made this work. I think we need to unbundle that a bit, interestingly enough, and think about how and why that's happening. So first I think there's clearly been a greater commitment to telehealth on the part of those systems. They recognize the value, they have invested in it, they have more experience and frankly they've had the evidence in their own systems where they can see the success. You can't see the success, it's difficult I think to make that leap. The Kaiser folks, Pat and others can certainly give you better data but at least from what I was able to read now KP of Northern California, correct me if I'm wrong now has more virtual visits than in-person visits with increased patient satisfaction. That's really telling but how do we move I think other systems to that place will be challenging. The VA now exceeds more than two million remote visits per year. Two million remote visits. So again, what are they doing that's different. I think a lot of this it's just been woven into the fabric of the way care is delivered and I think that's part of we have to think about how can the successful interventions become part of the way we do our work. In many of these systems telehealth is part of the same system, the same clinicians provide both in-person and remote care that they have the same electronic platform. They probably have I hope seamless access to whatever happens whether it's in-person or in terms of something telehealth and there's not as much certainly fee for service pressure in terms of being able to get reimbursed for something versus something you won't get reimbursed for that you may not do even if it may in fact be in the best interests of everyone. So I think we need to think about what those experiences are and I hope we'll hear more of that today from many of you who live in those systems. What are I think the opportunities to spread some of what KP has done so beautifully to others. There was a survey just last week actually that UPMC put out where they interviewed the 35 largest health systems in the United States about what was their interest and experience to date with telehealth. The largest health systems and these are the big guys less than half of them so far had incorporated any remote monitoring or virtual care. Less than half I must admit my prior assumption there was gonna be it was sort of 80 20. There are probably some laggards. No it's less than half and if they did they have focused on the areas I mentioned earlier where there's a clear business model. It's telestroke it's tele ICU. It's not remote monitoring. It's not some of the virtual visits with patients that may not be quite as reimbursed. And when they asked them what was the most important rate limiting factor as I said earlier it was reimbursement. But what was really interesting I thought as well among the health systems who didn't yet have telehealth 42% of them cited patient demand would be the factor that would drive them towards greatest adoption. So this isn't just about docs and nurses and healthcare professionals. This is really also about a groundswell of patients saying I can be treated in a way that's better for me and hopefully that will also help drive greater adoption. It was an interesting example in the news recently I know if you saw there was a partnership announced between New York Presbyterian and Dwayne Reed which I guess are now Walgreens as well in New York City for somebody who grew up in New York City every corner in Manhattan has a Dwayne Reed. I mean every single corner has one of those pharmacies and they've now set up an arrangement where you can go into Dwayne Reed go into a private space and be seen by a New York Presbyterian emergency department provider. And again those data are then part of that system. So when they interviewed the people who are part of this at the NYP side they fully recognize that it also allowed them to connect these patients back to their health system. So again there's a different vision there of I think why they'd want to engage and what they think they could get out of it. So lastly onto the part I feel like I could speak about with more authority which is really about how do we actually think about measuring the impact of telehealth and you'll hear more about this from my former colleague Jason Goldwater shortly about the measurement framework that we recently did for HHS. But really part of this is identifying which measures we can use oftentimes the same measures that allow us to look at the outcomes of care however it's delivered whether it's delivered virtually whether it's delivered in person and begin to see what those differences are. And I think we also have to think about what are the special kinds of measures that maybe we'd add to our measurement framework that may give us a better glimpse into maybe what telehealth brings to the table that may not be just looked at with our traditional quality measures. So measures like timeliness, travel time costs in addition to the patient experience and outcomes. So when we did this work we ultimately came down to four elements and I won't steal Jason's thunder but ultimately he was really about access to care as being one of the most important ones and access for patients and families, for the care team as well as access to information. Financial impact and cost was number two, not surprisingly. We've got to see the impact to patients, to the health system, to all of it overall. And there are some examples as I mentioned VA remote monitoring has clearly been associated with fewer hospitalizations and ED visits. That's real financial impact. Patient experience, what's the experience of the caregiver? What's the experience of the team member in providing that care? And then finally and perhaps in many ways, most importantly from where I sit, this really what's the evidence of effectiveness? And I think it's both system effectiveness as well as clinical effectiveness. So system effectiveness and you guys can correct me but there's evidence that KP's use of telestroke for example has increased the use of appropriate TPA services as well as the improvements in time to imaging and treatment. Those are standard measures. Those are core measures for CMS right now. You're doing better by the use of telehealth. Clinical effectiveness, there's strong evidence for example teleICU has reduced mortality by 15% in some studies. So real opportunities there. It was a wonderful paper last year in the New England Journal of Medicine by Dorsey and Topol on where are we now with telehealth and if you haven't seen it, I'd recommend it. And they gave a great example that I thought tied nicely into this quality framework of how do you begin thinking about timeliness in a very different way? So the standard coin of the realm in terms of access measures is time to available appointment or time to first third available appointment. But as they pointed out there, if you think about the broader picture and they listed out it may be a 20 day wait for a 20 minute appointment with a doc with travel and waiting times totaling more than two hours. Getting that broader view of rather than saying I waited a week for an appointment, getting that full time period may allow us to see where the benefits of telehealth are in fact more striking than we've seen to date. But we can't look at just access quality and outcomes without considering costs. And this is a place where I think we collectively as a community need to think through where there may be examples of where in fact telehealth has increased costs and maybe not with a concomitant increase in outcomes. Atif Mahotra who we've worked closely with on a lot of this work who's an expert in this space in some congressional testimony he did last year referred to at times, are we having some services that have become over convenient? And by having them be over convenient they can be over utilized. So I think we also have to think about from policy context, how do we ensure that we've built in some safeguards that don't push reimbursement to drive people towards that over utilization of over convenient services? And again, payment reforms that push us to more bundled payments should hopefully limit that without as much emphasis on fee for service. So finally, how do we move forward? In that same paper by Dorsey and Topol they listed out four key areas that I think are really quite right in my review of this and as well as reading the literature. So job one again I think is demonstrating for reimbursement sake that telehealth has improved access, improved quality and reduced costs. We need both research evidence and I know ARC had a solicitation this year specifically asking to demonstrate the relation of telehealth to both the clinical and economic outcomes but we also need real world evidence generation not necessarily part of an RCT. We need to see more and more that explains how remote monitoring, how these virtual visits, how the provider to provider interactions are really working. I think we also as part of that effort again I think need to take that long view I mentioned earlier. It can't just be about visit by visit. It has to allow us to have that more longitudinal view of care where are these services provided in a way that can reduce some of the bigger ticket items like hospitalization. And we need to as we move towards more bundle payments and more experimentation with flexibility there how can we see what the successes are to help move that forward. So reimbursement certainly is I think the first and most prominent one. But there are a whole series of clinical issues I think we need to tackle to really make this happen and I've mentioned both of these. But one opportunity I think is really to focus on the areas with the greatest need. Really start with the areas where we know we have dramatic access issues around psych, around DERM, around some other services. And I was pleased that Joy invited several of my CMSS member societies who are very engaged specifically in telemedicine in those areas. How can they think about what they could bring to the table to meet those needs? How do we avoid fragmentation and care? This was a big piece of the article by Dorsey and Topol as well. That's one of the advantages of places like KP and VA is that you actually it's part of the system of care. But if my patient is going somewhere else for those services and they're not woven back in, does that actually only lead to fragmentation of care? And as our society changes and we have more millennials, will they care? And will they even note the impact of how much that it'll have a relationship on care with their primary providers and their usual sources of care? I also think we have to think about how to incorporate telehealth into practice. We need to share best practices about how it could be incorporated in a way that works best for both clinicians and patients. And I think we have to also, the third and fourth issues they raised were both legal and social barriers. There are a series of issues around licensing and other issues that I'm sure smarter people will talk about today. But we also can't forget some of the social issues. There are significant digital divides in our country between those who have access to digital services and those who do not. And it's not just a rural urban split. There are significant issues, even in urban communities and older patients who don't necessarily feel easy access to those services. And then I just wanna perhaps end on a high note. I think we have to just be very big and bold here. I think to really achieve the outcomes we need for our healthcare system, we have to think about ways of using these services in ways we may never have imagined. And it's a wonderful paper last year by Ethan Bash at Sloan Kettering where they did an analysis of, they offered electronic monitoring of symptoms for their patients with metastatic cancer. And patients regularly submitted electronically the symptoms that they were encountering and the nurses responded to those symptoms, whatever they could do, pain-wise, sleep-wise, nausea-wise, and what was so striking about this study was that the patients who had these remote symptoms responded to had lower mortality from metastatic cancer. They gained months of life from having these symptoms addressed. And there's lots of reasons why they postulated maybe better able to get their treatments done, things like that. But Ethan did a chart at the ASCO meeting last year where he showed that in fact the improvements in life expectancy associated with this remote monitoring was actually larger than most of the chemotherapeutic regimens for metastatic cancer. Again, putting this in a very different model of telehealth just woven into the way we think about care to drive real improvements in outcomes I think is really the game changer. So delighted to have spent some time with you today, so looking forward to hearing from the experts later today. Thank you so much.