JEFF: Well, good morning, everyone. On behalf of the Mayo Clinic School of Continuous Professional Development, I'd like to introduce you and welcome you to the Mayo Clinic COVID-19 webinar series. I'm Jeff [INAUDIBLE], and I'll be your host for today's webinar on COVID-19 and the Rapid Transition to a Virtual Practice.

So today's presentation will be supported for 1 AMA credit. There are no relevant disclosures for today's discussion. And of course, we'd like to thank Pfizer for their support of this educational activity.

So before I turn it over to our moderator and faculty, I'd like to go through a few housekeeping duties with you. If you'd like to claim credit after the webinar, make sure you visit ce.mail.edu/covid0728 Now, after you go to the website, if it's your first time visiting, you may need to create an account. But once you've done that and you're logged in, you'll see that there's the access code box. And what we'd like you to do is type in today's code, which you can see at the bottom of the screen is COVID0728, and this will allow you to access the course, complete a short evaluation, and then you'll be able to get that certificate.

I'll also direct your attention to the bottom of your Zoom window today is we have two chat boxes. One is going to be the chat function, which you can use for technical questions that you may have for our behind the scenes staff. But we have this Q&A function. So if you have a question that you would like our faculty to discuss today, make sure you put that in the Q&A function. If you use the chat, there's a chance they may not see that. So please be sure to use the question and answer.

Now, there is an upvote system with that Q&A a box, so if you see someone else has asked a question that you'd like to have answered, go ahead and just give them an upvote. It'll make sure that that gets to our faculty and our moderator today. So our learning objective today is by the end of this discussion, you'll find that you'll be able to describe an advanced care model that delivers innovative, comprehensive, and complex care to patients. We'll discuss the role that alternative care settings play amid an evolving health care landscape.

And so our moderator today is going to be Dr. John Halamka, who is the president of the Mayo Clinic Platform. He'll be joined by Emily Wampfler, an interim administrator at Mayo Clinic Platform and a senior director in our Corporate Development; be joined by Dr. Steve Ommen, chair of the Connected Care Subcommittee, professor of medicine, and a consultant within our cardiovascular disease department; be joined by Greg Anthony, who is the associate administrator of the Mayo Clinic Center for Connected Care. And with that, I'm going to turn it over to Dr. Halamka to introduce our topic.

JOHN HALAMKA: Well, great. Well, thanks so much. And what a timely webinar this is as we look over the last 14 weeks and recognize, as we hear from our faculty today, that we have seen a sea change in the use of virtual care. When Emily and I and the Platform group put together a 2030 plan, we said, imagine 2030 when there's a cultural demand for care at a distance. And we've instrumented homes. And there's reimbursement waivers and regulatory change to incentivize remote care.

Well, guess what. That 2030 plan has become the 2021 plan. And we'll hear from Steve Ommen and from Greg about some more detail as to what transitions have happened in Mayo clinic practice, and how we've seen trends nationally. But let me start with just some high level comments, and then go into our advanced care in the home.

I think many of you probably had the chance to read Seema Verma's July 15 article on health affairs. And in that article, she does an analysis of Medicare and Medicaid claims for March 17 through June 13. And what did we find as a country in that period March through June?

Over 9 million Medicare and Medicaid beneficiaries received a telehealth service during this COVID crisis in those two months. In rural areas, 22% of beneficiaries used telehealth services. And that compared to about 30% in urban areas.

So obviously, today we'll be talking about inequities and digital divide and disparities of care, but it's fascinating that even in rural areas, you're looking at 22%. And much of that has to do with, what is even the definition of virtual care? So 1/3 of those beneficiaries that received virtual care did so on a phone, right?

Virtual care doesn't necessarily imply high speed internet connectivity and home monitoring, although that, of course, is necessary in some situations. Much of it can be store-and-forward or asynchronous or phone-based. And in this analysis, which admittedly it's two months, it's a singular Medicare-Medicaid data set, there was no significant disparity found across race and ethnicity in groups receiving telehealth services in those two months.

Again, we're going to talk about today about inequities quite significantly, because I think we needed to drill down on that. But that's just a brief summary of Seema Burma's article showing you the radical change in cultural expectations that have happened over the last 14 weeks. And one exemplar-- I'd like to take you through this case study of radical change-- is delivering acute care in non-traditional settings.

Sometimes we think of virtual care as, oh, I'm replacing a face-to-face visit with a FaceTime or a Zoom session. I mean, sure, that's one kind of virtual care. But what if you are an immunocompromised patient in renal failure with hyperkalemia? Well, that sounds to me like you need an acute care hospitalization in a bricks and mortar facility.

But as we've discovered in the Mayo Clinic advanced care in the home activities over the last month, there are many patients who actually really don't want to go to a bricks and mortar facility that is filled with patients who potentially have COVID-19. And so what must you do if you are going to deliver acute care, high intensity care at a distance in a nontraditional setting? Well, certainly, it has to start with expertise.

You have to define what patients are likely to benefit from such a service. What are the ranges of diseases, instrumentation, monitors you'll need? Are there certain patients with mobility issues that work or don't work? You have to think about all the factors of how to stratify patients, and what experts are needed to provide services.

Of course, there are going to need to be technology access, technologies placed in the home that will do remote patient monitoring, and video visits, and audio connectivity, and emergency response connectivity. You must make sure that you have care plans and partners that are going to deliver an effective service. And this is complicated, right?

So it's everything from supply chain. How do you get gauze to a home? How do you get meds to a home? How do you deal with what may be physical manipulation? How do you get appropriate services which have different levels of licensure, whether that's a paramedic, or a nurse, or a physician, into that home, sometimes in proximity to the patient, and sometimes at a distance?

And of course, there must be a level of reliability. A sort of silly example for you. I'm coming to you from Unity Farm Sanctuary where I have 250 animals, but 103 iterative things, monitors, spread throughout the farm. And Steve, do you know, at 4 AM this morning, the entire Nest infrastructure of the world went down? And therefore, I was unable to monitor animals visually, or look at temperatures, or exercise any of the controls for about a three hour period.

Well, that's fine if what you're doing is standard care for animals on a farm. Not so good if you're dealing with an acutely ill patient in the home. So it must be highly reliable. We need to engineer for that. Next slide.

And so when we think about the components here, I'm going to use a strange analogy. So I'm looking at Steve and Greg. In your lives, have you ever operated home security systems? You know, oh, there's ADT and there's various components.

Well, back in the '90s, these were all closed, proprietary, purpose-built networks where you couldn't swap devices or service providers, and everything was a one-off. Well, it's 2020. You're going to instrument a home. You're going to want standards-based, IP accessible, internet connected, platform-based approaches to these services.

You want to be able to say it's modular. And if I don't like one module, I can swap out another module. If I don't like one vendor, I can swap out another vendor. And so the advanced care in the whole model is creating this core platform of audio-video connectivity, emergency medicine connectivity, and device connectivity within curated technology in the home. And by curated, I mean it has to be reliable, it has to be redundant, it has to be backed up for things like a power failure, an internet failure, spotty cellular connectivity, and that sort of thing.

And then we know that we can't do this all alone, right? If we're going to do an advanced care in an alternative setting, it cannot be that Mayo Clinic is providing every staff member or every supply chain in every locality. And so think of this in a strange way as care B&B.

We're arranging the visit. We've got the care plans. We've got the logistics. We've got the connectivity. But then we would ensure that qualified local suppliers and providers are providing contracted services for some aspects of the care. So that's where you see curated in-home technology, core platforms, and local services connected to that open platform. Next slide.

Now, the care team, of course, is Mayo-based. We have a command center at the moment in Jacksonville, Florida, staffed 24/7, with patients and their families having direct access to the care center and the Mayo team. And that command center has 24/7 access to EMTs, nurses, the supply chain. We've even had to, of course, arrange for in-home medical meals.

And just in our early experience, this is how complicated this gets. We think about the whole patient. Now, we had a patient recently-- and don't worry, Emily, I'm not going to violate HIPAA in any way here-- who was quite acutely ill. But at the same moment, this patient's spouse was also going through an episode of illness, more of a chronic illness.

And therefore, when we had to arrange for home meals, we felt, in the interests of cure, we actually had to serve the whole family. We had to bring food in for the patient and the patient's spouse, and treat this episode of care as if it was a whole family episode of care. And so think about, again, the complexities of dealing with the patient and their families in an alternative care setting like the home versus a bricks and mortar hospital and all the logistics.

And I mentioned the word home, but it doesn't necessarily need to be the home. We've also admitted our first patient to what we call our care hotel. And really, to be honest, if you feel like you're going to be most comfortable in a setting like a hotel, why can't we deliver high quality medical care and instrumentation into a hotel room? And then the answer is, we can, and we've done it, and it's been successful so far. Next slide.

And so here are just, again, some of the components when you think of the logistics. Blood draws and stat labs; being able to deal with IV access; being able to provide any kinds of meds, both the supply chain and an administration; providing a variety of medical professionals of different levels of licensure, which can be PT/OT, behavior health nutrition, nursing, and paramedics. And on that point, one of the fascinating changes we'll talk about, I'm sure, in our discussion today is regulatory change and waivers that have enabled different practices in different locations than pre-COVID.

It used to be that paramedicine was, oh, I pick you up at your home and I transport you to a hospital. And my scope of practice is only in the ambulance and the hospital. Well, because of regulatory change and waivers, we can now deliver paramedicine services in the house.

And this is really changing the game, because we're seeing so many waivers in state licensure requirements that we do not require state level licensure for certain premises for care delivery. So as you can see, remote monitoring, local NP team, centralized MD/RN specialty teams, and all the physical work delivered by paramedicine. And next slide.

And this is our last slide. I just want to make sure you understand that the care delivery model in effect is Mayo-in-a-box. And that is, imagine that you are going to deliver care to a rural area for which fiber-based internet connections are not available. Well, although it's true, my mom, for example, lives in Southern California and has a pretty unreliable internet service. But she does have 4G LTE, 5G coming.

And so we have to be able to recognize that you need to deal with all types of power and connectivity requirements, providing remote patient monitoring systems that function over a 4G LTE modem, with a backup power system, and allow patients and families and doctors all to communicate, and emergency medicine to be summoned should the patient be compensate, and ensure that we have appropriate monitoring of vital signs-- so pulse ox, blood pressure, pulse, and the like. And so this package of certified electronics is delivered to the home and installed by what potentially could be a third party installer, and then connects back to Mayo Clinic, enabling it to scale across the country.

So there's the brief view. We have been in pilot in our Florida location this month. We're going live in our Northwest Wisconsin location on August 3. And we've also helped out Kaiser and Tufts and others with this activity, and are going to be expanding it across the next year to nation scale.

So one case study, one examplar of changes in virtual health that were accelerated by COVID-19. But hey, let's go to our panel now, because I know we have a series of questions already queued up. And so let me start with asking the group, do you think digital practice will endure after the pandemic? And how can we work to help non-adherent patients to properly stay on treatment?

So I imagine, Steve and Gregg, Center for Connected Health, you have opinions on that one.

STEVE OMMEN: We do. Thanks, John. Great introduction. And maybe just by way of starting, I'll explain to those of you who have joined today's webinar what the Center for Connected Care Connected Health is at Mayo Clinic, because what John just described, the advanced care at home, is the evolution of that. And what we do in Connected Care is our team is responsible for the patient portals, their digital front door to Mayo Clinic.

We're responsible for curating the video visits that people may have in their own homes or offices with their providers. Our team also builds out the acute care telemedicine activities, like telestroke, tele-emergency medicine, teleneonatology. And our team runs the remote patient monitoring activities with a less advanced care solution than what John just described. But this is allowing patients to have physiologic monitors in their homes, with the data uploaded to our cloud, our centralized nursing pool who can look for patients who are starting to veer from their expected recovery or health journey, and then can intervene on those patients sooner to keep them at home and healthier.

And so it's a broad portfolio of activities that we have built going back for a long time, but specifically over the last five years, building out the suite of products so that the Mayo Clinic team was ready to turn this on and use it when the platform began to burn in February and March, and the COVID pandemic started. So we have been anticipating that digital health care solutions will be the wave of the future. This current public health emergency has totally put the need in front of all providers.

And to the question, I do think that digital health care solutions will endure following the public health emergency. I think that we've seen that across the country, and at Mayo itself, there was low utilization of these services prior to March 1. And then a rapid adoption, almost complete conversion of face-to-face activities to almost complete virtual activities.

And now we're seeing that curve start to come down again to where, nationally, it's kind of settling out. About 20% of interactions are now going on virtually. I think we will see that slowly start to rise, because what we've all done, all medical centers have gotten their feet wet with this. They've gotten some experience.

And now everyone's trying to figure out, now, how do we do this even better? And as the business cases, the value cases for these activities are built, there'll be higher adoption. And then last comment, and then I'll see if Greg wants to make anything.

I also think that patients are going to demand that these services are available. They've now gotten a sense of what it feels like to get care remotely, and they're happy with it. Our patient satisfaction scores are tremendous for the virtual care they've had delivered.

And people are going to want to get their health care just as conveniently as they can do their banking and travel planning and grocery shopping online. Health care online with trusted providers is going to be what we need to deliver. Greg, what would you add?

GREG ANTHONY: I think there's only two additional comments, I guess, that I would add. And I would echo everything that Steve has stated. I think one of the first is that through this rapid deployment and experience that our care teams have had, we are now seeing care team members who previously really didn't express interest now have a little bit of experience, and they're conceiving new use cases that we can apply these technologies to for the future.

So I think we're going to start to see an uptick of even alternative use cases that maybe haven't been explored in the past in the very near future. I think one of the factors that is unknown for all of us here within the States is going to be, where will the regulations, where will the payers land post-COVID when some of the easements in the regulations, potentially nationally, would roll back? But we know there's discussions in this arena, with the hope and intent and desire that regulations will retain some type of easement to enable these services going forth in the future.

JOHN HALAMKA: And Emily, I know you had a comment.

EMILY WAMPFLER: Yeah, I think specific to the advanced care at home model, because it is high acuity, when we launched we were nervous. Pre-COVID we were nervous how it would be received by patients and their families. But the one positive thing about COVID is because of this acceleration, everybody who's been in the program loves it.

And we hope that continues. And I think when we go forward and think about telehealth, it is just another option for patients that it would be really hard and difficult to take away from them. If I think about how I text on my phone today, and how I did 10 years ago when I had to press the number 3 button three times to get to the E, I don't want to go back to that. So I think there's going to be a certain number of patients who really like these new options and won't want to go back to previous ways they had care.

JOHN HALAMKA: I think that's well said. And so the American Telemedicine Association hashtag is don't roll back. And certainly there is a great movement across patients, providers, payers to continue this. And in my conversations with [INAUDIBLE] and CMS leadership, I have been told directly, there is no intent to roll back the regulations or waivers that have been put in place during the COVID period, because as Emily just said, the patients are demanding it. It's been a cultural shift.

But here's an interesting challenge for us. How do we decide what patients are going to benefit from what service? So again, my mom is almost 80. And I say, hey, Mom, wouldn't you love a Fire-based JavaScript object notation data-based patient stewardship with real time, three-way audio and video teleconferencing? Of course, she says, like, I don't know what you're talking about.

And so you say, oh, well, does a patient require a certain level of technology experience or comfort? Do they require a certain level of education or literacy or connectivity, or is it triaged purely based on level of illness, mental status, mobility? And so many factors to consider. So I open it to the group. What do you think is going to be a successful remote patient or virtual visit? And what characteristics do we triage?

STEVE OMMEN: Yeah that's a really good question, John. I think that, to your point, you don't want any of the patients to worry about all of that ITEs that you just regurgitated at us. But we want them to have it as easy as their smartphone.

I mean, there are portions of this country and the world that have no infrastructure, but everyone has a smartphone and knows how to use it. So our mission, when doing these things, is to develop tools that are that simple to use, so patients don't have to understand whether they have Fire or 3G or cellular, or whether it's interconnectivity between the various platforms. They just want it to work when they launch it.

But I think to the point of which patients are best served by this, I think we're going to learn a lot of patients will be served well by this. It will depend on the situation for which they're being evaluated. For instance, someone who has a new mass or a lump, maybe you can look at that, but ultimately, someone's going to need to feel that. That's not a great use case for virtual medicine.

But someone who has longstanding heart rhythm difficulties is an ideal person for this, because we can monitor their heart rhythm anywhere in the world with the current technologies. We can use AI to process those signals and predict if that person's course is accelerating or decelerating. And then if so, escalate that care to their care team to help them change their course.

I think that one of our philosophies has been that the first time you meet someone, it probably needs to be as rich of an experience as possible. So that has traditionally been face-to-face in the same room. I think video offers a great opportunity to still build those relationships the first time.

But if you're seeing a patient who's got a chronic condition, and you have a great relationship with them, you and that patient may have such a good rapport that you know that you can do it by phone, or you can do it through asynchronous secure messaging within your system's EHR environment. And so I think that we need to learn to use these tools in medicine, just like we all do socially. The analogy I've used before is that every time one of us these days wants to make dinner plans with friends, pre-COVID, it started off as a text.

And as soon as it got complicated, then someone got on the phone. We need to be able to shift the modality that we're interacting with our patients based on the need that's present in that moment. So if you start off with a video call with someone, and someone's network goes down, well, don't get flustered. Switch it to a phone call and complete what you can that way, and then recover.

Or if you started off with the messaging and the patient came back to you with a list of 10 or 20 questions, that should be your signal, this person needs more direct attention. Let's set up a time to have a dialogue rather than a text exchange. So we have to get comfortable in flexing back and forth in communication channels with this.

JOHN HALAMKA: Well, I think well said. And Emily, maybe you could comment on, as we admit patients into our advanced care in the home, there's absolutely a process by which we assess the suitability of this technology for the patient, but also for the patient's home setting.

EMILY WAMPFLER: Exactly. We do a home assessment to make sure that their home setting is appropriate for that level of care. Now, I think that gets into the interesting aspect about health equity as well and why we have explored other sites. Because if the home isn't safe or isn't the right setup to deliver this form of care, is there another place where they can still have that option?

So I think we're just starting to understand the new data types that we probably historically haven't captured that may need to start capturing to understand, what are the right options for patients beyond just their clinical presentation, but what is their technology preferences? Are they technology literate? What are their technology home setup? And we may need to capture that so we know more quickly, what is the right option for this patient?

JOHN HALAMKA: Greg, any comments you would make on the, how do we ensure the right virtual technology and process is used with the right patients? You're on mute, Greg.

GREG ANTHONY: I'd come back to the basics of just understanding what that particular situation is for the patient, and put it in a context of their condition, clinically, what is needed, or the appropriate type of care. But then what are those capabilities of the patient? So I'd come back to those basics.

JOHN HALAMKA: That makes great sense. So really, all you're referring to is the social determinants of health is just as important as the screening of the physical location of the home and the medical conditions. And we have to put all this together in our evaluation. Which brings us to this next question, which Emily has already raised, which is, what do we do about disparities and inequities, and ensure that these technologies of virtual care are available to all, regardless of income, education, literacy, et cetera?

And here's a quick just comment for you to start the discussion. I think, Steve, you've probably heard me tell this story. But about a year ago, a major Silicon Valley company sent a number of engineers to Boston and said, we really want to go look at a Medicaid clinic and understand what might be some of these challenges.

And some 28-year-old engineers in our Medicaid clinic went up to a homeless gentleman and said, so what's your favorite wearable? And he said, socks. And it was very clear that these engineers were not meeting the patient at the level of the patient's technological literacy. And so what are we going to do to ensure these technologies and these techniques are equitable and evenly distributed? Welcome comments.

STEVE OMMEN: Yeah, great question again, John. So a couple things. I actually think that these digital solutions actually break down some of the disparity barriers in certain ways. So for instance, there are many people who weren't seeking care in the traditional model because it meant they had to stop their life in order to come to our bricks and mortar building to sit with us and then get testing done.

And now they can pause for 15, 20 minutes and have a conversation with their provider by video or by phone, or they're wearing a device that they know is being monitored. And so they are going to have access to care that they previously couldn't avail themselves on because they're working multiple jobs, they are a single parent with multiple kids they're trying to manage. All kinds of barriers to even coming into our facilities are now open to them in a much more reasonable way.

I do think that you're right. There are portions of this country, there are portions right around where I'm sitting today in Minnesota that don't have great broadband access. That is a disparity. And we've been actively working with the FCC trying to figure out how do we make sure that every person in this country has access to these services if this is the new normal. If

They don't have the right devices already, how do we make sure that for an episode of in-home monitoring, or advanced care at home, that they have the right equipment? And I think that's why the teams that Emily is working with and our teams are working with these tools need to make sure they are as user friendly as possible, and that we can deliver them to the patients when they don't have those services themselves. And I think it's going to be an ongoing, constant state of change and evolution to make that happen in the best way possible.

EMILY WAMPFLER: Yeah, I would just add to that, put an emphasis on that last comment of a constant stage of evolution. I think it's hard to predict how this technology will be used in the future. We've had multiple experiences where technology can be a force for good and also used for not so good. So I think it will take some close monitoring of how the technology continues to be used, and to gather the information to know which populations are benefiting and which ones might not be.

JOHN HALAMKA: And Greg, any comments?

GREG ANTHONY: No, I think it was well stated. I think one of the examples Steve has cited in the past is it gets even to the payer side of the equation, whether it be a government payer or otherwise. And the barrier of just, we'll provide services in a rural setting but not in an urban setting. And so I think it's going to take all parties involved in the delivery of care-- payers, providers, patients, technology companies-- to work on this together to really make it work for all.

JOHN HALAMKA: And Steve made an important point in that some of these virtual care technologies will actually enhance access. And let me give you a quick example. So it turns out that I happen to be in Boston right now where there are more MRI machines than Canada. I have 10,000 specialists within a five mile radius of where I'm sitting.

Now, imagine that you need high quality cancer care and radiation oncology planning in rural Montana. Well, how many academic medical centers can you drive to in an hour? None. So one of things Mayo Clinic has thought about as we think of the spectrum of virtual care-- this will also include AI, autonomous chatbots, a whole variety of technologies-- is we're working on the capacity to do radiation oncology contour planning at a distance.

So you go to a-- well, it could be a critical access hospital, as long as they have a linear accelerator. We can program all of that remotely and deliver the same care you'd get in a Mayo facility in a rural location. And so I think there's all kinds of interesting examplars of what virtual health will become. We'll increase the access to specialty care and expertise and algorithms at a distance.

Then next, what kind of actions could be made in health care to assure inequities are addressed for the future? And let me just start with one idea. Because we've already talked about this theme a bit.

There is a New York based company-- remember, no conflicts of interest. I am not endorsing any company or service here-- called Unite Us. And Kaiser has outsourced their social determinants of health management to this particular company. And what do they do?

Well, they recognize that a large component of wellness is what you eat, who is in the household with you, what are your transportation options, where do you live, do you have an internet connection? So it's this theme that all of us have been talking about, is that it's not exactly part of the medical record today if you have reasonable internet connectivity. But Unite Us as a service goes out to the home and makes this comprehensive assessment to understand if there is a lack of access.

Maybe as Emily said, it's better for a health care provider to pay for you to get internet access than to have you visiting ERs multiple times and not dealing with wellness and preventative care. So certainly, Kaiser, which has payer and provider components, companies like Geisinger, all these other kinds of systems that are aligning total medical expense and quality and outcomes, are going to be much more interested in the reduction of these inequities and social determinants of health. But other comments?

GREG ANTHONY: So from my perspective, one of the things we tried to look at as we look across the digital solutions is really, what ultimately is that patient's journey? But I think we need to broaden that further. We sometimes forget and focus in around just our components of their life that they touch.

But I think whether it be vendor companies, others, we need to look holistically at the people, the patients, not only for the care that they need, but what are those other factors of their life that influence that? And I think so often we all focus in our narrow domain. And we need to sometimes step back and look more holistically about the needs of the patient and what influences what component. But that's something all of us can do from the various angles that we may be approaching this particular topic.

JOHN HALAMKA: Great. Well, thank you for that. So next we have a very interesting and specific question, for which I imagine there's going to be a variety of commentary. Can you speak to home prenatal care and home fetal monitoring?

So let me start off with actually taking that up to a more general question. I've spent a lot of time in the last few years in Israel, with Israeli entrepreneurs, as part of a Boston and Israel innovation accelerator. And there are companies in Israel that are creating a whole variety of new instrumentation for patients.

And so one simple example is your five-year-old woke up with a fever and an ear pain. Oh, what does that imply? Oh, I have to go to a pediatrician's office.

Well, what if you had $100 kit in your home that would enable a high resolution tympanic membrane photograph to be taken by a totally unexperienced parent, because it uses some augmented reality to put an otoscope equivalent camera on the ear, or eye, or throat? There are companies creating wearable ultrasound or echo devices, right? Huge numbers of new sensors are coming online.

And I know Mayo is involved with a company that is working on remote fetal monitoring technologies, fetal heart rate monitors, and a whole package of prenatal care at a distance. But comments the group would make on these evolving sensors, and specifically around prenatal care.

STEVE OMMEN: Well, I don't have any specific comments from prenatal care other than this exemplar for nearly every specialty will have use cases where a monitor that a patient has with them all the time can enhance the care team's ability to react to changes or questions they get from the patient. So fetal heart tones or fetal heart rate would be one of them. And if you're someone who has had part of your colon removed and you're having-- the first time in your life you have an ostomy, understanding your ostomy output is a use case that someone wants to deal with.

Again, if you're a heart patient, and you-- my blood pressure and heart rate are going to be important. Every specialty will have these things. If you're recovering from orthopedic surgery, your range of motion of your just recently replaced knee is going to be monitored by a physical therapist in the future to know whether you're meeting your rehabilitation goals.

And the companies are too numerous to name, as you know, John. They are rapidly developing these tools for every condition you can imagine. And sometimes they're inventing sensors for which there's not a problem yet, and they're trying to find problems to solve with those sensors.

And I think, then, the next wave of all these sensor devices is going to be-- and there's some questions in the feed there I see regarding use of AI and machine learning to process the vast dataset that we'll get from all these devices to start to be predictive on what, oh, this is a person who's not going to do well because their parameters today are saying this. And we know that 10 days from now, that's what that's going to mean in the future, I think that we are just barely dipping our toe in the water of how we're going to be able to use the data and predict patients' course going forward.

JOHN HALAMKA: And so very well said. One of my colleagues, Michael Seres, created a company in the UK called 11 Health. He recently passed away. He termed the company 11 Health because he had 11 different cancer episodes in his life.

And he was an ostomy wearer. And what he recognized is that ostomies are very problematic. They leak, they fill, they have gas pressure. So he said, why not have an instrumentation of your ostomy bag, and then notification before you get a leak, or it's full, or you get over accumulation of pressure?

And so that's what the company has done. So you're seeing this, as you say, over and over and over again in almost every domain. But Emily, Greg, any comments you'd make?

EMILY WAMPFLER: I just would say and echo Steve's comment that there is a lot out there. And that's actually one of the challenges is to understand which are the ones that are going to actually have a beneficial use case. And then when there are multiple options, how can we ensure that the data streams coming off of those multiple options can be aligned in some way, so when a patient maybe shifts to a different device, the data can still be compared against each other?

JOHN HALAMKA: And of course, this will be our, I imagine, the next year to two of work, Steve and Greg, is figuring out these open platforms for receiving remote patient monitoring of all kinds. As you say, then orchestrating its delivery to AI algorithms, its interpretation, and its response. Greg, any comments?

GREG ANTHONY: Yeah, I think the open platform is going to be a key element, as you stated earlier, just getting everything connected. So I think that is going to be critical going forth for us to really optimize and move more quickly in the space.

JOHN HALAMKA: Now, here's a controversial question, which is, of course, at Mayo, the patient comes first. We do everything for the patient. But as we change the entire health care system, we do have to recognize that this virtual care will have an impact on our providers. Our providers workday and cadence, their emotions and their stresses.

And so the broad question is, how do we see virtual care impacting our providers? And in fact, are some providers saying, aha, I can no longer lay hands on, and therefore, I feel I am disadvantaged because I can't palpate the mass or do a physical exam?

STEVE OMMEN: Yeah, John, I think-- I mean, provider burnout is already a hot topic in this country and elsewhere around the world before this pandemic hit. I think that virtual health can both help ease that and contribute to it. I mean, you've all heard about or read about Zoom fatigue, because we've forgotten that when we were in physical meetings we had an opportunity to walk from one meeting to the next, and run into someone in the hallway and have a brief interaction, which is resetting and recharging and a mental health break.

And now what we do is we hit Leave Meeting, Start Meeting, and we don't move. And so I think there's going to be burnout just from that technological activity. And we're going to figure out the models and a calendar to help people stay physically and mentally healthy. Job satisfaction from delivering care virtually, I do think it will be, some providers are going to find it not being as fulfilling as sitting in a room with someone and having that conversation and that rich discussion there.

Others are going to find this more rewarding. They'll be able to see more patients in a more convenient way. If they are a hyper-specialist in something, they can now extend their hyper-specialization far broader than the number of patients who could travel to them. So there's going to be gives and takes that we're going to have to learn, but I do think that we will have to learn how to create a day in the life of a provider in a virtual world that is going to be slightly different than it was in the day in the life of a provider in an office setting.

JOHN HALAMKA: And I think you could argue that we're going to need different tools. And the different tools would take different forms, such as if you give a doctor who is already at the edge of burnout 10,000 new remote patient monitoring streams to examine every day, they will quit. So it's raising to the clinician those events that require interpretation and action.

And that requires AI and lots of filtering technologies. And recognizing that charting is going to be different. And new tools and technologies that get that telehealth visit recorded, documented, and in a way that's appropriate for Medicare regulations and billing, but is probably less administratively burdensome than the way we document today. So as you say, many elements to this. But Greg or Emily, any comments on the provider side?

GREG ANTHONY: I think one of the things, and Steve has gotten to this in his remarks, but again, as we talked before about understanding the patient's journey, it's the provider, the care team's journey. How do you dovetail these digital interactions in with other interactions throughout the day? So their workflow.

I think too often we've seen in the past where solutions are layered on top of things without a concerted attempt to actually integrate it so it becomes efficient. And then people are more willing to want to use it, because their personal experience is critical to how they view this. So we've got to look not only at the patient experience, but we also have to look at the care team experience and set it up in the way for success.

JOHN HALAMKA: And Emily, maybe you can comment on this related question, which is, we were asked in the Q&A box, so if you've got a care team sitting in a command center, just how many patients can they care for simultaneously while delivering high quality, safe care, and avoiding the kinds of burnout or fatigue that Steve and Greg have talked about? I know you and I have had a lot of email traffic with AJ on that question.

EMILY WAMPFLER: Yeah, that's a great question. I think it may differ between providers and the patients that they're seeing. And it certainly differs on the role of the provider.

So someone that is having more interactions with the patients on the nurse side of things, where you need to be doing maybe some daily video consults, that person can probably manage six, maybe up to 10 patients. 10 might be getting a little bit high.

If you're a physician and only interacting with the patients maybe once a day or just providing oversight, you can manage a higher patient load, perhaps up to 10 to 15. We're still rightsizing our own model of care here. We're just scaling, so we're trying to find that right balance.

JOHN HALAMKA: Right. And so I think the fair answer to this is, we're learning.

EMILY WAMPFLER: Yeah.

JOHN HALAMKA: It's a work in process. I've heard numbers, such as the Florida command center could have 60 inpatients being cared for simultaneously, given the infrastructure and staffing. But we'll be learning over the next couple of months.

And then here's a question. Outcomes. So Steve and Greg, have you, in this last 14 weeks, been able to figure out as we move from 4% virtual to 94% virtual, if there's a change in outcome? Anything that we're doing better or worse?

STEVE OMMEN: Yeah, that's a great question, John. I think that we do have data, even before the pandemic started, that in-home monitoring of patients who are at high risk for decompensation and hospitalization, that having monitoring, a monitoring system monitored by nurses trained with that system, and having providers supervising those nurses can reduce readmissions by up to 50% at 30 days. And that's going to be big cost savings for the hospital systems.

In this current environment, the more people you can keep out of the hospital, the less likely we're going to get in the situation where we've seen hospitals overrun with patients. So we do have data in that regard. I think we don't yet have the outcomes on all of those patients that we saw virtually in March and April and May who maybe were deemed they needed to have an operation performed, who are now coming for that-- are there differences in that outcome? We'll probably get that data over the next quarter, two quarters of time to see that.