Dr. John Halamka, Mike Baird, Dr. Lyle Berkowitz, Dr John Korangy, and Roy Schoenberg at Converge2Xcelerate Conference (Boston, MA)
- Telehealth has the power to provide more honest & transparent data collection
- 5% of patients represent 50% of healthcare costs
- 55% of healthcare applications will have adopted blockchain for commercial deployment by 2025
INTERVIEW TRANSCRIPTS: Dr. John Halamka, International Healthcare Innovation Professor at Harvard Medical School, Mike Baird, President of Consumer Solutions at American Well, Dr. Lyle Berkowitz, CMO of MD Live, Dr. John Korangy, Founder/CEO of Careclix, and Roy Schoenberg, CEO of American Well
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 00:03
Okay, well, welcome to the tele-health Titans group. This is going to be my favorite panel of the day because I know these characters pretty well and I promise we’re going to have fun. So where we’re going to run today, you know, introductions from each of you and who you’re affiliated with. And I’ll, we’ll ask you the really tough questions about the future of digital health and telehealth because at 4:30 I was supposed to give the closing keynote with the answer. So you got to help me here. So Mike, please go ahead.
Mike Baird – President of Customer Solutions, American Well: 00:32
A quick background. So Mike Baird, I’m president of customer solutions at American Well, I work very closely with Roy. I run the health system side of our portfolio was previously the CEO of Avizia. So most of my focus has been on the acute care side and tell help.
Dr. Lyle Berkowitz – CMO, MD Live: 01:08
Okay so my name is Lyle Berkowitz. I’m the chief medical officer at MD live and the president of MD Lives medical group. I’m an internist. Primary care by background. I worked much of my career at Northwestern medicine in Chicago, a large academic medical center where I did practice as well as head escalate and physician executive roles in the informatics and eventually in the innovation side been with MD Live for almost two years now. Focus more on the outpatient perspective. You know, we do you know, a lot of urgent care, telehealth visits but you’ll be hearing, we’re expanding beyond that in a variety of primary care ways as well as deliver behavioral health, dermatology, etc. to the nation.
John Korangy – Founder/CEO, Careclix: 01:35
John Korangy CEO for Careclix. My background, I’m a radiologist. I’m a neuroradiologist. I’ve been involved with tele-health for probably 20 plus years. I grew up in the teleradiology world and then found a Careclix few years back and we’ve been doing various types of tele-health type services as well as technology for different organizations.
Roy Schoenberg – CEO, American Well: 02:15
Hi, I’m Roy Schoenberg I’m the CEO of American Well had the pleasure to be across the office from John about 25 years ago or so.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 02:26
He’s actually gotten better financially than me.
Roy Schoenberg – CEO, American Well: 02:29
Yeah, hard to tell, but being in telehealth pretty much ever since. But American well is a telehealth organization based in Boston that’s providing a lot of different types of telehealth services primarily as an infrastructure for a lot of the usual suspects of healthcare with these are the payers that I think everybody is familiar with, all the health systems pretty much kind of spread evenly between consumer oriented, telehealth and clinical acute telehealth. And just looking forward to the conversation.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 03:02
Well, great. Why don’t I start off with just even asking what is telehealth, right? Because tele-health has so many definitions and let me just point this out. So I do 900 telemedicine consultations a year myself. Now, how would I possibly do that? So I am the nation’s expert on poisonous mushrooms and plants. Very bizarre. And so every poison control center in the United States, when they have an ingestion context, me and what is a telehealth consultation, they send me a photograph of a half-eaten mushroom and say, what is this? And will the child die? And the answer is most of the time the kids are fine. It’s the adults with the Audubon field guide. You got to watch those. And so how does this work from a mechanistic or billing standpoint? Well, Harvard malpractice ensures me for a telehealth practice and I am credentialed by a group of my peers yearly as to am I competent in delivering this telehealth service.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 04:02
So this is not just me in a casual fashion picking up the phone, it’s, there is a record with a photograph, there is credentialing and there is malpractice insurance, but it’s store and forward. I’m not doing FaceTime, telepresence or any of the things you might think of or Realtime video chat. And that’s a kind of telehealth. Another quick kind of tele-health. I don’t know if any of you heard that about a week and a half ago. I had a syncopal episode while at a conference. Don’t worry, I’m not going to faint on you. This, I was at health catalyst. I was in a room with 20 people that had capacity, maximum of 10. We had no fluids of any kind. It was really hot and I hadn’t slept in two days. I stood up and I fainted. And of course I was wearing a prototype and engineering sample of a continuous ECG monitor where they’re then able to send a continuous ECG tracing to the head of electrophysiology at Harvard and say, so can you look at this? And he said, Oh, it was a vasovagal faint. It was just a nothing, don’t worry about it. And that was a kind of tele-health internet of things of a device I was wearing and everything in between. So maybe we’ll start with Roy. Maybe you can comment on, so American Well, you know, what do you think is the scope of your practice?
Roy Schoenberg – CEO, American Well: 05:18
So, first of all, we reserve the right to have completely different opinions. I think, you know, we’ve been searching for the definition for quite some time because over the last 12 years of our existence, this industry, this area of industry has morphed completely. I think the one that currently to me spells out or explains to the health of best away is it’s the delivery of care over technology, which is a little bit kind of maybe simplistic, maybe kind of pithy, maybe high level, but at the end of the day, it essentially means that an industry that has been, you know, for many decades being perceived as something that is brick and mortar based, that is you have to go to healthcare wherever you need it, is now fueled by the notion that technology can project its skills. It doesn’t actually specify whether the projection of skills is mushroom knowledge or whether it is, you know, an EKG. But the notion that the resources of healthcare, that the skills of healthcare, that the inventory of goods of healthcare, which are primarily clinicians but not only can be projected over technology to wherever there is a need is a concept that has transformed retail. It’s a concept for the transformed media. It’s a concept that transformed banking. I just think that we are, you know, our glacial industry has arrived at the point that this is actually transforming healthcare. But that’s it. That’s a very simple definition.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 06:48
Okay, so there you heard it’s technology enabled health care writ large, John.
John Korangy – Founder/CEO, Careclix: 06:55
Yeah. I oftentimes tell people my night, so what’s tele-health? I just tell them, you know, it’s just healthcare and a lot of people have said this before by I see telehealth kind of just as a word, that’s kind of common. It’s going to disappear as this sort of, like I said, technology sort of gets into embedded within healthcare delivery models and a, and I even have different mediums where people see patients whether they’re inpatients, outpatients and out these virtual consults or whatever you want to call them. The ultimate is going to be all one unit of ways of definitely healthcare. So I think the term will kind of disappear as time goes on a little bit as people become more comfortable with delivering these sorts of care.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 07:33
So, John raises this really important point that I think is probably true, which is this morning when you were on Amazon, did you say, honey, I’m doing e-commerce right now. No, I’m buying things. We don’t use these terms anymore. You know, e-banking, it just banking. Right?
Dr. Lyle Berkowitz – CMO, MD Live: 07:56
So I’m not going to have the definitions are spot on. We all agree. I think what’s more interesting is how we’re applying it, right? It’s a tool. Just like you say, EMR is a tool and so much technology is a tool. So I think the, the shift, I know that, you know, we’re thinking about now, MD Live particularly is what problem are we solving with this tool and these, this parade of tools. And I think in many people’s minds, you know, when you hear tele-health, you think, Oh, you’re trying to sort of duplicate a 15 minute office visit with a 15 minute video visit and there’s some goodness to that. You know, that solves a problem of access, etc. But it’s not really scalable. It’s not really disruptive. So, you know, one of the things when I came in was said, let’s shift our mindset of what problem are we solving problem we’re solving should be, how do we take care of a medical problem as quickly, easily, cheaply, and high quality as possible using whatever technology we have, video, phone, asynchronous storing forward, remote patient monitoring, etc. Because that just opens up a whole other process of what we do. Because otherwise, you know, all we’re going to do, if I were doing this sort of virtualizing the current model that’s not scalable, it’s not going to help our healthcare system should, it would be like your Amazon example of going on to Amazon or the bank and doing it, saying, Hey, I’ve got a book seller that I can do a video conference with who’s in Seattle and he can help me find a book that’s not scalable, that’s not going to work. Automation and self-service is the same components we need to bring into tele-health.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 09:35
And so, you know, what he said makes certainly a great sense. And as we think about the platform, and I’m not here to criticize any company or service, don’t, none of you guys don’t worry. But some years ago Cisco said, we’re going to create a big multimillion dollar kiosk and is going to have 3 dimensional radar and every single and you just walk into the kiosk and do your thing. And of course that didn’t work out so totally. So to his point of, we were thinking back then of digitizing an existence, physical office visit, kind of like a medical record was digitizing the paper as opposed to let’s redesign the workflow to do what you need. And it’s, since I’m in Israel a lot, you know like I was talking to Phyllis there a few weeks ago there is a company, again not endorsing any product or service called Tido Care and that you probably work with and their idea is don’t you hate going to the pediatrician’s office with your kid? Cause then they’re getting coughed on by every other kid in the waiting room. What if we could give for under a hundred bucks parents a kit that you could then use for a telemedicine consultation and whether it’s with you or you or any of you, it’s they got the kit and they can do the tympanic membrane photograph without having medical expertise and that’s solving a business problem with a piece of technology. You said you were going to argue. Let’s see it. Let’s see it.
Mike Baird – President of Customer Solutions, American Well: 11:00
It’s hard to argue with all these great answers. I will note that I was at Cisco during that time and that health care group, but I think there was a passionate article over the weekend, I think from the CEO of tenant where he said, I’ve banned the use of the word telehealth and my organization, it’s just health. And I actually laughed a little bit because people like Roy, you’ve been saying that for at least five years. Right? And the reality is medicine has always evolved from, you know, hands on touching two stethoscopes to you know, an otoscope or whatever it may be. And this is just a broader spectrum of tools that can be used. And it comes down to, and every single use case use the best tools. We’ve shown in some use cases like behavioral health, that patients are much more honest on a video visit than they are in person. We’ve seen things like a colonoscopy where you would never dream of doing that over tele-health. So the reality is we’ve got a wide range of tools that are available for physicians and other providers to use to do the best things for their patients. And that’s really the spectrum that we play in many respects. That is technology. But we’re just here to help patients. And I think if you look at on our platform, we’ve got over 150 different use cases that are as broad as you could imagine for delivering care. And physicians will use their good judgment to do that in the best way.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 12:13
Excellent. And so he makes an important point about how telehealth actually might lead to weight better and more honest history or data. And so let me give you an example. So Brian, I looked at your take. How much do you drink? In doing that, there was a human to human interaction, and it was a judgment and he’s going to say, Oh, me, Oh, you know, I had one beer last week. Whereas, and I tell you this example, not because I know Brian, but because Beth Israel Deaconess 30 years ago when Warner Slack first started doing this on the link, one computer found that patients on average when they had a tele-health interaction reported double the number of drinks every day because there wasn’t a judgment associated with providing data. So think that’s really interesting. Okay, so here’s a controversial question for the group. So as I said, I was in Amsterdam two days ago with 250 hospital CEOs from 40 countries. And what was the theme? This happens to be the Siemens Healthineers conference, but what was the big major theme these hospital CEOs said in 5 to 10 years? You know, who knows what the number is?
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 13:28
The function of a hospital is going to be very different than heads in beds in a brick building. In fact, it’s probably going to be where your care traffic controller, you know that is you subscribed to our service and then we figure out where you should get the best quality, lowest cost, right setting of care. And we may contract some of that out. And some of it may be internal providers or who knows external providers. So, I’m going to start with Roy and ask him this controversial question. These hospital CEOs are worried and it’s an existential worry about all these giant brick buildings that they’ve put billions of dollars to. When do you think we’re going to start to see the transformation? And maybe the answer is William Gibson told us it’s already here. It’s just unequally distributed.
Roy Schoenberg – CEO, American Well: 14:17
Well I think the credit goes to the credit from, it goes to a Christensen, right? I mean he said this 20 something years ago where he talked about the needle moving change in healthcare is not going to be this technology with the other. It’s going to be technologies that lower the care setting that is needed for any specific kind of care and lower the skill sets of clinician doesn’t need it to actually deliver it, which essentially means patients moving out of the hospitals into the outpatient clinic, outpatient community practices, very importantly the lowest cost care setting, which is the home, which also happens to be the most humane place we want to be at the end of the day. And we all know that the, you know, the whole notional graceful aging and all that is huge. I think they’re worried about it. I think we actually, we have a lot of health system clients who are actively incorporating the notion of projecting their services and creating telehealth based products out of the services that they’re very good at, which is kind of a digital equivalence concept where they say, when we think about our five year plan, it’s not going to be about whether we open up another service line.
Roy Schoenberg – CEO, American Well: 15:33
Everything that we’re going to do is going to have a physical and a digital counterpart. And that’s the way that our organization is going to grow. Assuming that somewhere along the line, state licensure is going through either relax or be more manageable in terms of insurance coverage so that they can project the services and we have a couple of examples Cleveland clinic, Intermountain, some of those have done a better job than others and kind of reinventing themselves. I think the part that’s going to help that is that change about Medicare, you know, newly kind of a new coverage to tell the health that’s beginning January 1st for Medicare advantage. But that’s a start. At the end of the day, don’t get me wrong, we’re not complaining about how we use telehealth to care for the flu and the, you know, stomachache and all that kind of stuff.
Roy Schoenberg – CEO, American Well: 16:23
All of these kinds of urgent care pieces that are still the biggest volume of telehealth. Most of healthcare dollars aren’t on the flu. They’re on heart failure and cancer and elder patients afraid of patients and patients who are challenged from getting out of bed. I think the revolution of telehealth is going to be how do you let those health systems that you mentioned do their magic in the home environment in an effective way. And this is, you know, Devita was kind of a little bit of a pioneer in a very different fashion by saying, you know, home dialysis with the right kind of envelope can be applicable for more patients if you use technology. And that has changed. You know how instance real diseases is being managed. I think this is what we’re going to see with telehealth. We’re very myopic in the way that we see today. We think of it as the, you know, here’s an app that can allow you to see a doctor. I think we were going to be very surprised of the next two or three years as to telehealth actually comes to be what it can be.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 17:25
So he’s mentioned a really important barrier. And as I practice in 50 States, and do you know how hard that is? And here’s how I do it. Don’t worry, it’s not a magical business model that you can steal. It’s that the physician who is licensed in a given state does a specialty consult to me using the license in that state so that I’m not licensed to practice in North Dakota, but that physician who is consulting me, here’s my advice, takes it or leaves it and it’s all okay. But so shouldn’t it be in the future that we have a single framework, even if state laws vary, but a framework by which we could deliver telehealth services across this country,
Roy Schoenberg – CEO, American Well: 18:22
It’s the most powerful mechanism to distribute healthcare that we’ve encountered in the last century.
John Korangy – Founder/CEO, Careclix: 18:31
So you know, I think that you know, the reality is some of these health systems and in general around sort of telehealth, virtual delivery is that appears drive a lot of this, right. So, you know, the reimbursements aren’t there, then none of this will happen. So as we mentioned, has Medicare is now transforming and started paying for some these Medicare advantage programs and other sorts of real monitoring and so forth. As those are being adopted and put into place by the, by the payers, then the technology will follow along and it’ll grow and those hospital systems will, you know, will reap benefits as they start putting the roadshow programs together. But otherwise, you know, the technology for a lot of the things, I’ve been there and been there for awhile. But the adoption has been, so, I mean, one is the payer side, but also the, on the providers side physicians as a whole grow slowly. They change slowly. They’re used to doing things in a certain way. And until there’s forced upon, in many cases, they’re not going to change the way they’re used to doing things. And I think, you know, at least in United States, the payers drive a lot of that. And so as that’s that, now they’re seeing that the benefits of providing virtual care, the cost benefits behind it, and hence you’re seeing payers paying for this and how the adoption.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 19:46
So it talks about alignment of incentives and payment. And so at Beth Israel Lahey where I work, roughly 70% of our contracts are value based purchasing risk contracts, some kind of shared savings program. They’re not traditional fee for service. So in fact, if I can see a patient in their home, it’s actually to our advantage because we really don’t want to get more examination rooms and build more real estate and all the rest. So I think you’re correct. We’ll do it when we’re paid for doing it.
Dr. Lyle Berkowitz – CMO, MD Live: 20:19
Yeah. I’ll try and do this in three points. Point number one is Blockbuster. Around 2000, of course, you know, they had lots of physical presence stores. Netflix came to them and said, Hey, things are going online. They said, no, people want to come into our physical buildings. They want to touch and feel and talk, et cetera. Does that sound like a hospital? A little? You know, what can hospitals learn from the point that consumer demand is shifting? Point number two is many years ago, even a little before our time, you know, the primary care doctor took care of everyone in the hospital. And then intensivist developed in the 70s, and then we saw the rise of hospitalists. And I suggest that we’re going to see another split between the primary care doctor and outpatient setting.
Dr. Lyle Berkowitz – CMO, MD Live: 21:11
There’s, you know, has to see sort of everything, although urgent care is really start taking the lightweight stuff. But I’d suggest the rise of the virtual lists is being the type of doctor who does take care of the easy stuff, the flu, the sinus, and really the cracked disease that stable. And even though 5% of patients represent 50% of healthcare costs, 50% of patients, right represent 3 or 5% of the costs. The issue is how do you load balance that cause those people clog up the system. So I’d suggest that we’re furthering and see a split or primary care doctors into the virtualists who are going to take care of hyper convenient care. It’s very scalable using telehealth and virtual online technologies and complexologists. We’re starting to see that right with the Oak street groups and gen meds who are having a much smaller panel sizes but really set up well. And so the hospitals, the future I think will remain doing what they’re doing, taking care of the really sick people who come in, but there’ll be able to increase their panel size by using technology to load balance. And I think we’ll see the rise of virtual primary care groups and the primary care groups and all those buildings they have today I think will become complexology centers. We’ll be taking care of less people but in a more intense way. But then there’ll be able to scale around that now either using partners or doing it themselves.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 22:33
And so what he said is a trend. I actually have heard all over the world that is we’re going to still have a physical building. It’s going to be the emergency department you go to when you’re hit by a car, you’re stabbed, you have a heart attack, a stroke, you know, that sort of thing. And an ICU tower right next door, which will take care of the sickest of the sick that can’t possibly have home health care. You know, maybe they are going to need a level of intensity that could never be moved out of such a place. But other than that, all the ambulatory care stuff and all of the, this simple stuff, it all gets moved into the home. So when, what do you think, what is this transformation happening?
Mike Baird – President of Customer Solutions, American Well: 23:10
The time has already passed and it’s actually too late. I think a lot of health systems are operating in an old model. And for many of them, they have virtual monopolies because of certificates of public need or whatever it may be to take a long, long time to build a new hospital. And so the model that’s worked for them to make money has been all about beds and heads, right? Do a billion dollar building. The reality is that building’s going to take 20 or 30 years to get an ROI. And if you were to look 20 or 30 years, I think there’s some virtual certainty around the trends and value. Certainly the trends around reimbursements. And if I were to fast forward 20 years in the future and think where those care dollars are, what’s going to save a chronic disease patient or someone that’s on dialysis or has diabetes or whatever it may be, is not going to be another billion dollar building.
Mike Baird – President of Customer Solutions, American Well: 23:56
Now they may want to remodel some of the ones they have. That’s fine and you can output, you know, make every room have tele-health in. And I’m okay with that. But the reality is I think that distributed care model is the future. And if they’re not making that transition now, all they’re doing, you’re going to see this model where every hospital, 10, 15 years from now is going out of business because they’re trying to pay for these expansive campuses they’ve built that have no people in them. Like the Blockbusters of today, we were down to one. I think there’s still one in Alaska somewhere that’s holding on for dear life. But that’s what’s going to happen if they don’t start moving now.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 24:27
So to his point, and I went off for a great investment opportunity for you guys. So Ross Perot jr is buying golf courses, which are largely flat. And it turns out golf courses aren’t as popular cause everyone’s riding bikes these days and you need too much water. And he’s building condos on golf courses and making a vast sum of money repurposing this thing that’s kind of archaic. So the WeWork model not going to work so well, but what do you say? We rebuild virtualist centers in what were formally known as hospitals.
Roy Schoenberg – CEO, American Well: 25:00
I was going to make the exact same statement, not knowing that you’re going to talk about the golf course. Yes. The hospitals as they are today, the buildings, you know, to the point that Mike said are not going to make the ROI, it’s just not going to get there. However, if we actually rethink about the hospitals, excellent centers and we allow them to manage the care in their disciplines and the geography that is much larger than where they treat today, they may have a second life. If you think about, you know, God forbid we have cancer, we would love for our care even if it’s locally deliver it to be coordinated by the right oncologist, or you know, we would love for our you know, the way we manage an endocrine disease to be managed by Mayo clinic specialists that’s there.
Roy Schoenberg – CEO, American Well: 25:50
This means that those kinds of nodded centers are going to become national corporation centers and they’re going to be rendering the coordination of care, the local supply that is next where I knew, but the care coordination is going to come virtually through the places that have the best knowledge. By the way, the other side effect of that or the other kind of upside with that is that those areas or those hospitals that specialize in something are going to have an enormous case pool. So from a research standpoint, if most of the cancer is going to be handled by or coordinate all the care of that cancer would be handled by a single center in the US our knowledge is going to explode.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 26:37
Right. So here’s this interesting point and this is related to the physical buildings going away. Worry of these CEOs. If some were to ask you, what’s the address of Mayo clinic? The answer is Mayo.org right? I mean there’s not a physical address that I would think, I know it’s just here. You know, it’s continuous care. I can reach the virtualist 24 hours a day, be triaged if I need to be to a physical location, but the address of a hospital will actually become a Blockbuster kind of question. That’s my guess. Now I’m going to ask one last question before we open it up to the guests and you guys don’t know about this one. It’s going to be very hard to answer. So I have people who tell me, Oh, there’s no possible way you can safely run telehealth because the difference between a cold and bubonic plague is not so much you’re going to adjust. You need that in person hands on thing. Comments.
Mike Baird – President of Customer Solutions, American Well: 27:39
Millions and millions of patients would say that you were wrong at this point, right? This is certainly something that’s been proven out over and over again. The reality is there are cases where that’s true and people will need to see that. But I think the vast majority, you know, you talked about the 50% in the middle, that’s not the case. And instead, if we’re taxing the healthcare system where people don’t show up for follow-up appointments, they don’t get physicians to practice at the top of their license, they don’t get access to the very best care available in that specialty. Well that’s actually not something to bring the best care either. And I think when we look at our industry and the things that we can do, we help on all of those fronts. We provide much better access. We get you to a much better specialist. We help make sure that that appointment wasn’t missed. And all of those things ultimately do a lot more for the public health good and for individual good than insisting that every doctor goes to, or every patient goes to an average doctor who may or may not be the best person to take care of them. If you’ve got the bubonic plague, I’m sure you want to go see a specialist. But I think that just isn’t the case when it comes to your average patient.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 28:43
So he raised this interesting point. I only raised this as sort of a controversial topic because you hear the naysayers out there saying, you know, buggy whips are good. Right. You know, and so he is saying effectively this, it is far better if you have a mushroom problem for you to connect to my phone than to see any primary care doctor in America. Right. Cause chances are I’ll get it right. Any comments you’d make on quality safety, things you’ve seen along your journey there?
Dr. Lyle Berkowitz – CMO, MD Live: 29:11
There are a couple of important points. One, there’s this fallacy about comparing to the office visit. The national quality foundation did a great white paper about two years ago. And what they said was like, it is so wrong to try and compare the quality of a telehealth visit to an office visit. What you have to compare it to is what often would have happened if you didn’t do that telehealth visit, which is either delayed or no care at all. You know, until it’s too late. And so, you know, it’s the maybe non delicate way saying something’s better than nothing, but we have people every day come to all of us who would not go or would have significantly delayed care. We have more and more people calling us from their cars. Why? Because that’s the only time they have in their lives to squeeze in a little healthcare.
Dr. Lyle Berkowitz – CMO, MD Live: 29:57
They work jobs that they can’t leave. They’ve got families to take care of. They have a little time to take care of their health, 30 minute commute, and that’s when they’re calling us. And you know, we have to really be much more sympathetic to the access problems that we have and the fact that we simply don’t have enough to, I often say we don’t have a doctor shortage as much as we have a shortage of using doctors efficiently. And the truth is online care can and should be scalable. It’s, you know, it’s a combination of synchronous, asynchronous, automation, chatbots, etc. We have people come in and work with our chat bot before they even get to a doctor. And by doing that one, by the way, that chatbots probably going to always ask the question, doctor won’t always ask question. Two, there’s no evidence necessarily that being in the office and doing a physical exam and a lot of these cases makes significant difference.
Dr. Lyle Berkowitz – CMO, MD Live: 30:46
There’s very scant evidence on that. And some of us who practice, no, you know, if someone has a problem, they’re usually going to point to it. And part of our job, even telehealth, is to triage patients to the appropriate level of care if we think something else is going on. But the truth is it brings access to a lot of people who simply don’t have it and can prevent problems before they get worse. So I’m a big advocate when those people bring that up of saying, well, you look at the alternative and it’s much worse these days.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 31:14
All right, so he’s brought up this really important point of access and sort of two issues there is I do some work for the Gates foundation in Northern India and an Africa. Try getting access to a specialist if you’re in Northern India, you know, it’s just not going to work so well. But yet they’re using Wawai phones over 4g connections in rural neighborhoods to bring you a propriate specialist when needed, without having to travel or wait. And then the other thing is if you were to ask for an appointment with a Harvard specialist, any idea, just generically how long you’re going to be waiting. The answer is about 22 and a half months.
Dr. Lyle Berkowitz – CMO, MD Live: 31:55
Yeah. Another analogy is when people say, Oh, you know, I got to listen to their lungs. I’m like, well really that’s not that great. What should we just do? Access techs and everyone who comes into the carpet really maybe a cat scan or maybe a pet scan. Like at what level do you stop? And so it’s a, you know, again, a false argument to sort of say that, you know, tele-health alone isn’t as good as the office visit cause offices and isn’t as good as an ER visit or hospitalization or an open lung biopsy. If you, if you believe that. Now it cut them all open.
John Korangy – Founder/CEO, Careclix: 32:23
Just to follow along with that. I agree. I think that most people who are, you know, if they’re pricing position, you’re probably would let’s say the stethoscope, all I use, it has limited value for me cause I’m going to get a chest X-ray, right? Even if you have a broken arm that the orthopedics is going to get an extra grade, right? Or if you’re going to get you to do laps or lab tests. So I think tele-health falls into line with that where we are essentially, like you said, we’re going to triage these people, put them in the right category and whether it’s something you know is hyper acute or acute or subacute or whatever it is that we treasure appropriately and put it in the right spots. And again, the care when they need it, how they need it, and they’re getting the access to help them get the care at the right time because at least the United States, again, you know, take an ology with imaging and lab and all these sorts of things, you know, overrides these were a touch and field anybody does. So you know, conceptually people may feel a, you know, I’ve got to touch the patient, or patients may feel the doctor hasn’t touched me. The reality is most doctors would tell them, probably all of them would tell them that that touch is kind of, I do it, but I’ll never act upon it.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 33:22
And so again, it’s going to say something very controversial. I am a physician, the physical exam and it’s positive predictive value ain’t so good. And so today, okay, Lyles NIMBY, if I give you a stethoscope right now, could you hear that S3 rub on Roy? It’s like, Oh, I remember 25 years ago when I was in a medical situation. What an S3 rub is. I haven’t listened to one in 25 years. Well, what if in fact because we’re so consumerizing these devices, right? I got blood pressure cuffs and bathroom scales and pulse ox simmers and glucometers and all these other things in my home for cheap. It’s not in the so distant future that you’re going to have wearable small echo devices that you’re just going to strap on your, Oh, okay. I see your ejection fraction. I may already in Israel get to back to Israel. There are fetal monitors that you can just wear on a belt and it will do a full fetal ultrasound exam from your belt. So comments on quality and safety?
Roy Schoenberg – CEO, American Well: 34:27
Yeah, I, I think that we’ve, we’ve arrived at the point in time until telehealth world. I think this question is no longer necessary. We fought this for 10-12 years to prove the telehealth was safe, that you could deliver meaningful healthcare over the oncology and I think that that ship has sailed. I don’t think that anybody’s debating this anymore. There are, as you said, there are industries have, are forming to help the remote clinician get information they need to care. Whether it’s, you know, the ultrasound or the title device or the scale that gets through the corner metric they felt with the home monitoring devices that can do that. I think this ship about whether this is safe medicine or not has sail. I think the other question or maybe the analogy we’re just going to using an analogy to explain this, you know, what was the effect of text messaging on our ability to conduct relationship?
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 35:19
Total destruction of romantic relationships.
Roy Schoenberg – CEO, American Well: 35:24
Tell you that I sometimes I shared with opinion and sometimes I would argue that that allows us to be much more connected, much more close. Instead of saying bye bye and meet again at like eight o’clock in the evening, are trying to get through the day. I think that there is a positive and negative in the way that we read in event the way that we communicate. I think there’s going to be bad apples with the music. I think they’re going to be unbelievable. Applications are going to make healthcare completely different kind of world, but I think we need to learn the lesson of the fact that introducing a new modality for way something is done is not the culprit.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 36:02
And of course, I’m just joking with him, but it’s fascinating because my mom who’s 81 grew up in the Smith Corona. You typed a letter, it took two weeks to go across the coast. I grew up in more the fax machine generation. My daughter of course is in the texting generation and then beyond her it’s the Snapchat generation. So we’re all getting to different communication modalities. I just worry about what it’s doing to our brains. But other than that, we have five minutes left. Let me open it up to you folks. You know, these are the Titans of our industry, so please, you know, questions, thoughts? Yes.
Speaker 1: 36:42
Carol Robinson Cedarbridge Group. How do you two questions, one in terms of telehealth can you describe a little bit about how you are accessing a patient’s record or if you ever had the opportunity to add a health information exchange data tropes. And then the second is around how you’re managing patient consent across you know, the various state to state regulatory environments.
Roy Schoenberg – CEO, American Well: 37:19
Very quick answer, in terms of patient consent and state by state, we go by the law and recommend the blockchain is a very clear about what consent has to be acquired. What determines image community both by way of coverage. It’s very important by way for licensure credentialing and we literally had to code capabilities into our products that make it a no brainer. I mean this is the way it works. You will not be able to see on any one of our systems, someone who is not right for you or not ready to deliver care for you. And the consent is being acquired. From a medical record standpoint, we can’t fix everything. I mean we go for, because these are national systems, we actually hone in on things that are, you begin to see available. For example, we’re much better in getting the medication list for a patient from the likes of Surescripts than we are getting a medical record that was created in some kind of practice. In the cases where it’s unavailable, we tell the clinician that it’s unavailable and they do what we do in the office. Patient came in, no records available. They need to do a different kind of workup for that patient to create comfort and treatment.
Dr. Lyle Berkowitz – CMO, MD Live: 38:28
We’re the consent part. I mean it’s you know, we are very careful about that on the records, you know, we of course have our own ability for patients to put in the records. Sometimes they’re good at that, sometimes not. If we’re working with a health system, we’ll often do CCD fire or some type of data sharing both ways. So we have some of that and then for our health plans now they’re starting to also send us a CCD, which we’ll summarize as a PDF, but also we’ll start pulling in discrete data that the patient or the doctor can change, right? So now we’ve got the medication that they’ve been in and similarly we’re starting to work with Surescripts to pull some of that. And we’re also, we have some work with some data exchange, some HAES, etc.
Dr. Lyle Berkowitz – CMO, MD Live: 39:17
So it depends a bit on the particular client, although we’re starting to look at some of the national players as well to get the data and then share the data. We always ask the patient if they want their, their information shared with the primary care doctor of which, you know, we have a record we basically wind up in, unless it’s, we have a relationship with a health system, we’re faxing that cause that’s the standard these days, but at least it’s something. And then the patient also has the ability to download the summary of their record and bring it in.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 39:45
So what you’ve heard is we kind of do what we must, but as we see the evolution of networks like CommonWell and care equality, or there’ll be more generalizable ways to get this. And my favorite model not going to work for everybody for sure, is that as you look at the notices of proposed rulemaking from February of 2019 basically it says every doctor and every hospital has to have an API available that grants to the patient full access to at least their basic medical records so that the patient could receive it and share it or the patient could delegate the sharing of it. But it’s the consent issues sort of go away a bit. If the patient says, I’m going to delegate to you to get my record from this API and we’ll watch how that rule evolves because it could help you all. Well I think one last question. Yes.
Speaker 2: 40:35
Finance type road is actually efficient as well and work with Saba. With the physician short JMC predicts that there’s going to be a 46,000-90,000-person physician shortage by 2025. Do you think that what you’re building with telehealth can reduce the time required number of patients understand and hopefully address that issue or are we still having to essentially trade more physician to try and accomplish that goal and then maybe restructure the life decision is being trained in order to accomplish the telehealth?
Mike Baird – President of Customer Solutions, American Well: 41:13
Okay. I think you can certainly help. I mean, I think tele-health does a great job and helping get a doctor to practice at the top of their license or another provider. So, for example, there’s a lot of things you can do with the nurse practitioner over telehealth. And I think there’s a lot of things we can do to speed along that visit. We’re working on lots of concepts around AI where a patient in a waiting room can do a lot of the work and sort to make that a very efficient and yet very impactful visit, all of which will ultimately help some of the utilization of our providers. So there are a number of things that tele-health can do to help with that.
Dr. Lyle Berkowitz – CMO, MD Live: 41:34
And let’s be clear, I mean, our system is broken. There’s no future where we can make enough doctors to continue our current system. And that’s, yeah, it’s just not happening. So we all have to figure a way to scale this. Like I said, we have less, there’s no shortage of physicians as much as a shortage of using them efficiently. It’s like saying there’s a shortage of vice presidents of banks. If we made every vice president of bank, you know, be the person who gives you your change. That’s what we’ve done with doctors. So using automation, chat bot, self-service, what every other industry has, that’s what we have to think about.
Dr. Lyle Berkowitz – CMO, MD Live: 42:24
So we’re not, we shouldn’t be looked at as companies that are simply, again, trying to put a doctor online to do a 15 minute, you know, face, you know, video of it said that’s not going to be scalable and solve what we need. And there are instances on the high end where you really need that specialist to do that time. But also in that lower end and that big chunk of 50-75% of Americans who have routine repeatable care, we have to figure out how to automate as much as possible and only bring in the doctor. So yes, those virtualists, we’ll be able to see, not a panel size of 2000 but I may action 5 or 10 or 20,000 patients by using this technology. And then the complexologists we’ll have a panel size that’s maybe 500 that’s a load balancing. That’s where I’m skating to where that puck’s going and thinking about.
John Korangy – Founder/CEO, Careclix: 43:30
It looks like these patients, they’re going to file through the other virtualists like you described. And it goes down to, you know, if it’s a complex case and I’ll get filed out to that specialists who’s a mushroom person who can manage that, the mushroom case a in and kind of triage accordingly. But I think that’s the way it’ll evolve.
Roy Schoenberg – CEO, American Well: 43:32
I think there’s just one of the things that we don’t think about, we always think about telehealth or the consuming part of the patient part. Then the availability of services to them was, we tend to forget is that this is going to have fundamental impact on the lifestyle of clinicians as well. And we’ve seen in places like Hawaii, when we rolled the system, there were clinicians were burnt out and didn’t want to do this, didn’t want to hold the practice, didn’t want to handle the Inglis negotiation with the payers for fees and everything else and say, well, I’m not going to hold a practice. I actually love treating patients and I’m going to make myself available for a couple of hours every day from home. And we’ve seen that a lot of physicians who were out of the business coming back. I don’t think that there’s a single thing that we can do to change the supply of medical services then to bring back a lot of the clinicians that in some shape or form are on the sideline. Maybe because they are, you know, they have a young family maybe because they’re burnt out maybe because they’re retired and I think that help is going to make a significant the opposite them. It’s kind of the positive then of bringing those cycles back into the form at least.
Dr. John Halamka – Int. Healthcare Innovation Professor, Harvard Medical School: 44:37
And I would agree with everything they’ve said. There is an Israeli company, always an Israeli company working on ways for healthcare. The shortest distance to wellness for you right now is X taking you to the person who’s practicing at the top of their license for the issue that you have. And that’s it’s, as you all have said, it’s better tree and better utilization of a limited supply. Well, thanks so much to these Titans. Wonderful conversation.
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