October 2023 - Scientific Assembly 2023 Section Meeting

- So welcome everybody, hopefully everything's going well in Philadelphia. I'm Emily Hayden. I am the chair of this section and I'm not trying to do this by Zoom because I believe so much in telehealth. I am myself, am a patient currently still not allowed to travel after having surgery at the end of August. So thankfully Ryan, thank you for getting this set up for me to be able to do this by Zoom. So what I wanna do is we're gonna have a full two hours, but it's not gonna be in those seats. We're gonna also get a chance for people to do some networking here. I feel that that's something that whenever I've been in section meetings before, there's so many things going on and so many people doing great things that I always wanted to catch them, but then people stream out of the room or you have something else to do or you have the cash bar that's going on after the closing session, which I heard is going on right now. It's a cash bar, remember it's not an open bar so you gotta stay here for a little bit and so we'll have those built into the time here. And so I have that scheduled where I'll see the schedule here. Lemme just, I lost my... There we go, so we're gonna do introductions. We are doing definitely hybrid right now. Some of our executive committee is there on the ground, boots on the ground and some of us are on Zoom here. So we're gonna do that and then you'll see the rest of this schedule here right now. So I'll do a quick introduction myself again, I am the current chair. You guys are stuck with me with one more year. The chair positions are two years and so I'm the current chair. I'm Emily Hayden. ]I direct telehealth at our Mass General Emergency Medicine and have been, was co-founder of our Virtual Observation Unit as well as our mobile response program and have been in the world telehealth since 2016 and really excited to see this section continue and especially with all those who went before me with Aditi Joshi, which you'll meet in a moment too as past president, immediate past president, as well as Etch Shaheen and Hartman Gross. So really appreciate all the work that's gone into this section so far. And I think we just keep growing and with a lot of things happening in our specialty on this. I'm gonna pass this over to our president-elect who is there on the ground. Mike Baker, do you wanna introduce yourself?

- Yeah, hi, I am Michael Baker, work over at St. Joseph Mercy Hospital in Ann Arbor. I'm one of the national directors of Telehealth with Envision and I'm certainly happy to have all of you here today to talk about telehealth and sort of get some of your ideas on where this section should be moving forward to next as we move on here. I've been doing telehealth since 2014. When you say doing telehealth, I guess it's like developing, you know, working on projects, learning how to do it and I'm happy to to work with Dr. Hayden on all the projects that she's been endorsing for this year. Happy to see some of you all in person. Some of you have been on those amazing video conferences that we've had monthly that Dr. Hayden has set up. So appreciate your participation there. And if you're not already aware of those, please be aware of them. The section does put those out monthly with lots of good topics of conversation. So that's all I have.

- Great, thanks, thank you. We're gonna move along to our secretary, Rishi Khakhkhar. I always say that wrong. So many K, Hs, yes.

- Hi team, I'm Rishi Khakhkhar. I run the virtual urgent care at Mount Sinai Hospital and I've been lucky enough to be the secretary of the section for the past year or so. Got to host a couple of panels on acute care on the home and hospital at home. Really excited to kind of see what everyone has to say today.

- Thank you, let's see here, we'll go to our alternate, I'll our, not our alternate, our counselor Aditi Joshi. I think you are also on Zoom.

- I am, Hi everybody. I know I was around for council earlier, but I had to head off. I'm also the immediate past president, so I'm glad to be here and speak to you later.

- Great, thank you and is Sata there in person? Sorry, I can't see the actual speaker side.

- [Section Member] It doesn't look like she's here yet.

- Okay, all right, well we will get to her when we talk about her newsletter too. So I wanna go through an overview of the past year just for those who are new to the section and may not have known much about what we've been doing. I wanted to make sure that people were aware, sorry, I'm trying to do so many things on the, there we go. And so I wanted to do just a quick overview of what we've done this past year as a section and then we'll go into the board update after that. So what did our section do? So we had several things we were doing this past year and it was along the lines of sort of dissemination of EM telehealth information. So the speaker series that Dr. Baker mentioned a few minutes ago, advocacy and connecting. And we're gonna go into each one of these just real briefly. So we had the speaker series and we had monthly speaker series where we had people, mostly within emergency medicine, if not somewhere along those lines of emergency medicine that had either innovations or perspectives that were maybe a little bit different than some of the mainstream and or maybe mainstream also. So just getting a chance for everybody to hear about things going on and understanding better how telehealth might be able to be more than just a substitute for in-person care. And so here we see that it's, they're on our website and how many views we've seen. If you haven't watched some of these, I would definitely recommend you watching them. These were all really great and I think everybody came away with it with something, some nuggets that they hadn't known before, even if they have been in telehealth for a long time. And then the ones on the bottom here haven't been uploaded onto to our website yet, but the hospital at home and then observation telehealth. So those will be coming on soon. There's a little bit of a delay as ACEP processes them so that they don't capture the little chitchat in the very beginning and make it a little bit more professional looking. So those will be coming on soon. So that's the speaker series we did monthly. We also were doing advocacy, so working a lot with Jeff Davis on legislative slide before he moved along to other pastures with McDermott. And so working on the emergency medicine evaluation and management codes with all the work to preserve or to at least extend the reimbursement waivers availabilities for emergency medicine-based telehealth. So both for the emergency medicine E&M codes 1 through 3, having those continue on and then having the observation codes extended through December, 2024. And then other things with engagements with other sections and committees. So we've had engagements here. I also am the chair of the Health Innovations Technology Committee, so there's a sort of a direct line there and we now have a telehealth subset subcommittee there. We have Coding and Nomenclature Committee representation. I'm on that one. I know there's multiple other committees that we're sitting on. And I hope that if you are not on any of the other committees or in the other sections that overlap with the work you're doing, please consider this. I think that there are many that haven't an idea of what telehealth is, but may not have a clear understanding of it. And especially with, for those of us in emergency medicine and in telehealth to understand what barriers that we need to either break down or maybe not unintentionally put in our way in the future for emergency medicine and telehealth. And so for that resilience, it's important for our voices to be at the table to make sure people are aware of what decisions could be a challenge or a boon for us later on. So, and then also other sections too. And then maybe Dr. Joshi, when you speak about the council role, maybe you can also speak about your role now with the AMA and telehealth too, getting the emergence medicine voice out there too. We have dissemination of information, not only the speaker series, but our quarterly section newsletter. And this is one that Sata has done amazing work on this. Each one of these has a regulatory update, Voices From the Field and something that she is called five Awesome Abstracts. And so if you haven't had a chance, we only have, we're definitely delayed from the the website, the ACEP section website having the summer and fall posted, but the spring one is already posted. And then you can also go back in the engage section if you are a section member and you can see where these have been posted as the newsletters, the quarterly newsletter. And then just to dig a little bit more in the Voices From the Field, these were the different topics that we had that she covered to sort of really be a Voice From the Field of what's going on out there. So yet another way that we're trying to show what's going on in emergency medicine telehealth outside of the speaker series. so having one about rural telehealth and how telemedicine's leveling the playing field with Dr. Kelly Rhone from Avel in the spring, as well as Emory's Rural Tele-EMS in the spring. This summer we had the post-EM care from the VCU folks and then Project ECHO and then there was a TeleDisaster interview from this past fall. So she's always looking for other contributors and she probably will reach out to you if she's heard a great thing that you've already been doing. But if you do have anything or/and if you have anything you want to make sure to have in our newsletters, please, please do email her and we'll try to get more and more of our good work out there. And then our other thing with connecting, so trying to connect people. So not only here at the actual conference, which it's hard when we have it hybrid right now, I see there's people there in the audience avoiding the cash bar at least a little bit longer. And then there's those of us on the Zoom, but we also have had other connecting where we've had sharing meetings. So on our monthly meetings, there were two times this past year where we had no speaker scheduled and just basically an open mic and had everybody go around and speak to what they do in telehealth and then have an opportunity for people to sort of talk about challenges and so on. And I think these have been... They're very much sort of fireside chat around the fire, you know, very informal. Yet I think all of us came away from these sessions just really surprised by what all everybody's doing. And for me, I know several people who are on these calls and I know what they have been doing, but maybe not aware of what they've been most recently working on. And so these are just really great for us too, I think, so. So that was the year in review. I wanna make sure we just were aware and those who may not have joined yet, understand a little bit better about what we're doing in this section and really trying to work on the... For me, what I wanted to do during the time as I'm chair is to really work on the messaging, making sure that people in emergency medicine are aware of what telehealth can be and is already, as well as trying to help listen, like an ear to the ground, to hear about any myths or other misconceptions that we can sort of work to help dispel or to look into potentially. So with that, I wanted to keep an eye on time and keep us rolling here. So I know Dr. Haddock, who is now our president-elect for ACEP, who is also our board liaison, I believe Dr. Baker, you have the, what she would like to update if she was actually able to be here right now.

- Yeah, so I have just a couple comments from Dr. Allison Haddock. First of all, she has been a stanch supporter of this section for several years now as our ACEP board representative. She has been instrumental in working with the ACEP telehealth task force and trying to get that ACEP telehealth task force released for general consumption. She's still continuing to fight and work for getting that report released. I think that Dr. Hayden kind of explained Dr. Haddock's absence. She stopped by here for just a minute, but she has a huge new role as president of ACEP. She's president-elect this year, she'll be president next year. And so she has enormous amount on her plate now and unfortunately was not able to join us for this section. And she really wanted to be here and she sends her regrets for not being able to spend time with us today. But besides trying to get that task force report released, she was very impressed with the debate that occurred on the council floor. And I won't steal Dr. Joshi's thunder there, but there was a pretty good debate about telehealth and its benefit to rural and other emergency centers that may not be staffed with the board certified emergency physicians. So there's a fantastic debate on the council floor, really changed a lot of people's minds I think, or at least had them starting to think more about it. She is also continuing to, you know, support telehealth as far as reimbursement, the HIT committees, alternate practice models. Her message to us is to, as a section, is to communicate about the work that you're doing with telehealth to others so that others understand that telehealth really is part of emergency medicine. You know, we don't, we don't call it, you know, computerized banking anymore, we just call it banking and so telehealth and emergency medicine is no different. It's not telehealth emergency medicine, it's just emergency medicine. So, and the more we talk about that and the more people realize the use cases and how we can improve our practice, help us with our careers and longevity and improve the care that we give our patients, the better off we'll be overall, so appreciate that. And again, she extends her apologies for not being able to be here today and I'll turn it back over Dr. Hayden.

- Thank you, all right, and now I'm actually gonna pass the mic to Dr. Joshi on her updates on the council update.

- Thank you, thanks everybody. I'm glad to be here. This is my first year as your councillor. So we met up this weekend and I have a couple of updates. So first I'm going to say that Dr. Baker's been very generous about the discussion that was happening. So just as a a bit of a background, there was a resolution about having onsite physicians be the standard and that the gold standard is emergency medicine physicians. But you know, obviously that's not always reality, but there should be a physician. And so we thought that the other opportunity here is to discuss having telemedicine as a provider to provider consulor for maybe a physician who wasn't emergency medicine, the way that we think about telestroke. So that was our intention. I will say that that is not what happened. There was a bit of misconstrued, it was misconstrued. They thought that we were saying that we did not want any physicians on the floor. So it did not go well I'll say but, so I wanted to let you know that. I just wanna also let you know that I would never on behalf of the section or myself ever advocate for not having a physician in the emergency department. But our goal eventually was to try to think through how do we help out those physicians who don't have emergency medicine training and be able to give them support and telemedicine being one of the avenues. We're hoping that next year or in the future we can have a better, more broader discussion and maybe clear up some of these misconceptions because it doesn't seem like we got there unfortunately. I know that many of you have been in this section for a long time or even if you're new, you know, that telemedicine is still a bit new. But it turns out there's still a bit of work to do to figure out how to communicate with our colleagues and figure out the right way to figure out that balance. So we'll see what happens next year. And aside from that, I'll say that most of the resolutions that were out there, there weren't a lot that were really on telemedicine per se. And so as far as that was concerned, we were just part of there. We were voting but we did not have a bunch of other things to discuss. And then as mentioned, what we did vote on and is very exciting was the election. I'll go through the other candidates as well, but as everybody knows, Dr. Haddock has been a our board liaison for years. And so it's with great pleasure that she won and is gonna be our president-elect, that's very exciting. Some of the other winners, just for you guys to know. So our new speaker is gonna be Melissa Costello, so she'll be that next year. The next vice speaker is Dr. Michael McCrea. And then we also voted on four new board members, or actually some of them were incumbent and that's going to be doctors Abhi Mehrotra, Henry Pitzele, excuse me, Chadd Kraus and James Shoemaker. So also I would say, you know, generally we've actually had resolutions in the past almost every year. This is probably the first year we didn't have any. So if anybody does want to work on them, especially help clear up some misconceptions that we might have restarted this year, please let me know. I'm happy to work on any of them with you, whether it's something that's important to you, it's important to where you work. This is especially true if you're in a place that is maybe critical access or a rural hospital or a place that we really don't have as many resources, we'd definitely like to hear about it. So thank you, I'm happy to take any questions about this or what happened also in case there's all rumors flying about

- [Emily] Dr. Joshi, can you also speak maybe briefly, I know if someone has a question, I wanna make sure they get that opportunity to ask that one. I also was hoping that you might be able to just throw a little bit in about your role now having the emergency medicine voice with telehealth at the AMA.

- Yeah, so first of all it's not actually telehealth. So in the last year, you know, ACEP has been advocating to get more emergency medicine physicians on various other committees around. And so I applied and was successfully added to the DMPAG, which is a digital medicine payment advisory group at the AMA. And what they do is they basically look at any of the digital medicine pillars and try to determine what kind of coding, billing and how do we think through that process of creating that. So I will say they didn't create the telehealth codes, but they do re-look into it, try to determine if any changes need to happen and then maybe they edit it, they bring it back to CMS, we go for comments all over the place and determine like how do we change it. One thing that's happening right now is we're actually changing the RPM codes. I'll say that it's great to have someone from Emergency Medicine because a lot of the codes and the way they're written don't really take into account the acute unscheduled care that we do, this is very true for RPM. For example, had there maybe been a voice for that, we may have been able to bill for some of the Covid devices and pulse oximeters at home that we were monitoring people through covid with. But the way that it's written, we can't based on the timeline. But going forward, I'm hoping that with my voice we'll be able to change it. I should also just say as a caveat, I am not there on behalf of ACEP, I'm there as myself, but obviously I'm emergency medicine so I take into account any of that. They're very clear about that. This is not an ACEP position, this is a just a individual position. But, of course, if anyone has input or interest in that, please let me know. It's actually, of all the things I do, I feel like this has a lot of impact for us as a specialty and for digital medicine in the future.

- Awesome, on that I guess any questions you have for her on maybe either of those and we also have the open networking session, actually you're not there in person, so that'll be a little harder. We can connect the two of you somehow if someone had questions. But right now if anybody has questions, please come up to the mic regarding council or otherwise

- [Michael] About council comments, experiences that you saw at the council meeting You know what? I will add that, you know, I was impressed that Dr. Becky Parker also spoke and made some of her thoughts available to the council at the council floor as well. She made an amendment to one of the resolutions that was there that really got a lot of conversation going about telehealth and its role in, you know, these smaller emergency centers that may not be staffed with board certified emergency physicians and may be non-board physicians that may be PAs or NPs. And so I think that the, the way that conversation went, my recollection was that initially everybody was sort of like, well, you know, the gold standard is that we need to have an emergency doc in every ER. Great, we agree it's been 55 years. How when will we get there? How will we get there? And I think at this conversation that we had at council really helped some people start understanding, oh wait a minute, maybe there is a way we can get there and maybe there's a way we can get there and preserve jobs for emergency physicians in terms of making new opportunities for them. So I really appreciate the opportunity for us to have had that discussion on the floor. Obviously we weren't expecting to have ACEP do a complete 180 and all of a sudden say, oh my goodness, you're right, let's all have telehealth everywhere. But at the same time I think we got the message across the minds that needed to hear it so well done.

- That's true, I will say that I always forget that sometimes you're not gonna hear the most vocal people are not necessarily gonna be the ones that talk about or who need their minds changed, right. Maybe enough just bringing that idea forward. It didn't feel like that to me, but I appreciate it, Mike.

- [Emily] Oh, I see someone coming to the question there, yes..

- [Frank] Sorry, Aditi, it's Frank from University of Pittsburgh. How are you?

- Frank.

- [Frank] So one of the things that kind of resonated with me and I apologize 'cause those of you know me know that I've just been the horse I've been beating to death for a long time. But, you know, as you look into these structures that will allow physician, physician or clinician and clinician consults, you know, absolutely, totally agree where if you have a non-board board certified physician or if you have an APP that is looking for telemedicine assistance from, you know, from a board certified emergency physician, that's absolutely a great thing. The other thing I would, other instance I would consider that is in the same vein is as we, you know, develop these regional hegemons and these larger hub spoke models for care, the upstream management and transport medicine components are really important as well. So it may be a board certified physician in a critical access or rural hospital that needs to transfer a ordinary care but it may be a very complex patient where a telehealth consult could benefit that patient and the physician.

- Thanks Frank, absolutely agree. I saying that we'll have to figure out the billing, you know, I got follow up questions from people who didn't understand he would bill for it. How do you make sure the, there's no EM multipliers and I think these are all solvable. We've all had these discussions, absolutely. But these are gonna be the ones that... Well, these are the questions I've heard, which at least tells us we've taken a few steps forward. It's not what is telehealth and how's it gonna work, it is all these practical questions that are coming up about how we're actually gonna do it. So I think that's true and I'll just say Frank, I know for a long time and he's been really, really instrumental in getting some of this work done. So, and I thank you for the question.

- [Frank] Yeah, sorry, I was just gonna say too that, you know, in system we've been able to figure out ways to bill it as a consult, but I don't know how to do that. You know, there's no structure to do that outside of your health system.

- [Michael] Yeah, it is a bit interesting that emergency medicine is one of the only, emergency medicine is one of the only specialties that you can't actually bill for consulting emergency department.

- [Emily] Someone else is coming up, all right.

- [Mike] Hey Joshi, Mike Ross here. I'm sorry I was not in the council meeting but I just have to ask, last I checked, I think there's about a thousand critical access hospitals in the US there about 25 beds or less. So I don't see how you could possibly staff all those hospitals with board certified emergency physicians and with the new CMS designation of a rural emergency hospital, which is basically an ED with an S unit, it seems like that's perfectly suited for telemedicine. So how did that, I'm kind of dumbfounded by the resistance setup here that hit from the council.

- Well, let me just clarify that the problem was that everybody thought that, I was saying that instead of any physician that we could use telemedicine with an emergency physician to oversee PAs and NPs, whereas their absolute minimum was a physician of any sort. So there was a bit of miscommunication. I absolutely did not mean that. I meant that if you can't have an emergency medicine physician, but if you have a family practice physician, you could use a telemedicine emergency medicine physician to improve, to like increase that consult for certain areas. That's what we're trying to get across basically, is that there are other avenues to get emergency medicine physicians into emergency rooms if you can't feasibly get them in person.

- [Mike] And and speaking to the intent of the original resolution, Is that on?

- So just speaking to the intent of the original resolution. The original resolution was built upon something that occurred in Indiana where they developed a model legislation to require a physician at an emergency center rather than just having a staff by a PA or nurse practitioner. So the resolution had two parts to it. One was to require a physician at every emergency center. The second part was what is the gold standard? And so one of the challenges that we were concerned about that we tried to express on the council floor was, was simply that we should be advocating that we could have an emergency physician in every department. That we shouldn't just set the gold standard as only a board certified emergency physician on-site at the bedside, but rather the possibility of having that tradition be there virtually as well. So that was the opportunity for the discussion. We didn't want the resolution to close off the possibility that telehealth and telehealth consults with board of emergency physicians would be something ACEP would support. And so I think that's where I think we succeeded in getting them to think about this other possibility. Because when they first started the conversation, everybody who stood up to the microphones, their first thing was a board certified emergency physician is the only person who'd be seeing emergency doctors and emergency patients and emergencies. And if it says emergency across the top, there should be an board of emergency physician there. We agree, how do you get them there? That's the question. Yep, exactly, so good, good question, thank you for that. Any other questions, statements? Alright then, thank you Dr. Joshi-- We'll try again next year, thank you guys.

- [Michael] Yeah, thank you for all your work, appreciate it.

- Thank you, all right, next on our list is going to be a regulatory update by Ryan coming up here and I will get slides up for you Ryan.

- And apologies to everybody on the call for the unfortunate angles we have for the camera.

- One moment here, I'm just trying to get... It'll just take me a second here, sorry about this.

- And then my colleague Fred Estes is in the back as well. He's one of our other lobbyists in the DC office. If there's a signup sheet in the back or sign in sheet as well, if everybody could just fill that out so we know for meeting attendance for minutes purposes, that would be very helpful. Fred, if you wouldn't mind passing that around to folks.

- [Michael] Can I just add also on the sign in sheet as it's going around, if you have like a telehealth like project you're working on or something of interest, please add that too besides your name. So we kind of get an idea of what everybody's up to and what everybody's doing, would be fantastic. Kind of understand what people are, you know, what people's experience are. And if you, if you're just interested and don't have any projects or experience, that's great too. We'd love to have you here, that's what this is all about.

- Perfect, okay, so I know Dr. Hayden said regulatory update, but I'm the legislative affairs... I'm the congressional affairs director for ACEP. Regulatory is not my strength, that's why we relied so heavily on Jeff Davis who left us for McDermott plus. However, we still just constantly flood him with requests on the regulatory things and I probably make him work harder than he did before. So again, if any questions I can probably refer to him, but we'll go ahead and get started here 'cause again, there's both legislative and regulatory actions that are, I think coming down the pike for anybody involved in telehealth. So there we go. Since the last time we talked, as many of you are probably already aware, there were a lot of the Covid-19 related public health emergency telehealth flexibilities that had been tied to the end of the public health emergency. So a lot of those were tied to a 151 day after the end of the official end of the public health emergency. Some of those were explicitly on the end of the public health emergency, the Consolidated Appropriations Act of 2022. This omnibus spending package that Congress passed in March, 2023, you'll notice that it was a little bit delayed for the fiscal year there. It did extend most of those flexibilities to 151 days beyond PHE. The Consolidated Appropriations Act of 2023, which passed at the end of last year, extended a number of provisions through the end of 2024. So December 31st, 2024, we got a two year extension for a lot of the sort of core key provisions. And I can go into those on the next slide. So again, two year extension, so among the highlights, again, things like removing geographic requirement and originating site requirements for telehealth services, expanding the types of providers available or practitioners eligible to furnish telehealth, FQHCs rural health clinics. Again, some of these allowing for the furnishing of audio only Telehealth services. Again, that's been a little bit of a divisive topic within the larger house of medicine. You know, ACEP has generally been on the side of pushing for, you know, not having parity for both, for audio only versus video as well. You have organizations like family medicine and some of the primary care specialties that have pushed for those audio only, that has still come up a lot in debate, at least in terms of congressional action and what some of those groups are pushing for. You know, the argument is that you have a lot of those provider types have high populations of seniors who are not necessarily as comfortable with video and those kind of things. So they're more comfortable just making a phone call. So again, that's still sort of floating around as we look towards long-term extensions of telehealth policies. And finally, there was a study on telehealth and Medicare program integrity. One of the big challenges that there has been in an congress, or at least at the federal level adopting telehealth, has been the concerns about cost and utilization. The way that the congressional budget office scores legislation, they assume generally it feels like they always assume that utilization is going to skyrocket and increase utilization means increased cost to the Medicare program. However, I think the data that we have seen that it is available is that again, it increased access. It's not necessarily a different type of healthcare. I think as Dr. Baker was saying earlier, it's white. We don't call it... What was your, what was your term you used? We don't call it the... Yeah, anyway, we just, we don't call it telehealth, it's just healthcare, right. So anyhow, that study is ongoing and will be part of any efforts that congress in the future does in terms of making these extensions. Either extending amount, again, sort of punting, kicking the can down the road. They love doing that or making a lot of these policies permanent. I think the big lesson that we have learned, and I've heard, and I know Fred has heard from legislators like, and I think that the indication from the administration is that telehealth is here to stay, you know, the cat's out of the bag. And I think that legislators in particular and regulators are more comfortable with the concept and we'll see a lot of these things, the ball started to move I think, next slide please. Another provision that wanted to flag here was as well is there was an extension of the safe harbor for the deductibles for telehealth. Essentially, there again, there's a two year extension of the flexibility allowing employers and plans to provide coverage for telehealth for individuals with high deductible health plans coupled with a health savings account. The reason this has come up is we actually just signed onto a letter, but if we go onto to the next page, or iI think I have it somewhere else. Some of the things that were not addressed in the Consolidated Appropriations Act. Licensure waivers for, again state licensure face-to-face evaluation requirements prior to home dialysis. The hospitals without Walls initiatives, enforcement discretion for types of platforms that practitioners can use. So things again, like Skype, FaceTime, ability to use those has expired as well. There were some issues with controlled substances telehealth prescribing that were not addressed. Reimbursement of Medicare telehealth services and direct supervision. And finally, telehealth as an accepted benefit under ERISA. So looking forward, included this slide here. This is actually a letter we signed on today. And not just to pad my presentation, but to act something that we support. There is a piece of legislation called the Telehealth Expansion Act of 2023 that would again align those, the deductible provisions with health savings for high deductible plans with health savings accounts to the end of December 20, 31st, 2024. So we just signed onto that today. As far as regulatory updates go, there were, again, there was broad waiver flexibility for controlled substances prescribing, even for initial encounters under the public health emergency. On February 24th of this year, the DEA issued two regulations that we had been anticipating. So one was for controlled substances and one was specific to buprenorphine and there was a lot of consternation from stakeholders generally, you know, why did you have to split these two? That's part of the problem we've been trying to address for years. There's no reason to address these. We did submit a regulatory comment letter in response. We focused most of our comments on that buprenorphine rule. But again, there was a issues with the DEA regs because they actually came out as significantly more restrictive than what were actually in the public health emergency waivers. So we, our issue and many others was that we're taking a step backwards here, but again, I think that's also emblematic of the DEA's approach on a lot of things. But in October 10th, so two days ago, right, yesterday? Yeah, no, yesterday, DEA combined those regs actually into a temporary final rule. So they've listened to the stakeholder feedback, we have just one final rule, it came out and it does sound like they made some of those changes and made them more flexible than what was originally proposed in that regulation. So a victory that we have there. Yeah, and again, that's just the rule that came out and that is also retroactive from May 10th of this year as well. And again, extends this flexibilities to align everything to December 31st, 2024, next slide, perfect. Another regulatory item that we've been keeping our eyes on is that in the physician fee schedule rule that was just released, the final rule CMS is adopting, Centers for Medicare Medicaid services, excuse me, adopting a new taxonomy for telehealth services. So instead of categories one, two, and three, which have been a little bit of a challenge in trying to get services approved beginning in January, there will be just provisional or permanent categories. This is something that we've supported, again, we've had some issues with the category two criteria in particular as I understand it, so this makes it a little bit easier. Again, there's just two types, provisional or permanent. And CMS has indicated to us that they, anything that goes on that provisional list, they assume will become permanent. So that's also a good sign as well. So it's not just a, you know, sort of a crapshoot and maybe we have it for two years and then lose it again, but we should have some certainty. If you get something on the, that's provisional, there's a good sign it's gonna be permanent. Another letter that we also signed on today, again, not just pad numbers here, but there is an issue that CMS has put out. There's probably not as pertinent to emergency physicians, I would imagine. However, it's more one of those that we've, it's more of alignment with the greater house of medicine and other practitioners. There's a concern that CMS is going to require home the publication of home-based locations. So that practitioners would have to report who are practicing at home-based locations would have to report their private residents to the federal government for the purposes of enrollment or billing. As you can imagine, there are concerns about privacy or safety in, in a lot of these scenarios. So we have signed onto a comment letter and again, to push back against these requirements allowing for and for allowing for some sort of alternative ways to sign up that would capture, you know, a residents or geographic regions zip code for purposes of billing and that kind of thing as well. Other than that, oddly enough, you know, there's not a whole ton of regulatory action that we're still anticipating other than those. A lot of the what's, you know, what I think is next on the agenda is legislative action. It's really gonna come down to Congress's role. The feedback that we've gotten from a lot of the congressional agent or the administrative agencies is that we've extended about as much of our authority as we can, what we believe we can do under our regulatory authority. We need Congress to act. So that's the message we received. And you'll notice that again, a lot of those regulatory actions that have been taken have extended those deadlines to the same that Congress set in the appropriate in the consolidate Appropriations Act. So everything comes down to that December 31st, 2024 deadline. Again, it's a good thing because that way we're not dealing with a multiple sets of deadlines for bits and pieces of telehealth policy. It's always easier when we've got one thing rather than, you know, sort of a shotgun approach. So anybody who's paying attention to Congress right now, you probably know if you're checking Twitter, you probably know more than I do in the last hour. But a little bit cheeky it's a good question as what can actually happen. If you can go to the next slide, Dr. Hayden, we talked about this last year as well, I use this phrase a lot and there's nothing Congress loves more than deadline and the fact that that deadline is 2024 and not 2023 means that they don't have a whole big sense of urgency right now. And again, given some of the uncertainty with the Speaker of the house being vacated for the first time in history, we are in uncharted waters. And even things like keeping the government funded under continuing resolution are sort of under question right now. So again, it's a good thing that we have a little bit of leeway and we have some lead time on getting things done before, that we don't have to do it at the end of the year. You know, I think there may be, again some work at the fringes. You may see some smaller bills that go through Congress to address some of those things that were left out from the previous bills. But other than that, I wouldn't anticipate a whole ton of congressional action on telehealth until the absolute last minute when they try to cram thing everything together in a year end package at the end of the year. We call it the Christmas tree package where everybody gets their presents, so. Happy to answer any questions, but my email is rmmcbride@acep.org. Please feel free to shoot me a note anytime. And then I've also included Erin Grossmann, who's our new director or manager of Regulatory and External Affairs. She handles all the comment letters to federal agencies. So things like CMS DEA when we have more comments, she's the one who works on those. Fred and I work on the legislative approach, but obviously everything that we do rolls straight into the regulation implementation stage. So we work very closely together. Dr. Hollander, please.

- [Judd] So I just sort of have an asked, I mean, one of, one of the problems we all have with this legislation is it carves out, you know, people with two left eyes and one thumb they could get telemedicine if they live in a rural area.

- Yes.

- [Judd] And what we, I'm gonna say do wrong, although it's appropriate for us is ACEP lobbies on behalf of emergency physicians, which leaves social workers to lobby on behalf of social workers and cardiologists to do that knowing that we really do have a year before anything gonna happen. Maybe we could just all get our act together and go in together rather than pitting one specialty against another 'cause nothing's worse like neuros stroke is okay, but where else do we have geographic restrictions, right? It doesn't exist anywhere else. So I think if we could agree on a big package of priorities across all medical specialties, we would be better off than if we each just fought for our own thing. Because having the rural group fight to do it in rural areas where we have trouble in urban areas, it just doesn't make any sense to me. So something for ACEP board to think about.

- Certainly, yeah. And you know, to that point, that's why some of those letters that we posted there, those are large sign-on letters, that's part of a... Those came out from a group that we're part of called the Alliance for Connected Care. So we do have all of our asks on the same page. Again, having worked on the hill, I can tell you there's nothing that legislators hate more than when everybody's telling them, you know, there are bits and pieces and nobody has... We're not singing off the same song sheet, right. So we do try to do that. and I think, again, those large provisions that we're passed, removal of geographic originating site restrictions, those are the low hanging fruit. I think that's the thing that everybody agrees on, generally. I think you saw from the responses to the DEA's rules that came out, everybody was on the same page and that had a positive impact. So you're absolutely right. I mean, once as long as we have a sort of coordinated ask, we do try to do that as much as possible.

- [Michael] Ryan, would you say that the kicking of the can down the road to 2024 in some ways represents them actually listening to the feedback they've received and trying to incorporate what to do with all that feedback because they're sort of taking some of the things that we sort of have in place right now and saying, well let's just continue that while we kind of figure out exactly how we're gonna make this move forward.

- Yes, and I do think that they've incorporated a lot of that. I think part of it is also due to the fact that they wanted more data to be able to justify extending these things or making them permanent down the road. And then also to be able to get a better estimate of the costs, particularly outside of a public health emergency, to understand sort of the... Hopefully we don't have a, you know, world upending global pandemic every other year or so. You know, when things do get back to normal, we have a better understanding of how telehealth is used in a more everyday operational approach. Again, I think a lot of it really does come down to cost 'cause that's the bottom line for anything that Congress does. And so they want some more data on that. One thing that always comes up too is you have legislators who are concerned about misuse or fraud and they want to see, you know, more of that that, you know, it is something I know that we've probably all seen reports about, you know, some particularly egregious actors, right. that always gets people's attention, especially on the hill. You know, it's not helpful for the 99% of people who are doing it right, but that is something that grabs the headlines and grabs legislators attention. So that's something they want data on as well. I do, I again, I think the overarching message we've heard from people on Capitol Hill through from staff and legislators alike is that, again, telehealth is here to stay. It's in what form and how expansive is it? But I think, again, it's more likely to be more expansive and and just be a part of healthcare rather than thought as something different.

- [Michael] Ryan, can I ask, is there any sort of way that our section members can sort of stay in touch with what's happening in the legislative regulatory arena with ACEP? Is there any kind of network maybe that--

- Yes, We do a weekly newsletter called The 911 Network newsletter. It's an update of legislative and regulatory updates, things that we work on every single week. And again, great segue, we put that out again every week and we provide updates basically, you know, if there are congressional hearings or if there are bills that pass that we care about, anything related to emergency medicine that's relevant and then links to letters we send to Congress and to federal agencies as well. So that goes out, it's The 911 Network newsletter. So please sign up for that. And then also, again, you can feel free to email me or call me anytime. I'm always happy to answer any questions and appreciate really any insights that you all may have as well.

- Yeah.

- [Section Member] I dunno if this is getting a little bit too into the weeds, but I don't think I saw it in your sites and it's been mentioned somewhat before about, you know, it sounds like there was some debate the council about, you know, provider-provider consultation for between docs, between ED providers. But what about from, let's say rural ED doc to the primary care center that's maybe not in in your network or health system, but not necessarily to talk to the ED doc but to talk to the neurosurgeon about, you know, does this stable head lead really need to be transferred or this stable head... This maybe an unstable head lead, you know, if we're gonna transfer them plus the best management route, that type of peer-to-peer or provider-provider or consultation that--

- I wouldn't say that it comes up specifically at least in the conversations we've had with legislators so far. I think that's broadly the intent, right. We want it to be just another tool in the toolkit to be able to facilitate any interaction that's necessary. So I think that's our sort of general approach if that helps, but we'll keep in mind too.

- [Emily] All right, well thank you Ryan, really appreciate it. And maybe, I'm gonna be pulling together an email to send out to all the section members and I will put in that link for The 911 for the regulatory information, so.

- Thank you.

- Great, thank you, all right, so what we're gonna be doing now, and I'm gonna have to ask those on the ground there if I am doing correctly, my math counting, it looks like is there 14 out there in the audience or is there maybe more outside of the view that I actually have right now? Everybody look around. Someone just gimme a number.

- [Section Member] 18.

- [Section Member] 18.

- 18, all right so great, so what we're gonna do is all 18 of you are gonna speak and yet if there's a microphone that actually can be handed around, what I'm gonna do, lemme pull up my thing. So everybody likes to have the thing we're going do basically introductions. 'cause what I'm gonna do after we do very quick one minute introductions, we are going to, let me get to the slide here, bear with me everybody. I had this and then I had to take it off. Okay, here we go. So we're gonna do from this slide, so we're gonna do introductions and what it's gonna be, it's gonna be quick. So we have 18 people, we're gonna do this in 18 minutes, all right? So it's gonna be like the one minute elevator speech and even less if you want to, we're emergency medicine. It could be 10 seconds if you wanted it to be. But basically your name, where you're coming from and your telehealth back background and or programs. And the reason of doing this is one to just put a face to the name and I know some of you know other people and you know what people are doing. But I'm gonna open this up right after our 18 minutes or less of this to have some networking session for everybody to sort of mingle there and sort of ask questions or get to know more about the different telehealth programs. And so this is the way to sort of a version of speed dating where everybody hears what everybody's doing and then we're gonna let you scatter for like 15 to 20 minutes after this. So if we can have, I think yes, Dr. Baker has there, so if you wanna just hand it to the first person. You guys are just gonna move it around and I asked you please use the microphone only because those of us, there's several of us on the zoom we cannot hear otherwise, so.

- [Sandy] Good afternoon everyone. Sandy HoHoku, I'm a resident over at the University of Buffalo, just generally interested in the state of telehealth and wanted to drop into the meeting to see where we're at, pleasure meet everyone.

- [Michael Cuba] And I'm Michael Cuba. I'm the service line chairman for emergency medicine in Ochsner Health, based outta New Orleans, Louisiana. We have a bunch of different initiatives and mostly tele-triage with a lot of nursing tele-intake so we can do the the front end as well as disposition with virtual nursing to try to help augment our staffing. Quickly just two interesting things and I'm being immersed you, I work with the hospital system in Mississippi that has PPS that are remotely managed, not by my ER doc. So it's like not my comfort zone, something I'm learning, I'm being immersed in. So it's becoming very important to me. And the other thing was what you mentioned about, you know, at Ochsner we have a robust patient flow center and so we have a pilot, a physician and lead of triage or of transport. And so from our outside facilities and our owned and operated facilities, a lot of great data on our and the number one, if the transport happens, of course in in three hours or six hours, the improved outcomes. But even when we miss our times, if the pilot's involved, especially from our outside facilities, the it's like 0.3 drop. It is really significant the impact of us talking with outside, you know, maybe not as trained clinicians.

- [Neil] Hi, I'm Neil Sitka. I work at George Washington University. We primarily for a long time have had a maritime telemedicine program that's kind of our core business that we provide services to most of remote austere environments. We are doing some research related to the use of augmented reality and remote training. So being able to potentially one day supervise less experienced provider through a complicated procedure using moment augmented reality. And we are also working quite a bit in this space of digital health literacy, trying to help improve patient access and comfort with using technology to interface with the healthcare system. And we have two two fellowship programs. One is a wilderness telemedicine combination program and a telemedicine digital health fellowship program.

- [Kathy] Hi everyone, I'm Kathy Lee. I am coming from the University of Washington in Seattle. I am actually a health services researcher by training, but a lot of my research focuses on telehealth and how we can optimally use it to improve access to emergency care and kind efficient care delivery. So both looking at looking potentially teleemergency care from the standpoint of like maybe seeing patients and keeping 'em out of the ED if they're lower acuity as well as telemedicine for to improve transfer coordination. So if you are a site that has a lot of data and you're an operational person that doesn't really want to analyze the data, hit me up.

- [Col] Hi, I'm Col Hood. I'm also from the George Washington University. And not to repeat myself, but I helped Neil with most of the programs that he discussed, remote events and maritime telehealth. And we even had a small teleurgent care work point to.

- [Frank] I'm Frank Ian from the University of Pittsburgh. And we have a telehealth program that is primarily based on retrieval. So based on critical care transport out of hospitals to tertiary hubs, similar to Neil and the GW folks. We do telemedicine for commercial airlines as opposed to the maritime industry. So we do a little bit of direct to consumer and a little bit of clinician to clinician and we build ML algorithms for decision support, which we hope to integrate into telehealth as soon as somebody figure out how to regulate that.

- [Josh] I'm Josh Reynolds from Michigan State in West Michigan, Grand Rapids and this is my first time in this section meeting and curious to hear what others are doing. We are exploring some novel applications in terms of evaluating patients while they're sitting in the waiting room, potentially moving towards a disposition while they're the waiting room and looking ways to keep people outta the hospital. At most, also, Michigan State, same interest, same projects. My best Merv Griffin impression for those of you that are seasoned after your call.

- [Section Member] Very good.

- [Ethan] My name's Ethan. I'm a health policy fellow in county where we have a community care medicine program that I helped start like a decade ago thinking about ways we can do more mobile integrated health with that program.

- [Paul] And Paul Hudson, the chief operating officer for STATUS Health Partners. We staff about 40 critical access and now one rural emergency hospital. So we're consumers of this in the sense that the use case that you demonstrated where the emergency physician is family medicine trained for the most part and collaborates via telehealth with the emergency medicine physician.

- [Mike] Mike Ross from Henry University in Atlantic, Georgia. I'm chief of service for office mason medicine firm, healthcare director of telehealth for the Department of Emergency Medicine. We kind of developed a full spectrum telehealth service with pre-hospital tele EMS for TeleCritical care to about 75 cases. We just four months ago along launched direct to consumer nurse call line driven tele-emergency medicine, but a lot of covid cases, but it's kind of lower acuity cases. We've dabbled in in teletriage during the pandemic with running orders and seeing patients with variable success. But our biggest emphasis has been tele-observation or we staffed two of our observation units virtually. We're about to staff two more. Finally, were involved in a a disaster grant, have tele preparedness for disaster training and developing the observation units for disaster preparedness

- [Ed] Ed Barthell, emergency position from Wisconsin and been involved in a lot of informatics projects for the college over many years. More recently, I'm leading a company called EmOpti that does telehealth for, to support hybrid care models. I think the thing I'll plant a seed for here is I think we're talking a lot about hybrid care models in terms of people helping that are maybe remote helping onsite staff. And I think it's gonna be very interesting and I just heard about first word AI that has everybody's hair on fire. I think it's noting to be people remote, but machines that are actually helping with these hybrid care levels.

- [Judd] Judd Hollander actually from the building connected to this building at Jefferson, kind of stinks having ACEP in your hometown. But aside from that, so we do sort of everything and I run the telemedicine program for an 18 hospital system with you know, 40,000 employees. But, but the coolest thing we're doing right now is, I got nurses, believe it or not, at different hospitals to allow us to randomize rooms to get audio, video, telemedicine capabilities. And so we're actually doing a real randomized control trial of inpatient telemedicine where one is an academic medical center where we'll use it probably more for tele-observer and tele-sitting and maybe some consults and maybe clear some people out on the weekends. And one is a community hospital that transports anybody with any degree of acuity for a consult somewhere else at a cost to Jefferson. So they will probably bring the consults in. And so we'll combine these things with for a real RCT and I was like blown away when I said to the nurses, I'm like, "It'd be way more useful if we could randomize people." They're like, "Okay." So we actually will install it in some rooms on some wards and they'll staff the nurses accordingly so we can do a really good clinical trial of something in I'm teleheath.

- [Tony] Hi, Tony Fabiano, I'm a fourth year resident at the University of Cincinnati. I'm about to contract fellow next year. So just kicking off my career and getting started in all this.

- [Christopher] Christopher Alban from Epic. I am a media . My job as I run the list. It's that there's a bunch of Epic customers here and we try to stay as much as we can on top of what you're all doing as well as all the regulatory stuff just to support all the stuff that happens. Something happens in Epic, some doesn't matter. We're just trying to stay on top of it and learn as much from you guys to as we keep up with the development to support as much as can be done in there. So appreciate everybody's feedback.

- [Andrew] Good afternoon everyone. I'm Andrew Underhill. My accent is different than everybody here I think so far. I'm originally from Ireland, spent the first 27 years of my life in Ireland, but I'm now based in Melbourne, Australia for the last 15 years. I'm an emergency physician there and why am I here? I'm director of the our virtual care emergency virtual care program at the Alfred in Melbourne, which is a large tertiary center. Why I in Australia at the moment and is that or why am I America at moment doing sabbatical here? Looking at various different clinical models of telehealth care just to understand and see what the innovation is of spending some time here next few months. I'll be here since September, spending some time up in Boston with Dr. and we'll be reaching out to a couple of you later over the next few weeks. And then I'm going over to Europe to spend some time there, some their models as well. What we've been doing in our space in Australia. It really, again, like here, I guess it's still a very rapidly evolving area. I'm part of the network for the Australian College of Emergency as well on the executive network. At my institution, what we're doing, we're looking at a lot of it's been reading clinician to clinician provided care, secondary consultation. So we've done a lot of work in the state of Victoria on, I guess what you call ET3 model and we've got a lot of experience with that now that's really working quite well. There's been some policy changes on how it's gonna be run, but it still will continue to run, which is good news. I had a lot of them just published a health echo paper on that and success of the cost savings for the health system. So we've been involved in that. We're also doing a lot of work at the moment in terms of secondary consultation support for remote and regional urgent care centers across states. That probably kind of resonates with a lot of those here we've got states which are, you know, got a maybe one large urban center than a lot of very rural areas. So for particularly for the state of Victoria, which has got geographically it's about the same size as Great Britain, most of the populations condensed into to about 5 million people and then 1 million people scattered across a huge regional area similar to I think someone said about getting emergency decisions into every urgent care center and every ED in Australia. Again, probably waiting for the same thing. We're very well oversupplied on the urban side and then remote areas again that kind of ongoing challenges. But we're having a lot of good success in supporting a lot of these urgent care centers are often just nurse practitioner led and really being able to, you know, give more, I guess you know, better qualitative and more expertise in terms of whether someone needs to be transferred out and whether she can remain in site and support family care providers in those areas about what next steps should be. So looking forward to networking and chatting to you everyone later.

- [Ryan] Thank you Dr. Hayden, that's the room, I think. Anybody I missed before we move on? Oh, one more, sorry and then we'll move on to the virtual people.

- [Fred] I'm Fred Essis, congressional lobbyist with the American College of Emergency Physicians. Someone would say I'm the second best lobbyist here at ACEP.

- [Ryan] All right, I think that's the room now. SI said virtual people, the people are not virtual, they're just virtually here, I suppose.

- Yeah, why don't we start, 'cause we've also had a couple of these, why don't we... Dr. Landry, do you wanna introduce yourself there? I see you on video.

- Hey, good afternoon everyone. Dr. Kim Landry here based in Pensacola, Florida and basically I've been practicing using telemedicine for the past 15 or so years. I'm an EMS medical director for a large number of agencies and I use telemedicine pretty much to keep a lot of patients from being transported to the hospital when they dial 911 and our EMS crews arrive on scene and recognize that the patient does not have a real serious problem, but in fact may can be treated in place. So it's been a very successful program and it's gonna expand given the fact that the majority of 911 calls are not really emergency and can be potentially treated in on scene.

- Thank you. Dr. Darr are you able to speak? If so, just you can come off mute, awesome.

- Sure, I don't know if my video's working. It's really dark in here. I am Carly Darr. I'm not actually with one institution, I am with a private independent group. We staff five URS at three different institutions. We have done a couple of programs with like ET3 EMS at our sites and some tele-urgent care. We dabbled a little bit in the tele-triage during Covid, but it didn't really stick and unfortunately with the ET3 stuff, we'll probably be limited to urgent care after the end of the year.

- Interesting, all right, Sata, you've come on. Dr. Emeli, do you wanna, if you're able to--

- Yes, yes, hi everyone, my name is Satta Massaquoi Emeli I'm y'all's news and editor. I'm working...

- Oh you just actually went on to mute. You said you were working a and then you went on mute.

- Oh, sorry, I'm working a string of nights so I wasn't able to come up earlier. But I work with Dr. Ross and he has done a wonderful introduction of what we're doing and trying to achieve with a spectrum of tele-emergency care here at Emory. And I also serve as everyone's newsletter editor. So from the introductions I heard so many wonderful things going on. We have a section in the newsletter called Voices From the Field, so if anybody's interested in putting down on paper and sharing with the group so we can all learn the lessons and see the wonderful work that's going on, that'd be great, and that's it, yeah.

- Thank you, and I actually earlier, I did plug your Voices From the Field in the newsletter and put your email up there so hopefully people wrote that down. Let's hear, I think that's everybody who hadn't been introduced before. If we wanna speak a little more. So we aditi, do you wanna speak more to what you're doing outside of the realm of councillor position and AMA?

- Sure, so I actually work as a consultant now. I work for various digital health companies, some governments and really looking at how they're implementing telehealth and then also doing a lot of research on digital health evaluation in the market, that's a very brief one. And yeah, so I was at Jefferson prior to that, so I used to work with Judd for about five years and then obviously I had to leave because it's Judd, what can I say? I'm just kidding. I'm just kidding. But yeah, so since then I've been doing this work.

- Awesome, thank you, Aditi And then Dr. Baker, do you wanna speak any more to your telehealth specific rules?

- I've said a lot already, but.

- Yeah, I've said a lot already, But a lot of what we're doing right now has to do with the mobile integrate health and ET3 program working with EMS across the country to try to head off patients before they hit the ER or in many cases try to talk them into going to the ER 'cause we're seeing a significant number of patients that have really terrible disease going on and they're like, no, no, I'm staying at home. You're like, dude, you just fell and you're like on Eliquis and you've got like this big lack across the front of your head, you need to go to the ER. But it's surprising how many of those people are just like, no, I'll grin and bear it, I'll just do it myself. So get stapler out I guess. But yeah, no, that's a lot of what we've been doing is looking at that, looking at those opportunities to really both, you know, take care of real problems before they become more serious and to try to take the less serious problems and keep them outta the ER. So we appreciate that.

- Great. And to finish up Dr.Khakhkhar, do you wanna talk about, if you're able to speak to the, there we go.

- Yeah, totally, we, at Sinai, like a bunch of other health systems had like a duct tape and spit telehealth program that we set up during Covid. So a lot of what we've been doing over the past couple of years has been putting some structure around that actually having faculty work real shifts on telemedicine instead of this like sort of moonlighting thing that we were doing before, building a quality structure, building a bit of a care model so you can order labs and x-rays. We go a little bit beyond just Zoom a doctor kind of stuff. We also have a pretty active community paramedicine program where we had a panel about this, a few different folks I recognize where, you know, I have similar programs at their institution where you sort of have a medic in the home and then you're taking care of sort of sicker high acuity folks. Really great trying to expand that care model as well and grow that, and trying to take a bite out of some sort of value-based care contracts and go beyond sort of fee for service emergency medicine, using the ability to sort of keep high risk folks at home. And then lastly, I lend sort of an operational hand to our hospital at home program and a bunch of what we've tried to do is get good at identifying patients sooner upstream. We've gotten really comfortable, especially at my health system, at taking patients who've been stable for a few days off the floor and sort of completing their hospitalizations at home, but pushing the hospitalists and pushing the institutions to really take ED borders and use hospital and home as a solution to our ED border problem. So it's a bit of a sample of both. I've been working on for the past year or two.

- Great, all right, thank you. So what we're gonna do, I'm gonna do... We're gonna do open networking. I had two sessions for this, I know there's lots of things going on right now. Let's do this open networking, just so we have a chance to connect. We're gonna rejoin onto this to as this bigger group. I hope all 18 of you stay there. I'm keeping an eye on you and then we'll do... Because I really am curious to hear sort of some of the surprising things you might have found out when speaking to others too and then we can probably end a little bit early after that. So end a little bit after four, so please come back. But this is your chance, you heard for those who are virtual, we're not gonna do a breakout room. We can, you can just go off video for a few moments and be able to walk around and then we'll come back at 4:00 PM and then for those in the room chat, that gives you 14 minutes. And so whether catching up with people you already know or with people you don't know. So we will join back again at 4:00 PM Eastern time. So now it's 13 minutes. All right, everybody get up, move around. I, I can see people are sort of slouching so it's time to get up and move a little bit. So, all right, four o'clock we'll start back again. All right, everybody in the room there. Thanks for those who stuck around. It's like 16 seconds left. So if you can kindly end your current conversations and get back to your seats for a few more minutes of us sort of summarizing and looking to the year ahead. All right, I'm gonna go ahead and jump in to the next part here. All right and then I think Ryan, I think the video might be frozen on your phone. Do you mind just double checking that? All right, I'm curious from the networking.

- we're working on it.

- We're working on it. I love it. Any I'm curious, surprises, no surprises, things that are challenges that we need to be looking ahead on? You can just yell out. If I don't hear it, I can have Ryan or Dr. Baker tell me too.

- [Christopher] So hi Emily, it's Chris. The the interesting, just having a real conversation with Andrew from Australia and part of the thing we always about is sure there's the technology so much again and again and it comes up in our agenda. The regulatory, the building, how they vary from country to country is so much a big piece of this. Yeah, we can try to keep up selves with kind of the technology, but man,oh man, only on the regulatory over rises everything and it's different. Canada, it's different in Australia, it's different in England and it's different everywhere we try work on so, heavy sigh. Well, I would say one thing that we probably haven't really talked as much about and that is the ability to utilize telehealth or health platforms such to extend the non-physicians within our emergency centers. You know, our registration clerks make it easier for them by having patient interest and stuff on their own or walking through virtual history taking or triage processes and things like that. And I think that might be something that we'd love to hear more about if anybody's doing those things over time. And we heard briefly about somebody doing virtual nursing programs. I know my own hospital's got some virtual nursing, but they're doing the mostly on the floors, not in the ER right now, but hopefully we can bring it to the ER with, you know, the more experienced nurses being available to help to less experienced nurses and things along those lines. So also things for us to think about, look forward to, especially when we talk about, you know, the systems that we have in place and how the systems can help us do work in addition to the providers, you know, just showing up on a screen by video. Anybody else?

- [Section Member] I've learned my problems are not unique.

- [Section Member] We're struggling with getting reimbursed for pre-hospital MS critical care and largely driven by payer mix and that's really not unique that's an emergency. So if anybody has any thoughts or ideas, it's something that would, I would hope maybe ACEP can take to the payers because we're providing a great service to these critically ill patients. But it's a horrible payer mix and it's kind of a, it's a problem going for a solution.

- Yeah, I think Covid helped a little bit with that. We've got a little experience with payers. Is that off?

- [Section Member] You're good.

- We got a little experience, a little bit of experience or more experience with payers paying for things with Covid. And I think that's what Ryan was talking about before is that, you know, our fear was that they were just gonna cut the spigot off at the end of Covid, the public health emergency has ended, but yet the spigot is still on and it's not even on a dribble. It's still on almost full blast and hopefully we can continue to keep that happening, so.

- Can I actually piggyback on that with what Mike Ross said? Ryan, I'm curious from ACEP side, I know that you work the there on the Hill, however, with the payers, my assumption is this usually is like, well let's try to get whatever Medicare does 'cause payers should and sometimes and usually sometimes do follow suit. But how much does ACEP actually work with payers for the emergency medicine reimbursement?

- You know, my understanding is that we do work with them on these things as well. You know, again, I know we're also used to payers doing the things outta the goodness of their heart and taking up things voluntarily. I think telemedicine has been one of those areas where they've just, they, you know, everybody else was doing it and we'll just keep doing it. So I think we have seen that, again, Dr. Hayden, to your point, a lot of times payers look for guidance from the federal government and that's why it's so important to have Medicare reimbursement for these things. So yeah, I think the fact that a lot of payers have done this voluntarily or have continued to do it, even despite the regulatory changes has helped. And I do know that we've had conversations with some of those payers on some of those things. Another point I also wanted to touch too is, you know, the comment about the different regulatory environments that folks deal with and how challenging that is. You know, a big challenge as well. and I'm glad that, you know, on the Epic front, it's one thing to legislate it and then go through the regulatory process and say, okay, now this is what to do. Then you have to actually implement it. Then the, the platforms have to implement this. So it's not a just, you can't turn the switch on and off. And I think that's one thing that congress and especially the regulatory agencies tend to lose a lot of the time and why it's important to have a longer lead time instead of a three month, four month punt. Because again, you'll have programs that'll say, you know, if there's no certainty, if I know if I can get paid for this in four months, I'm not going... Why it's not worth it to do the uptake, right? So I think that long-term stability is very key and that's another message that we've been trying to get across is that these... It takes a lot of work, it takes a lot of manpower to keep these things running and, you know, it takes money to do it.

- [Judd] So since a Aditi, I don't know if she's still on the phone since she hinted I could be mean, you know, even if it's a joke, maybe it wasn't. I wanna be mean to everybody and I honestly, I want to challenge everybody. We're looking at it wrong. There's no payer in the world that ever said this is a really good idea, let's pay for it. So they will forced to do, but yet our whole discussion is our problems the payers. So Aetna in Philadelphia, which is one of our largest payers, just stopped covering Telebehavioral Health. Now, you might've noticed, or they announced they're going to stop covering, you might've noticed there is a need for behavioral health within one block of the convention center. They just stopped covering Telebehavioral Health, right. This is an issue. So if we're gonna wait for Ryan to make magic happen in Congress, we're gonna be waiting a long time. So I'm saying this 'cause somebody was mean to me and they made me better as a result of it. So I challenge you to, you know, I'll be mean to you the the same way. Second thing is, I was talking to an academic chair and he said the problem with everybody in academics is we all think if we yell louder it's going to change what people do, right? And all we're doing is yelling louder, the payers, the payers, the payers. So the thing that made me change my tune, I was told if you want a program, tell me how you're gonna pay for it with hard ROI, tell me what line is gonna be cut from the budget. Don't tell me you're gonna save downstream money. And I got so challenged, one of my examples was for the program I was talking about was we'll save money on PPE. I knew the exact math. We have 405 patients in the hospitals we're going to who are on isolation. I know how much we pay you, you know, a discounted rate for every piece of PPE, how much PPE it was, we would save two to threefold the cost of the program, just in PPE alone. And and the answer was, "I'm not counting that. I'm like, "What do you mean you don't count it? It's simple math. There's this many people, there's this much PPE, it's $1.05 million." He says, "You are right. Your rooms with cameras will spend a million dollars less than PPE but it's still gonna be purchased and sit on a pallet in my warehouse because supply chain's not actually gonna buy less PPE for the first year or two. So that's not your ROI." So you know, we had to go back to drawing board and eventually we found ROI that he could believe and people were willing to remove things from the budget to make it work and we did it. But until we start thinking how are we gonna really fund this? Nobody's gonna let us really do it and it's just fun and games. There's not a lot of telemedicine programs that have an ROI on demand stuff doesn't, care at home doesn't, Tele-intake is, a shame ED left that actually really does 'cause you get no, no more left without being seen if you're seen right away. But we have to develop the programs that will pay for it in the current environment and stop what the chair said, yelling louder or praying for congress to save us 'cause the payers aren't coming to save us.

- So Judd, before you go too far back--

- [Aditi] Yeah, I just wanna say I was also joking, Judd, I was joking. Judd, a question for you. So we're gonna meet, I think next year's in Vegas. I think we're gonna be meeting as a section again in Vegas in a year. What would be like... What do you wanna see, if you're gonna really push us, what do you wanna see? What do you wanna hear from some of us saying that look and we did this and this is where we're at?

- [Judd] Great, great question, I want people to come present their finances of self-sustaining programs, not pilots. I want people to look at the programs they started and tell us how they funded it with real dollars and cents that, you know, I'll say Emily, at Mass General, I want you to finance people to sign off on the economic model you're gonna present here to say it is real and it's savings and we should start growing out the programs that we can grow out that have a financial ROI and don't require to payers to change anything. And indeed, I was just kidding back to that. Don't, don't feel bad, but I think that would be a cool thing. 'cause there are some programs that have ROI and we gotta start looking and growing out things that you, you know, particularly 'cause most of us are emergency medicine and most of us are just looking at this through emergency medicine. But most of us probably would like to have a larger institutional role. You find a way to make telemedicine have ROI, you're gonna have a larger institutional role running telemedicine. So I that I think that would answer that. that's what I would say, Emily. I'm sure there's a million other things, but that's the way I would look at it.

- Thanks.

- [Section Member] I was gonna say, you know, unfortunately, like some of the... When we think about the economics in demonstrating ROI, some of the levers for and incentives are just completely backwards from what we want 'em to be, right, and and this is particularly true for tele-EMS. You are taking money away from the hospital by diverting the patient. It doesn't matter that you're solving boarding problem or that they can't... The hospitals don't actually have the capacity to treat the patients in the first place. But you are decreasing revenue and you're a threat. So if you present that, oh, I can keep these people out of the hospital, your CFO is not gonna be happy about that. And and unfortunately until we change the incentive or reframe that, we're not gonna have any purchase with the finance folks.

- [Section Member] What else?

- [Section Member] Good.

- All right, If there's anybody else speaking right now on this stuff, I'm gonna go ahead and move along 'cause I know there's a cash bar maybe. Maybe that's the next networking thing. Maybe one of you can buy for everybody. But let's see here, so just looking ahead, just remember that we have our monthly speaker series every second Tuesday from 2 to 3:00 PM Eastern time. Our next speaker's gonna be Dr. Kelly Rhone, She apologizes, she wanted to be here, but she is wasn't available to come to ACEP this year. She's the chief medical officer of Avel eCare, formerly Avera. And she's gonna speak to us about sort of the newer things that they've been doing there in South Dakota and where they reach quite far from there. And then some of the other speaker topics, Dr. Baker mentioned this too, the idea of the tele-nursing. How are we using this in emergency medicine or how could we be using this? The healthcare at home models. and while we've already had panels on hospital at home or acute care at home, I think we also heard at one of our sharing sessions, one of our members had spoken about models where there's actually dispatching APP, sorry, non-physician providers or nurses out in Ubers to provide care for patients, be able to do telehealth that way. So hearing more about models for that, tele-sitters, tele-triage, tele-PIT, back to what Judd was saying about one of the ones that actually have shown an ROI, Tele-SNFs, AI and telehealth. So Dr. Barthell, it sounds like he left, but also the machine learning pieces and then also question mark of what else might be out there. So if you have of any of these topics listed under other topics that you're doing or you know somebody doing that, please let us know. We're gonna be searching for sort of those key people to be presenting on these over the next year. So that's looking ahead there. Looking ahead at the newsletter. So we did talk about the Voices From the Field, contributions, please email Dr.Emeli, here at Emory at that email address. And then we're gonna continue to advocate for the reimbursement. And also, I didn't get a chance to throw this on here, but we have a year to come back with our financial discussions and showing the ROI for our programs. I take that as a challenge and so I'm already working on how I'm gonna do that, Judd, and then the succession plan. So like I said in the beginning, you're stuck with me. Another year I will be in person next time once I'm cleared, after surgery to actually travel again. But there will be voting. So starting in October of next year, Dr. Michael Baker will be your chair and so there will be a voting a vote then for the chair elect, the secretary and the newsletter editor. So feel free, please email me if you have any questions, if you wanna nominate yourself or nominate anybody else. Sometime over this next year I will start sending emails out and they'll get more frequent once it gets closer to scientific assembly next year. However, just keep that in mind, especially I know there's some telehealth, almost telehealth fellows, some residents, some junior faculty and sort of across the whole board. So if there's anybody interested in serving, in pushing the needle forward for telehealth and emergency medicine, this is one way to do this. And I think the last thoughts mainly, it's a big thank you. And so I realize we're ending early, this gives you a little time to do a little bit more networking. Technically, we are in this room until 4:30. And like I said, I know there's a cash bar somewhere and there's bars everywhere. So please do connect some more right now and then thank you. Reach out if there's any questions, I'll send emails out before the next meeting and really look forward to seeing everybody in person when we're all able to be in person again.