November 2023 - Rural and Critical Access Hospital EM

- So happy November 14th, everybody. Middle of November here. I can't believe the year is going by so fast. We are lucky to have, fortunate to have Dr. Kelly Rowan here to speak about the work going on at Avel eCare. And so I, without further ado, I'm actually just gonna hand the mic over to you, Kelly, and if you wanna give a little bit more introduction to yourself before the program too and we will let you go from there.

- Sounds good. Well thank you. Appreciate being here. Thanks to all who are joining now or later on the recording. I'm Kelly Rhone, I'm an emergency physician. Been an emergency physician for 20 years now and do tele emergency through Avel eCare. I've been with the company since 2011 and then took over as Chief medical Officer about a year and a half ago or so. So I just wanted to give you a little bit of a peek into the building. It's, you know, you kind of go outside the building and it looks a little bit like a strip mall and then you come inside and then you know, we have, it's kind of, we move into our digital world. We have a bridge here that we bring people in who wanna tour, et cetera. So you can kind of see on the left there, that's our EICU and then in the middle is our hospitalist and then on the right is the emergency, which is where I work in my clinical time. And so I'll show you a little bit about that. We are Joint Commission accredited. We are up again for accreditation in 2024. So, you know, getting all ready for that and all that that means on the telehealth side, as some of you have probably been through that piece. For those of you who are not aware, so Avel used to be called Avera. So we were part of Avera Health System, which is headquartered in Sioux Falls, South Dakota. That is where Avel is also headquartered. In 2021, Avera sold their telehealth arm and we became . So we are a standalone company at this point and so some people are just kind of wondering where we came from or those kind of things. And happy to answer any of those questions. We went from being under Avera to having them be our largest customer. So have great relationship with Avera still. And our mission remains the same. I mean just like all of you, and I know I'm kind of preaching to the choir, but you know, we're really there to increase access to care. And on our emergency side, it's really about access, just increasing access to board certified emergency physicians. Certainly if I could put an emergency physician that's residency trained and board certified in every single emergency department across our country, I would, that is not gonna happen. Particularly with our very rural sites, which is where we typically work. And so, you know, this is a way to really increase quality and expertise to those patients who really need it when they need it. So we've been doing this for 30 years. We celebrated this year, our 30th year in telemedicine. And we have more than 800 sites now in over 40 states. So I've had a lot of growth. That's one of the reasons why Avera decided that we could stand on our own. We were well outside their five state footprint and so we, they felt like we were self-sustainable and it was time for us to stand on our own and it, so it's been a really great transition. This is just a little bit of our timeline and kind of some of our other services. I'm not really gonna go into that, but it kind of shows where e-emergency started in 2009. We worked really closely with the Helmsley Charitable Trust, which helped us to get our start in that service line. So we're always really appreciative for our work that we've had with them. All right, so let's look at what this looks like. So as opposed to some of our other service lines in our emergency service line, we actually all work in the hub. So we don't work from home, that could change in the future, but at this point we all come in and we work shifts just like we do when we work brick and brick and mortar at the bedside. And we also work with nurse physicians, so also similar. So this was really built to be like an emergency department and to have the experience that our far off sites can reach out to at any time. And if you look at these kinda cubicles, each one of those, if you think of it as a room in an emergency department, that's what that is. So kind of in the forefront, you see Dr. De Young here working with a patient and she may be seeing a patient in Texas and then kind of in the background you see Dr. Knight with our nurse Rachel seeing a patient over there and he may be seeing a patient in North Dakota, for example. So each one of those is, represents a room and then the nurse always stays with the patient and the physician may move from room to room. So same with an emergency department, right? So that allows us to really see a lot of patients at one time. Our patients are really pretty sick. We do really high acuity through our department. You know, we see an average of three codes a day. We did about a thousand codes, we did over a thousand emergency airways last year. And I'll talk a little bit about that later. So it's really, you know, amazing to work with people from all across the country in areas that are kind of all sizes. But we typically do work a lot with the rural health kind of critical access hospital, frontier hospitals, tribal hospitals, et cetera. And this is what it looks like on the other end. So we use a fixed camera on the wall. We do that really intentionally. We wanted to make sure that when someone comes in and they don't have a pulse or they're not breathing, that we're not grabbing a cart and setting it up. Because particularly in a small critical access hospital, a lot of times, especially in the middle of the night, the provider may be at home, but if they are there it's them and maybe two nurses. So if you can imagine when you have, you know, a level one trauma or a, you know, cardiac arrest or whatever is coming in the door, it's kind of all hands on deck. And so, you know, we just knew people wouldn't take the time to do it. The other thing that may be a little bit different is if you can see, it might be look kind of small on your screen, but there's a little red box on the wall, looks kinda like a fire alarm and that's how you activate the system. So we wanted it like a code button. So they simply push the button and it rings into us, they tell us what room they're in and we pull them up. So we are up and live usually within a minute, sometimes 30 seconds and we're available 24/7, 365 and then they can call us for whatever. So there's no magic acuity, you know, we meet them wherever they're at. Sometimes it's a very, you know, just, hey I just got a question or can you look at this wound to, you know, can you run the code? So it's kind of all things in between. Our calls can be just a few minutes where we're kind of discussing an EKG and helping them to risk stratify a patient, to patients that are critically ill and maybe were on for multiple hours, especially if we can't get transfer, especially during COVID we would be on calls where, you know, patients would be maybe on a ventilator or we were doing a lot of BiPAP settings, et cetera. And we would be on forever and you know, sometimes, you know, back and forth for days until that patient got on. So we, they would just kind of check in periodically until we could get that patient out to a higher level of care. Most of these places don't have any form of an ICU to keep those patients. So they do stay in the emergency department and then we help them. Same thing goes in with weather. A lot of times we're helping to care for those patients because maybe there's a snowstorm we can't fly situation and can't get them out by ground. So kind of see what that looks like. And then the other thing I really like about this is we have a bird's eye view so we can really see, I have a 30X zoom lens up on top of that TV. So I can see an EKG across the room just like it's sitting in front of me and then I move the camera, so from my end, so they never have to touch the camera and I can see exactly what I need to see, so I can move from looking at vital signs on the monitor back to the patient, you know, looking over at the EKG machine, whatever I need to see in the room. So this is just some of the things that we do in our ER program. The other thing I would say is this is a, we set this up so it's like a subscription. So I would say it's kinda like, you know, having a gym subscription, so you can use it as many times as you want. And we don't add cost to that. We don't want people to make decisions on whether they're gonna push the button, on whether the patient has insurance or whether they've already hit the button five times. They can hit the button as many times as they want and the patient is not charged for it. So, and it's based on their average yearly census and kind of what they've been seeing and what we kind of think that we're gonna gonna have to help them with. So instant access to specialty support with emergency cases, we can see multiple cases at a time if they have multiple patients from a rollover. We do behavioral health assessments as well. So any, we actually have a second set of behavioral health nurses who do those assessments. And then we can initiate diagnostic testing. So if they're advanced practice provider or physician on the far side is either in with another patient, say they have multiple patients again from a rollover or something. Or in many cases in these small towns the, at night the provider is at home and takes 'em about 20 to 30 minutes to come in. So we may be there with the nurses helping with getting that patient started and helping with resuscitation during that initial point. And then we also help with transfer. So you know, we'll talk to the staff and say like, looks like they're probably gonna, you know, think about moving this patient, doesn't seem like you're gonna be able to keep the patient there. We have that discussion and we certainly want to keep the patient there whenever that makes sense. But we're certainly not trying to keep a patient where they would need, say a procedure at a higher level of care. So we'll go ahead and we'll call the transfer center for them, get the accepting provider. We do have to be involved in the case in order to do that. We wanna make sure that we know enough about it to give a really good report. And then we'll also call for either air support or ground support to help move that patient as well. We offer translation services. And then one of the things I think that's a little bit different and maybe interesting as the last two years have come across is we've always had nursing documentation and nursing support. So what is now called virtual nursing we've been doing since kind of the beginning. I think it is a game changer, honestly. I think nurses really enjoy having that. And then when they're done with those cases, then we can send the documentation, it's all ready for 'em. So that's been really helpful as well. So I wanted to show this, this actually came out of the ASAP Rural Emergency Care Task Force report in 2020. And if you, this is ED Physician Density and you can see that there's a lot of places where we have emergency physicians and a lot of places that we don't. And you know, I think this is one of the reasons why this, that started in our region, up in the upper central states, is because there just really aren't enough of us up there. In fact, so I've been an emergency physician now for 20 years, but when I went to residency there weren't any residency trained physicians in my area of the state in the entire eastern part of our state, in our largest city and in many of the areas near us. So that has improved certainly, but it, there's still huge areas where we don't have any physicians versus, much less board certified emergency physicians. And then, so this is our eCare emergency footprint and you can see that it sort of matches really where that need is. And so we'll go kinda of wherever there's a need, but we have concentrated in areas that we really feel like the need is the most. So for this service line, we're in 15 states. As of today, we're in 232 hospitals across those states. And we've had, that should be 215,000 encounters. And I think I already told you about these, but you know, those full rest and airways are things that, you know, we do every day. I think we push TPA most days on strokes. We do a STEMI almost every day. So we're pushing lytic on a lot of those patients because the time to get them to the cath lab is long, 'cause they are many hours from a cath lab certainly much of the time. And people ask us what we see. So this kind of gives you a little bit of the feel, certainly, you know, the biggest thing we do is cardiac and chest pain. We read a ton of EKGs, we do trauma, a lot of trauma, and neuro, but behavioral health comes right up there close. So that is just a huge pain point for our partner hospitals. So adding those behavioral health assessments and helping to get placements for those patients who need placement has been really helpful. If you go all the way down to the bottom, you'll see OB/Gyn, I have officially delivered more patients or more babies virtually than I have in real life or at the bedside. It is my least favorite thing to do over the camera, because none of these hospitals are supposed to have births in their hospitals. And so it's always a little bit anxiety provoking, but I'll knock on wood, 'cause I'm working all weekend, but most of the time it goes quite well. But it is difficult for sure. But that just gives you a little bit of a look at what we do within our cameras. And I wanted to show you this. So the other thing I think that's really anxiety provoking, our airways, you know, when I first started, most of the hospitals that we worked with did not have video laryngoscopy, that has changed, you know, now they all have video laryngoscopy of, in some form or another. And we have now done over 10 years of the difficult airway course. We bring Calvin Brown in from that course every year and we do a hands-on course in Sioux Falls, South Dakota. And offer that to our partner hospitals to come and spend some time really doing hands-on, because we, you know, as you know, there's just no substitute for practice and you know, doing airways themselves. However, you know, when I, when I started practicing, we of course didn't have video laryngoscopy. So you know, I remember my attendings always saying like, Kelly, what do you see? And I'd have to describe it. And that's how we did this initially, because we couldn't see what they were seeing. We now can put cables into the rooms and then they can actually just hook those up to their video laryngoscope and then we can see the airway in my full 36 inch screen. So that has been incredibly helpful. You know, if I say what do, what do you see? And they say pink, you know, I know they're probably in the esophagus and really deep, but it really helps to be able to see what landmarks they're seeing in order to kind of help 'em to be successful in getting that tube into the trachea. So, you know, and I will say that, you know, if it's not a crash airway, there are times when, you know, if I know that I have an aircraft landing in five minutes we maybe get ready and temporize until maybe we know we have a little bit better backup, because we always will err on the side of safety. Whereas if I'm seeing 'em at the bedside, I'll just tube 'em, right? But we certainly sometimes just have to intubate the patient. So we'll ask, you know, who will be doing that there, you know, a little bit about, you know, what their experience is, because sometimes it could be a locums or someone that I don't know, oftentimes it is someone that I do know that I kind of know what their capabilities are. And then, you know, I might be saying, you know, I think you need to pull back. A lot of times when people put these scopes in, they go just way too close and so it's really hard to pass the tube or they're just not lifting up correctly. So you can kind of give them some direction. And then the other piece that's just super nice is we can see the tube going through the vocal cords and so I feel confident that they're in or they're not in and then you know, we can talk about, you know, whether we use a bougie after that or you know, what our next steps are, and or if we're gonna put an IGEL, all of those things or things that we work with through that. So just some kind of quality outcomes. On average we're available about 17 to 20 minutes sooner than the local physician. A lot of that is because the local physician is in clinic during the day or they are home at night or they may be caring for another patient and we're coming in. So that just is, you know, 20 minutes of the golden hour or of cardiac muscle that we are there to get things started. We also work really hard with our partner sites to see if we can help them with recruitment and retention. Obviously in rural areas it's always difficult to have recruitment and we've heard loud and clear from many of them that this is something that really helped them to get someone to sign at their facility. And then really often when I'm going out and traveling to sites they'll say, you know, this has really helped me stay out here, 'cause I know I'm not alone on an island. And you know, the residents and students that I work with, they are familiar with this. They, they've seen this in their rotations. And so oftentimes, particularly our family medicine colleagues that are going through residency are looking for someplace where they're gonna have some support when they're working in the ER. So our airway management, we're consistently successful about 95% of the time. So that's on that first pass, we wanna be successful obviously, as much of the time as possible. There are certainly some times where we have to put in an IGEL or something like that or we'll come back with a second attempt and kind of talk about, well what are we gonna do differently to be successful this time? Our time to EKG interpretation is within six minutes. So a again, when we are looking at just time to looking for STEMI-ing and moving those patients out, when we first started, oftentimes the lab would come in from home and then they would do the EKG. So we've really empowered the nurses at the bedside to do that EKG and let us look at it, so we know if there's a STEMI or you know, a critical finding on the EKG. And then our patients consistently receive fibrinolytic within 30 minutes when we're involved. One of the things I would say that is for those of you who don't do rural medicine in this way, one of the things that's really a rate limiting step is radiology, because they're also not in-house. And so when you're looking at stroke, you know they have to come in from home and then, you know, get CT ready. So really getting within that 60 minutes is sometimes pretty tough when you're looking at stroke. And then we're also, you know, reaching out to the neurologist, regionally to transfer that patient. But our TPA compliance has consistently been a hundred percent. So we are moving them through to try to get, make sure that we get that CT done as soon as possible. If we hear that a stroke or a potential stroke is coming in from outside, we make sure to tell 'em, make sure you're calling in radiology. And then that same, we like to get that chest x-ray before we give lytics for STEMI. So they also have to come in. So that's all just kinda working on those quality projects and you know, training the nurses that if they think that if they got have a chest pain coming in, we really need to get lab and x-ray in so that we can get the best information that we can. And then we support the bedside team with anything that comes in. But we do a lot of pediatric critical care as well. I just took care of a neonate that was born at home about 14 hours previous and came in not breathing, you know, and you know, no prenatal care. So, you know, those are always tough cases. I think, you know, we, I think this summer one time we had three pediatric arrests in one day, because we kinda see the worst of the worst. But then I think the other piece that is really helpful for our sites is, these rural sites, they know everybody in their town. I mean, these are small towns and those are hard cases. I think, you know, the most of us have cared for critical patients and dying patients of people that we know and it's always harder, right? And so they have someone that they can kind of reach out to. We can kind of help them make those really difficult decisions about ending care or having those conversations with family. And we've also showed that that we're really as good in pediatric out of hospital cardiac arrest as urban centers. And we did research study with, we worked with Dr. Kevin Curtis out of Dartmouth. I'm not sure if you're on Kevin, but we always appreciate all of the collaboration that we do with our partners out there as well. So that was really great research and great, great to feel that we're kind of making a difference in rural areas with kids as well. So I wanted to take a little bit of time too to talk about kind of our new venture this year. So we went live in EMS in the state of South Dakota one year ago today. So similar to our rural areas, not having emergency physicians, we also have difficulty with getting people to work in our EMS agencies across rural areas. They are primarily volunteer, unpaid volunteer, so they have jobs elsewhere and we have trouble just recruiting and getting people to work in these areas and so important. So we partnered with the state of South Dakota, with our EMS initiative. It was a nationwide RFP. And brought the same services now mobile into our ambulances. So today we have 86 sites live as of today, and we've done just over 800 calls. I was on an EMS call this morning, not a, not a clinical call, but we were on an administrative call and at that point we'd already have three calls just this morning. So these can be EMTs or they can be paramedics and we're really helping you know, them to give care. We're giving report to the hospital. So again, there's a lot of times just one person in the back of the ambulance with busy hands. So we're calling report early so that the hospital can be ready for whatever's coming in. But the other thing that I think, you know, we have found is it's just really nice to have that extra 20 to 30 minutes that it takes to get that patient in to figure out where that patient needs to go. Oftentimes these patients are going to a critical access hospital, but if we can clearly tell that, you know, it's a major trauma that's going to need to be transferred out, a really unstable patient or a STEMI, then we can work to get aircraft on the way and get that patient then onto definitive care even earlier. At the same time, we can really support the EMTs and paramedics in the back of the ambulance and make them feel like, you know, they have someone to reach out to just the same as the ER. So, you know, I think for those of us who work clinically, there's always something that you haven't ran into and you have questions on or can I run the, run this by you type stuff and then there's the, you know, all hands on deck type things, and all of those things are things that we help with. And we use the same team, but we have added a couple of paramedics to our weekend shifts just for volume. And that has been really successful. And this is what it looks like in the back of the ambulance. We have a microphone up at the top. So as you can imagine we're, you know, a year ago we were asking people to be part of this program and then we're asking to drill holes in their rigs, you know, so it took some sweet talking, I'm gonna, I'm gonna tell you that it really did. And then on the back wall you can see that those are the speakers, that's actually gen generation one speakers. They look like they should be on the back of an ATV, that's what it is. And so we're now onto generation two where it's a little bit more compact but still gives us good sound. And then we have a tablet up on the back of the wall. We really had to look and see where the best place was it so we could place for those, for the camera, so we could still see everything. And then at this point we're asking them not to take it out of the ambulance just because, you know, there's a lot of elements outside and although they're pretty tough, they're not invincible, I think we'll start letting them take them into, it is certainly capable that they can bring them say into a house or whatnot. But really what we found, which is interesting, is even our paramedics are saying, you know what, this really, what it's really done is it's made me move that patient to the rig earlier so that I can get some support. And so that's been really, it's been really cool and fun to work with. You know, I think most of us who work in the ER have worked really closely with EMS in, throughout our career and so this just felt like a natural kind of extension of our team to be able to do this. And we are now just signed a contract with state of Nebraska, so we'll be doing some ambulance departments there and had one sign up in Minnesota. So I think we're feeling the need for it and we're certainly feeling that it's appreciated by both the patients and the EMTs and paramedics. This is a look at some of the ambulance departments that we work with. This is literally how they show up to the ambulance. You know, they're in their normal job. They might be a banker or a rancher or you know, work at the hardware store, whatever, and they leave that job or their home to go get in the ambulance and pick up patients. And so we're so thankful that they're there. They're just wonderful to work with. These are all South Dakota EMTs and paramedics, so just really fun groups to work with. So yeah, today we went over eight, 800 encounters and we're at 86 sites, about 20, almost a quarter of the encounters that we do have are trauma related, things that they really like is us calling report, helping them with that initial assessment and triage and then rarely, because most often they know where they're going to have to go, but sometimes we'll impact that transfer destination, because we want them to go to either a closer site or to a site that maybe is better equipped for the patient that they have. And same about 80% of the agencies really believe this is gonna help with recruitment. And that's another reason certainly that we're here and doing this work. I'm not gonna read these, but couple of nice testimonials from some of the people that we've worked with. And I think it wouldn't be, you know, an ER presentation if I didn't tell a little bit of a story. So this guy with a fantastic mustache and beer, that's Jim, he's a rancher in central to western South Dakota. He's a but he's a buffalo rancher. So I do wanna be clear that we don't have buffalo just like roaming, because some people think that, you know, we're still really the wild west out here in South Dakota, but he does ranch buffalo, so he sells them. And early this year, still winter, I think it was February, he was going into feed and he had a smaller buffalo, and by small, I mean it was seven foot tall and over 2000 pounds, that he had raised from a calf, and it was kind like a puppy to him. It always followed him around and just kinda, you know, lick him and you know, kind of nudge him. And for whatever reason that day it got mad and it started throwing him around multiple times. He was thrown around, he ended up underneath it at one point with a broken arm and, you know, couldn't move that side. He knew he was very injured, went to run for the gate and just as he was getting to the gate it gored him with its horn right up kind of through his groin and then subsequently threw him another three or four times up in the air. And he said, you know, I don't remember how I got out of that pen. I do remember sitting in the snow outside of the pen and looking down and the snow just becoming red all around me from the blood that was coming out of my body. And so he was able to get in his loader, which is a, you know, huge piece of machinery. I had no idea how he got in there and was able to drive then like three miles to his house and get them to call 911. So, you know, we were able to get on with him and really assess his injuries and call ahead to get in a helicopter on the way, which saved about 30 minutes of time, so that they were there really almost at the same time that he arrived at the Critical Access Hospital. We were able to have x-ray there and also the physician there. And he had bilateral hemopneumo, he had, that horn went actually right up into his groin and through his rectum, he had multiple broken bones, about 13 rib fractures, he was in some bad shape and he had a cervical spine fracture. So we went out to see him later. And in the ATV you can see Casey is one of our nurses. And then on the, outside on the left, that's Dr. Katie D. Young, one of our ER docs. And they got to meet him and he calls them his angels, but he is super appreciative of the help that he got during that day. And we were also able to be on camera then in the Critical Access Hospital where we have cameras and we're able to help with the placement of those chest tubes. But then we also had cameras in the tertiary trauma center when that patient came back to Sioux Falls. And so we're able to just have continuity of care throughout that entire time. So it was just really kind of, I think that's what this is made for. It's moving patients and getting patients the care that they need, where they need it, and then preparing for that next step and getting the people and the, you know, equipment ready for what we're gonna need when that patient arrives. And then this guy on the right, he was actually in the ambulance that day. That's Edward in the middle, that's his dad, Maynard. So they are the two guys in Kimball Ambulance that take most of the calls. And then this other gentleman was driving the truck that day. And you know, we had gone live the week before with Kimball Ambulance before that happened. And Edward was not a fan. He did not, he didn't think, you know, he's like, I've been doing this for, you know, 20 years. My dad's been doing this for 40, 50 years. And he is like, you know, like didn't really think that I needed help. And now he's just our biggest supporter. And I think sometimes with telemedicine you have to do that, right? You have to get that big win and then, you know, then they can't use it enough. So it's just been a great ride with them. All right, well I am gonna take a couple of breaths, but I wanna, that was just a taste. I'm certainly open to questions. If there's time I'll let Emily decide that. But wanna thank you for your time and I'm certainly open to any questions or comments that anybody might have.

- Thank you so much. And I'm sure, oh, there's already questions coming in the chat there. I'm sure there's gonna be questions and I just, I really appreciate all the work that you've done on this, Kelly. And the whole team there. I think it's just reminds me in sort of that telehealth space that it's technology is part of it and it's critical part of it, but it's also all the people and all the things that you've done to grow the team that you have there and all the resources and all the support there. So I have some questions, but I'm gonna let others ask first and maybe they'll beat me to some of these questions. So if anybody wants to come off speaker and or come off mute. And I also, there's one question already in the chat. Dr. Friedman asked "What is the economic model?"

- Yeah, so, you know, I think partially people just understand the need. This is actually pretty affordable to be honest. It's really about the cost of a nurse a year. Many of our Critical Access Hospital can also put this on a cost reporting. So it's actually pretty economical for the Critical Access Hospitals. You know, most of them have a physician that has been on backup and a lot of these places have one or two physicians in their practice. And so they're either on call for the emergency department or on backup call for their APP. And CMS ruled that we can be backup for an APP in the emergency department many years ago. And in most states, as long as we meet trauma regulations, et cetera, that can happen. And so they don't have to pay someone to be on call, but, you know, usually it's the primary care doc in the background to be on call, but it also allows their primary care doc to go on vacation once in a while. So it's a huge ROI for them because they, you know, we've kept people in their communities working for much longer and they don't have as much turnover. So, you know, while they don't, they don't bill for our services, we definitely know that they're seeing the value there. The other thing I think is we really, a lot of times help them to keep patients local. And so that also helps their ROI, so.

- Other questions?

- Just to kind of pick it up back off of the like, model question, sorry if I missed, like how many people are working in Avel eCare at a given time during the day? Like what's the volume of calls? I mean you showed kind of what the overall trajectory is, which is amazing, but just like thinking practically, what do you guys deal with daily?

- Yeah, so I should say so we take about 50-ish calls a day, 24 hours. And some of those are short and some of them are long. And then, so at times I have about five nurses on at a time, sometimes six. And then we can pull from, you know, we have several of us that work administratively so you know, we'll get pulled if it gets really busy. 'Cause a lot of times we're in the building at least during the day. And then we have overnight we just have one physician on, which seems crazy. But these are, again, low volume typically, most of our places are low volume, so we're seeing like the worst of the worst in all of them. But, you know, we may not see a patient in one of them all day if, you know, if they, some of these places have extremely low average daily expenses. And then, and then we have two ER physicians on for about 12 to 14 hours a day, we can flex. So if that answers, and then again, if I'm around then I'll get pulled in oftentimes to the, you know, awful, you know, they're like, "Hey, you wanna do the delivery?" And I'm like, "No man, I don't do the, I'll do the trauma." But yeah. So yeah, so it seems amazing. But we keep track of every single, you know, every single call, how long they last, what time of the day. And so just like you do in your bricks and mortar emergency department, we map it and you know, are there times that it's overwhelming? Yes. And are there times where it is, you know, not and we have a little downtime? Yes. And that's just the same as an ER. And then just the same too is that we triage. So you know, if there's a code and there's a stable abdominal pain, you know, my nurse will start the stable abdominal pain and then I'll get to a point where I can leave, you know, a code and then come over. So they tee it up pretty well. Our nurses are all, they're all trained really seasoned nurses. A lot of 'em have flight backgrounds as well. So they're super high functioning. So really fun to work with.

- There's a question that came in, given you have so many physicians and you said 15 plus states in all the different places, how many state licenses does each provider have? I'm assuming each provider has all 15 plus licenses or state licenses.

- Yep, so, yep. So we have to be licensed and credentialed in every single place that we are at. So we have a credentialing team that works, you know, I think we have eight, but full-time people, that's all they do because, you know, for all of our service lines, they cover all of our service lines, but they keep us together. We also use some programs that help us, because the other thing too is each one of these states are becoming more complex to keep, if anybody has, you know, connections to make that easier, I'd be all for it. But, you know, doing six hours of opiates for, you know, education for each one and an hour of something for Texas and an hour of this and that, it takes time, right? And we actually, we have our own fingerprinting machine and people that can do that. So, you know, we've gotten better at it over time just because we've had to, but a lot of my docs that don't work on the ER side are remote and you know, they're in the different states across the US and so, you know, we, they obviously have to go and get their fingerprints elsewhere, but our credentialers work with all of them just to make sure that we keep it all up.

- And, going along on that piggybacking, whatever I wanna say is, how many EHRs, because I'm seeing someone here also from an EHR company, like how many EHRs? Because these physicians and these nurses are all documenting within the EHR at the sites, right? This isn't like you have your own EHR and somehow you scan in whatever to the, or transmit to their EHR.

- So. There has to be savviness or facility with multiple different EHRs, correct?

- Yeah, so we actually do read only for our EHR. In the ER, in our ER program. And we actually use our own software to do all of our orders and that is scanned in because at 230 places, I mean I think all of you guys understand that Epic looks different every single place you go, right? It's not like, oh they have Epic and it'll just look the same. And you know, same with Meditech and Cerner. And then we get into these really small places that have these really obscure EHRs that are not easy. We work with Indian Health and are in many of their sites as well and their EHR is cumbersome, I'm just gonna say it, so. But I'll say our ICU hospitalists, they all work directly into our pharmacy program. They all work directly into the EHR and so we have, you know, password managers and all sorts of things to help them. So far on the ER side, we've been, we've made it a little bit easier on ourselves and I'm not sure how long that will last, but, and the other thing is we can have them push all their imaging to us so we can look at their imaging as well. And I think that has been really helpful in many ways.

- I'm just gonna keep asking questions and if anybody else, put your hand up, so I see someone else or just go off mute, we'll be cognizant of time too coming to a close soon. You mentioned that there's the other programs, right? You've got the EICU, you've got the hospitalist, you mentioned the pharmacy one just recently too. What proportion of sort of the whole kitten caboodle of the telehealth there is the emergency? Is this sort of a, sort of the marquee program now? Is this sort of still smaller than the other ones? I'm just curious.

- Yeah, so it's program size wise, I mean site wise and it's certainly not our most, you know, pharmacy they get, you know, a jillion calls a day or they do, you know, so many different orders a day. But it is our largest and I would say, you know, especially for these critical access hospitals, I think, you know what I think is the trifecta, right? Is that when they have e-emergency hospitalist and pharmacy, it's like a game changer, you know, because they don't keep typically ICU type patients, we also offer something that they call critical care on demand. So if they keep sometimes a little bit of critical care, then they can have access to our intensivists and you know, I think that is where we really can make a lot of difference because we can support them then on the inpatient side too, because you know, they may feel comfortable taking care of them, but maybe the nurses don't, so the nurses can help on the inpatient side too. So, but, I hope that answers your question. I probably went too far there.

- Mike Ross put into the chat, I think you mentioned earlier, this is, it's subscription, but are any of the physician services billing, evaluation management codes or the, like how does that sort of work?

- Yeah, so we don't, on the ER side, like I said, that's subscription. We actually don't do any billing from Avel eCare, but in some services we will turn over billing to the site. So you can't have a similar bill, you know, so if they're doing an ER bill and we're doing an ER bill, you can't, you can't bill twice, right? And so that's kind of the reason and we always have someone on that side. You know, we we're never working in an emergency department where there's not a provider at some point taking care of that patient. There are hands on that side, but we turn over billing rights in ICU, we turn over billing rights in hospitalist and then they can bill. So we'll, you know, write it all out and then they can bill and then they get some return on their investment that way.

- Hey Dr, this is awesome, thanks so much. I get the value add in a really big way on the really high acuity care that seems to be really clear. I'm curious about sort of lower acuity stuff. I can imagine a scenario where someone comes in with like biliary colic, but it's not worth like a PCP coming in for 30 minutes to, do you ever just like see and get the ultrasound and dispo these patients on your own and then, and sort of totally do the care for those low acuity visits too?

- We don't, people really want that, but we just feel like, you know, there is value to someone putting hands on that patient and doing that exam with us and then we don't bill either. So it's really, we're consultants and they're the primary. But we do have a lot of, you know, while we do the big bad and ugly and that's kind of the thing that all of us went into emergency medicine for and it's the fun stuff. I, it's all fun, but that's the really fun stuff. I think, you know, there are things like the biliary colic where, you know, they're still kind of asking that question about, so I don't have ultrasound available here, you know, is this someone that you would transfer to, you know, three hours away for an ultrasound tonight or do you think I can do that tomorrow? I mean there's a lot of bread and butter that we do all day long, you know, get this patient and they got a kidney stone and it's four millimeters and you know, what do I do? You know, I mean, just a lot of bread and butter there. And then there's also kind of what I think is lower acuity, but it might be like a shoulder dislocation where we're just walking 'em through, you know, kinda showing 'em on my nurse what I would do and then saving that patient a transfer to a higher level of care because they couldn't get it in. So I don't know if that answers your question, but I do think that one, I think that it behooves us to have somebody lay hands on patients. I still, I do my work virtually and I still highly believe in the power of touch and what it gives us for information. And then yeah, I think just, and we, and we just empower them. We have people who it's like their first day outta training and people who've been out 20 years, and those people are gonna use us very differently and we let them. And I think that's what's cool, you know, I had a nurse practitioner pull me aside and was like, can I hit the button every single patient? And I was like, yep. And she didn't. But you know, like, and then you, it's fun. It's like, you know, when you have residents or students, you see them grow over time and become more comfortable and they just become colleagues. So it's been, it's been a pretty cool ride.

- Awesome, thank you.

- Yeah, you're welcome.

- Coming close to the end to be able to get people a little bit of time for their next potential meeting. Any further questions? And or any last thoughts you want or Kathy, Dr. Lee, you wanted to ask me the question?

- Oh, I just wanted to ask, so, you know, I do some telehealth research and I've like read about Avera eCare like for many years going back. So it's really exciting to hear all this. Would it be okay if you, would you mind sharing your email address so I can just maybe reach out to you to chat more in depth? I have lots of burning questions, but I don't wanna like dominate the reigning four minutes.

- There you go. It's in chat.

- Awesome.

- Thank you.

- And then Dr. Rhone, do you have any last thoughts or anything since this is the ASAP emergency medicine telehealth section, so there's people doing lots of different things, thinking about doing lots of different things. We have people to do advocacy. I know you guys work hard on the advocacy too, but any final thoughts to this audience? Wishlists or go get 'em or whatever you think you wanna say?

- I mean, I think, you know, when I started, obviously this wasn't a thing, right? And did I ever think this was going to be my job? No. But I think we're just only touching the surface. I think AI is gonna give us some really cool, fun toys and, you know, I think don't be scared of doing things and I think, you know, this is a way that we can really make a difference in our field. So, you know, go out there and do it. If you have any questions, feel free to reach out.

- Thank you so much again for your time, your expertise, all the work that you guys have done up there and look forward to seeing what next year, if it's gonna be like 480 different sites or something like that. So, all right everybody, enjoy the rest of the November, your holidays and we'll see everybody again next month. Take care.