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Episode Teaser // Jessicca Moore, Petaluma Health Center (guest): ...I think that there are so many pressures in primary care on providers and staff that if the platform is not extremely easy and extremely intuitive, you're just never going to get the uptake. And from the patient perspective as well, you know– “If I have to download another app to do a different thing with another password and another user...” Everybody's just sort of full with that kind of thing, even those of us that are very digitally literate, so it has to be easy, as effortless as possible. Health Pilots podcast intro:
Welcome to the Health Pilots podcast presented by the Center for Care Innovations. This podcast is about strengthening the health and wellbeing of historically underinvested communities. Every episode offers new ideas and practical advice that you can apply today!Jessica Ortiz, Center for Care Innovations (CCI): Hello, everyone. I'm Jessica Ortiz with the Center for Care Innovations, and today we're talking about one of the exciting projects that Petaluma Health Center has been working on for about the past year. Our hope is that by sharing the highs and lows of this digital health solution, safety net organizations can apply the lessons learned to their own challenges. I'm here with Jessicca Moore, member of our Tech Hub Learning Network, which is comprised of 14 tech-forward, California-based community health centers, clinic coalitions, and primary care departments in county health systems that are working to accelerate the adoption of innovative technologies. We partner with our Tech Hub members to vet, pilot, evaluate, and spread innovative digital health solutions serving Medicaid markets and historically under-invested communities, and we are excited to bring you this story today. Jessicca, it’s great to have you on the call today. Could you start by introducing yourself and letting folks know a little bit about you and your organization? Jessicca Moore, Petaluma Health Center (PHC): Sure. So my name's Jessicca Moore. I'm a family nurse practitioner and Director of Innovation at Petaluma Health Center. Petaluma Health Center is a federally qualified health center and it's in southern Sonoma County. We have sites in Petaluma, Rohnert Park, and we recently expanded to West Marin County. We have about 40,000 unduplicated patients, and about half of those have Medi-Cal Insurance. Jessica Ortiz, CCI: Thanks, Jessicca. It's great to have you. So I'm just going to jump right into this. I know today we're we're talking about telehealth and how Petaluma is approaching that. So how did you get started? What was the problem that you were facing and how you decided to make this transition? Jessicca Moore, PHC: Sure. So early in the pandemic, we just started with the platform that we had for telehealth. So eClinicalWorks is our EHR and they had a telehealth module. So we said, "Well, that's what we have, that's what we'll use." We pretty quickly learned that there were some significant limitations and challenges, both on the patient end and on the provider and staff end. So, we were looking for, "Okay, what's our next pivot? What's our next best thing?" We use Cisco Webex and Webex Teams in our organization. And in talking with our IT department and informatics and kind of looking at the different options, we said, "Well, we have this and we use it internally. It looks like it has the capability that we need for telehealth, so let's do that." So we piloted that and then launched it widely within the health center. It worked better than eClinicalWorks, but there were some persistent challenges. So about a year ago we took a step back and said, "Okay, we've been really pushing this for a year and a half now and we're still not getting the kind of uptake that we want. There's still too many barriers, both on the patient end and the provider/staff end. This is far from an effortless experience. What can we do differently? Is there another platform?" So we had been using Doximity for our audio-only calls for quite some time, since early in the pandemic, but we hadn't experimented with the video calls. That wasn't a part of the offerings initially, and then we realized it was actually included in our plan. So we'd actually been paying for it for a while and hadn't been using it so we're like, "Well, we should at least try." So Dr. Oryn and I initially piloted it with some of our patients and were shocked at how simple and effortless it was, and we felt really silly for not trying it earlier. Jessicca Moore, PHC: So the thing that makes Doximity really nice, both on the patient end and the provider end when you're talking about video telehealth, is that there's absolutely no setup that's required on the patient end. So with Zoom, with WebEx, with a lot of these different telehealth applications, the patient has to either have it on their browser on a laptop or they have to have an app. When we were trying to get patients to download the app on their phone, a lot of patients didn't have enough space on their phone to download it, they didn't know their password to get apps, and it all just took time. There was way too much set-up, and so patients would quickly say, "You know what? I don't want to do a video, just let me do the phone." The other thing that was challenging is that there had to be a unique link sent ahead of time; there wasn't a place to connect that to the EHR or to send out in real-time easily. So with Doximity, it allows us the flexibility to go between phone and video on the same call effortlessly. So I can start a call with a patient on the phone and then say, "You know what? I'd really like to see what you're talking about on your toe," or whatever. They made the appointment for a diabetes follow-up, and maybe that would've been fine as a phone visit, but now you're talking about something else that's going on, and I'd like to see that. So within the phone call, I can just push a button that texts them a link that they click on. Again, no downloading of anything required. They click on the link, “allow video,” “allow audio,” and, without ever hanging up - it's transitioned into a video visit. So patients love it. There's been such little resistance to patients across all demographics, our monolingual Spanish speaking, our elderly patients. As long as somebody has a smartphone, there's really no barrier to it. The instructions on the patient end are from Doximity, it reads what language your phone is set up in and it communicates the instructions for the patient In that language. They have over 20 languages that they're communicating the instructions. So, that's been really, really nice and it also takes some of the pressure off of our staff. So while we were trying to get more patients engaged in video visits, we were asking staff to do a lot of selling of the video visit. And then you have to get people set up and download this thing, and it wasn't really realistic for somebody in our call center who's managing hundreds of calls a day to also be expected to say, "Oh, let me tell you about the benefits of a video visit. And this is what you have to do to set it up." We had tried getting some volunteer staff to follow up with patients who were scheduled for telehealth to get them set up, but it's so hard to just connect in real time with a patient. So our volunteers ended up wasting a lot of time putting calls out to patients that were never returned. Really, from a patient perspective, they're motivated to talk to their provider, and they want to get their needs met, and how can they do that in the least disruptive way for them? And partly because of their initial experiences with telehealth and our video visit, various video visit platforms that were not easy, it took a lot of setup. It was kind of annoying; we found that there was a lot less willingness on the patient part to say, "Yeah, I'll do that video visit," because they had kind of a bad taste in their mouth. So now, the way we do it is they offer a telehealth appointment, but they don't really specify. They don't really say in the call center that, "We'd like you to have a video visit." There are a few things, a few visit types, that we would say, "Can you ask them to do a video?" But from the provider perspective, it doesn't really matter. Because I can call that patient when I'm ready. And I can get them on the phone and then say, "Hey, I'm going to text you a link. Can you just click on the link? Because I'd really like to see you." And it's rare that if your provider is telling the patient that that they're going to say no, right? It's much easier for them to tell everybody else in the health center no. But if your provider says, "I'd like to see you on a video," they don't say no very often. And because it doesn't delay my visit, I'm not having to go into some other system and then wait for them to get the download, it's really not a big deal on my part. Sometimes, even before I call, I'll just put in the number and then text the video link. And then the patient, if they see that, they'll just click on it and join and we start a video, even maybe if that's not what they were planning or expecting. It's so easy to go back and forth, and it gives the clinician a little bit more control over the things that are most appropriate for a video and some things a phone visit is fine for. So it's really taken a lot of the hassle out of our telehealth. And we're primarily doing telehealth in the context of our in-person clinics now. So we do have a few providers that are doing remote telehealth, a dedicated shift of remote telehealth, but a lot of our telehealth is done in the context of in-person clinics. So we have our exam rooms set up with a little gadget rest that attaches to the monitor. And so the MA essentially designates, "Okay, you're going to see this telehealth visit in room 16." The provider goes in the room, puts their phone on the gadget rest, dials the number, sends the link. If the patient doesn't answer right away, there's some embedded messaging. I can text the patient and say, "Hey, if you're able to join me later, up until noon or whatever, go ahead and click on that link," and then I'll get a text that says my patient is ready and waiting. And from that point, I can message them. I can send them another text that says like, "Hey, give me five minutes," or I can just join the call. So it's been a game changer, I would say, and I'm so glad that we finally have landed on something that feels simple and easy across the various users. Jessica Ortiz, CCI: Wow, that's exciting, Jessicca. And also, it's funny to hear that you had the ability to do that and didn't know about it beforehand. And I was going to ask a question about the ease of transitioning from Webex to Doximity, but it seems pretty clear from what you said that it really wasn't that much of a transition for the providers since they had already been using it for the phone calls, and it was just a matter of getting used to, I don't know, maybe the way the video looked on the app versus Webex, but that it wasn't much of a change, at least for the providers, and there maybe wasn't much training involved. Jessicca Moore, PHC: Yeah, it was really minimal. I mean, it was funny that, I found out along the way, that there had been some providers that two years into the pandemic had never actually used Doximity for their telehealth visits. They had just been calling, blocking their caller ID or whatever, or doing it from the health center using a health center phone. And so, there were a couple of funny things like that like, "Oh, wow, you never started using Doximity. Well, let's get that onto your phone now." But the vast majority of the providers, it was a pretty easy transition. I will say, some were hesitant or were like, "Well, I need training," or, "Do I need training?" And I would just go around the huddle sometimes and be like, "Okay, who hasn't used it yet? All right, let's just look at it real quick." And it was so simple that everybody who saw how it worked, we would just test it out with me and them or one of our trainers, and they're like, "Oh, okay, that's great. That's– Jessica Ortiz, CCI: You didn't need a full curriculum before– Jessicca Moore, PHC: (Laughs). No, no, it was pretty much nothing. You're like, "Push this button." That's it. Yeah. Jessica Ortiz, CCI: Yeah, that's great. And that makes it so easy for the patients too. I did have a question that came up for me when you were talking about that. Have you found that there are any limitations with Doximity? I know that you said that there is support for materials in 20 different languages, I think that you had mentioned. Are there any challenges with interpreters during the calls, if that's needed? What are some of the challenges that you're facing, if any, with the platform? Jessicca Moore, PHC: Yeah, so you can add a call just like you can on any phone. So for our interpreter, when you need an interpreter, we just add that person to the call. It has been really easy across the board, I would say. Jessica Ortiz, CCI: And I'm curious, I know that you had access to Doximity, you were using it already previously. Were there any other platforms that you kind of looked at before you made the decision to go forward with that? I'm just curious what that process was like. Jessicca Moore, PHC: Yeah. So I think I mentioned that we had recently merged with a health center in West Marin County, and they were using Zoom. And so we kind of looked into what that would be like for us to transition over to Zoom across all of our sites in this process. Before we landed on Webex, we did look at something else, but honestly it's so long ago, it's a little bit of a blur. But yeah, once we just tested Doximity in this really small way and saw how easy it was and that the patients, really, there was no resistance on the patient end, and that it was so flexible, there was no setup that was required. And my medical assistant could call and let the patient know she's running late or whatever, but it didn't have people waiting on a platform for me forever. I could just message them when I am ready to see them and then they hop on. And it just seemed like, "Oh, of course, this is what we're going to do." Jessica Ortiz, CCI: Thanks for sharing that, Jessicca. It's really great to hear, and it makes sense that that's the decision that you ended up making. I'm curious, with going from audio to video and using this platform, are there any metrics that you've used to identify the success of the project and any ways of identifying which types of patients are more likely to utilize that video capability when they get the link? I'm just curious what you're learning so far. Jessicca Moore, PHC: Sure. So, we have been tracking for a long time the number of telehealth visits and the percentage of audio only versus video. We don't have a way of tracking the conversion rate of those that were scheduled as phone but that became video, but we have seen... And it still varies by provider. I think, really, with this system, the provider is the biggest variable. So, we have providers with as high as 50% of their telehealth visits are video visits, and then providers who are as low as 3% to 5%. So, there's quite a bit of variability. And so, we're in the process of talking to our providers and learning about those who are doing this a lot like, "Okay, what are the things that are making you successful with this? What are the drivers and the motivators?" Right? And then from the folks who are really what we see as under-utilizing... Because our goal is not that every patient has a video visit, but that every patient gets the kind of visit that's most appropriate for them and that best meets their needs. But we're pretty sure that that's higher than 3% of video visits, right? So, we're in a little bit of a learning process with those individual providers. When we look across demographics, definitely when we were using Webex and eClinicalWorks for our telehealth platform, we saw the demographic skew much more English speaking, younger patients were much more likely to do the video visits, but those differences are really leveling out with the implementation of Doximity. It's much more uniformly accepted regardless of age, language, ethnicity. Jessica Ortiz, CCI: That's great to hear. I think the conversation now is, "We've launched telehealth. It's here to stay," but then also, "How do we do this in a way that's equitable and not continue to deepen those disparities that existed before?" So it sounds like you're having a good experience using Doximity. Jessicca Moore, PHC: Yeah. Yeah, absolutely. I had a visit this morning with man in his 40s. Actually, he was, yeah, in his 40s and he was working construction, couldn't come in for the visit, had initially scheduled as a phone. And I was like, "I need to see this thing that you're telling me about," and messaged him the link. He's a monolingual Spanish-speaking patient. He got on. Very easy. And we're finding that across the board, with our elderly patients, and it's really encouraging to feel like we are actually able to offer a more equitable service across our patient population. Jessica Ortiz, CCI: Yeah, that's great. Another question that's coming up for me around that is, I know that you explored Zoom initially, and there's the opportunity to have different members of the care team. And I'm just wondering, what are your thoughts around how to make telehealth a little bit more integrated? And are there any conversations or plans for Doximity to have some of these capabilities? I'm just curious if that conversation has come up at all. Jessicca Moore, PHC: Yeah. So it's something that we initially fell very heavy on the side of integration, and we want everybody in the care team to come into these telehealth visits and to be able to connect with the patients and to do all the things. And I think what we heard from patients consistently was a lot of the times when they are scheduling a telehealth visit, it's really, at least partly, if not mostly, out of convenience and the need for an economy of a visit, right? They're not signing up for a bunch of different things. Like, "I have this thing that I want taken care of and I can't take time off work, or I don't have a car right now, and I really just want to connect with my provider." And so we definitely still huddle on these patients and review their care gaps. And so if they're due for labs or screenings or whatever, things that they're going to need to come in in-person for, we're setting those up. But for most of our telehealth visits, we have found that this robust team experience is not exactly what our patients are looking for in that telehealth visit. And so we focus a lot of those resources on our in-person visits. If there's a telehealth visit that then does need some navigation support, or does need behavioral health, or whatever, we can accommodate that; it's just not at the exact same space. They're not coming into the same Zoom room or whatever, which I think was something that was kind of a dream. We thought, "Oh yeah, that's, of course, what the patient wants," but that wasn't really what we saw so much. Jessica Ortiz, CCI: That's really interesting. Yeah, it also makes me think. I mean, thinking from my own personal perspective, I like convenience too, and that's why I would do a telehealth visit. I'm also thinking about certain individuals that might prefer more privacy around that and might not want to have to interact with a bunch of different people. So that's something that came up for me as you were sharing that. I'm curious if there's anything else that you feel like for someone else who's listening and is really thinking about what platform should I use, how should I engage my patients, this process that you went through and the experience, what advice do you have for people? What would you like to leave people with today? Jessicca Moore, PHC: I think that there are so many pressures in primary care on providers and staff that if the platform is not extremely easy and extremely intuitive, you're just never going to get the uptake. And from the patient perspective as well, patients are largely... And myself included: “If I have to download another app to do a different thing with another password and another user...” everybody's just sort of full with that kind of thing, even those of us that are very digitally literate, so it has to be easy, as effortless as possible. And I think that sometimes we get excited about creating this perfect thing that's going to have all the bells and whistles, and we can do this, and I can bring this person in, and then I'll do that. And in this space at this time, I think the first goal has to just be ease and simplicity. And then you can find out, once you have that foundation, "Okay, are there things that we're actually missing? Are there things that our patients are asking for? Are there things that our providers and staff really need?" Or, "Is this a good experience for everyone?" And you're not even going to get to learn those things or go any further if it's so complex and difficult that nobody's even using it. Jessica Ortiz, CCI: Right. Yeah, having it be easy is driving adoption I'm assuming. Jessicca Moore, PHC: Yes. Jessica Ortiz, CCI: Yeah. And then you can go from there. Once people are actually used to having the option to do a telehealth visit, whether it's audio or video, there's a comfortability that's developed over time, then maybe if you want to get more complicated there are ways to do that. Jessicca Moore, PHC: Yeah, absolutely. Yeah, we can always get more complicated. Jessica Ortiz, CCI: I do have a question for you because, Jessicca, you're a part of our peer learning network and we're big believers in collaboration and not reinventing the wheel. And I'm just curious, I know that you already had Doximity in your workflows, but were there any peers or resources or other sources of support that you've accessed while you've been thinking through doing this work? Jessicca Moore, PHC: Yeah, so we were part of one of the CCI telehealth learning collaboratives, and that was great to be part of that community and to kind of hear from other folks in our process of implementation of our various platforms how people were thinking about talking to patients about telehealth and what are the drivers of provider behavior and staff behavior. And so, absolutely, doing this work in community and collaboration is one of the things that I enjoy most. And I'm so thankful for all of the support and input, both from the Tech Hubs community and from the learning collaboratives. Jessica Ortiz, CCI: Thanks, Jessicca. And, of course, we love engaging with you, so that's mutual. I'm curious, what's the next step for this project? Is there anything new that's coming up in the future related to this and your innovation work at Petaluma? Jessicca Moore, PHC: So we've started using the Doximity video visits just on our phones. And, like I said, primarily our telehealth visits are happening in the context of in-person visits, but we do still have some providers that are doing telehealth remotely, and we started exploring the web browser version of Doximity. And so that has an opportunity for screen sharing and some other functionality that we're experimenting with that has been nice to be able to show patients lab results or to look at exercises with them to do. And so, it kind of gives you an additional way to connect and share resources and results with patients. So, that's something that we are thinking about, “how do we roll that out in the context of our in-person visits, our in-person schedule where we're doing these telehealth visits...” Yeah, so that's one thing. Jessica Ortiz, CCI: I look forward to learning more about that in the future. Thank you so much, Jessicca, for joining us, for sharing your expertise and your experience. I'm sure there's a lot that can be learned here from what we've discussed today, so thank you. Jessicca Moore, PHC: Thanks for having me. Health Pilots podcast outro:
Thanks for tuning into Health Pilots hosted by the Center for Care Innovations, with podcast production services by Wayfare Recording Company. If you like what you heard, please spread the word and be sure to subscribe where you listen to podcasts. For more information about the Center for Care Innovations or for upcoming programming, events, and funding opportunities, please visit our website - careinnovations.org - and connect with us on LinkedIn and Twitter. We’ll catch you here on the next episode of Health Pilots!
