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Transcription:

Katherine: Hi, this is Katherine Steinberg, Vice President for the Center for Payment and Delivery Innovation at Avalere Health. We are here for one of our digital health podcasts. In this podcast, we’ll be discussing the promise of telehealth technologies with Jamey Edwards, CEO of Cloudbreak Health. Cloudbreak Health delivers clinical and language telehealth services to more than 500 hospitals in the United States. The mission of Cloudbreak is to humanize healthcare and give patients access to the best specialists. In this podcast, we will talk more about how technology has the promise to achieve this mission, the successes of Cloudbreak, and what stands in their way to full implementation of telehealth. So first, thanks Jamey for being here.

Jamey: Thank you for having me, Katherine.

Katherine: Can you tell us a little bit about this mission to humanize healthcare? Humanizing is not always something we associate with technological interventions. What does it mean to you?

Jamey: My job prior to Cloudbreak was actually running an ER, hospitalist and anesthesia group here in Southern California that saw about a million patients a year. One of the things I witnessed was that the physicians on the front line of care were largely disenfranchised. What we saw from patients, was that patients felt very entitled to their care, so they treated these physicians like cogs in a wheel. And as a result, the physician population suffers the highest burnout of any workforce in the United States. I think the statistic is 49% of physicians and one of the main symptoms of that burnout is they treat patients as if they were objects. So the ability to take a step back and realize that if we can make healthcare a little more human, and we can do that by making technology easy to use for the people who want to use it to actually build a connection, as opposed to intermediate the patient-provider relationship, as most technologies that have been released in healthcare have done. An example of that is electronic medical records. We still haven’t seen this promise of the EMR as it was supposed to have been envisioned, and a lot of that is because we haven’t developed an understanding of what to do with all the data that comes out of them yet. But largely, someone’s documenting in the EMR and talking to the patient at the same time. A whole industry has popped up in scribes to address this issue. So we looked at that as a fault of the technology.

If we could make the process of actually treating the patient more about eye contact with you and your physician and create technologies that makes the physician’s job easier, then they will treat those patients more like people with a story. Patients feel entitled to their care, due to the fact that insurance companies pay the bill for them largely, or Medicare is, or Medicaid, or whatever it might be, and so they feel entitled to their care as something they should be given. One of the things we wanted to do is also create a situation that improves their satisfaction, so putting technologies in the field that help speed care, reduce health care disparities, and really make it more about that patient-provider connection. And that’s what we try to do and that’s why our mission is to #HumanizeHealthcare. It’s about bringing the people quotient back to healthcare.

Katherine: I love that concept. And I am curious, Cloudbreak, as I understand it, has two main pieces—clinical services and language services. Can you speak a little to how that works and in particular talking about how that improves the connection you were talking about between providers and patients?

Jamey: Absolutely, absolutely. The first product and service that we had, and the company was actually founded on was a company called the Language Access Network. It was founded back in 2003, by Andy Panos in Columbus, Ohio. And his main goal, because he experienced this when he traveled abroad, was to help make sure that patients who are limited English proficient, or deaf and hard of hearing, have access to an interpreter at the point of care. Being in a hospital, it’s scary enough when you speak English. When you don’t it’s absolutely terrifying. So as a result, when you show up and you don’t speak the language, and you’re in the emergency department and the doctor can’t communicate with you, ER doctors refer to that as practicing veterinary medicine. They order a bunch of defensive medicine tests [to make their diagnosis]. What a crude way to talk about how to treat another human being – we’re going to treat them like an animal because we can’t speak with them. Our main focus as a company was solving this initial healthcare disparity. That’s what the company did for the first six or seven years of its existence.

Over time we realized that we had created a few different things. One, because we connected to our clients over our own private broadband network, we had built one of the largest private broadband networks into healthcare in the country. All our hospitals, we’re actually up to 650 plus hospitals today, are connected to each other over this private path network. Two, we created a telemedicine platform. And that telemedicine platform could be used for other things besides just bringing an interpreter to the point of care. A year and a half ago, we set out to build new case studies using this existing platform.

One of the big problems in telemedicine today are the silos that are built up between all the telemedicine platforms in hospitals. We’re using X for our E-visits at home, we’re using Y for stroke, Z for tele-psych. And what happens when you need all three? Bring all three separate devices into the room? Not very collaborative and not very patient-centric, and not provider-centered either. So one of the things we set out to do was bring together all of these specialties on a single platform and integrate language services into it, so we can address the one in five patients who speak a language other than English in their homes, and that population is growing rapidly. America is becoming a majority minority country in the next ten/ fifteen years, and so how are we going to deal with that from a healthcare infrastructure standpoint? And one of the things that we discovered is that the language interpretation services were the gateway telemedicine drug. People could really understand that use case. What we set out to do over the last year, year and a half, is build other use cases like tele-stroke and tele-psych. We’ve actually had some great partnerships in that area that have allowed us to build our number of encounters. Our platform this month is going to do north of 65,000 encounters across the US. And that makes us as big as Teledoc. We’re the biggest telemedicine company no one has ever heard of, because we’re an enablement platform. Our goal is to enable the existing continuum of care, not create a new one.

Katherine: Really interesting. Today, telehealth is very broad and diverse set of technologies as you described bringing them all together from a capabilities perspective. I think many people still think of it only as iterations of the original “nighthawk”–type model, and expanding specialty care from big cities to rural areas. Can you provide a framework for our listeners to use to categorize the different facets of telehealth today? And help us see the paradigm for which Cloudbreak fits?

Jamey: Sure, first of all, our view on telemedicine is that it should be integrated into the daily practice of care. There are thousands of specialties out there and all of them can integrate some aspect of telemedicine. We look at it as the new stethoscope. When people started using a stethoscope did they say “well, how are we going to bill for this?” No, they used it as a way to improve care and they saw a function for it. Now every doctor has one strung around their neck. We feel the same can be true about telemedicine, and when it comes to the different modalities we look at it as creating an enablement for the existing care continuum. And it can be integrated in that continuum. And it can be used as a care coordination tool.

There’s literally thousands of different use cases for it. We were just at a CNO conference a few weeks back, and we learn something every time we speak to someone about how they might want to use it. People are using it to prevent patient falls out of beds, and they’re using it for patient falls out of chairs too—that’s called tele-sitting. There are different technologies that can be used to ascertain whether a patient is moving out of bed, using motion detection software and things like that to enable that to happen. There’s obviously tele-stroke and tele-psych—all those different specialties that help not only to save lives, but also the big decision in tele-stroke is do I or do I not push TPA, which is the clot-busting drug, and there is very much a golden hour concept. If you can speed access to a neurologist, or if you’re in a hospital where they don’t have access to a neurology on-call panel, and you can provide it, that hospital can become an accredited stroke center. We actually have a deal here in Los Angeles with Avanti hospitals, which is an inner city urban hospital, because by the way, while everyone talks about the applicability of telemedicine in rural environments, there are just as many medical deserts in some of our nation’s biggest cities today. That has to do with hospital payer mix and serving under-served patient populations, and again it’s just another health care disparity that we as a company want to solve.

We brokered a deal between Avanti and University of Southern California, so that Avanti could get tier 1 academic stroke consults in their facility, the patient gets to stay in the community, as opposed to being transferred out to a higher level of care, and patients who can stay in their community and in their support network have better outcomes. Studies have shown that. So from our perspective, there are those applications for it clinically, and then there’s other collaborative applications for the video platform once it’s in place.

During the last nursing shortage, there were a lot of nurses who came off the bench, who were highly qualified and very good, but they’re now retiring for good or they don’t want to work in a clinical environment anymore. So what are our hospitals in the US left with? Nurses fresh out of nursing school, and nurses from foreign nursing programs. And so what happens when that nurse is in a situation that they don’t understand how to handle? We were asked if our platform could be used for tele-mentoring. If a nurse has a difficult needle stick or has to put someone in restraints and they haven’t done it before, could they do that by using the platform and bringing in some of these very experienced nurses over tele-med? And the answer is yes. So whether you’re taking a home health or population health approach and integrating telemedicine into that, putting remote patient monitoring, using pulse oximeters, thermometers, stethoscopes, etc… plugging those in and using an iPad to bring all that data back and having people monitor it, and then having that launch a telemedicine call, and then having that telemedicine call dictate where the patient goes – i.e. do I keep them at home, is it an antibiotic that needs to be prescribed and link into their local pharmacy, or do I need to bring them into the facility for something that’s more acute, or do I drive them do an urgent care center – that care coordination activity alone can save the healthcare system billions of dollars. Why does an ER doctor need to see someone with the flu? They don’t.

Katherine: Are you seeing these technologies being used for some of those more innovative models? So, I see that that’s a need, and you’re figuring out those needs and trying to apply it to those? How expansive are you seeing care coordination being supported through telehealth or nursing mentoring?

Jamey: Early stages. We’re still in the early stages. People see the value in those use cases, but unfortunately, our healthcare system isn’t incented around innovation. By that I mean people tend to be pretty risk-averse. Hospital CEOs don’t get fired for maintaining the status quo, but they would get fired for trying something that would be considered risky in implementing some of these programs. So our goal as a company is to help show that there is not a lot of risk associated with that. That this innovation can be done in a very controlled environment with things like pilots, and with very collaborative processes that help assuage those concerns but drive value at the same time, and help push the innovation ball forward.

Katherine: Great, I know that Cloudbreak is not your first foray into healthcare. Can you tell us a little about how you got here and why you landed on telehealth as the thing to move forward with?

Jamey: Yeah, my path has been a windy one for certain. I started off as an investment backing and private equity guy. But over time after I’d seen a lot of companies do it right and do it wrong, I did a little consulting for someone who’s my uncle, who was one of the first ER doctors to come out of residency in the United States when it first became a specialty. His name is Dr. Irv Edwards, and I helped move him out of his home office to a real office and taught him and his partners about revenue and cash flow and brought my finance and strategy skillset to there. And their company started to grow. Eventually they said we’d like you to come manage this business full-time. So I left my job at Lehman brothers back in 2006 when it was still a great place to be — I have a lot of pride of having worked there and left to run this small ER group in Southern California on the operation side, with Irv and his partner on the clinical side. We implemented a lot of changes into the system and I learned healthcare from the ground up for the next ten years.

I saw the challenges that doctors faced. I saw the challenges that patients faced, and really developed an internal mission to help solve these problems. So we successfully grew that business over the course of the last ten years. But in 2008 we came across the Language Access Network, and, it was at that time a public company, we structured a deal to take it private. We really turned the company and revenue model on its head. We worked with the founder to help deliver on the original vision of the business, which is solving this initial healthcare disparity. Over time, we realized the assets that we have and realized that unified telemedicine is really where the country should be going, which we call telemedicine 3.0. Telemedicine 1.0 was pick up the phone and call your doc. Telemedicine 2.0 was “great, let’s add video.” Most of the video that was added was centered around things that were web RTC-based, or the lowest cost video you could get, and you can’t really federate web RTC and it’s not an interoperable platform.

So we took more of an enterprise approach. We built a standards based video contact platform that allows us to work with Polycom, Cisco, Vidyo, or Skype for Business seamlessly. So when we go to hospitals we can say “you don’t need to rip out that technology investment you made. Let us show you how you can turbo-charge it, put it on our private broadband network, and attach it to our ecosystem of these 650 hospitals that we call our marketplace.” And these hospitals have a two-way street. They consume services from us on the one side, or they can provide them services on the other, but it turns this investment in telemedicine that they made into a strategic asset for the healthcare system, hospital, or the clinic. We think there’s a lot of power in that.

Katherine: Fascinating, thank you for sharing. I’m curious, I’m sure you’re aware that there’s been some recent press on telehealth actually increasing utilization. Can you talk a little about what you’re seeing in that space? And how we should understand that as it relates to telehealth solving all of these other problems that you’ve articulated.

Jamey: Sure, well if you take a look, I think that was a Rand study that came out, and pointed that out if I recall correctly, and I think you have to take a deeper look at that study. That study was basically looking at Teledoc on the payer side, or the employer health side. And that’s not your existing continuum of care. We view telemedicine as the best tool to enable your existing continuum of care to see you. So what happened in that study, is someone is at home, they call Teledoc, and Teledoc is naturally as part of their discharge instructions is going to say follow-up with your primary care physician after this. We’ve treated your symptom, but follow-up with them afterwards because that’s part of your existing continuum of care.

And that really is why that study pointed out that telemedicine increases usage, or utilization of an in-person visit after a telemedicine call. But the fact of the matter is if you use telemedicine, for example if you use a pediatrician: if your pediatrician is enabled with telemed, and you’re at home and you have the opportunity–“oh, my child has a fever. I’d like to check in with my doctor.” And instead you do a telemedicine call instead of calling the pediatrician from Teledoc, then that pediatrician knows your child’s history, they have access to your child’s patient record, they know that full continuum of things that your child is facing, in terms of co-morbidities or any other types of symptoms or illnesses, and they can give you the proper care path and a proper diagnosis. And they will then decide if the situation is urgent enough to warrant an in-patient visit or not, right? And that to us is how telemedicine should be used. It shouldn’t be done around driving a new continuum of care, it should be enabling the existing one.

Katherine: So when you’re speaking of continuum of care, you’re referring to working directly with established relationships between patients and providers, and expanding on that?

Jamey: Correct. For the most part, people that don’t have a local healthcare system or a local health care provider – it’s enabling that local healthcare system, the UCLAs, the Cedars, or the Avanti’s to see their patients at home and to help to intervene and decide where that patient is going to go for their care, to keep them in the community.

Katherine: What about post-acute care? Could we send patients home from hospitals or rehab centers earlier if we use telehealth? Where do you see telehealth fitting into that part of the continuum?

Jamey: Yeah, well I think there’s one: keeping them out of the hospital in the first place, which is a huge driver of cost, efficiency, and quality in the marketplace, so doing things from a care coordination standpoint to keep them out. After you’ve been in the facility and been discharged, you can do post-discharge follow-up calls for wound checks: “we sutured that wound, and want to make sure it’s not infected.” When we do a follow-up call with you, the patient just puts that wound in front of the camera and we can see it and we can determine whether it has become infected or not.” All those different types of things are possible today.

In addition, there are companies who are out there – we’re working with a company called PeerWell, who we’re partnering with – that does something call prehab for surgeries. So their goal is to get a patient more fit prior to having a procedure, so their outcomes post-procedure, post-discharge, can be better. And then they also have ties into physical therapy afterwards that ties into things like wound checks. There are people who are using, obviously telemedicine, for population health and chronic care management post discharge. All of those things can absolutely be done, and we’re seeing more payers get into the mix from that perspective, because they realize that everyone wants to reduce readmissions. We saw that over the course of the last year or two. Medicare flags that as a big issue. Telemedicine can help solve a lot of that. There’s a lot of stuff that we can do in the home now – which by the way is the care venue where the patient is going to be most satisfied in relative to having to come to the facility, or even employer health. Employers want to handle this problem and figure out how once a patient is done with a procedure, how they can keep them at their desk and keep them productive, which the patient wants as well.

Katherine: So these all sound like great opportunities, but what about the money? Do folks actually reimburse for these new care settings? What are you seeing in terms of things like prehab and those types of things?

Jamey: People are looking at it from an ROI standpoint. Which, by the way, we think is the right way to look at it. It’s not, “hey, how are we going to get reimbursed for this?” It’s “does this improve care? Does it make us more efficient? Does it improve satisfaction?” When we take a look at healthcare systems, there are always the three parameters we run down: efficiency, quality and customer service. And telemedicine can help do all of those. It helps drive more efficiency. It decompresses emergency departments. It allows you to time-shift care the same way your DVR allows you to time-shift watching TV. Asynchronous technologies are a big part of the future of telemedicine. Patient being able to, in a HIPAA-complaint way, record their discharge instructions for their caregiver. A doctor who may be seeing some lower-acuity patients such as dermatology, i.e. being able to take a picture of your mole, sending it to your physician, having the physician round on it at the end of the day and then saying “you know, I’m not worried about this one, you don’t need to bother with coming in” or “this looks a little irregular to me. Schedule an appointment on Tuesday.” Those are the different types of things that we think can really make a difference. And they help improve the whole financial structure of the system, without say, driving direct reimbursement.

That being said, CMS is doing a lot now with Medicare Advantage plans on reimbursing for telemedicine services. There is a concept called parity states, where a telemedicine visit can be reimbursed the same way as an in-person visit can be reimbursed. I think those things are going to continue. Especially on the payer side, you’re actually seeing telemedicine companies like MDLive, and American Well and others, get reimbursed on a per-member, per-month model. It’s almost like taking risk, if you will. I think the challenge companies like Teledoc, American Well, and all those guys face, is figuring out how to get to the right number on the per-member, per-month costs. Because right now, one of the big challenges in telemedicine has been around engagement. Great, we’re paying X-hundreds of thousands of dollars a month to use the platform, how do we get engagement above one percent or above two percent? So we, at Cloudbreak, drive engagement by taking people we call “client advocates” and putting them in the field and driving the culture or behavior change required to adopt the technologies we implement.

But I think the other way you drive engagement is focusing on the existing continuum of care, and treating telemedicine just like another tool in the provider’s toolkit,. People are for some reason very hesitant to see a doctor on telemedicine that they don’t already know. So those are the types of things at the end of the day that we think can drive value. People should be looking at it on an ROI basis, but reimbursement is coming and I think there’s a lot of changes. Legislatively, the FAST Act and the CONNECT Act are really coming along to drive reimbursement in telemedicine and make it a little bit more official.

Katherine: Interesting, so we talked about money, you talked about engagement as two examples of some of the barriers to scaling telehealth. Can you speak a little more, are those the main barriers? Are there others that you’ve encountered or potential solutions you see, particularly on the engagement side to truly working to getting that adoption?

Jamey: I think there are two big barriers right now to the adoption of telemedicine. The primary one is just culture and human behavior. We are used to doing things in very specific ways and changing those synapses in our brain to do something a little bit differently is hard to do. So being able to take a step back, the way that we work through culture change is with our client advocate team. These are the teams of people we dispatch to our facilities who make sure that the equipment is in good working order. They do all the initial in-servicing for the staff, they work with a difficult physician, who says “I’ve been practicing this way for 25 years, I don’t need your telemedicine. I know what’s right for my patient.” We will sit side-by-side and work with them during their first few encounters until they’re comfortable using the platform and can actually see the value in it.

From the patient side, if you take a look at the closed healthcare systems today, like the VA and Kaiser, they are very successful in rolling out telemedicine. And it’s because they can dictate the care modality to the patient. So more of our providers need to that. It’s much more difficult to do in an open community hospital, because you’re competing in an open market. But Kaiser now claims to do more visits digitally than in-person. And the VA has been ramping up their telemed in huge ways and they have ROI statistics to show it saves on average 63,000 dollars a year per patient. It saved travel costs, productivity and other factors for the patients that they are serving.

So we know that it drives value from that perspective, and success statistics also help drive culture change. But I think the toughest part is actually on the consumer side. And I think the way that you change the behaviors on the consumer side is continually showing value and by continually showing them convenience. Patients are getting used to an on-demand culture: they have on-demand TV, they now have multiple venue opportunities for their care with retail clinics, urgent care centers, and time has become a huge value-driver. With telemedicine, we can now help some of these bigger healthcare systems convey that same value of time that some of those more nimble operators can convey, and it levels the playing field for them.

Katherine: That’s interesting, in my experience on the provider setting is that once folks try something new, then they’re big believers. But it’s getting them over that initial hump of trying a new modality, whether that’s the providers themselves, but even more-so that patients.

Jamey: Convenience and acces — those things will drive changes in patient’s behavior.

Katherine: Well, thank you so much for your time today, Jamey. This has been a fun conversation.

Jamey: My pleasure, thank you for having me.

Katherine: Thank you for listening to our Avalere podcast. Speak to you again soon.