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Page 1: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Patient Centered E-Visits

Seth Bokser, MD, MPH

@SethBokserMD

Associate Professor and Associate Chief Medical Information Officer

University of California, San Francisco

Page 2: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Conflict of Interest

Seth Bokser, MD, MPH

Has no real or apparent conflicts of interest to report.

Page 3: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Learning Objectives

• Define e-Visit and virtual care

• Understand the drivers for the exponential growth of e-

Visits. Consider where the market may be going in the

future and what that means for you and/or your

organization

• Consider a framework for increasing satisfaction,

appropriateness, and outcome of virtual care.

Page 4: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

The E-Visit: A New Age…Finally

Page 5: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

http://www.himss.org/ValueSuite

Where Medicine Lived

Office Visit Institutional Care

Page 6: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

http://www.himss.org/ValueSuite

A Whole New World

Office Visit

Assisted Living

SNF

Hospital

ICUs

E-Visits

E-Visit E-Consult Telemed

Page 7: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

http://www.himss.org/ValueSuite

E Visits Definition (Broad)

E-Visits

E-Visit E-Consult Telemed

= Virtual Care

"evaluation and management

service provided by a

physician or other qualified

health professional. . .using a

web-based or similar

electronic-based

communication" AAFP

Page 8: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

http://www.himss.org/ValueSuite

E Visits Definition (Narrow)

• Non Face-to-Face

• Asynchronous

• Structured Questionnaire

• Non-Urgent

• PCP only

• Secure/Portal

Page 9: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Ohio Health. http://bexleyprimarycare.com/getattachment/Our-Services/E-

Visits-and-Video-Visits/E-Visit-Step-by-Step-Guide.pdf.aspx

The Spectrum of Virtual Care

Page 10: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

The Spectrum of Virtual Care

Page 11: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

The Spectrum of Virtual Care

Page 12: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Growth of Virtual Care

Page 13: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

What’s Driving E-Visits: “Liquid Consumer Expectations”

13

Page 14: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

What’s Driving E-Visits: “Liquid Consumer Expectations”

Page 15: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

What’s Driving E-Visits? Value-Based Payments

Page 16: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

What’s Driving Exponential Growth of E-VIsits? Consumerism

Kaiser FF / HRET Employer Benefits Survey 2015

Page 17: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Traditional Fee-For-Service Reimbursement Coverage Growing

Page 18: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Traditional Fee-For-Service Reimbursement Coverage Growing

E Visits (narrow definition) CPT code 99444

• Established in 2008

• Medicare and Medicaid Still Do Not Pay

• Private Insurers by Special Contract

• Patient Willingness to Pay

Page 19: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Supply can meet demand: Gig Economy

Page 20: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Clinician Supply can meet demand: Gig Economy

Medscape Physician Compensation Report 2015

Carol Peckham | April 21, 2015 http://www.medscape.com/features/slideshow/compensation/2015/public/overview

Page 21: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Clinicians more comfortable with technology: EHR Uptake

Office of the National Coordinator for Health Information Technology. 'Office-based Physician Health IT Adoption,'

Health IT Dashboard. http://dashboard.healthit.gov/dashboards/physician-health-it-adoption.php. October 2014

Page 22: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Creating a System of Patient-Centered Virtual Care

Page 23: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

E-Visits for all: Bridging Disparities

Page 24: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Patient Centric e-visits: Design Beyond the EHR Portal

• Web-Based

Access

• New User

Interface for

Patient Forms

• < 1 Hour

Response Time

Results = 188 visits per month to >250 month

Butcher, L. Patient Friendly Evisits Improve Access. Feb 2014. http://www.hfma.org/Content.aspx?id=21982

Page 25: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Patient Centric e-visits: Invest in Support

Page 26: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Online Virtual Care is Your Front Door

Page 27: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Patient Centric E-Visits: Limit admin/compliance documentation

"Of course we need to hold professionals accountable. .

. .We are hitting the targets but missing the point."

-Bob Wachter, MD NY Times Jan 16, 2016

Page 28: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Even the most empowered consumers need experienced partners

Page 29: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Even the most empowered consumers need experienced partners

Page 30: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Even the most empowered consumers need experienced partners

• ± 250,000 Employees

transitioned to high

deductible plan

• Median Income

$125,000 - $150,000

• Spending dropped

13% annually

• Demand dropped for

both expensive lab

and imaging tests &

for high-value

preventive services

e.g., mammograms

and colonoscopies

Brot-Goldberg ZC. What Does a Deductible Do? The Impact of Cost-Sharing on Health Care Prices, Quantities, and Spending Dynamics (NBER Working Paper No. 21632) Oct, 2015

http://www.nber.org/papers/21632
Page 31: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Patients and families need more information

• 46% of healthcare professionals say that

they will introduce mobile apps in the

next five years. (16% are prescribing)

• 86% believe that health apps will

increase their knowledge of patients’

conditions.

• 72% believe that health apps will

encourage patients to take more

responsibility for their health.

ResearchNow 2015. http://research-now-

study-are-mobile-medical-apps-good-for-

our-health.pdf

Page 32: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Evidence for what mode of care is safe and effective?

Page 33: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Patients and families need help navigating the care spectrum

https://myupmc.upmc.com/anywhere-care/

Page 34: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

It is about you. . .but it’s not just about you

Page 35: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Patient Centric E-Visits: Balance Consumer Directed Care with Public Health Interest

Uscher-Pines L, Mulcahy A, Cowling D, Hunter G, Burns R, Mehrotra A. Antibiotic Prescribing for Acute Respiratory Infections

in Direct-to-Consumer Telemedicine Visits.JAMA Intern Med. 2015;175(7):1234-1235. doi:10.1001/jamainternmed.2015.2024

Page 36: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Patient Centered and Population Centered

Page 37: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Patient Centric E-Visits: Transaction versus Relationship

Page 38: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

http://www.himss.org/ValueSuite

Patient Centric E-Visits: Information Continuity

Click to add text

Bobinet K, et al. ONC White Paper Designing Consumer- Centered Telehealth and E-Visit Experience

https://www.healthit.gov/sites/default/files/DesigningConsumerCenteredTelehealtheVisit-ONC-WHITEPAPER-2015V2edits.pdf

Page 39: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

E-Consults

Cardiology

Endocrine

Endocrine

Nephrology

Sleep Medicine

GI

Urology

CK

D

COPD Diabetes

@GleasonMD

Nathaniel Gleason,

MD

Page 40: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Results: eConsult Value to PCP at UCSF

42 12/4/14

This eConsult response influenced my care plan:

N=101

Strongly Agree

Somewhat Agree

Page 41: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Results: Specialist eConsult Time at UCSF

12/4/14 43

How much time did you spend on your eConsult response?

N=121

<10 Minutes

10-20 Minutes

Page 42: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Empathy and Relationships Matter

Page 43: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Relationships Matter

Kelley, J. M., et al. (2014). The

Influence of the Patient-Clinician

Relationship on Healthcare

Outcomes: A Systematic Review

and Meta-Analysis of Randomized

Controlled Trials. PLoS ONE, 9(4),

e94207.

http://doi.org/10.1371/journal.pone.0

094207

Page 44: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Relationships Matter to Doctors too

http://www.medscape.com/features/slideshow/compensation/2015/public/overview

Page 45: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Relationships can be built and sustained both in-person and online

www.humanizaingmedicine.org/infographics

The Arnold P Gold Foundation

http://www.humanizaingmedicine.org/infographics
Page 46: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Patient Centric E-Visits: Nourishing Therapeutic

Relationships

• >144 Pain and Palliative

Care Telehealth visits

• Patient Satisfaction (4.9/5)

• Provider Satisfaction (4.9/5)

• Reimbursement = clinic visit

• Time Saved (Average 5

hours per family!)

Dr. Cynthia Kim

Page 47: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Chief Complaint

Medical History

Family History

Medications

Genomics

Exposures

Content Email E-Visit E-Consult Telehealth Visit

Access/Decision/Triage

Artificial Intelligence, Optimized Workforce

Continuous,

Bid

irectional

Diagnosis

Treatment

Education

Listening

Therapeutic

Relationship

Economic incentives, reimbursement, social policy/safety

nets align to support growth

Inte

ropera

ble

EH

R

Page 48: Patient Centered E-Visits - HIMSS20 · Patient Centered E-Visits Seth Bokser, MD, MPH @SethBokserMD Associate Professor and Associate Chief Medical Information Officer University

Thank you

Seth Bokser, MD, MPH

[email protected]

@SethBokserMD


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