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Join Lyle Berkowitz, a physician executive, as we explore the challenges faced by health systems during this time, from overcrowded emergency departments to increased demand for care. Lyle shares insights into traditional strategies employed by health care systems and discusses the potential drawbacks associated with them. Additionally, we explore the power of virtual care solutions in addressing these surges, including telehealth and virtual consultations, and how they can enhance access to timely care while optimizing resources.

Lyle Berkowitz is a physician executive.

He discusses the KevinMD article, “How health systems are improving preparedness for winter surges.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Lyle Berkowitz. He’s a physician executive. Today’s KevinMD article is “How health systems are improving preparedness for winter surges.” Lyle, welcome back to the show.

Lyle Berkowitz: Hey, thanks, Kevin.

Kevin Pho: So we were talking offline, I think Lyle’s been on about a year ago. For those who didn’t listen to your first episode, just give us a 30 second synopsis of your story.

Lyle Berkowitz: So I’m a physician executive, entrepreneur, internal medicine primary care doctor who worked at Northwestern Medicine in Chicago for 20 plus years as a primary care doc, but also system executive in the informatics innovation space. I’ve been involved with a lot of digital health companies, including the telehealth space, and started KeyCare about two years ago as a new type of virtual care company. The difference being, instead of building our own tech, we work on Epic, and we are purpose-created to support and augment other Epic health systems with our virtualist workforce.

Kevin Pho: All right, so today’s KevinMD article, you’re going to talk about some technological approaches to winter surges and improving preparedness. So tell us what your article is about for those who didn’t get a chance to read it.

Lyle Berkowitz: Yeah, and it’s less technical and more sort of operational, strategic. As a physician executive, I saw every year, we saw, how do you prepare for a clear influx, increase of certain types of problems in the winter? Your colds, flu, et cetera. This important issue that overwhelms our ERs, our urgent care centers, our primary care centers, et cetera. And we shouldn’t be surprised by it, and yet every year, in both the office-based setting and the telehealth setting, it often felt like it was more than we expected and we weren’t fully prepared.

But hospitals have for years been thinking about it. At Northwestern, I recall we would shut down our annual wellness exams and preventive care type of visits during that winter season, maybe starting December 1st through February, and have more room for the urgent care type of work. Over the years we also built urgent care centers, but they got overwhelmed as well. But there was some strategy around how you schedule, when you schedule.

Ironically, a lot of patients are trying to do their general checkups or annual wellness exams near the end of the year, and sometimes you come into crushing competition and patients are complaining they can’t get in.

And so as a virtual care augmentation service, it’s one of the things that we do, of course, is take care of colds, flu, et cetera, really efficiently. And so the challenge in a health system: hey, how do you use a partner to help with some of this huge load, and how are we going to get more efficient at handling that over time? So that’s what that article was focusing on.

Kevin Pho: All right, so give us some examples or scenarios about how your virtual solution, how would that help with surges?

Lyle Berkowitz: So first of all, simply access, bodies, right? We’re prepared for this, we’re going to staff appropriately for this. And technically we’re going to set up to make it very clear and easy, go down this pathway.

This year we’re rolling out e-visits. So in addition to video and phone visits, we’ll actually have asynchronous e-visits, which can be really good for these straightforward types of issues, colds and flu, et cetera, where you’re going to capture the same amount of information, you’re going to do some triage, and if appropriate, you’ll be able to handle these cases asynchronously.

We actually are creating an e-visit simply for the antivirals for COVID. And if you don’t meet the criteria, then hey, you’re not going to even need to move forward. We’re not going to make you wait, we’ll let you know ahead of time. But if you do meet the criteria, we’re going to make it really easy to get the appropriate medication.

And just in general, colds, flu, et cetera, we’ll let you know, can we do it asynchronously, does it have to go to video, do you have to go into the office? Let’s triage appropriately and then take care of you really efficiently.

Kevin Pho: So give us a sense of what those asynchronous visits are like. Would it be messaging back and forth? So walk us through a typical scenario.

Lyle Berkowitz: It can range a lot. In the Epic world, the e-visit technology is usually pretty straightforward. We ask a series of questions, if you meet the criteria you’ll move forward, the doctor will review and reply to you.

We set it up in such a way that we have some initial screening questions. If there are any red flags, we’ll stop you and redirect you to a video visit or even to an office visit. Assuming you pass those screening red flag questions, then we’ll capture your information in a pretty consistent way. How long have you had this? How much is it affecting you? What have you tried to use? Do you have these specific symptoms, et cetera? How is it compared to past? The type of information that a doctor is going to need to make a good decision.

And then within two hours you’ll hear back from the doctor. If they need to talk to you, if there’s additional information they need, they can always call you and move to a more synchronous approach. But we believe most of the time they’ll be able to handle it without even having to call you.

Kevin Pho: So you mentioned staffing. Of course everywhere is understaffed. So eventually, if we need to move to a synchronous video visit, who normally staffs that?

Lyle Berkowitz: It’s the same doctors. So doctors, NPs, et cetera, with the training in urgent care. So primary urgent care type of physicians and other providers. And they may alternate between doing some video and some asynchronous. But the idea is you’re going to get sort of a consistent approach, and the more we can collect information ahead of time, before the visit, the more efficient it is, whether it’s asynchronous or video.

This is not a new concept. Doctors have been talking about this for decades. This is simply executing on it in a coordinated way, in a consistent way that makes sense.

Kevin Pho: Now these doctors, would it be a patient’s primary care doctor, or would it be your own set of doctors from your company?

Lyle Berkowitz: So in our case it’s going to be our doctors, who are working in coordination, right? Because we’re on Epic and the health system’s on Epic, we’ll actually see the primary care doctor’s notes, the patient’s allergies, meds. And anything we do, as soon as we’re done, it gets sent back to the health system, and in fact an In Basket message can notify the PCP the patient’s been seen.

Now, the PCP can do as much as they want themselves, but the truth is they’re usually full. We are the overflow group. But over time we want to make sure that we’re doing things in such an efficient manner that it would just make sense to use us for these routine activities, so the doctor in the office, what I’ll call the officeologist, can really focus on the higher order of complex activities that need them.

We’re the virtualists, handling what I call the triple threat that drowns our health system: routine, repeatable, rules-based care. Let us do that really efficiently. Often in a health system that has a lot of office-based assets, those are loss leaders, they’re going to lose money on that. KeyCare, as an asset light organization, we can make money on doing that. But we’re going to need to be really efficient. I can’t make new doctors, so I’ve got to make sure the doctors I have are really efficient at doing the care that we do, in a very quick but high quality, coordinated way.

Kevin Pho: So it sounds like one of the advantages from KeyCare is that you have access to Epic, access to the patient chart, in contrast with, say, another third-party virtual care solution. Is that correct?

Lyle Berkowitz: Exactly. We are helping expand access, but doing it in coordination with the nation’s health systems. Because we have Epic, and Epic has a Care Everywhere connectivity, any health system that we work with, we immediately are able to share the data on our mutual patients and see that history.

It’s going to get really exciting as Epic starts to roll out more of their AI functionality, right, to summarize data, et cetera. It’s going to get better and easier, and we’re really going to be a partner with the health system PCP, not a siloed individual separated third-party telehealth vendor, but a true partner that is doing things in coordination, just as if we were sitting next to them in another office. It’s the same concept as when I cover my colleagues, I have the information from them.

Kevin Pho: So tell us a scenario where you are having a video visit with a patient and it goes beyond the scope of that visit. Through that interview you realize that patient is sicker than you thought and requires more intense care. What happens in that scenario?

Lyle Berkowitz: In the pure on demand space, it’s common, 10 percent of the time, that we’re going to have to escalate. In fact there have been some recent studies Epic published that showed, in an office setting, 3, 4 percent of the time a patient will need some follow-up. In a virtual care setting it’s probably closer to 5 to 8 percent of the time, which is pretty much expected.

So part of what we do is, we can’t treat everything. Part of what we do is triage and help the patient understand where and when they have to go see someone else. And so we may say, look, what you have is serious enough, you have to go to the emergency room. They needed to hear that. Patients sometimes just need someone to explain to them, when is it appropriate, or can I just wait a couple hours and go to urgent care tomorrow morning? And a doctor’s able to help triage.

We may not be able to cure everything all the time, but we’re able to help guide the patient, to say, hey, if this doesn’t get better in the next 12 hours then you need to go into urgent care. Or, hey, you have to go right now, you’re having a stroke, you have to hang up and call 911. But that patient may not have done anything if they didn’t call and talk to a doctor. So that is part of what we do.

As we move into more scheduled type of care, because on demand is a bit more generic, as we move into scheduled primary care coverage and on demand and urgent care coverage, we’ll be able to actually do a referral directly to the health system and do even a more distinct handoff. In the general on demand period, we’re going to tell someone that they should see a higher level of care, really help direct them, but we may not do as close a handoff, although our information will be available to the health system, so they can either take the handoff after we’re done and/or when the patient shows up they can see what we were thinking, why we sent them in, et cetera.

Kevin Pho: Now, what diagnostic testing, and if your clinician decides that patient needs, say, a chest x-ray or some blood work, how would that workflow work?

Lyle Berkowitz: In the on demand urgent care, right, by definition these are going to be more routine things. What’s interesting is patients are able to start buying things over the counter right now that they’re used to doing. COVID testing, they can do flu and strep testing. There are places that offer that type of home testing, and they’ll actually take a picture of it, show it to the doctor, so we can use some of that diagnostic. They can also send in pictures of a rash, back of their throat. If they need higher order testing, though, that is something we would explain to them, you’ll need to go in and get that, this is why.

As we move again to scheduled care, that is where we can have interfaces that allow us to order things like the short-term quick labs, et cetera, as well as things that might be chronic care gap closures, colonoscopies, mammograms, et cetera. We’ll be able to actually connect our two Epic instances and make those orders. We see the results, as scheduled doctors we actually would be responsible for those follow-ups as well. So now we’re really extending the care team for the primary care doctors.

Kevin Pho: So give us a success story where your solution partnered with the health care system and really alleviated some of their burden during the winter surge.

Lyle Berkowitz: Well, WellSpan is one of our earliest sites. They’re a group in southern Pennsylvania where we probably saw easily double the regular volume. So we were seeing, I think, 70, 80 patients a day at times, and their own clinics were just completely overwhelmed. The flu season had hit, and they really needed to have an overflow valve to be able to be there for their patients, right?

It’s really horrible to have to tell patients, we don’t have any appointments, and if you go to the urgent care or ER there’s going to be multiple hour waits. But hey, if you go online, you’re going to be able to see someone who’s going to be able to review your situation, manage your care. Usually, even in the height of flu season, we try to see everyone within the hour. Even if they had to wait two hours, it’s still better than the overwhelming nature. Now, in general, our average is closer to under 15 or 20 minutes, but during the flu season everyone’s overwhelmed.

So our goal is to make sure no patient ever has to be told you can’t be seen. We would make sure we could see them. And let’s face it, when you’re sick you’d rather just be able to take care of as much as possible at home, and you certainly don’t want to go to a waiting room where everyone else is sick and you’re even going to get more sick from that. And so that was very satisfying.

I’ll tell you another story. I won’t say who, but another one of our clients didn’t have us up and ready in time. They turned away hundreds of patients a day who they couldn’t see. We were not turned on yet for them, and so they had not moved fast enough for the winter season. And as a result, where do those people go? They don’t know, we don’t know, but they were either not taken care of, they went to the ER and overwhelmed the ER, they went to an outside service and therefore their care continuity was lost. And so we’re thrilled to be able to make sure by next season we’re going to be ready, and we need to prepare, which is why we’re rolling out the asynchronous options and staffing up even further.

Kevin Pho: We’re talking to Lyle Berkowitz. He’s a physician executive, and today’s KevinMD article is “How health systems are improving preparedness for winter surges.” Lyle, as always, we’ll end with some of your take-home messages to the KevinMD audience.

Lyle Berkowitz: Listen, I think part of what we’re trying to express is that the age of the siloed third party telehealth vendor is over. We really need to start doing things in coordination, and health systems need to rethink how they manage a population, particularly primary care.

And my suggestion to health systems is that, to really manage a population, you need to be OK with identifying the lower end of the population that has these routine issues, they’re commodities, and feeling comfortable sharing with a partner who can do that at scale online, so that everybody wins. The patients with minor issues can get easy, consistent care online that’s coordinated, while those with more complex issues now will have more access in the offices, where the higher complex patients should be taken care of by the officeologist. Let the virtualists take care of the lower level, easier stuff, and all of a sudden we can improve access in a coordinated way, get it all covered by insurance, and improve quality and overall satisfaction with everybody. We get to start solving for cost, quality, access, all at the same time.

But health systems need to be able to know that what they’re great at is the more complex care, and maybe it’s OK to have a partner who can handle some of the more routine things. In fact, if they look internally at their own dermatologists, anesthesia, dental care, et cetera, so much of care in many areas is spread across a team. Now being spread virtually, there’s ways to do this where actually everybody wins.

Kevin Pho: Lyle, thank you so much for sharing your perspective and insight, and thanks again for coming back on our show.

Lyle Berkowitz: Thank you, Kevin. Keep it up. I love hearing you talk, especially to doctors trying to change the system. You’ve been doing it for years. Really appreciate it.