In the ninth episode of Telehealth Heroes, we interview Dr. Tania Elliott, one of the biggest names in telehealth. Join us to learn all about her time as Medical Director of Doctor on Demand, the future of telemedicine, and how doctors can make the most of their telehealth calls.
Episode transcript
Brandon:
On today’s episode, we have Dr. Tanya Elliott who has almost too many accomplishments to name. First. She is dual board certified in internal medicine and allergy and clinical immunology. She was the medical director of doctors on demand where she helped develop the nation’s first virtual physician workforce. She is now the chief medical officer for virtual care at Ascension health. One of the largest healthcare systems in the United States. She chairs the telemedicine and technology task force for the American college of allergy and asthma immunology. She’s made numerous TV appearances on talk about telemedicine, internal medicine immunology on programs like CBS this morning, Dr. Phil, good morning America. And most importantly, she is a mother. So Dr. Elliott, thank you for joining the podcast today.
Dr. Elliott:
Thanks for having me.
Brandon:
Great. So how did you first get into telemedicine?
Dr. Elliott:
So I have a funny story. I worked in park avenue and allergy practice shortly after I completed my fellowship training. And after like a few months of working, I thought, you know, as an allergist, who would be so great to see and a patient’s homes, that was one thing because I’m constantly talking to them about what’s in their environment that could be making their symptoms worse. So if they have does my allergy, do they have carpet? Do we have bedding? And I remember my office, we would hand them a piece of paper and a crayon and have them kind of circle, oh yeah, there’s carpeting here. We’ve got drapes here. And I said, what would just be so much easier instead of asking these questions and pulling this information out of a patient, if I could just do a walk through of their home. And then the other thing was patients would come to me would take three weeks to get an appointment.
Dr. Elliott:
By the time they came in to see me, they would talk about how bad their rash was three weeks ago. And I would pray that they had a picture. And if they didn’t, it was really hard, you know, to get a clear picture of what exactly it was that was happening. So I thought, gosh, it would be easy to just have an on-demand visits or something with my patients, get them to connect with me, save a picture. So I had a business idea. I thought, well, maybe I will do home visits and I’ll go to people’s houses, my doctor bag, you know, reinstate kind of the home visits. And then in New York city, I’m like, okay, well, there’s no way. I, first of all, spent all my money in cab fare, maybe see three patients. So that’s not scalable. So I told my mom about this idea because I’m a nice Italian girl.
Dr. Elliott:
I tell my mother everything. So I tell my mom this idea and she’s like, well, it sounds like a great idea, honey, go for it. And then she calls me back a week later, very upset. And she says, Tanya, Dr. Phil stole your idea. And I’m like, what are you talking about? She said, he starting a company with his son. It’s called Doctor on Demand. You have to look into it and figure it out. So Dr. Phil kind of so mighty, he did it, but they had just started doctor on demand. This was November, 2013. And she saw on television that on the doctor’s CV and Dr. Phil showed, they were showcasing this sort of video visit on demand offering where you can download an app, click a button and connect with your doctor. So I reached out to you, the chief medical officer at the time.
Dr. Elliott:
And I said, Hey, I think this is a great idea. I’ve been thinking about it for my allergy patients, but I could also see value across other specialties. And they were like, great, come join us. So I first joined as a doctor, just seeing patients on the platform. And after just a couple of days of working, I’m like, this is amazing. Well beyond just like being able to see environmental triggers into a home, I’m developing great relationships with patients. There was this whole new, like patient guided physical examination. We were going through together as developing strong relationships patients. They were asking me if I could be their, their primary care doctor. And so I was hooked on telemedicine and I was really passionate about it. And that sort of kicked off my whole career.
Brandon:
Oh, that’s amazing. So when you were, so you started off as a regular doctor for doctors on demand, but how did you progress on up and what were some of the biggest challenges you faced and that you had to tackle as, as a leader at doctors on demand?
Dr. Elliott:
Yeah, so I progressed quickly, I think because it’s actually interesting because I had like broadcast media experience. I had really good. What I term now is Webside manner where I’m like, this is just like television, where you have to think about, you know, how your lighting is and your hand movements. And I use my hands a lot. And so you have to think about all of those things. So I kind of developed the skills rather quickly to effectively communicate with my patients through this modality. And I thought, gosh, it’s going to be really important to recruit the right kinds of doctors with the right personalities, or if not, train them with certain competencies on how to effectively communicate with patients this way. Because as you know, we’re trained in medical school and it’s all about if a patient is sad, put your hand them a tissue in person it’s all based on in-person.
Dr. Elliott:
So what does that look like? What does that doctor patient interaction look like through video? And I truly believe that there’s, it could be delivered is equivalent, so, but it required training. So in speaking with the, you know, their leadership there, I eventually became their medical director and I was responsible for recruiting, hiring and training the doctors and really having this virtual as physician workforce nationwide, you know, they were, they were fun challenges where even doctors who had signed up to be part of doctor and a man were still at some trepidation, or maybe they were first signing up because they said, okay, well, I don’t want to go into the opposite anymore, but I still want to work. And so they were kind of coming in with all different reasons, you know, maybe it was a work-life balance thing. What have you, but it was that first onboarding and training that I would do with them, which was like the aha moment, like, oh wow, you can do a physical exam.
Dr. Elliott:
This isn’t just like a telephone conversation with my patient and like glorified triage. I can develop relationships with my patients. This is really neat. And so we collectively like gathered feedback on best practices and training and over the course of, you know, the three plus years with Dr on man really like learned from one another to figure out like what virtual care should really look like? What are the guardrails? What are the standards? So it was a great experience sort of working with the physicians and, and kind of getting them to be on board, a bigger challenge, which we still face today, which is like, you know, people not understanding that whether that’s business leaders or selling into a payer or an employer, or even still my own family who despite even encouraging me to go into this will still still think they have to go to the doctor to get their prescriptions changing that behavior and helping people understand that virtual care really could be the standard of care.
Dr. Elliott:
And so sometimes you feel like a broken record saying the same thing over and over again for, you know, eight, 10 years. But I would say that that’s the biggest challenge is kind of framing up to people, the value of virtual care and that not making an apples to apples comparison to brick and mortar care because it’s not the same thing. And it’s also not that you could compare, okay, this is what happens in an in-person visit. And this is what happens in a virtual visit. And let’s make sure they’re equivalent we’re in this for the long game. Like virtual care should be part of the standard of longitudinal care delivery care delivered over time. So that’s kind of the work that continues to be done in this space.
Brandon:
Oh, that’s fantastic. So I’ve read your paper on that you published last year about patient perceptions on physician interactions and the data came from, I believe, 2016. How do you think those perceptions have changed as a result, as a result of COVID and everybody really having to do it and try and get more experienced with it?
Dr. Elliott:
Yeah, so I, I think the findings and we looked at reviewed, basically the paper was looking at reviews of over 50,000 patients that we saw through Dr. Pan and actually looking at the ratings, the comments, right? Because at the end of doctor on demand and lots of these virtual care platforms, you can do a star rating, one through five stars. I started to notice as a doctor, the value of the patient feedback, because at the end of every shift, I would get feedback anonymous from every single one of my patients. We also had a process in place where we would actively review all of the one and two star cases, all the negative feedback to say like, Hey, what happened? And that would help inform our technology if it’s a technology issue, or if it was an issue where the patient was disappointed, they didn’t get antibiotics or disappointed because maybe the communication of the physician, the skill, the communication skills of the physician were not ideal.
Dr. Elliott:
We would leverage that as for like as real time feedback. But then I said, well, what about all the five-star ratings? Like, what is it about the interaction? What is it about virtual care that makes patients pleased with the care that’s being delivered? So what drives a five star rating was what I was trying to get at. And when you first think about it, it’s like, well, of course it’s convenience. You know, of course it’s a cool app. Of course it’s technology. Well, it wasn’t the case actually of those 50,000 reviews over 30% of them were around rapport building the doctor actively listened to me, I felt heard, or maybe it was, the doctor was so thorough. I really had a good understanding of my overall care. The doctor spent time with me. I didn’t feel rushed. Meanwhile, we knew the average calling for a virtual visit for a virtual urgent care was about eight or nine minutes.
Dr. Elliott:
So there was really something special about that doctor patient interaction. So what we did is we said, okay, let’s look at core competencies of communication that were trained in, in medical school, like sharing information and providing guidance and active listening and shared decision-making and then match those comments to those core competencies. And that’s where we found it was about the relationship building the rapport. So I think if, if for nothing else, if we had redone that study today, we would just have more numbers supporting that. And I think the fact that with the, we see B virtual behavioral health, probably being the specialty, that’s here to stay where we’re at 50% of behavioral health visits are virtual. It makes sense that doctor patient relationship through video is impactful. It’s meaningful and should not be underestimated. And also the fact that primary care doctors were doing virtual care and felt like they were able to maintain their relationship with patients. It reinforced what we found in 2016.
Brandon:
Oh, that’s fantastic. So, so you were doctors on demand. What, and now you’re at Ascension health, but between that, were you also involved in telemedicine and other other hospitals organizations?
Dr. Elliott:
Yeah. So a couple things. One was, I was chief medical officer of a preventive health company and we, it was called EHE. And what we used to do back in the day was executive health exams. That’s what EHE stood for. And then, you know, it was a privately owned business. And then it was bought by a broader company that really had the vision of saying, you know, you know, doing these comprehensive examinations to find a needle in a haystack to keep it executive healthy is kind of old school. What we need to do is real population health and employee health and keeping employees healthy. So they challenged the organization to rethink the annual exam and preventive medicine. So I was brought on as chief medical officer to reinvision that clinical program. And what we did was we said, okay, how you think, how you move in, how you eat.
Dr. Elliott:
That’s how we’re going to keep healthy people healthy all year long and the doctor’s visit to make sure that you’re checking the boxes for age and risk factor, appropriate screenings is important, but it’s not the whole picture when it comes to your overall health. So how can we engage patients 365 a year round and give them quote, surround sound with other digital tools? Like we give them a wearable device. So we, I, we instituted a program called a wearable device, onboarding, you get an apple watch or a step counter. What do you do with it? How could it impact your overall health? Let us medicalize this space for you and say, Hey, you’re going to have a goal of 7,500 steps a day, but we’re going to give you a coach. That’s sort of with you every step of the way, and for how you eat, let’s keep food diaries and digital food diaries.
Dr. Elliott:
Maybe we can serve up to you a healthy food deliveries on seamless or things like that. So we were thinking about ways in which we could leverage technology to improve patient’s overall health. But at the same time, there was always a position as the quarterback. So that was the work I did at EHC. And then I was recruited over to CVS Aetna to help them with their tele-health reimbursement policies, to help with some of their chronic disease management programs for women’s health care for cardiovascular disease, all through, you know, ways in which we can leverage technology, put devices in the hands of patients, and then act upon that data that’s coming through to keep people healthy at home.
Brandon:
Hmm. So a reimbursement, let’s talk a little bit about that since you’ve worked on that policy with COVID a lot of the reimbursement restrictions have been lifted just because, Hey, people need care, but there’s the concern in the industry of all those restrictions are going to come back. I’m curious to know how do, how do insurance companies view telemedicine? Is it something they fear is that there’s some that are trying to keep from getting out? Or is it something that you see them actively encouraging because they see the value in it.
Dr. Elliott:
So there are a lot of myths out there as it relates to telehealth reimbursement insurance companies, absolutely believe in the value of tele-health. It’s been proven out for virtual urgent care and been able to reduce unnecessary ER visits. And that’s why almost every insurance company offers virtual urgent care on demand is a carve out as it’s just a separate car back. They know that they can reduce unnecessary, ER, visits that way and improve access to care for their members. Almost every commercial plan had a telemedicine reimbursement policy in place pre pandemic, and a lot of the big plans reimbursed with parody. So it’s a little bit, we’re confusing things a little bit. When it comes to some of the restrictions around telehealth being lifted, there were a couple of restrictions that were left to go back. One is the licensure piece, right? Once a pandemic kit multi-state licensure, or did it matter, you didn’t need a license in that state and you were able to practice across state lines.
Dr. Elliott:
That’s likely to come back. That has nothing to do with the payer that has to do with the state licensing boards. And we, as physicians need to continue to advocate for licensure compact, just like nurses have licensure compacts. The other is reimbursement for telephonic visits, and that’s still a debate that’s going on. And we continue to advocate for it, especially because there are certain areas where you can’t, there’s what their wifi deserts. And so it’s either telephone or nothing. And so those patients should receive that. But overall, we should be concerned. You know, we should really be working towards doing virtual video visits wherever we can, but there should be, we believe exceptions around allowing for telephonic encounters, especially in patients where they don’t have access to wifi, but those are the two main things. The other area is in terms of what’s covered on the telehealth services list.
Dr. Elliott:
So all of your standard ENM codes, your routine follow-ups or regular business, behavioral health visits, all of those things were covered before and will continue to be covered, but they expanded the tele-health services list to include other things like speech therapy, PT, OT, and a number of other things, which are not the majority of telehealth visits that are conducted today. But that list may go back to pre pandemic. If that’s not impacting your general primary care doctor or most specialists, it does impact others. And we will continue to advocate for as long as there’s quality standards are met. Those other specialties should be able to have those types of visits. I think more data is needed and more advocacy is needed around there. The last thing that I’m going to say about reimbursement is that states have, oh, I believe it’s 42 states have laws in place around telemedicine reimbursement.
Dr. Elliott:
Some states require parody, meaning you have to reimburse for virtual visits as well as, as the same rate as in-person and others require reimbursement, but they don’t say that you have to reimburse at the same rate. So it’s just important for us to understand telemedicine reimbursement is not going away. Once the doors are back open and we’re back to normal, most state plans like Medicaid, most state Medicaid laws and regulations have implemented things that will continue to remove originating site requirements. And some of those other requirements that were in place. So most state Medicaid plans have already put actions in place to, to remove originating site requirements. And we know, and we’ve been following CMS very closely that they’re moving forward with removing and bridging dating site requirements as well. So crystal ball moving forward in the future originating site requirements are likely to go away. Jury is still out around telephone, but tele-health visits through video will absolutely be reimbursed. And it’s a matter of which states require reimbursement with parody versus reimbursement without the rates of reimbursement.
Brandon:
Oh, that’s fantastic. You mentioned, you know, data needing data to make some of these decisions. Well, over the past year and a half, there’s been a ton of people using telemedicine and through the pandemic with all these people using telemedicine for OT, PT, and these other maybe non traditional telemedicine services. Is that going to be sufficient data for these insurers to make some type of informed data-driven decision about keeping the reimbursement place for those types of services?
Dr. Elliott:
I think directionally it’ll be accurate, but there’s so many things that occur during the pandemic, you know, ambulatory surgeries were canceled, you know, entire clinics were completely closed. The only, you know, so your data’s really dirty. Well, real really advocating for is more time. Now that the world is back open, or at least from a healthcare perspective, you can access care anywhere. And it’s not that ambulatory offices are closed. We’re going to need another 24 months to be able to collect the right kind of data to prove out that there aren’t any, there aren’t issues as it relates to virtual care. But again, it’s so important for us to not make apples to apples comparison, to in-person visits and think about the incremental value of virtual visits. For example, you could have a visit with your doctor, your primary care doctor, your cardiologist, and your GI doctor on a call focused on you tell me that that’s not superior to a patient showing up in three different doctor’s offices and that day, and then having to recall and retell their story.
Dr. Elliott:
Oh, my primary said this, my, my cardiologist told me this, the GI doctor said that. So how could it not reduce medical error? If you’re leveraging technology to do three way conference calls, for example, how are we not improving care? When you’re enabled, you’re able to include caregivers on a, on a virtual call without having them a whole slew of people show up in your doctor’s office. So I think that there are, we have to think about things that virtual care can do that brick and mortar care can’t do. And we also have to think about that. To some extent, some of our cadence of followup with our patients is arbitrary. Your diabetic patient comes in every three months. Where’s the data that supports that every three, every 90 days, you need to see your doctor in person face to face in order to have improved outcomes. So what I’d like to see are more hybrid care models. Once a year, you go in to see your primary care doctor for all of your, you know, in-person vaccinations or your retinal screenings or your foot exams and everything. And then the other touch points are virtual. And maybe at the text-based interaction, maybe the patient’s on remote patient monitoring program. Maybe they’re interacting with a coach. Maybe it’s a virtual visit with a doctor, but we really need to start evolving our care models and stop comparing it to these arbitrary standards that we’ve set.
Brandon:
Right? When, when we created doxy.me, that was the original thing was we were looking at prenatal care and asking the question, do pregnant moms really need 15 in-person visits. And we’re like, no, probably need three or four in person visits. We can do the rest at home. And that’s the that’s that knee that caused us to create doxy.me. And essentially it’s so it’s, it’s reflective to what you’re doing there. So, so you you’ve moved over to a such in health. How are you applying these principles to your current job?
Dr. Elliott:
Yeah, cause it was a great question. And I, you know, I just learned that yesterday that that’s how doxy.me was founded to improve prenatal care delivery. And if you look at now, the Aycock has come out with guidelines to say like, yeah, you know what? This is just as good as standard of care where you don’t need to have every single visit in person. And I know after having two kids, I’m like I have to come in every week in my third trimester already hitting me, like get my blood pressure checked. I asked my doctor, he said, look, can I just have a blood pressure cuff at home and tell you what my blood pressure is like, what else? You know, I’m happy to have a conversation with you and talk to you about what’s going on. And then my feet are swollen, but why am I coming in every single week for 12 weeks?
Dr. Elliott:
This is anyway, I really commend you for that. It makes complete sense. So the work we’re doing at Ascension a few things, one is virtual care should be the standard of care to make sure you’re providing good access to care for patients. And by that, I mean, all doctors should be comfortable offering virtual visits to their patients for routine followups, really thinking through, does this patient actually have to come into the office? Do I have to physically put my hands on the patient? Do they need a procedure or a vaccine, or is it really about sharing information, providing guidance and getting a few objective pieces of information that I could get through a video visit? So that’s, you know, and we’ve had over 7,000 of our doctors do virtual visits. The second piece is when a patient’s calling up, let’s say to cancel an appointment, maybe you address some of the challenges and say, well, how about if it’s a virtual appointment?
Dr. Elliott:
You know, and then we’ve actually seen a reduction in cancellations or people who are no showing for appointments by operating them virtual. Cause we know there’s lots of challenges as it relates, especially to social determinants of health. And we’re really committed to serving poor and vulnerable patients. They can’t take off of work. They can’t find childcare for their kids. They don’t have transportation. So we should be proactively offering virtual visits for those populations and making sure that they stay engaged. So sort of as like a baseline, that’s an expectation for our Ascension doctors to be offering virtual visits provided they believe it’s good quality care for their patients. The second is really the hybrid care model work that I was just alluding to before, which is which patient, which visits should be virtual, what should be in person and what are the touch points in between?
Dr. Elliott:
So we’ve got a comprehensive remote patient monitoring program. Our Ascension has one of the most mature programs in the country. They’ve been going at it since 2015. So we’ve got disease management programs for diabetes, joint replacement, post-operative care, cardiac care, a number of different ones and also prenatal and postnatal programs where we provide people with devices, FDA clear devices, and we’re monitoring that information. But the goal is really to keep patients healthy at home. So we’re going to continue to expand our remote monitoring capabilities and then thinking through new care models of the doctor, doesn’t need to be pinged with this information all the time, but they do need to be made aware of what’s going on with their patient, but really expanding and thinking of new, innovative, hybrid care delivery model, hybrid care delivery models that really leverage technology and these real time data insights that remote patient monitoring can give us.
Brandon:
What are the biggest challenges you face as you’re building these hybrid care models and, and how are you trying to overcome them?
Dr. Elliott:
The biggest challenge is we are trying to fit all of this into our existing workflows, which are created for brick and mortar care and our existing reimbursement structure, which is based in a fee for service world. So the biggest challenge is asking everybody to take what they know about the way that healthcare is delivered and reimburse and forget all of it. And then sit down with a blank piece of paper and write out the job that needs to be done. What’s the job that needs to be done. We need to interact with our patients, educate our patients and improve their health outcomes. So now we have all these tools within our armamentarium, which tools would you use in order to effectively communicate with patients? You have an option to bring them into the opposite of you need for procedure based care. You have an option to send services into the home, including diagnostic lab tests.
Dr. Elliott:
If you wanted to, you have an option to ask your patients a question every single day and monitor and track what their response is, how are you feeling today? Maybe that’s the question we should be asking our patient and that improves outcomes. So we need the freedom and flexibility to start to test and learn. And the beauty of these technologies is we’ll learn quickly. We can fail fast. So we could beta test all of this so that we can figure out what the ideal cadence of communication is with patients. And I don’t think that it’s once a year in the office or once every three months in the office for chronic conditions. I think that it’s leveraging different types of technologies to be able to interact with patients, with the goal of keeping them healthy, doing their everyday life, instead of having to stop everything and, you know, show up in my office, I want them to continue to live their lives.
Dr. Elliott:
But with that is also who’s the right care team. Isn’t nurses as a coaches. At what point is the doctor involved? What information is the right information? So what we really need is an opportunity to just test and learn, which is why we’re hopeful, maybe in a value-based care world where we’re really just focusing on keeping people healthy and not worried about fee for service. Maybe that’s the environment to do that, or, you know, grants from the government or what you, but in the, in the ideal world, we can kind of test out what the ideal care model looks like. But that’s the biggest challenge. We have an infrastructure that’s set up for in-person care and fee for service,
Brandon:
Right. Have you seen any early success with this model?
Dr. Elliott:
So I think some of the startups have done it really well. I think, you know, Lavango has done a good job. Vieta health has done a good job. There are numb, you know, there’s the armadas of the world. So I think that there are a number of startups that have been able to test and learn and do that. I think one of the challenges is how does it integrate into the in-person care? So I think some of the most successful programs, although it’s hard to scale are the ones that have a brick and mortar footprint and a virtual footprint, but that’s sort of why I came to a health system to say like, look, we already have that brick and mortar. We’ve got surgeries. If you need surgery, we have hospital. If you need hospital, we already kind of have that footprint. So then now how can we take some of this and digitize it and then make sure the patient gets to the best care. But at least we have full view. We have full visibility into the full spectrum of a patient’s needs. So we’ll see that, you know, I think the jury’s still out in terms of who’s going to win at this healthcare, you know, disruption, but I’m sure you would agree that it needs to happen because our current system is broken. It’s redundant and it’s costing us way too much money.
Brandon:
Yeah, absolutely. I was just going to say, this needs to happen. So you read my mind perfectly. So you’ve been a big, big advocate of the quadruple aim. Can you talk a little bit about that?
Dr. Elliott:
So it’s really comes down to being delivering high quality care in an efficient and cost effective way, right? And you have two customers, you have your patients as your customers and you have the physicians and the care teams as the customers. So it’s really making sure that those customers have the optimal experience. So high quality cost-effective care and, and a great experience for both patients and their care teams.
Brandon:
What is the out, what is the desired outcome of this quadruple aim and what do you hope to achieve with it?
Dr. Elliott:
I think that’s through the lens, the lens through which we should be developing all of our programs, right? And a lot of times we’re focused patient experience, patient experience. We want to have a slick app or they could click a button and access X, Y, and Z. And sometimes we forget about the clinician and care team experience. Well, that app is not connected to my EHR, so I’m not going to be able to engage with the patient. So they could be really happy with maybe their appointments scheduling and a couple of things. But if their doctor doesn’t have like visibility into the care that’s being delivered, it’s not going to be a good patient experience. So thinking about designing each program, and we actually have a design team with human centered design thinkers that partner with us on the development of all these new patient programs, but it’s making sure that we’re thinking about it through the lens of the physician, through the lens of the care team, through the lens of the clinical and nonclinical staff and through the lens of the patient, and then anybody else was important for that patient’s healthcare. And we run each of the programs that we deliver through each of those angles, so that we’re making sure that we are not kind of solutioning with technology first. And we are keeping kind of all customers, so to speak happy with the overall care that’s being delivered and the experience and a, patient’s not going to be happy if their doctor is not the technology or whatever kind of care. So it really has to be both.
Brandon:
Right? Absolutely. That’s one of the biggest things that we talk about here is you can’t solve one problem with another problem. So you don’t want to solve, you know, a provider’s problem, but make it a huge headache for the patient because the patient’s just not going to do it. And the provider is not going to benefit benefit. So you gotta make sure everybody’s on the same page S same page with this. So when you started medical school and where you’re at today, how has your perspective of healthcare changed over that time period?
Dr. Elliott:
I didn’t know anything about healthcare when I was in medical school, you know, and we actually, we started, we created a graduate medical education curriculum for virtual care at Ascension because we re there’s, I didn’t, I didn’t even know what telemedicine was when I was in medical school. I certainly didn’t know anything about the business of healthcare. When I was in medical school, I was just studying the books and trying to stay above water, you know? And you, you Marine would surgical procedures are supposed to do and all that stuff. So the, my perspective has completely changed. I think, you know, the biggest shift was really when I was in private practice, recognizing the challenges of our existing system, you know, as an hour, just lots of testing that’s performed or patients coming in wanting testing for food allergies and thinking they have an allergy.
Dr. Elliott:
And, you know, sometimes demanding that they wanted this test because there was a lack of information about what the tests were for. And some you go to some doctors they’ll touch you to a hundred different things with me. I really spent the time educating patients. Here’s a reason why we do the tests, here’s what we would do with the results. But at the end of the day in a fee for service world, it’s, there’s a perverse incentive to just do more tests and maybe explain later. So there was, it was, it was, you know, a challenge, I think, where you realize you want to provide the best possible care for patients, but that’s not, you’re not necessarily going to be compensated for your, for your efforts that way. And then the other was, I felt completely restricted by being in an office. I wanted to, you know, we have a patient come into the office and strip off all of their clothes and be in a gown.
Dr. Elliott:
I have no context, no cues about what is going on in that patient’s life. I wanted to be able to see a patient in their home environment so that I could get a full picture of what’s going on and really have a comprehensive treatment decision made with them that gets at the root cause of a problem for a diabetic patient. Maybe their hemoglobin A1C is, are nine, are really out of control. I sure. I, if, and when I’m in the office and I have my blinders on and I’m just at lab tests and staring at a patient and a down, I’ll start them on a medication when I have a little bit more contacts and I understand they just went through a divorce. They’re dealing with aging parents that at nighttime, they’re not getting enough sleep. My treatment plan is going to be completely different. I’m not prescribing the medication, we’re making some lifestyle interventions. So I realized I was doing my patients a disservice by just looking at them in an office and treating them just like, almost like a number. And again, everybody looks the same. So that’s when I realized I had to do something different in healthcare.
Brandon:
How did you, how did, so they didn’t teach that to you in medical school, you figured it out on your own. How did you go about learning all these things and, and, and how would, how would you recommend teaching this to other young doctors? Is there in medical school and entering the field,
Dr. Elliott:
Just learn by doing and questioning the current state and the status quo and asking why like, why are we doing this? Why is my patient coming in? You know, why am I seeing them every six months for this? Like, that seemed like a pointless visit. If I were in my patient’s shoes, I wouldn’t have want to have to come in. I wish I could have just like texted with my doctor. And so, you know, medical school gives you the foundation and the core learning to be able to, you know, understand pathophysiology, like understand disease, states, everything else you’re kind of learning on the fly. So I learned it on the fly and I learned to ask why, and I learned to kind of challenge things that didn’t make sense to me in terms of how we can do this. You know, how medical students can, could learn this.
Dr. Elliott:
I think we need to put together curriculum and educational curriculum for them and educate them on all of these digital technologies that exist. Like have the, you know, the chief medical officer of a, of a successful startup come and give a grand rounds at medical schools. Like we need visibility into these new care models, med schools, aren’t teaching it residency programs, aren’t teaching it. And then once you’re in the real world, there’s not much around graduate medical education. So I would challenge these startups and encourage them to actually put together their best practices. What’s good about the way that care is being delivered story and then provide education to our students and residents and other physicians. And that’s been a passion of mine, which is why we put together the GME curriculum for virtual care. And we do onboarding with every single new doctor to Ascension on the principles of virtual care. And it’s synchronous video visits and appropriate website manner. It’s remote patient monitoring. It is device list monitoring, or now remote therapeutic monitoring. It’s, facility-based monitoring like Tel ICU programs and telestroke and telling her apology, and it’s this whole world of digital therapeutics and clinical informatics. So we teach everyone that every physician or clinician that walks through Ascension doors, we train them with those core competencies. And I think it’s so important and it needs to really be the standard across all med schools.
Brandon:
I’m just curious how to, how to do that, how to take what you’ve done in, in Skalla. Have you guys considered how to take what you’ve taught and bring it outside of essential to, to benefit the entire industry?
Dr. Elliott:
I made a bunch of videos. That’s actually, I think I posted a bunch of videos on how to conduct physical examination. I think, I think memorializing the things that we’ve learned, and like I said, I would encourage startups to do that, you know, to actually walk through what is your clinical protocol? What are your clinical programs? What are your outcomes? What are your patients saying? What are your clinicians saying? Like, and we need to actually, you know, record that, tell those stories, study that, and then really define best practices. And I think the other place to do it is to look at national societies like the American telemedicine association and encourage them to bring health systems together and startups together on the same room so that we could define the practice standards for digital health.
Brandon:
Last question, what is the future of healthcare look like to you?
Dr. Elliott:
Great question. I think that it will be a highly efficient world. It needs to be a highly efficient world. Well, I’ll say this is what I want the future of healthcare. It’d be, I don’t know if it will be this way, but at least this is my vision for it, highly effective and efficient world. Just like every other industry was upended by technology. And like, you know, I, I always do the example of like blockbuster video. Remember when you had to like walk in and get your video off the shelf. And then all of a sudden there was Netflix and it was like, why on earth? Would I walk into a video store? I think that to some extent, you’re going to see a little bit of that with like ambulatory practice. Everyone’s going to be operating at the top of their license. Physicians will likely be interacting for exceptions when it comes to, you know, data or information that we’re getting from devices that are placed in people’s homes.
Dr. Elliott:
Would there be intervening for the exception and saying, Hey, this data doesn’t make sense, or what else is going on in your life or so, so for a complex diagnostic decisions, most of the touch points with patients, I think will be digital self-service tools like an app for meditation app to help me sleep and what have you. And to some extent that might display some pharmaceuticals as we move more and more towards lifestyle interventions to improve overall health. So it’d be digital self-service tools, maybe coaching and, and, and nonclinical care team members that are supporting people in almost being there like daily health assistance, or, you know, in another layer of maybe advanced practice, what have you. And then that last layer being the physician. And then that will enable you to scale because we’re not training enough medical doctors for the amount of people that are in this country.
Dr. Elliott:
So we need to have highest and best use of our physicians. They need to be able to manage populations, not just individual patient practices. And then again, we can leverage technology to do that. And so with that, you’ll see docs practicing across state lines. You can have, you know, listen than a sub-specialist in a sub subspecialist so that you don’t have to train a million neurosurgeon or surgery is different, but you know, million allergists immunologists, they could be practicing at the type of they’re practicing at the top of there’s going to be a different type of medicine that they’re practicing.
Brandon:
Dr. Elliott, thank you so much for your time today.
Dr. Elliott:
Thanks for having me. It’s been great.
Brandon:
Great.
