Telehealth Best Practices: Rob Andrews of Health Transformation Alliance On How To Best Care For Your Patients When They Are Not Physically In Front Of You
Ease. Have an easy way to gather and convey data about the patient. When did they first get the fever, dry or wet cough and have they had this before? What other symptoms do they have? Think of this as the data you would include when you check into the doctor’s office — the forms on the clipboard in the waiting room. That information needs to be gathered, protected, and conveyed to the person who is doing the diagnosis. It is a huge deal.
One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?
In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing Rob Andrews.
Robert Andrews is Chief Executive Officer of the Health Transformation Alliance (HTA), a cooperative America’s leading employers that have come together to fix our broken healthcare system. Prior to the HTA, he served as a Member of the United States House of Representatives for nearly 24 years. President Barack Obama praised Andrews’ service as “an original author of the Affordable Care Act…and a vital partner in its passage and implementation.
Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?
I am honored to have had the privilege of serving my fellow Americans in the United States Congress for 24 years. Among other priorities, I was deeply focused on and committed to working on health care policy for Americans. During this time, I found myself in far too many meetings stating a very clear and ongoing problem: that in one of the richest nations in the world that has groundbreaking innovations and investments in science and medicine, miraculous healers and health care providers, too often too many people either have 1. mediocre health care 2. very inferior health care, or sometimes 3. no health care at all.
In addition, far too often people pay too much for health care, no matter its quality. I have found too many American’s overpay for health care and don’t get enough quality for it.
During my time in Congress, I worked on the Affordable Care Act legislation under the Obama Administration. I am honored to have been a small part of the efforts to write laws to help address the broken health care system. After a while, enough frustration grew in me as I realized that the laws weren’t enough. I decided I wanted to do more to address the challenges all American’s were facing within our healthcare system and I have been working on it ever since.
When the opportunity to join HTA came about I found another path that could help channel my passion and efforts to address health care in America. I am now part of an amazing team at HTA, and I am humbled and honored to be a part of making an impact on people’s lives everyday — not just talk about these problems — but work to solve them collectively.
Can you share the most interesting story that happened to you since you began your career?
Like so many families in our country, we have had health care shocks. I had a family member who was told they had a significant, life threatening disease. It turned out to be a serious misdiagnosis.
I stepped in to help as I thought that my background and knowledge around the system would be beneficial. Originally, this misdiagnosis would have led to a significant, aggressive chemotherapy program that might have ended tragically. The chemotherapy was unnecessary because the diagnosis was wrong.
I was able to navigate for this family member and connect them to a qualified specialist. The diagnosis was corrected and the care that this family member received was now the appropriate care.
And of course, after all that, the family member’s insurance wouldn’t pay his bill.
So, I got involved in that because an unqualified person at the insurance company said that the treatment provided was not medically necessary. I helped get appropriate letters from the specialist saying just how crucial it was to his care. So, this to me is pretty typical of what a lot of people are forced to confront. Fixing issues in health care is not just a matter of making people happy, often these are life and death decisions.
As I tried to help them sort out the issues with this misdiagnosis, I then saw first-hand how difficult it is to navigate the American healthcare system. Whether a significant misdiagnosis, lack of insurance payment or processing claims, people have to confront these issues every day in America.
Now let me tell you an experience I had at the HTA that was quite revealing. I was sitting in a meeting with a member of the HTA and the insurance carrier administrator that serves that company. Our member wanted to find the best, highest value doctors in the city where the member had the greatest number of employees.
The insurance company was there to present how their high-value network would service this member’s needs for their employees. The member asked, “How do you know these are high-value doctors, and that they are the best choices? What’s the data behind that?”
And about a half hour later, they talked about committees they have, and protocols they have — but they never explained how they figured out this high value network. Because frankly, the high-value network was not a high-value network.
It was a very broad network that was designed to spread volume widely to a lot of providers, good, bad and mediocre — as the business model of the insurance carriers is to do that. Now, that’s not illegal. It’s not unethical. It’s not wrong. It’s the rules they play under.
The bottom line is that those rules aren’t any good. It was revealing to see the customer, our member company, ask a really intelligent question. Then the customer was smart enough to say, “We don’t really care that much about your committee and your protocols. Can we see the data and the scorecard on which these doctors were evaluated?” At the end, the answer she got was, well, someone at a higher level would have to make that decision other than us in this meeting. In other words, no.
That’s part of the problem. In a country where transparent markets serve purposes that are very beneficial, health care is not a transparent market. I should have always understood that. This experience reignited my sense of why the health care exchanges will succeed.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
Seems counterintuitive but it is very true for me and my career. When you try something and fail — it is only a failure if you don’t learn something from it.
In my opinion, nothing is a failure if you learn something. Personally, I have learned a lot more from my failures than my successes and I have yet to meet a successful person that has not faced a failure.
When I have interviewed people for a job, and asked them what their biggest work failure has been, I have found that for me, there are three categories of people:
People who tell you about an insignificant failure that they believe will address the question, but also not reflect poorly on them.
Those who tell you “I have never made a mistake.”
The third group of people will get the job. Because they admit the big mistake, where they really screwed up, and then tell you what they learned from it.
I never met a successful person in any field who hasn’t faced up to failure, understood it and learned from it.
None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?
When I was serving in Congress a local primary care doctor, Dr. Howard Shivers, invited me to spend a day with him and his patients. I have never forgotten what I saw that day — how much pressure he was under to see a lot of patients.
This incredible variety of diagnoses he had to make — and how he would explain to people what was going on regarding their health. Some could clearly understand their diagnosis, others couldn’t.
Then most revealing were the questions he asked of patients that didn’t seem like medical questions, but they were awfully important for him to understand what was going on with the patient. I got a perspective of going to a doctor as a patient coming in — and I got to see him interact with perhaps fifteen patients that day. It was an unforgettable life lesson about health care.
Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunities because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?
There are obvious advantages to telemedicine, such as people don’t have to subject themselves to the risks of infection by going to a doctor’s office and interacting with other sick people. Yet patients can still get high value, high quality care at their convenience — and convenience is too weak a word. They can still see a doctor when and where it fits into their lives, whether that is caring for their children or going to their job virtually. And I do believe that throughout the pandemic, without virtual health care, the cost of foregone care would have been even more staggering than it was with people skipping checkups.
In fact, a recent report based on the paid claims data of 1.8 million U.S. employees of the HTA member-owners and their family members, showed three key findings:
The Spring saw a pronounced COVID-19 dip in use of the health system by adults.
Preventative screenings fell overall.
Dramatic increase in telemedicine visits, up 28-fold — making up nearly 1 in 5 visits.
We can see from this data that telemedicine was critical throughout the pandemic -representing 20% of total visits — and we expect this trend to continue even as the pandemic wanes.
The other thing that I think virtual health care has done is to get us collectively thinking about how our healthcare system could be made better and provide additional access. Yet, I do want to caution people to not get too obsessed with the technology and ignore the importance of ongoing human interaction with your healthcare provider.
Patients and providers still need to focus on things like how much time does the physician have with you? What does she know before she sees you? What actions can she take after she sees you? What kind of support does she have for the patient and for herself?
My hope is that we can avoid getting too dazzled by the technology and forgetting that the technology is a means to an end. In this case, the end is optimizing the value of the relationship between that physician or provider and the patient.
On the flip side, are there challenges that arise when a patient is not in the same space as the doctor? Has there been resistance to telemedicine by employers/employees?
One of the disadvantages is that there are vitals that can’t always be taken, data that can’t always be collected in a virtual setting. I have a watch that measures my pulse rate and can actually do an EKG, but I think I’m still in the minority. But my watch can’t take my temperature. There are probably some devices out there that can. So, I think that one problem is the lack of bio stat data including temperature, pulse oxygen, and resting pulse rate. While there’s probably a product in the market that is addressing these issues and more, those products are not yet matured and they’re not yet widely distributed or available.
Then there is the problem of the doctor not being able to feel what is going on in your body whether it is a manipulation of the knee or feeling the glands in your neck. There is some value lost from that direct contact not being able to take place. But I think those are fixable problems.
We’re in a hybrid system now of virtual and in-person care. The question is, what is the right balance? Of course, this will change as technology advances. During this phase of rapid change, there should be some natural resistance.
Not all resistance is demographically driven. It’s not only that older people are more worried than younger people. Lots of people are worried about privacy issues — is virtual really private? Conversely, when I’m sitting in a room with the door closed with the doctor, unless the walls are thin or someone’s recording something, I know it’s private. When I’m on the Internet, people worry about privacy and they should.
People worry about the difficulty in “feeling” a conversation as well as just having one. We have all spent far too many hours sitting on Teams or Zoom or whatever. You just can’t get the same feel for a person necessarily on a screen. Great physicians pick up anxiety. They may pick up changes in your speech pattern or they might notice fidgeting with your legs or your hands. Similarly, the patient can’t necessarily size up the physician, look her in the eye, or shake her hand or see her smile.
So, you do miss that ineffable human contact. You don’t miss it altogether, but it’s diminished. I also think empathy is an incredibly important part of health care. If the provider is empathetic and listens, they’re more effective than if they are pedantic and a lecturer. You don’t quite have that same human bond that might help someone pick something up. I always think back to that day with Dr. Shippers and the non-medical questions he asked to truly understand the patient.
I always remember my parents having a true partnership with my pediatrician. I came along in the 13th year of my parents’ marriage- my dad was 48 and mom was 39. They were afraid — and understandably. I think they just didn’t know what to do with this little creature they had given birth to.
They put all their trust in their pediatrician — and they got to know him as they built trust during this critical phase of their lives as new parents. They developed a great relationship, and he was a north star, if you will, for my parents. My parents knew he understood what it felt like to be at that stage of life having not raised a baby before. So, there is a risk of a virtual setting not being quite the same as in person.
For me, I think the answer is hybrid. I don’t want a doctor I have never seen in person, but I don’t always have to see him or her in person. I think that is what most people are going to conclude from this.
Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are “5 Things You Have Learned from The Medical Community to Best Care for Patients When They Are Not Physically in Front of a Doctor/Provider?” (Please share a story or example for each.)
- Ease. Have an easy way to gather and convey data about the patient. When did they first get the fever, dry or wet cough and have they had this before? What other symptoms do they have? Think of this as the data you would include when you check into the doctor’s office — the forms on the clipboard in the waiting room. That information needs to be gathered, protected, and conveyed to the person who is doing the diagnosis. It is a huge deal.
- Privacy: This has to be absolutely assumed and non-negotiable. The idea that the contents of that clipboard could be hackable by some person using your computer — it just can’t be, or else people won’t give information as privacy is an absolutely existential feature technologically, and legally.
- Time: While it is more convenient to be seen virtually — how does the quality stack up? How much time does the physician have? How long is the interaction for? How much time does the physician have to evaluate the facts I just talked about before he or she sees the patient? The technology might be really cool, that I can sit in my kitchen and talk to the doctor. But if the doctor doesn’t know what’s going on and she has six minutes to talk to me, technology is great, however it may not be a very good interaction. The bottom line is that convenience cannot outweigh the quality of the care.
- Necessary Next Steps: There has to be the next step. If the patient pushes the ‘end meeting button’ on Zoom and that’s it — and gets an email or documents from the doctor to go to the pharmacy and ask for specific drugs — and remember any special instructions with that prescription — if that’s all just sort of thrown at the patient and there is no follow up, it’s not going to work. Some of us are lucky enough to have a spouse, or navigator, that sits there during the appointment and takes notes. That can still happen virtually, but there has to be follow up, particularly with either chronic or acute illness. They might have a torn ligament, or they might have Cancer. You’ve got to have a follow up. So, when the telemedicine interaction ends in these cases, that can’t be the end of the relationship — it must be the beginning of actions to be taken.
- Integrated System: Finally, I think another key to this, and telemedicine doesn’t solve this problem, just as there has to be a navigator for the patient, there has to be an integrated system. Let me give you an example we are all living through. Your doctor gives you a prescription, but it’s the pandemic and you don’t really want to go down to the drugstore, pick it up and stand in line with 14 people that might be sick. So how does the drug get to you? Now there is an answer. Today, CVS has universal home delivery in most cases. Amazon is getting into this field. Others do as well. But somebody has to tie all this together in an integrated system — particularly during a pandemic, or a situation where people don’t want to leave the house, which is why they did the virtual visit in the first place. So, an integrated system is necessary for this to work. You can have a really great functional care visit. But, if a patient doesn’t know what they’re supposed to do next — and if the next step is really hard to do with your care being managed by different bureaucracies, it probably isn’t going to work. It has to be an integrated system.
Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example in working with providers/tech companies?
I think our work at the HTA with the City of Hope Cancer Center exemplifies the synthesis of in-person care and virtual care in the program Access Hope.
Let’s suppose a patient who is located 300 miles from a university cancer center gets diagnosed with a rare blood cancer. It’s the first time that his oncologist has ever seen this cancer, and it’s terrifying. Working with Access Hope, with the patient’s consent, the patient’s oncologist can virtually bring in oncologists from the City of Hope, which is a globally known cancer center. The oncologists from City of Hope may have spent their whole career working on this form of cancer and therapies. That’s all they do.
With the records, blood tests, labs, and patient history shared with the patient’s consent, all of a sudden, instead of this lonely oncologist in a rural town figuring this out, he or she is a part of a team of world-class oncologists. The diagnosis gets re-examined. This is really important because 30 percent of original cancer diagnosis is a misdiagnosis. The first thing you need to do is find out if the diagnosis is right. And if the diagnosis is right, it can lead to the right treatment.
They’re probably going to have chemotherapy and that’s most likely not going to be done virtually. But the doctors working on the problem can be part of a virtual care team that can maybe save the person’s life. This is something that we’ve become involved in.
And, if you think about the five points we just went over — we aspire to have all five in that example.
Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experience, which tools have been most effective in helping to replicate the benefits of being together in the same space?
Let me give you an example of how we are seeing telehealth help improve access to care for those with a behavioral health issue by giving our Member companies access to Pear Therapeutics, which provides prescription digital therapeutics for behavioral health. In essence, it gives those suffering from behavioral health issues, access to digital treatment of substance use disorder, opioid use disorder, and chronic insomnia.
Now, I’m not a behavioral health specialist, but common sense tells me that the first step in avoiding or dealing with a behavioral health crisis is being able to talk to a person who knows what to do if someone’s having a severe problem.
By definition, the in-person health system can make it very hard to do. Granted there is access to experts at a time of need such as help lines, emergency lines, emergency rooms, and urgent care centers. Yet, even if you can get to those places quickly, very often they don’t have a psychiatrist, psychologist, social worker — a person who might be extremely adept at handling a specific problem.
So, the role of virtual medicine in these instances is hugely significant because the ability to talk quickly to an expert is vastly expanded. That doesn’t mean that they’re going to get it right all the time, but it means it’s much more likely to have a better outcome.
If you have a group of people who have easy access to high value, high quality, highly qualified specialists in this field versus people who don’t, I think the first group is going to have better results than the second group. I think behavioral health, in particular, is an area where we can see a lot of people have better outcomes.
It’s about a virtual point of access for a person with a drug or alcohol problem in particular, as well as with other behavioral health problems.
It seems pretty simple to me that in the instance of behavioral health issues, if your choices are 1) work it out on your own, 2) go to a general health facility where there is somebody who deals with sprained ankles and coughs or colds, 3) do nothing, or 4) be able to connect quickly with a person who is a specialist — I want number four.
Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?
The most powerful thing a patient can have is access to is their health history. It is a benchmark for a doctor, or care provider, to assess the situation.
To figure out a diagnosis is a process of elimination. If someone has had a lot of weight loss, the person probably doesn’t have a malignancy, but sometimes they do. It’s not 100 percent true, but significant weight loss is almost always associated with cancer.
That is one example of how changes in health are indicative of health issues.
The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?
I tend to go back to the basics of people being informed about their health. So, what I am excited about and believe is most necessary in the near term is immediate access to patient information to make the right health diagnosis and treatment.
A lot of this can be solved with patient directed software — or programs that can collect critical bio stats — temperature, blood pressure, pulse oxygen, weight, resting pulse, and other important vitals. We are starting to see a lot of products coming onto the market that make this type of interaction possible. For instance, I just gave the example of a person who had a dramatic weight loss.
Another example would be an instrument to measure your pulse oxygen level — the percentage of oxygen flow to the extremities of your body. Here is why that is so important. A normal person typically has a pulse oxygen level of 97 or 98. If it’s 89, there is a serious problem — they’re not breathing right or their heart is not pumping right. Something significant is going on. And that’s a statistic that if I call a tele doctor today, they’re not going to know and I’m not going to know it either. So there probably is some device that is on the market now that would help solve that. But there has to be access and wide use to the device or technology.
One other thing just to follow up is that some people are definitely allergic to certain kinds of drugs. Some people are allergic to penicillin, for example. And they just may forget to tell the tele doctor. If the doctor prescribes penicillin, it could have disastrous results. Data can be lifesaving.
With access to the right data at the right time, the overall quality of telehealth increases dramatically.
Is there a part of this future vision that concerns you? Can you explain?
The main concerns will always be privacy and security. For consumers, privacy regarding health and finances are paramount in their lives.
If you could design the perfect Telehealth feature or system to help employers/employees in managing health, what would it be?
It would be what Uber is to ride share. Imagine rideshare without an integrated platform like Uber.
You would find the driver on Craigslist, use Google Maps to tell the driver how to get to the airport, get to the airport and then pay the driver. No one would do that. It is so complicated and chaotic. That is how I describe the healthcare system.
It’s all over the place. You can see a doctor, but if you want your drug delivered, you have to talk to your pharmacy benefit manager. And if you want to have the claim paid, it’s got to go through your insurance company.
We have made tremendous and breathtaking progress over the past 50 years in healthcare in this country — from vaccines, to cancer, to premature babies and so much more. Yet access is difficult, and the legal and economic infrastructure system surrounding it is complex and challenging for anyone to navigate. The incentives in our healthcare system are simply not aligned for all stakeholders involved and that needs to change. I envision a system where patients, providers and insurers are all working together to provide the best possible outcomes for the patient.
Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)
I’ll reference my meeting between the insurance company and our Member company. The insurance company noted they had created a high-value network that really was not a high value network. We need a healthcare system that rewards the best health outcomes at the lowest cost. It does not mean the cheapest doctors, it means the best, and most competent for the price. We need the right alignment of incentives. While I am optimistic we are on our way, we are not quite there yet.
How can our readers further follow your work online?
Health Transformation Alliance website
Thank you so much for these amazing insights. This was so inspiring, and we wish you continued success!