Current and Future State of Workforce Training for High-Quality Telecare

- All right, so this June we are going to have a panel of two, hopefully three, hopefully Neel Naik's able to get on soon, a panel presentation about what's going on in telehealth education. And I do think you're probably gonna be surprised by what actually is happening, 'cause I think many of us know that it needs to happen, but may not be doing as much or maybe trying to do some at our own institutions, our own hospitals, our own medical schools, and so on. So, I'm gonna have our panelists introduce themselves. And then we have three panelists, and again, I'm trying to find the third one here. But if we can maybe start. Lulu, do you wanna start? And then Shruti, you can go next of just an introduction of who you are, many people know you already, but who you are and sort of your hat that you wear in the telehealth education sphere, so.

- Sure. Happy to. Hi, I'm Lulu Wang. I'm currently at Georgetown MedStar Health in the D.C./Baltimore area. Wear a few hats as it concerns telehealth education across kind of the spectrum of our learners. So, I teach a course at our med school on telehealth. I also run our resident electives and as of three weeks from today, will be program director for a telehealth fellowship. I also provide a little bit of faculty and associate teaching as well.

- Great. Shruti?

- My name is Shruti Chandra. I am at Jefferson, and my major role in telehealth right now is actually through the AAMC. So, the AAMC created some telehealth competencies that some of you might be aware of, and I was part of the group that did that, and I'm currently the lead of the education subcommittee at the AAMC and am also a consultant for the AAMC for certain telehealth education endeavors, specifically education grants that currently many of you may know about, have applied for, and/or are members of. At Jefferson, I used to run a telehealth graduate certificate program that we have now sort of broken down into some more digestible portions for faculty, residents, students, anyone who's interested in doing telehealth. So, that's my educational role at Jefferson.

- Great. Thanks, Shruti, and thanks, Lulu. I'm just looking, too, I don't see, so Neel Naik from NYP Cornell was supposed to also be joining, too, so hopefully he's joining. I just pinged him as well. So, why don't we jump in. And so, I have a couple of questions for you guys, and I'm sure there's others on the call that may also have some, but I'd like to sort of just get a general sense of what's the current state of telehealth education. So, Shruti, I'm gonna reach out to you first, especially with the roles that you have on the AAMC because there's emergency medicine-specific telehealth, right, and then there's the whole rest of it. And so, I'm curious, what do you see as the, or what is the current state right now of telehealth education?

- Sure. So, from the AAMC perspective, I think they have a very good view of sort of the institutions that are associated with medical schools, obviously 'cause it's AAMC, and what the education looks like from the medical school, undergraduate to graduate level, to the faculty CME level. And I think everyone would be surprised to know that a lot of the majority of the institutions have started to adopt some sort of telehealth education because they've seen that there is some role within education for telehealth in the future for all of their practices. And that education varies from asynchronous materials that is provided by various organizations to clinical rotations, to simulation with assessment. And at this point, we're actually looking at a lot of people's adoption and assessment of these and what that's gonna look like for other schools to adopt. So, I think the general view of education and telehealth is that it's already happening in a lotta places, which is a positive for people who don't have anything because there are a lot of places to look at for models to adopt, or people that are working on sort of generalized curricula for people to adopt for any level of education that they want, for medical students, graduate levels, as well as for CME.

- Yeah, building off of what Shruti said there, I think starting from undergraduate medical education level is where we see the most rapid adoption and integration of telehealth education, and then as we get higher and higher up the chain, it dissipates a little bit. So, at our medical school, at Georgetown, for example, the telehealth is introduced in a few different ways. We've got a telehealth thread, which is a longitudinal four-year little snippets of telehealth in their preclinical lectures and in some of their simulation cases, et cetera. And one of the holdovers of the COVID pandemic era undergraduate medical education is a lot of the standardized patient cases were designed to be virtual or telehealth during the pandemic, and some of them have carried over still today. As we get up further into graduate medical education, I think those structured education curricula or programs are a bit more limited. Some institutions have them, and I think this is where we see a bit more specialty specificity. So, in psychiatry, for example, in internal medicine where there's still fairly widespread continued use of let's say video visit, then we see some of that integrated in emergency medicine because there's a bit lower prevalence of EM telehealth programs. It's not quite as, it's not present at every single institution and hospital system. And some practitioners don't engage with telehealth day to day. And so, those structured curricula are less seen. And then as you continue forward with faculty and associates, it's very institution dependent.

- And just to add on, I think the faculty is institution dependent because they're just kind of focusing on those that are going to be doing telehealth, so there's more training than education for faculty. And I'm sure you might be seeing that at your own institutions, but it's training them in whatever platform or modality that they'll be using, and it's more of getting them ready to be in practice and not always what we might see as holistic education that we are providing to the medical students and the residents.

- And Lulu, you got into a little bit about what you're doing there at your institution. Shruti, do you wanna get into what you're doing at Jefferson or what you have been doing at Jefferson?

- Yeah, sure. So, we've actually had a lot of effort in trying to figure out where best to accommodate and put telehealth into practice. We probably have been most successful with the medical students as well because there's room for the curriculum, and also because I run a portion of the medical school curriculum so I can sneak things in and no one's really opposing me, so that's helpful. But there's a telehealth elective. There is some required curricula that they do before they get into their clerkships because many of these clerkships are in fact using telehealth in their practice and students get to see that and use it. There are a fair number of rotations, particularly psych related in electives that the students are doing care through telehealth. There's, like, a DBT one specifically. So the medical student curricula, there's a lot that's sort of telehealth, either specific to that specialty or even a broad general training. The residents, I think we have tried a bunch of ways to incorporate it and some have done really well and some haven't done well. We tried to get the residents to do some callbacks through telehealth and their patients that they were seeing. We tried to do other follow up. We have a telehealth rotation for the residents that is just an elective that they can do. Again, some were successful and some were not. So we keep going back and trying to see what we do. And then we have a telehealth fellowship that is for anyone, not just within emergency medicine, but outside of it as well, where we run their telehealth portion of it and then they get clinical support through whichever department or specialty they're working in. And then for faculty, a lot of it, again, is training based. So, there's that training of whatever faculty that are onboard at Jefferson. They all go through our telehealth training. And I had mentioned this graduate certificate program that's actually outside of the clinical department. There is a college under which it lives and it's open to not just the Jefferson faculty, but also outside faculty to take programs that are generally tailored towards those telehealth competencies.

- Great, and I think, and I did get a message Neel's was stuck in transit. He's gonna try to join soon by phone, but we're gonna go ahead and keep asking both you and Lulu. I'm curious 'cause I know some other people have asked me this, too. How many of you actually have... Is the telehealth education, this is what telehealth is, and then, like you said, didactics and simulations. Do you have actual residents performing telehealth calls and/or are you supervising resident education using telehealth? So I'm curious, Shruti, back to you right now, are you doing any of that currently?

- That's the thing that we had tried where we had the residents doing those telehealth calls for callbacks, and that was supervised through our telehealth physicians. We're not doing that anymore and we haven't gone back to it 'cause we haven't found a sustainable model to make that work with the hours that the students are trying to do. So, no. We're also doing some telehealth calls when we were doing triaging through telehealth, which we were doing for both of the institutions. So currently we're not doing that.

- Can I ask why not? There's probably other people trying to think, like, "Oh, maybe we could do this." And so, like, what are some lessons learned then on that one?

- So I'll tell you why not. We had to get buy-in from our residency leadership, which was difficult to come by. Since, the residency leadership has changed over. So we're gonna go back and revisit that to see if we can incorporate it again. So it was more about the buy-in from where to fit that within the curriculum, which I think is a struggle for any level of education that has a set curriculum, 'cause we're trying to find hours and fit it in in a way that doesn't add on hours to the students, whatever learners they are. So, more to come. I'll let you know what happens.

- How about you, Lulu? Are you doing anything, like I said, where it's the residents are actually, they're providing like billable telehealth encounters and/or are they having their clinical care supervised via telehealth?

- Yes, the short answer is yes, but only as long as it fits into the bigger clinical throughput. So none of the telehealth, clinical telehealth they're providing is in the primary interest of resident education. If a resident is working with an attending who's performing telehealth visits, then great, they do that. In our case, in the emergency department, we have residents who perform tele-triage. These aren't billable encounters, but they perform tele-triage to help move the triage throughput through the ED. But again, only as it helps contribute to overall clinical productivity. We haven't been able to convince or be able to work in any education first or education-based telehealth, unless they're on a, for example, two-week telehealth elective.

- So then, I'm curious, too, what will we need to do in telehealth or other than like Shruti said, trying to for the stakeholders. What are things that need to be done or barriers that we need to overcome to be able to allow residents and even medical students at one point to be able to do telehealth and not just simulated cases or not just listening about it or shadowing?

- I'll say that in other specialties where their telehealth practice is part of their general day-to-day practice a little bit more than for a typical emergency department, it's easier because the residents and students get, you know, just wrapped into doing that and providing the care, and then getting supervision through that. So, when I talk to internal medicine colleagues or psychiatric colleagues or even surgical subspecialties that are doing follow-ups through telehealth, they do have residents that do it. In emergency medicine, it definitely depends on what you are doing in your department and if you are allowing your residents to be part of that. So, like Lulu said, the tele-triage and we have that, we're kind of allowing them to do it. When we were doing telehealth on demand in like a location that's on campus, then we were allowing residents to come join us and sort of do those rotations and do those visits and kind of do what we need to. Now we're doing that remotely, and we haven't incorporated the students or residents remotely, even though I think we could if we did a three-way call. We just haven't gone ahead and done that. So I think it just depends. I mean, Emily, with your, like, hospital at home or the virtual obs unit or anything like that, if you've got the physician sort of doing it and your student is on an obs rotation, I think it'll be much easier to incorporate them into that. For those places that are not doing, that don't have the buy-in for even our own physicians to perform the telehealth care, then it's very difficult to incorporate learners.

- Lulu, anything to piggyback on what Shruti said?

- No, agreed.

- And late breaking, we have Dr. Naik who just joined us. Neel was able to finally find a spot to get reception to be able to be on the call. So we're gonna do a quick introduction for Neel who is also on the panel here with the work that he does. So, Neel, are you able to come off mute and then let us know who you are, what you're doing, where you are at this second right now, and then what you guys do for telehealth education because Shruti and Lulu have already gone through what they do for telehealth education, so.

- Sure. Sorry I'm late, everyone. I am in the middle of South Manhattan , but on a quiet street neighborhood, so it's quite fun. My name is Neel Naik. I'm the Director of Simulation Education over at Cornell in Manhattan, and also part of the faculty at our Center for Virtual Care. And so where I come into this is really in the telehealth education realm, and mostly with undergraduate and a little bit now with graduate medical education and also PA, APP kind of education as it pertains to telemedicine. We've been doing it since 2016 and it's definitely evolved over the course of especially the last four years. In the beginning it was a little bit of, like, trying to convince people that they need to know how to take care of patients over telemedicine. And now it's not trying to convince them, but it's actually trying to get them to understand that how we take care of patients over telemedicine requires a different skillset than how we take care of patients in person because the way we communicate is different, the legal landscape is slightly different. What we can and cannot do is a little bit different. And really it's this understanding that telemedicine is not trying to replace in-person care. It is an augmentation. It's another way that we can provide care, and so if we really think about what telehealth allows us to do better than what we can do in person, then we can start really kind of understanding when we should employ it and how we should employ it. And that in itself allows us to take better care of our patients. And so, we run classes using simulation to give people an experience of taking care of a patient, and then we discuss them and talk a little bit about how to approach it, how to do an exam, and how to communicate effectively when you're hundreds of miles away from the patient.

- Thanks, Neel, and a question that I asked Shruti and Lulu already, and I'm gonna ask you as well, do you actually have residents or students providing billable telehealth care, and/or are you using telehealth to supervise actual clinical care of the residents, that the residents are providing?

- So, we do incorporate residents a little bit as an elective, so during their fourth year they're able to take an elective with us. It's not quite them taking care of patients and us supervising them, although it sometimes turns into that. I think they probably get the best experience on our community teleparamedicine program. So, they do ridealongs with their teleparamedicine paramedics, so they get to meet the patients, be in their house, and be on that side of the camera as we, the providers, help take care of the patients. And then they also join us on the physician side of the camera, and we'll have them kind of help interview the patients and kind of almost tag team the care. But as far as like residents doing solo evaluations of patients on telemedicine, not really. Yet.

- We'll get to the future state, the vision and all that, but I do wanna open this up 'cause I've been asking a couple questions, but I do wanna open this up to the group right now, just questions about the current state. 'Cause, again, I wanna get to that, like, what's sort of that vision of that future state of telehealth education? But specific to sorta what people's programs are, or what they're doing, what they've spoken on already, what questions do people on the call have?

- I would be remiss to say Judd is on the call who runs some of the telehealth education stuff, so he could answer some of these questions as well.

- So, actually leaving most of the questions out, the theme, Emily, of many of your questions was about residents billing. And so, as many of you on the call know, I run the Enterprise-Wide Telemedicine program, and I'm a hundred percent sure compliance would fire me in three minutes if I had residents bill and there wasn't somebody sitting there with them. So, I think as Shruti highlighted, if you're not in emergency medicine and you're in the clinic and someone could look over your shoulder when you're seeing the patients, and you know, provide the appropriate input so that you can bill as a resident with physician supervision, that makes sense. I think the way, at least the way I heard what you said and interpreted it is, "Who has residents out there on their own doing this?" And I would hope that none of us do, or at least wouldn't admit it on a recorded phone conversation. So, I think the question is, how do we educate? I mean, Shruti answered with related to billing, and you know, and everything she says is accurate. We've actually had more success getting residents, and not so much med students. We have a bunch of med students that come through, albeit not emergency medicine, like an optho resident that's trying to bulk up their CV to go into optho spends two weeks with our team and does a project on optho telemedicine and may see some patients on demand, but they may not be eye patients, but they're getting some on demand experience in a project tailored to what they wanna do. We've actually had many residents rotate through, almost none of whom are from our own institution for the reasons that Shruti highlighted. But you guys know Tony Fabiano who's gonna be our fellow next year, and he came through as a resident looking from somewhere else to get some experience. So, I think we've been able to include people and where we've then had residents rotate in, we have multi-party on our platform and we just put 'em on as multiparty and somebody's there with them the whole time. And that's a little tricky because as Shruti said, we don't work from a specific site, so you have to make sure you're on with somebody who could teach, and somebody who could tolerate having a resident, and somebody who could fix the technology if the multi-party doesn't work, and somebody who's got the interpersonal skills to ask the patient to hang on so somebody else could join the call. But we've been able to do that with those rotators.

- Yeah, and thanks, Judd. Yeah, no, I was not trying to get anybody in trouble with compliance or fraud. Definitely. And what I did mean was that sort of the two different types of what you just described, the multi-party, where there's actually residents providing telehealth care, either that you're on a multi-party and/or you're actually in the same physical room while the the resident's on the video with them. So yes, not that this would be billable on their own, separate. So yes, I totally agree, and anybody for compliance, we were not trying to do that. If they are listening to this recorded session. And then the other piece was if any of you are using telehealth, especially during COVID, where potentially where there were some of your residents at sites such as rural sites, I'm assuming not, but just in case, like, where there's residents at rural sites, they have an iPad in the room with them and the patient and you are actually remote using the video to supervise that care. I'm assuming that none of you guys have been doing that in your sites just because it's not as rural. I'm seeing everybody shaking, not nodding, shaking their heads, no. All right. Other questions for those that are presenting on sorta their current state of their programs.

- Just before we get to that, I do wanna say one other thing, which is currently we're doing a survey of residency programs about what telehealth education they're doing. And we've only had about 50 responses so far, but I would say that maybe 4 out of those 50 were in the positive. And so, if we're talking specifically telemedicine education in residencies, I think that there are very few residencies that actually have it part of their formal curriculum. Again, that's very prelim data and we're working to get a bigger end, but it's, I think that there's a lot of roadblocks with it and I would love to hear from the group what roadblocks people are having at their respective institutions as well.

- Neel, what roadblocks are you having at your institution?

- Well, ACGME requirements, right, are fairly strict and fairly already a large amount of information condensed into a small amount of time, especially when we pair off the clinical and focus only on the didactic time. So, unless that changes from the top down, I don't anticipate many residency programs are gonna be raising their hands to add telehealth unless there's obvious clinical benefit, AKA, this department happens to be performing a lot of telehealth, the resident needs to know how to do that in order to contribute to productivity.

- So, Lulu, I think, you know, we may have had this discussion when we were all at SAM, but I'm unaware of any ACGME requirements that uses the word in-person in front of it ever, right? And so, part of it is our own institution's interpretation. So if, for example, you need to do cardiology, it doesn't say in-person cardiology. If, for example, you need to do urgent care or fast track, it doesn't say in-person urgent care or fast track. So, I think there's flexibility in the requirements. The inflexibility may be at the individual institutional level, and that's something that is addressable and is a roadblock that with the appropriate discussions can probably be overcome because we've had none of that. Like, that's just never been raised as an issue for us.

- Yeah, this is where culture plays in heavily. I will say some of the ACGME milestones, not for emergency medicine, but for some of the other specialties, do specifically call out telehealth and digital health. But I think it's only three or four until there's further revisions.

- Neel, back at you with the question about other barriers institutionally. 'Cause before you jumped on, we were starting to just touch upon it a little bit. So, what are some of the barriers, maybe not specific-specific to your program, but sort of what you've seen when people are trying to get these programs up and running.

- Yeah, I mean I think the cultural aspect is a large part of it and I think that concept of, okay, if I'm putting something in, I have to take something out. And Judd, to your point, it's not really taking something out, it's just changing the way that we do it. I think for a lot of programs it is, we don't have anyone local that's actually doing it. It's not part of the clinical culture, and therefore no one is pushing for it to be part of the educational culture. And there's also not resources necessarily that are easily available. Sure, if there was a PD that wanted to incorporate it into their program, they could go find resources that are available online and create a curriculum. But again, it's what is the driving force and until there is a true driving force where it needs to be part of the curriculum explicitly, I don't think many program directors are chomping at the bit to do that. And I don't know if many residents are actually asking their program directors, "Hey, do we get any experience with this?" if they don't see it in the clinical environment either.

- All great points. Before we switch to the future, just, oh yeah, Neel, go for it.

- No, I was gonna say hopefully we have some data to back up those thoughts shortly, but we'll find out.

- I do think just anecdotally, I hear a lot more interacting with medical students who are thinking about preparing for practice of the future, how AI and telehealth folds into that, how do I become a good doctor while being expected to practice with these tools? Residents thinking about education for the current are a little bit less focused on that.

- I'll just add that the same thing. So, my focus currently is a lot more in medical students in medical school. And I definitely think the students are a lot more conscientious about what this future's gonna look like with regards to any sort of technology within practice, and AI specifically now that that's the push, but also telehealth and how that gets incorporated. And they're the ones kinda pushing to make sure that's included in the curriculum. And in addition to that, we just had our recent review and there were questions about how do you incorporate telehealth or education, or are you teaching it? So they're starting to look at it as well to try and figure out if we are doing that. So, medical school level, I think it's a lot more open, and that could be a positive thing because as medical students then go towards residency and they come and see a void in any education that is related to telehealth, they might be the ones pushing to see if that's a possibility or not. I think everyone sorta sees this, but it's interesting the way telehealth education has developed and will develop going forward because the push is not necessarily coming from the faculty or the overseeing bodies or institutions. It's really coming from the learners that are seeing what the future looks like because it's them that are immersed in that technology-rich environment way more than maybe some of the faculty and the people who are creating the curriculum. And so, there's a lot of, hopefully, people listening to the voices of the students going forward. And that's why I think that there's so much more built within medical school. So I can at least from personal experience say that in my last review of the students that were graduating, a lot of them said what's missing in our curriculum is a required portion of AI education. And I was like, "Whoa buddy, we haven't gotten there yet," but they have and I think we need to get there. That's kind of what, that's what I'm learning.

- Love it. Love it all. Right, love that they're asking for it and the AI side and everything. Don't love all the barriers, right? But that, I think, if that's gonna be in... It's sort of to me back to when I used to do simulation that it was sort of in the very beginning, simulation, it was tough to get people to want to incorporate it into residency programs or medical school programs, undergraduate medical student programs. And then we started having medical students start asking for it and asking residents, like, "Well what's your simulation program? How can I train rather than on people, how can I train in these high stakes environments?" So, similar with this maybe here, too, just this innovation and that it's not always gonna be top down, at least on this education side.

- What were you saying about simulation, the ACGME requirements don't specifically mention you need to do so much simulation, but they do mention you need to do so many procedures that now we use simulation to supplant. So I think it's the same idea of, you know, it may not mention exactly what you need to do, but telehealth might be a route to get to that point, right? So I think we just need to start to think a little bit more broadly about how we're gonna use it. Not just teach telehealth, but really use telehealth as a tool to teach whatever other skills they need to learn going forward. Just like simulation.

- I think that's a great point. You know, the reason why simulation was never folded in as like you have to use simulation is because of the cost requirement. And they didn't want smaller programs to be at a disadvantage. And I can see a similar thing happening with telemedicine. You don't have telemedicine, we're not forcing you to have a telemedicine program. So, I agree, Shruti. Like, I think that may be the way that it ends up being incorporated down the line.

- This might be a nice segue, too, before we go to the future state. Lulu, do you wanna present on the project that you've been doing with SAEM in terms of providing that resource for places that may not have the time bandwidth or actually experience with telehealth for residents?

- Yeah, well, by "I" I mean a number of people on this call, you and Shruti included. This has been, so the SAM telehealth interest group has a sub work group that for the last about 18 months has come together and created a compendium of telehealth learning resources. We recognized there were a lot of really great educational resources online, but they were a bit scattered, and there was no single starting source for someone who wanted to learn about telehealth. So, we took the AAMC 2021 report of telehealth competencies and used that as a guide to find high quality resources and create a compendium. So, that's been submitted for publication and also to be made available open source on the SAM website, and I can alert this group when that happens. But the ultimate goal was just to have a starting scaffold of telehealth education resources. For example, that residency program for a resident or an individual learner who wanted to learn about telehealth but didn't have a structured program available at their institution.

- Thanks, Lulu. Yep, a lot of blood, sweat, and tears and edits for that one. So thank you Lulu, for persisting with this project and hopefully soon it'll be published and also available online for everybody here also. Judd.

- Can I ask a question, Emily? I have sort of a challenging question for people and it's a legit question. It's not, "Guess what I'm thinking." Are we helping or hurting ourselves by considering telemedicine a thing, right? Like, we take care of patients that have diseases or symptoms or conditions and we don't talk about we do it different in room 28 than we do in room 35 than we do on the fourth floor than we do in the ER. Yet, ultrasound has managed to be successful as a thing that isn't really a thing anymore than a stethoscope is a thing. It's a tool that we use to have a diagnosis. Telemedicine, like, it seems to me we're trying to make ourselves more like ultrasound, but maybe we need to be more like a stethoscope, which is just a tool, you know, a way we do it. And I don't know the answer over time, but we can't just keep saying telemedicine's just medicine, but we should need to teach you telemedicine, right? So, are we helping or hurting ourselves as we do this?

- I think it's a stepwise approach.

- [Judd] What's that?

- Right? I think it's a stepwise approach. Both are true. So yes, absolutely, telehealth should be folded into healthcare, is folded into healthcare. It's a mechanism, it's a vehicle, it's a modality. But because telehealth for most of the general public is still a relatively new thing, even though it hasn't been in practice, but for most people they are learning, it is a relatively new set of skills, both technologic and website manner that they're acquiring. So, ideally in some number of years from now, maybe not that many, but the at some point, telehealth, digital health, AI-enabled tools, all of that will kind of fold into a single care delivery.

- I will just extend into saying when we started, and even now, telehealth had to be a thing because people didn't know about it and we needed to do it. So, if we now transition to the future of what telehealth is, I think it's going to be, let's not make it a whole thing. Because as soon as we start to make it a thing, people are like, "I don't want another thing that we need to teach," or "I don't want another thing that we need to incorporate into a curriculum." So now I think it's, for us as, you know, as the committee and the groups and the people who are thinking about it, now it's trying to figure out how we're gonna rebrand so that it's not a whole thing. I just said thing like six times.

- And is it about rebranding or is it planning for, it sounds sort of doomsday like, right? But planning for eventual extinction in terms of those of us that have made this as our sort of rallying cry that we need to look at telehealth thoughtfully and how we apply it, right? And that it is like, it is a thing, and it's gonna become ubiquitous and so it's no longer its own thing, so then, you know, careers are gonna sunset because of this. And that's maybe a good thing, right? Like, that this, that the rally cry-

- I think one day, like, I think it's difficult to say, right? Wouldn't it be wonderful if one day everybody was super comfortable just doing all of the things that telehealth has to offer and just being part of our practice, and maybe that's what we should be working towards. And yes, maybe that means that they won't need the telehealth specialists anymore, but I don't think that's coming up anytime soon. So, it'd be nice to move-

- I'm gonna push back a little bit, right? Like, I think when you look at specialties, right, there are people that go into pulmonology and they do outpatient clinic and that's their entire job, and there are people that do inpatient medicine and that's their entire job, and then there can be people that do virtual care and that's their entire job. So, I think I agree with you all in saying, "Okay, it shouldn't be a separate thing. It should just be this is another way that we take of patients, and we should learn how to take care of patients across the spectrum." But then it could certainly be someone's career that they focus on one way of taking care of patients, right? And so, I view it a little bit, and granted I come from the sim world, but at one point in time, simulation was this other way to teach, and there was a separate sim curriculum. And now a lot of residencies have folded it into their entire curriculum as a whole, and they're just saying, "Okay, this thing we're gonna use simulation to do and this is gonna be a didactic, a lecture based way that we're gonna learn this, and this is gonna be a small group based way of doing this." And I think that eventually the hope is that it gets there. You know, you could make this similar argument for, like, transgender care. Right now it's a thing, and in curriculums we're trying to incorporate transgender care. But the hope is that after a while it just becomes part of every curriculum and folded in in a way. I'm not doing a simulation specific for transgender care, I'm doing a simulation and the patient just happens to be a transgender patient, right? That's, I think, where we're hoping to go. I don't know if we're there yet.

- So I'll say-

- And just to add on, we still have simulation specialists, right? Like there's people who only are really good at simulation, so maybe there'll be a market for somebody who's really good at telehealth always that can guide institutions' educational efforts in that direction while everyone learns it.

- We've almost found it easier to translate patients into telemedicine than providers into telemedicine. I'll give you two specific examples. We opened, you know, a nearly billion-dollar flagship multi-specialty building a month or two ago, and we created this thing called virtual checkout. Yesterday alone we did 650 virtual checkouts. Appointment was over, hit a whiteboard, checkout person's gonna pop on the screen, they'll give you your appointments and tell you what you need to know. Nobody was asked, "Do you want a real checkout in person or do you want a virtual checkout?" But that's now 650 patients that never left their exam room that looked at somebody on the TV and got their care. It's just the way we do it, and it's not an option. And so I think, you know, we've had data for a long time, many of you have similar data, that the best way to do a scheduled visit is to say your next visit's via telemedicine. Not to say, "Do you want it via telemedicine? Do you want to come in person?" And that drives utilization. So, I think, you know, Neel, it's exactly what you're saying. We just need to grow to incorporate it, imbed it, and I think Lulu and Shruti, you know, it's probably right. There's gonna be a time at which the scales change, but it's not gonna be everybody all at once.

- Emily, if I could add one thing that's generally in support of that concept, you know, from the perspective of an EMR vendor, and my history going, I've been around long enough to remember when all we had was either saw the patient in the clinic or you saw them in here at the hospital. And "Oh, we could give 'em a phone call." You know, and this in some ways, telemedicine is beginning to fill out the full continuum of care options, and at the EMR level for us it's building it so for any given patient it can be fluid. You can shift from a scheduled in-person outpatient visit to, "Oh nope, flip the mode. They couldn't get in. Great, go to telehealth." And you don't wanna go back to just a phone call, but that's always an option if you needed it. And so really, the continuum is getting fleshed out by better and better tools that let the patient, let the provider, let the doc, let whoever it is flex to what's possible and needed for the given level of care needed. And so, and really it supports a lot of this, that it's just gonna become part of the continuum of care, and you're just matching it up to the right situation, the right clinical, the right provider, the right patient, that sorta thing. I think that's where I see it going. It's certainly where we are going from an Epic perspective in fleshing that out and building those tools in. You know, to Judd's point about the virtual nursing, that is going like crazy because it works well. It's a great fit, and that's just happening, and it's an example where it won't be even, but you see it happening and going quickly.

- And Chris, I appreciate you bringing this up. And I know I've mentioned to you before the piece that sort of how Edward Tufte said like power, I'm maybe misattributing, but you know, PowerPoints sort of shaped the way presentations are given, same with like our EHR, right? If Epic makes it super easy to do stuff, then there's gonna be one less barrier. Or if it's just, it's all of a sudden there, then there's gonna be less angst about how are we gonna do this? And for most of us on the call, I'm sure we could all put up one hand or multiple hands of how many fingers we've had of the different types of modalities of technology we've had to use for all the different services we have for telehealth. So, the easier it becomes on that side, the easier it'll become for education side, too, right? It's taking away the friction, so.

- And the companion piece is easy enough for the patients to initiate, whether it's through MyChart, or even if they don't have MyChart, you know, on demand being able to say, "I think I need this," and the guidance to get an on-demand video visit or a virtual ER visit or a primary care visit, whatever the thing might be, that's the key companion to it, in the language that they need and, you know, whatever that...

- So, language is a whole other thing, Chris. And this is, you know, I'm going off on a tangent, but do you know how everybody knows what language the patient speaks when they call in? Like, they call into a center and they're not talking English, right? And so, do you know how they get routed to the right language translation? This is amazing. The person who answers the phone guesses. And then if they go to the wrong translator, they have no idea either. So, you know, they do really, really well with Spanish. But once you get into, you know, different Asian dialects, it's a crapshoot and patients get sent all over the translation service, and we're trying to solve that. And believe it or not, nobody has a solution for that, and apparently the travel industry doesn't either, even though they have the same issue. It's pretty wild.

- Yeah, that's a big opportunity to think about.

- You would think that for AI could come into play.

- I was gonna say, does Google Translate have a feature where you can speak the language and have it identify?

- Yeah, but you can't use it 'cause it's not a medically qualified translator. It's another thing where we just have stupid rules in healthcare that we don't in other places. So, services can translate spoken word to written word, right? They could do that. But believe it or not, doesn't exist to take a spoken word and route it to the right place for another spoken word, which shouldn't be that hard, but nobody's doing it.

- Yeah, one last thought on this transition away from telehealth as a special thing towards telehealth as a part of care, is that one thing we still haven't done a great job of doing is demonstrating to our providers and patients that telehealth is not just video visit, that it's not just a pandemic era solution. I think once we start integrating some of these other asynchronous RPM, whatever it is, then naturally people will see it as a part of care as opposed to a single ribbon replacement for in-person clinic visits.

- Great point. That's a great point.

- Yeah, one of the things that we do with our med students is we still run a 10 case OSCE with them, which is a throwback to when they had to prepare for Step 2 CS, but we've modified it in a way where now there is a phone case and a telemedicine case as part of their 10-case OSCE. And so, again, incorporating it in the curriculum, not as a separate thing, but as just, "Hey, this is part of it," it's getting there, actually. I think it's a slow process, but it's gonna get there.

- Yeah, actually it's interesting you said that. So, I created an end of medical school OSCE for our students that are graduating, and it is completely virtual. All of the cases are virtual. We don't market it as telehealth, they just do the entire cases with their standardized patients virtually through telehealth and perform whatever care they need to and do whatever needs to happen. The cases aren't all, like, physical exam specific, but there's all the other stuff that you do. There's counseling, there's, like, error resolution, there's a bunch of stuff. And so, they're all virtual, and the students are comfortable doing that because they've learned it and that's the way it's gonna be until I can say otherwise.

- Yeah, and to Lulu's point, it's not just, "Okay, this patient's calling me with this chief complaint." It's the follow-ups, it's the counseling, it's all those things, which is one of the areas where I think telehealth, like, shines, right? And some of these quick follow-up things. So, I think, Lulu, I agree with you. I think once some of these other aspects of telemedicine start becoming a little bit more known in the general public or general medical group, I don't know what word I'm looking for. I think it's gonna be better.

- So, transitioning a little bit more forcefully now to the future. I mean, we've been talking about this a little bit already, but I'm curious for each of the panelists of sort of what do you see part of the future? Is this that, like, you know, as part of our recertification for emergency medicine that there's going to be X, Y, and Z that's telehealth-like, right? That assessment drives, you know, drives instruction, then. So, I'm curious what you think, if we're gonna say, let's just pick a time, let's pick 10 years from now. Might be a little too far out, but still, 10 years from now, what do you think education with telehealth in it is going to look like? Shruti, I'm gonna start with you. And you're welcome.

- Honestly, I think we've talked so much about it already, right? About what it might look like. 10 years from now, I have no idea. I have no idea what it's gonna look like 'cause I think the technology is changing so rapidly around us and the possibilities are going to be so broad, so I think that 10 years from now it is going to be incorporated, already is and will continue to be incorporated in medical schools in one way or the other. Either through pure dedicated telehealth education, or through telehealth incorporated within all of their clerkship education, their assessment and strategies like that. I think further in residency and in faculty training, I don't think we're gonna get to the point where they're gonna require you to do anything telehealth related just to be certified or to get any sort of licensure or anything like that. One of the reasons is I think we as a group are divided against it. You know, some people want it, some people think it's a terrible idea and it's gonna be restrictive to other people who are training in certain areas. So, I think we're not gonna go in that direction. I think we're just gonna sort of grow and hopefully transition into a time where it's just incorporated within education as a whole. But maybe it's wishful thinking, I don't know.

- Neel, why don't we go to you next? Sorry, Lulu, I'm making you have the last word.

- Yeah, no, no. I agree, I agree. I don't think it's predictable because it's... and I think part of this is because the legal aspects of it we don't know, the reimbursement aspects of it we don't know, and I think that influences how the education evolves. In the sense of, okay, if it still is a minor thing because of restrictions legally and reimbursement wise, then I don't think it ever catches fire in education where it becomes this kind of ubiquitous incorporated aspect of things. I think if it does become part of our clinical care given some of those factors, then it does because I think there's then an impetus to get people trained and educated in it. That bottom up thing I think is real and I think residents, or med students and then eventually residents will want to at least have some knowledge of it. But I think that that only kind of, again, catches fire if they see that in the clinical environment it is becoming more and more of a thing and not being restricted by some of the medical legal aspects of it. And so, I think it's really hard to predict right now. I agree with Shruti.

- Lulu.

- Yeah, that's essentially what I was gonna say. Hard to put a pin in it. I mean there are internal forces, which is the culture of your institution. There are external forces which is legal and regulatory, and things like where reimbursement will look in 10 years. If we're moving towards more quality-based reimbursement, alternative payment models, telehealth really shines in some of those. One example, ED timely follow-ups. We're not able to get all of our patients with asthma into an in-person appointment within the set time, but we can get them onto a scheduled on-demand appointment. And so, I think a lot of the education will be driven by practice, how much of it is being used.

- Love this. And questions from the group before we start to close out here? 'Cause there's been a handful of us speaking and there's more than a handful of us on the call, so here's your chance to ask questions.

- Not to call out the other Neal here, but I know he is also deeply involved in telehealth education. Curious if your experiences are similar at GW.

- Hey. Yeah, I mean we've struggled quite a bit because we're just not doing all that much Enterprise-wide telehealth. But I think, at least at the medical school level, we finally have got, this is the first year we've integrated it into our principles of medicine course. We designed and developed a telehealth training module introduction which went really well this spring, and we've been providing some interactive training for our PA students. The nursing school has already kind of incorporated it into their OSCEs for the nurse practitioner program. That's kinda where we're at. Not much going on in residency except for trying to leverage telehealth with informatics and really kind of making the argument that our emergency physicians really need to be, you know, at least competent in certain informatic skills. And so, trying to slide the two together to find a space within the curriculum.

- Thanks, Neal, and thanks, Lulu, for putting him on the spot there. Sorry, Neal, and thank you.

- [Neal] Absolutely.

- [Aditi] Can I say something?

- Yeah.

- Yeah, so obviously Judd and Shruti can cover all the stuff at Jefferson, but I will say that outside of academics, if you actually ask around, there are a number of smaller hospitals and private groups that have no education at all. So just to the point of whether you need specialists still around, the problem is is that we're talking at it from a position of where most people are getting educated, but the reality is there's a huge gap of people, the ones who are actually practicing in the community, who are actually out there practicing who do not have access to this. And so, to that end, we're still going to need having these telehealth specialists or education disseminated for that. So I just wanted to put that out there because I am seeing more of that. And then second, and this is not related to that, but I'm gonna put in the chat if you wanna play with the language app. So there's an AI Meta one. It's interesting 'cause it's doing what Judd is saying a language app should do. But if you try to put in the medical language for different languages, it does not work that well. But the actual language itself does work well. So yeah, and it's good to see everybody.

- Thanks, Aditi. And on the first point that you said there in terms of that there's still gonna be a need for specialists in telehealth, as a closing piece here, a call for those who are interested in leadership roles. As I mentioned in some emails, we have our elections coming up at the Scientific Assembly, and nominations are due soon. So, if you're thinking about running or want to run, and basically what I'm trying to say is if you wanna keep the fire alive in sorta the telehealth and emergency medicine realm, this is a great opportunity to help really sorta shape the next few years from the ACEP side in terms of what are some things on sort of the advocacy for regulatory and legislative aspects for telehealth as well as sorta the education, the messaging. And as Aditi said, there's a huge gap there for education for a lot of our practicing colleagues in emergency medicine. So, please consider running. You can always reach out to any of us. One of the emails that I've sent out recently has the contact information for everybody who's currently on the executive committee for chair-elect, secretary, newsletter editor, and alternate counselors. So, please consider. Would really be great to see things continue with telehealth there. So, on that note, everybody, thanks for joining us today, and look forward to hearing how all these educational ventures sort of unfold more and more. And then, Lulu, we'll be excited to sort of see the, not excited, sort of, excited to see the compendium when you have that available on the website for people to access for the resources. So, thanks everyone and enjoy the rest of your day. Bye now.