ANDREW JENIS: Thank you for inviting me. I'm really-- I find it's a true pleasure to be here. Again, Andrew Jenis-- feel free to stop me at any time. Ask a question like that. As I kind of alluded to, I do-- I can run on. So I'm more than happy to talk. And this is a relatively short presentation because I know full well if I had 50 slides, we'd be here till tomorrow morning.
So I'm scheduled at emergency care and urgent telehealth. We'll sort of get that to the end. As I mentioned, I'm regional vice president of the US Acute Care Solutions, which is our largest physician-owned organization in the country. And that's just emergency medicine across the board. We have 2,000 physicians, 1,000 APPs, 22 states, emergency medicine, skilled nursing facilities, hospitalist medicine, urgent cares, and we're expanding out. So this is a great time actually to present this to you because we're doing some really innovative things. And also, I just happen to have an appointment through Columbia. I got that several years ago at another job that I was doing because I enjoy student teaching and resident teaching.
So as Brook mentioned, this is really who I am and kind of things I did. I graduated from medical school in '94. I finished my residency in emergency medicine. I spent two years in general surgery thinking I was going to be a plastic hand surgeon, realized that I'd have to be in residency for about nine years and decided, I think I got to get out and pay some loans and get to work.
As far as places I've been, I had an eight-year stint before I was this regional vice president where I jumped around the country as sort of a fixer for my company from little tiny emergency departments up to huge academic centers, two of which were residency programs. So I did that for eight years, maybe about 12, 15 different places.
So I've had the opportunity to see a lot of things. I've been a chief medical officer for a hospital, actually, a regional medical center. I'm not doing this to pat myself on the back, just to kind of give you an idea of things I've done so if you had a question about an area, I might be able to explain that to you. If you thought, hey, what is this? Who is this guy? That kind of thing.
I've been on the board of trustees. I've been a national scribe director for our company, a telemedicine startup. And also I happen to give the board exam for emergency medicine as well.
This is kind of my people. On the left-hand side, that-- thank goodness my wife isn't here. The younger one on the right, that's my daughter. She's actually going to join the school for the hospitality program in the fall. So I'm very, very proud that she's going to be there. I'm so really excited. And so those two on the right, very, very cold on their pads this morning.
So some causes-- I do this to give an idea is that a connection-- connection with myself, with you-- say OK. That's some stiff, stuffed shirt kind of person, some similar things. Just icons, if you recognize any of them. So this is the environment. So there are CDC about two years ago.
They are about two years behind to really tabulate all this. I'm not entirely certain why with everything linked with computers and costs, stuff like that, but 137 million ER visits. So this is sort of the area. And this isn't just ER. It's also urgent care. So really, this is the population that we're going to be talking about. So then you say, OK, only a third of these people, maybe a little over a third, get seen in 15 minutes.
And that seems to me, with doing emergency medicine as I long as I have, that seems really, really fast. Anyone who was been to an emergency department, an urgent care center, I don't think you were seen in 15 minutes. Maybe you were seen by a nurse in 15 minutes. But I doubt you were seen by an actual provider in 15 minutes. Now, you could really accelerate that with some process change.
Here's the other thing. $3.3 trillion dollars. Unbelievable space. So people are waiting. So 2/3 of people waiting, if you believe this, greater than 15 minutes in a space of $3.3 trillion dollars. Incredible. So now, I'm not particularly proud of that, being a physician, I have to say. But then, I just put this little thing off to the side.
This is the population where most of the money is being spent. So then if you're asking yourself, well, there's the urgent care population. There's the people that are the walkie talkie is going to walk in and out. Maybe you can interact with those people with computers and like that. That would be like an app or like that. But also, if you're really looking to have a huge impact on the cost of something, you got to go for the low hanging fruit, 10% of the population.
So 2/3 of the money we're spending, we're spending on 10% of the population. So if you're going to go after it, that's an area also to really focus your attention. So I mentioned it's a fractured system, but there's a lot of consolidation occurring. Actually, I should have put a slide up that shows what would happen with the ER groups. So about five years ago, there was probably 30 big emergency medicine groups. Big, defining how you want to put those air quotes, big.
Anywhere from maybe 10 to 200 sites. In the last five years-- so now, there's probably 10 sites or 10 companies. And really, most of that is consolidated in about five companies. And that would be 700, 500, 220, or 400, 220, which is mine-- my groups and then like 50. Oh, I'm sorry. About 130. So really, it's huge, much like banking and the insurance industry.
It's really, really consolidating, a lot because of this $3.3 trillion dollars-- people trying to get handed this. So much money is involved with this. And then the other thing that's going for it is that medicine is set up, because it's been so fractured, as a volume business, where let's try to grab as much as we can, charge the crap out of it, make a lot of money out of it, not a heck of a lot of oversight, and wow. What do we get?
So if you go to the United Nations and see how well is our care, the United States, compared against other countries, it's not so great. Now, there's some wiggle room in that, where people say that one of the criteria is how do you feel about your care. Very subjective. If you carve that out or remove that, suddenly US' system is one of the best in the world.
So then what do people want? What do you want from your care? So that's where all the money is. Then the question is for anyone that's going to be trying to jump into this space asking really what the consumer wants. This is why I'm so excited to actually get involved here, at Cornell. Because for myself, this is talking with people, thought leaders in this that are outside of medicine.
Here's where it's like any kind of industry. You can get very insular in your ideas of what people want. And then when you actually get around to asking, you find out, no, I don't want that. So what you need to ask yourself, what do you really want? I want an easy process. I want it to be quick. And I don't want a lot of anxiety in this.
Because when you're sick and you don't feel good, there's a lot anxiety. Even your most stoic person's going to have that. So my chief medical officer talks about quotes. He likes quotes. I don't have a lot in here. This is probably my only one. My chair of my company talks about this. This is why, actually, my company does what it does.
We could have just given up and sided with a couple of the really big groups, but we went out and were really trying to create something different. Who said this? Anyone know? Steve Jobs. He said this when he was forming Apple. So again, I think this is probably one of the innovator's quotes, a disruptor quote. And why just jump in?
Now, my group is getting big enough now, we are becoming one of the Navy. So it is what it is, but trying our very hardest not to be those type of people. So it wouldn't be anything better. This is the space that we've now set the stage for this area. So disruptive innovation. There are a lot of opportunities here. It's a ton of opportunity for anyone who's really got an idea, and has some energy, and wants to go after this.
It's that skilled nursing facilities-- so to give you an idea of how screwed up this would be, a person's at a skilled nursing facility, supposedly being checked on. And they get checked on. And they do like that. But something happens with them. The system, the current insurance system, let's say Medicare, is set up where the only way this person who's in a skilled nursing facility can get seen is they actually have to be seen by a doctor, in person.
So there's only one place that's going to happen 24/7, and that's in the ER. ER's also an incredibly expensive place to go. So every one of these people goes. So when I was a resident, you'll see talking the late 1990s, some geriatricians did a project. And the project was we're going to try to keep people away. We're going to do everything we can to try to keep people out. And they did that for six months.
Incredible savings, offloaded the emergency department. Great program. Showed all the savings, got some people to-- because it was part of also an academic center in the University of Buffalo-- crunch numbers, showed how much it was really saving, presented that to New York State, and said, hey, thank you very much for saving the money. But we're not going to change anything in our cost structure to do this. So what do you think happened the next day? All those patients showed up in the emergency department.
So this is an example of how can we figure out. So now, one is we have an idea. But then how are we going to actually align that with national now. Things are coming and improving. Jump 20 years forward, we're still struggling with how are we going to actually manage that. The office visit. People talk. I'm sure your grandparents or someone refers to or thinks about the office visit or something like that.
The people actually went and saw people at home. This is another with telephones, smartphones, apps, whatever. This is an opportunity, here. Rural medicine. I don't see him in the room, but there was someone I met last year that's from, I think, Louisiana. And the conversation we had was about telemedicine. So how can you figure out a way to get care to rural communities?
And you think about it, it's great to be in New York City, Chicago, name your favorite, big, metropolitan area that has, let's say Boston, a sub specialist of a sub specialist of a sub specialist for whatever condition. But if you're in wherever, you've got problems. If you really need-- if you have some interesting, different disease that no one's really heard of, and you've got to go to somebody who's never heard of that, your care is not going to be as good. It's like that.
It would be very good for the basics, pneumonia, hip fracture, whatever like that, simple stuff. But if you have some really, really narrow disease, you have to move. You've got to move. Let's say your kid, two years old, has some different, very, very rare disease, you can't live where you currently live. You've got to move yourself, find another job, get yourself to whatever that area.
If you have a Children's Hospital like that, you have no other options, otherwise. Community centers-- this actually goes with this rural one. So he and I had this conversation where in, say, the rural South, a major area of community is churches. So they're in the community centers. So how about if not everyone can afford an iPad, or something like that, or computer, or whatever it is, just put them at the community center.
Now, on Sunday, or Saturday, or whatever day when they're having their services, they have an opportunity, now, to go there. Someone could be available on-call. So maybe whatever their issues are, they could take care of all those people. Bam! Like that. An area of possible expertise-- disaster medicine, maritime. So again, you're on a ship, and you need a specialist. You've got problems if you can't be flown out or if the weather's terrible.
And just think about a helicopter and how sketchy that travel is. If there's any problems with the weather, they don't fly. So now, your care level-- now, on the really bigger ships, they have physicians and PAs and nurse practitioners. But if you're in something smaller range, they don't have that. Urgent care centers and primary care offices. The other thing would be like my care.
So let's say I'm taking care of someone in the emergency department, and they just send everybody. They just send everybody when they have any question, because they're a little worried. How about an opportunity to phone call away to this person to stay where they are? Or maybe even have that consult between the primary care physician, the patient, and the physician all at the same time.
And then you've got to send them over anyways, but you already had a conversation. So you have an idea so that the loss of data-- if you ever have the opportunity to look at a hospital EMR, you will be aghast at how bad they are compared to just your phone. You can do more on your phone than I can do with an EMR at the hospital. Again, there's a lot of reasons for that, but most of them are bad.
So let's get on to all disruptors really need to consider. So it's going to try to change gears from where we are, what medicine is like this. So resource realignment, some operational efficiency, and process improvement. This is the boring stuff, so I apologize. So resource realignment, this referral system. So a medicine is set up on a referral system. So you see your doctor, then your health insurance typically requires a referral to somebody else.
ERs were sort of carved out as this catch all, miscellaneous area. If someone says it's an emergency, and your doctor says it is-- and your doctor could really be a provider. We usually refer to a nurse practitioner, otherwise. Then you're fine. You can go. Urgent care centers, retail clinics, telemedicine-- trying to keep people out of the emergency department because it's expensive.
But it's a funny thing. If you watch the news, you would think that all the money that we're having is hemorrhaging in the ERs. I get back to that 10% of people. 65% of the money spent, that's really spent on chronic care. Really, 2% of our dollar is spent in emergency department. Of all that money, only 2% is really-- and for that 2%, we can get more done in three hours than your primary care physician can get done in two weeks.
So is it really that expensive? It's probably not. Now, that's not saying-- I don't want everyone showing up to ERs. We're already totally overwhelmed. But still, given ideals, when people say that ERs are the problem, or you see some news show, or like that, it's an easy place to go to start a story. And it's relatively sexy, because we got a TV show.
And people bend the emergency departments, and many people had a bad experience. Most people don't, because most people live and are fine. And they leave, and they're happy. And we take care of them like that. 99% or more are like that. But still, it's an easy thing to-- we're very used to getting kicked. And then triaging patients. I use this word. So triage is try to select out people, where you're going to put them, and like that. This really isn't that.
This is more like this resource realignment, sectioning, where are you going to put people, and like that. So you have the low acuity patient, someone who has a cough, pre-hospital-- so your ambulance. You could put a monitor, a video, or audio right on. We do audio all the time with the paramedics. But you could actually put a camera-- one way and a two way visualization. So now, someone's coming in. You could talk with them.
Maybe that person really doesn't have anything all that terrible, and you can redirect them someplace, potentially. That's really tough. Skilled nursing facilities, that's what the SNF is. Sorry for the abbreviations. In medicine, we have unapproved variations. Well, this might be an approved one. But we try to avoid abbreviations, because then all kinds of problems occur when we do that, and mistakes, and like that.
Specialist referrals to underserved areas, we talked about that. And then the ambulance based tele-consultation. So process improvement. If you're going to end up trying to get someone's attention, thinking about this resource realignment, how are you going to figure out a way to automate some processes? So we have automation, scheduling your referrals. Right now, I think the last year was the first time I was actually able, myself, to schedule an appointment on my phone to see my doctor.
2018, first time. I mean, really? I could have scheduled Genius Bar five years ago. I can book a flight to wherever, pick your-- Philippines. I could do that on my phone a year or two ago. You would think you'd be able to do that. So it's coming, which is great. Telehealth, we've talked about, then patient text messaging. So you think it's just texting back and forth, but it's all so many things you can do.
You could do-- thinking just checking in with them about how did you-- congestive heart failure is an example of that. The reason why people keep coming back to the emergency department for congestive heart failure is they have problems with congestive heart failure. What that means is that someone, for whatever reason, thought they can't get rid of the water that's in their bloodstream. They can't get rid of it for whatever-- there are multiple reasons for that.
But they basically can't do that. So they fill up full of water. When you fill up full of water, it starts to fill up, actually, into your lungs. And if it fills up into your lungs, you can't breathe. That's really bad when you can't breathe. So they come to the hospital, and we give them medicines. And often, they have to be admitted to the hospital. Very, very expensive. However, if you have an interaction with someone, you could say, hey, did you check your weight?
Because as you gain water, your weight goes up. So just reminding people, did you check your weight today? Did you check your weight every day? Did anything change? Your weight went up by a pound. Well it's not normal unless you chowed down on a bunch of cookies or hohos or something like that for your weight to go up in a day. And that would even be really weird. It's probably all water.
So take a little extra of your medicine to help you urinate more. Get rid of it. You potentially by doing that interaction, you just prevented an admission. And an average admission, probably somewhere between $10,000, $15,000 a person for that condition. And that's just if they just showed up. They just showed up, and it's simple. So one, two days in the hospital. One day in a hospital is probably about $5,000, probably more than that. It's probably gone up.
So a couple of days, you go to the ICU. You're really sick. Maybe just one stay, $50,000. Lots and lots and lots of money, here. And that's where that $3.3 trillion dollars comes from. There's a lot of ways you can figure out using phones. And I was astonished five years ago, when we started this telemedicine, that I had people who were like snowbirds in their 70s. They were starting up their iPads.
And one thing or another, and I'm like, wow. This is really, really great, grandma. I'm really impressed. Whereas I have other people that are a lot younger that are struggling, having all kinds of problems, can't set up. So not to malign older people, but man, I'm like, this is really, really great. The ways again, I was just really impressed at how easy it was and how easy devices are. And that was just five years ago.
Operational efficiency. So scheduling issues, I mentioned that. Advanced access, so setting up the force. In many ways, you could think of it as being access. They could be setting up an appointment. That's one way. Also could be I talked with someone before they arrive and have an idea what's going on of them, and then aligning supply to demand. So if someone says I want to go to this place, because my doctor's there, maybe they're well enough. But they don't, so let's say ER-wise, and then ER-centric, urgent care, whatever.
But you're going to say to them, the 911 system is being better in some fashion. We have to direct them someplace else. Or for that matter, let's say you have five hospitals in your area. One is getting completely overwhelmed and crushed, but people are still going there, as opposed to saying, hey, this place-- they're fine. Why don't you go there? You'll be seen quicker. And then aligning that type of care.
Telehealth. So let's change gears into this. This is totally in its infancy, right now. This is a disrupter waiting to happen. Five years ago, we started up a group, sold it to another group. I didn't really so much like that group, just because of the setup and the way that they just interacted with their providers. So I took a hiatus from them. Now, we're back, and my group has set up a relationship with this company, again.
It's two years forwards, and we're trying this again. And I think I'm supposed to have a shift on the weekend. It didn't work out. We had some issues just with technology that was supposedly resolved. So I'm back in the space, again. So it's in its infancy. Now, medicine is another one. They have these fractioned things because of all the way that our government is setup. So if you want a license-- I have 43 state licenses.
So there's 51 possible areas you can get licenses, because of the District of Columbia. So if you want to practice medicine in a jurisdiction, you have to have a separate state license. There's no such thing as a national license. So I've got to have 43 licenses. I've got to maintain every one of them. So the process of doing that, in order to do telemedicine-- and because if I'm caring for you, if I use telemedicine in California, I've got to have a license in California, because that's where you are.
It doesn't matter where I am. It matters where the patient is. So states don't really know what to do with a lot of this and are struggling. Some are incredibly antagonistic to it, because they have physicians on their medical boards that are worried, apprehensive-- bless you. Apprehensive about what this means to them in the future. You go to an emergency department, try to get an appointment to see your doctor. You can't get in quick. You're waiting.
So I think there's more than enough business to go around for everybody here, but they're still apprehensive that someone's going to be taking their cheese. And because of that, physicians are skeptical, apprehensive. People don't really know how to use it. Sorry, go ahead.
AUDIENCE: Along those lines, are you seeing your experience, on the payer's side, billing for telehealth intercodes with the modifier of getting it back [INAUDIBLE]?
ANDREW JENIS: They're really struggling with it, too. So it's not just states. Everyone is struggling with this. What does this really mean? How do we do it? The places that have been successful with this-- and we were for this start up, was that we went direct either to companies-- actually, it was more to companies that were self-insured. So if you go to a company that-- there's different ways you can set up your healthcare.
So if you buy healthcare as an individual, you may get it through Anthem, Cigna, United, like that. So you're an individual that gets it. I'm not certain how Cornell does it, but I suspect that what Cornell does is they probably take everybody's money, and abrogates it. And then your insurance may say Blue Cross on it, but they're more administering your money or administering Cornell's money, I should say.
So you could go to Cornell. We could go to Cornell and say we will cover all your lives. You pay a set fee, a tiny, tiny amount, and then there's a subscription cost, like people pay as they use it. That kind of thing. Insurers are really struggling with this. The government, which is a lot of this pay that's come out, they're paying a lot of it. They're not really even sure what to do with it yet.
Because the government's going slow, so everyone kind of follows what they're doing. Some people are trying to do it. But a lot of it's-- it really is, again, fractured. That's the problem with this. Any kind of change you want to make in a system is-- and because there's so much money at stake, it's slow going. The big ship turns very, very slowly.
Let's see, here.
So this is the other great thing about telehealth. It's in the eye of the beholder. And you could drop down to the bottom left. Peloton could be considered telehealth. So think to yourself. It's not just you saw your doctor. It's not you saw a PA. It's not this maritime convention. One of the hardest things for any real physician is dermatology. It's that, because you don't see enough. You see a lot of hives. You see a lot of cuts, things like that, but you don't see a lot of rashes.
So dermatology, huge opportunity for dermatologists, here. The pre-hospital I mentioned, rural, maritime-- yoga could be considered telehealth. You could very well walk some. I'll give an anecdote from telemedicine days, that a person comes in and says, I fell on my wrist. My wrist hurts. Do I need an X-ray? Well, I really need to touch you to determine if you really need an X-ray. You actually don't.
Hold up your hand. So you think the other things it could be like yoga or whatever analogy. Hold your hand up, move your fingers. These are the important areas. If you had a pain here, you had pain here, or you had tenderness, I should say, here, you need an X-ray. Person moves around. Can you move it around fine? Yes. Tenderness in these areas, and there are some scary spots that could develop into some problems two or three weeks later, months later.
You can walk someone through an examination. We have an associated group that's called dispatch health. And they have people where they put up-- they have a Prius that has, in the back, all kinds of health care aids. So if it sounds to the 911 operator like it's a low acuity patient, they send this person out to him. They can check him out. Nurse practitioner or PAs out there check them out and says, I think this is a minor kind of thing.
You just need some of this medicine I mentioned, because your weight went up two pounds. It'll help you with that. But then we were talking with the telemedicine. Could we do this? Let's use the wrist example. I said, oh, yeah, you do need an X-ray. 10 minutes? OK. I'll finish up with that. This should actually be at the end of this. And then how about, instead, I send a mobile X-ray device to you?
And then the X-ray is positive. So I could send this person, this dispatch health, to you to put a splint on you. You never had to leave your home. So it doesn't have to be always coming to the center. You could decentralize it. And really, the value of this telehealth is reducing hospitalizations. There are cost savings that I mentioned, and really improving some of their skills, and then integrating with a care team.
AUDIENCE: You have two more minutes to speak. And then we'll take some questions.
ANDREW JENIS: Oh, I got it. There you go. Look at that.
ANDREW JENIS: Look at that. And in this, this presentation is-- you're welcome to it, as far as for notes and like that. It is intentionally kept the way I do. I'm not a huge slide guy. I like to talk with people, and I don't want people really staring at slides. I had a mentor say, but you got to give them something. I said, well, OK. I'll give you something.
And there is a bit of a bibliography here, at the end. It's amazing what PowerPoint designs can do. So I played around with it. And this one's kind of boring, but it's kind of interesting what it'll let you do, here. And these articles, some of them you may have to buy. I suspect that from Cornell, you should be able to get them through the medical school. They should be able to find some of these articles, and Joseph has this presentation.
So if you want to take pictures, you can. But you're welcome to just get the entire presentation. So I think that is it. Yes. Questions?
AUDIENCE: So I have some of the questions. We'll do a couple of those and then--
ANDREW JENIS: All right, cool.
AUDIENCE: So how do you stress the importance of preventative measures as you work?
ANDREW JENIS: So--
AUDIENCE: Who put that question out there? This is so mysterious, because people submit questions. And I say who made the question, and nobody owns up to it. So go for it.
ANDREW JENIS: Actually, go ahead and repeat the question for me one more time. Sometimes, I hear what I want to hear, and I'll go off on a--
AUDIENCE: How do you stress the importance of preventive measures as you work?
ANDREW JENIS: So as far as on the job, it's rolling through with the person. Most of the preventive things you can really do are going to be smoking, are going to be what their disease specific issues will be, like following their diet, maybe it's their fluid intake. Mentioning this congestive heart failure, like I mentioned. Trying to avoid sugar. Obesity is a huge problem.
A lot of the issues that we have in medicine are related to lifestyle, as well. So it's part of the conversation with the patient, trying to mix it in there. You don't want to seem like you're lecturing people. People just turn that off very, very quickly if they think that you don't have their best interest in mind. The art of medicine is that connection. And the big issue with emergency care is that I don't have a lot of time.
So I have to figure out ways to engage people really quickly, and there are tricks to it. Well, one is, of course, the handshake, sitting down with people, laying of hands. People started to say, well, with infectious diseases and like that, you've got to figure out a way to-- walking up to somebody and putting your hand on their shoulder when you're talking with them may not seem like very much, but the engagement of that is huge.
Sitting forward when you're having a conversation with somebody. Part of my group, we set up a Patient Experience Academy. It's called something else, now. And part of it was that we brought the physicians in, and then we recorded them, and what they did, and to see how they interacted with simulated encounters with patients in very high stress type situations. It was funny to watch ourselves. It is so funny the things you do.
In fact, I even knew what I was doing. But to watch it and see, that obviously would turn somebody off. So that would be part of it.
AUDIENCE: A question back there.
AUDIENCE: So do you think that telehealth, in general, detracts from the personalized health care that hospitals show? For example, I know a lot of people go to hospitals rather than remedial centers and treating yourself in the case of a serious effect, and also because people want personalized healthcare. And so with telehealth doesn't that run the risk of reducing personal engagement of a doctor or nurse? At the risk of these, is that a problem you see?
ANDREW JENIS: It could be a problem, but it's interesting that people don't have that problem. People don't. Certainly, being in the room with somebody is valuable, but the one on one encounter with somebody-- if you are interested in them, and you engage with them-- I don't think it's necessary that you have to be in person. Is it valuable to be in person? Oh, certainly.
Doing audio telemedicine, there's some groups that will take a phone call and listen to them. I find that exceptionally difficult. However, the visual, they can see myself. I can see them. I can pick up a lot of cues about somebody and how sick they really are. Just in 15 seconds, looking at somebody, I can say, OK, sick, not sick very quickly. I can do that. So for me, the video encounter-- but I think the patients also like it, because it's on their time. It's when they're sick, when they want to be seen.
If not even so much sick, they have a question, I think human engagement and communication isn't just about being one to one. You can be in person with someone and be completely disengaged with somebody. So I don't think it's strictly just an issue of being actually in front of the person.
AUDIENCE: The last questions. I'll start from back there.
AUDIENCE: You mentioned there are the providers concerned just as the stage of what you want. What are the major concerns that the consumers have had--
ANDREW JENIS: Consumers or the physicians and providers themselves?
AUDIENCE: The patients. What are the major concerns that have shown up?
ANDREW JENIS: So the concerns? I'm sorry, I interrupted you. You said?
AUDIENCE: What are the main concerns about telehealth that patients have had that you've actually seen?
ANDREW JENIS: So you mean the actual diseases themselves or just worried about--
AUDIENCE: About care and how that care is given, et cetera.
ANDREW JENIS: And the trepidation with anyone that you don't know is also that the technology kind of gets us to work. And that is who is this person who's on the other side? Where are they coming from? Are they like me? And by liking me, it could just be from the same state I'm in, or can I understand them? A lot of the trepidation is that. It's like being videoed, that you think that by being videoed by something, that is going to be difficult to be videoed. And it's going to be stilting. And it will be problematic in that way.
But it's funny. Within about 30 seconds, you just completely ignore it. Then the interaction starts. And if you actually can engage somebody, it disappears really, really quickly. So then the cues. Someone's on there and says, I know this is really, really tough. This is kind of weird, but we're going to get through this together. The person's like, oh, OK. They're trying their best. They're with me here. They're trying to do this for me. Engage them very, very quickly.
AUDIENCE: On a similar note to that, I have two questions revolving around liability. So first is on that note with telecommunication. Is there any concern for that sort of information or video getting hacked or easily disposed of by various networks? At least with the NetHealth, in my experience, there are so many portals you have to go through. And then to even interact with someone, you have to be there, in person.
And then on another side of liability, if you're sending physicians out, and they don't have all the resources that they would have at a hospital, like an MRI machine-- we've talked about remote X-rays-- are you at a higher level of liability because you won't be able to give every sort of care option if it's determining something else at their own property?
ANDREW JENIS: Great, great questions. So the first is the worry of your information being captured or otherwise. One of the reasons why EMRs, or these electronic health records, are so bad is because of the requirements for exactly that-- because of all the extra steps you have to put in in order to protect that information. So secure connections. And not just secure connections. All the other different things that-- I'm not an IT expert. I would never even attempt to say I am-- there's a lot that goes into that.
That's why you have to jump around. There's all these portals to do that. And then as far as the liability of the provider that's out there, I would flip that, actually. I would flip that. The person who's sick, who needs your care, potentially could be really, really sick. I would much rather have a person out there seeing them and then calling for help than have that person be on their own.
So my group has flipped that and said, for our opinion, we put a provider out in our triage area. Some people are worried that someone will come in. Maybe they'll leave. But the number of people that we actually capture by being out there-- having that resource out there, the physician, or the PA, the nurse practitioner that has the expertise, that's seeing people as quick as they possibly can-- so it may capture subtle things. I would rather actually send that provider out and take that potential risk that you described, rather than having the person maybe not getting care at all or delay the care.
And not to bash or diminish what EMT and paramedics do, but again, they don't have that level of expertise. So I would much rather-- I think that we're in a much better place to send someone and call for help, and people know that. Yes, I used to do some consultation work for attorneys for malpractice. And I was on the dark side. I did it for the plaintiffs. And the reason I did it for that was because it allowed me to actually prevent lawsuits.
There was a lawsuit someone brought up or wanted to pursue something. I said hold on here. You're talking about a situation where a rural person, PA, saw a stroke, which you think that person was available at that time, as far as for thrombolysis, to try to prevent that. There's no way that's available in the rural setting. So you're going to waste your time with this. And he said, oh, OK. Well, definitely. I'm a lawyer. I don't want to waste my time. We're in a business.
So to answer that question, I'd be more worried that we didn't have people out there.
AUDIENCE: There's a question in the back of the room. My question was about the compliance of telehealth, but you already touched on that.
ANDREW JENIS: Yeah, that's pretty much it. Again, imagine if someone pulls their phone out, and they use video with you, one on one. This already is an implied consent, there, that if they're going to use their phone, and they're in a crowded area, that, hey, you've made this interaction. You've decided you want to do this. Now, because it's your phone, you can then go wherever. Find some private area like that, and have that conversation yourself.
But you're engaged in that. The bigger compliance for HIPAA really is someone comes into whatever the setting is and you just start talking to them in front of others about their care, emergency department hallway visits like that. HIPAA doesn't prevent you from doing it, but you've got to make a good faith effort to avoid that.
AUDIENCE: My question is that I wanted to maybe touch on the importance of telehealth for aging populations, and gerontology, and the idea of people being more comfortable in a place where--
ANDREW JENIS: Yes. So there's something that's called sundowning. And sundowning is when you take an elderly person out of their normal setting. They go to something very strange, and they basically freak out. And that's because as your facilities in your brain work, you get used to your settings. It's just easier. Just think of yourself when you're at home and then versus being at a hotel.
You know where your stuff is. You know where you can find whatever it happens to be just easier. So then it takes someone who has some cognitive problems, say some dementia, and take them to another setting-- and how frazzled they get. So yes, a huge, huge value for that person to have their care right where they are, as opposed to actually having to be moved.
And the same thing goes with pediatrics. I've got this great telemedicine story where a mother called in, and I said, I'm sorry. Your child has to go to the hospital. She said, no, that's OK. I love this service, because I got four other kids. And when I got to take my kid to the doctor's office, I'm not taking one kid to the doctor's office. I'm taking five.
And when it's two degrees outside, that means coats on every one of them. I've got to corral every one of them. I've got to fill bags full of stuff for them for food, and for games, and stuff. I got to pack them all up in my car, five car seats. I've got to drive them to the doctor's office. They go to the pediatrician's office. They sit there, we say, at least for an hour to be seen. They're going crazy and going bonkers in this room.
I see the doctor for about five minutes, and then I get to repeat that process in the reverse. She says, you know what? This is incredible. So just thinking of the opportunities in this space.
AUDIENCE: Can you share how some of the quality outcomes, capturing patients' feelings of value based care, and how that applies to telehealth, and how all of those metrics are captured and shared with hospital administration?
ANDREW JENIS: I'm sorry. I'm going to ask you to repeat it one more time. I started to answer the question in my head. And then I realized, at the end, you had some very good points. I'm sorry.
AUDIENCE: So in terms of value-based care, capturing the patient experience, quality outcomes, and all of that, I'm sure from the hospital administration side, they'd like to see what are the key metrics in how success is defined. If you could share some of the ways that telehealth actually captures all of that?
ANDREW JENIS: So this volume versus value that I mentioned at the beginning of the presentation, one is you're just grabbing everything you can. I didn't really get into the value piece. The value piece is outcome. What actually is the outcome of people? So some groups, and mine is one of them, entering the space is that like capitated care, saying, how much is the average covered live per year cost for your population?
Give us all that money, the average, and we will knock, let's say, like 25% off. But that's the risk corridor, there. If we, in that 25% that's left over, actually save you any of that money, we want some of that 25%. So then creating what are then the outcome measures to actually prevent that-- so we were trying to really prevent someone from showing up at the hospital. That's going to be the biggest one.
So showing up to the ER and then being admitted to hospital. So then the outcomes are going to be as mentioned. You could use weight as one of them. So for congestive heart failure, that's one. For asthma, it could are you actually taking your medicine. It may be astonishing, but maybe 2/3 of patients fill their prescriptions. A third don't fill their prescriptions. Multiple reasons for that. Maybe they can't drive.
It's astonishing. Sometimes you think, he has great access to a car with Uber, or like that. But if you don't have $5, you may not even be able to get to the pharmacy to actually get your medicine. Then it's figuring out a way to get them their medicine, have them actually take it. Diet modification-- so someone who can intervene for diabetes is a huge one. If someone can actually lose 10-15 pounds, their diabetes could potentially disappear.
So a lot of this outcome is just give us whatever this covered live money is, and then letting us figure out ways to do so. So from telehealth, it's going to be interaction with the person. So having someone drive out-- if you have 20 places you've got to be in one day, they maybe all be close. Maybe you're lucky, and they're all in the same apartment building. And that would be outstanding.
So I'm thinking maybe for geriatrics and a skilled nursing facility-- but if you're covered lives are scattered over an entire city, if maybe I can do 2/3 of these conversations through a telehealth platform, or an iPad, or something like that, wow. That may very well allow me to expand out and do more care. So a lot of these outcome measures are already in place. The biggest one is really keeping people away from hospitals.
AUDIENCE: I think you had some data. When doing one of those big surveys, we were asking people about [INAUDIBLE] medicine, it turned out that more of the population was more in support of it than the other population. Remember that result? Maybe for some of these reasons of inconvenience of having to deal with all the child-- does someone else have a question?
AUDIENCE: Where was it? Somebody brought up, I don't know who this was, specifically, but how you appropriate hospitality concepts in clinical settings. And you've seen measurable impact on the effects of the [INAUDIBLE].
ANDREW JENIS: The patient experience-- it's been thought of. I wanted to do something with it. And it's always been, well, if you go to the hospital of 10 years ago, they were really the hospital that was built 50 years ago. So now, people are building hospitals really thinking about people, and their lives, and the comfort for them. It's not just comfort. Hospitals are noisy places. They can smell. The food is terrible.
So if you're already feeling poorly just figuring out ways and then the alternatives-- just think of anything that would be hotel like. Now, that makes a lot of physicians like us cringe, but it only makes us cringe until we're the ones who are actually sick. And then we want all those things. And I teach by anecdote. I had pneumonia maybe two years out of residency. I was on the job figuring it out, actually.
And it was a late night. It was really slow, and I was feeling really dehydrated. And I asked a nurse put an IV in me. I said I'm going to sit in this back room, and just give me some fluids. That'll just help me, I think, with dehydration. And I sat in this room, and it was terrible. It was ugly. It was really uncomfortable. The fluids that they put in my arm were room temperature fluids.
They put a gallon of, basically, room temperature water into my body. You put just half of a bag of fluid into your arm that's room temperature, and your arm is like ice. It's like ice very, very quickly. I wasn't the chair of the place, yet. You can be sure that things changed. The next day, the conversations I was having is that we never gave room temperature fluids to anybody ever again.
It was going to be warm fluids. We found whatever the warmer they were-- just a little bit warmer than your body just makes you feel so much better. We didn't have the old school when you go see your doctor beds. A couple of months later, those were gone, where it's a hard thing. There was actually stuff-- it was the boring-est room in the world, too. And this was also the age where there was no smartphones.
So all you had was a magazine, and there were no magazines. And when there was maybe a magazine, it was labeled Kids Life, or something like that. So I'm doing the puzzles like that. I'm back there for two hours. Now, I could walk around and leave the room if I wanted to. But man, it wasn't a terrible experience, but clearly, there was not much thought of for our patients, and their comforts, and at least to keep them distracted.
AUDIENCE: And on that note, we would like to thank our speaker, today.
ANDREW JENIS: Thank you.
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The Cornell Institute for Healthy Futures: Health, Hospitality and Design Industry Seminar HADM/DEA 3033/6055.
The March 8, 2019 session titled: "Unscheduled Emergency Care and Urgent Health". The distinguished speaker was Andrew Jenis, MD, Regional VP, USACS; Assistant Clinical Professor, Columbia University College of Physicians and Surgeons. This course provides a unique opportunity to students to learn from successful industry leaders with expertise in Health, Hospitality, and Design. Speakers share their views about successful management styles, possible career paths, critical industry-related issues, and qualities conducive to successful business leadership. The speakers are chosen for their knowledge, experience, and proven success in emerging industries that combine the elements of wellness and health. As a student in this course, you will have an unparalleled opportunity to gain insight into the emerging industry at the directly from senior executives.