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Webinar Transcript:
Meeting Title: VBCEH & Connective Health Webinar (placeholder)
Date: Apr 15
Meeting participants: Shane Callahan, Ryan Hess, Garrett Schmitt
Transcript:
Garrett Schmitt: Well, hello everybody. My name is Garrett Schmitt and I am the CEO and managing editor of VBC exhibit hall. And I d like to welcome you all to today s live webinar hosted by Connectivehealth with special guests, Illuminati. And this one s called a readmission breakthrough. How structured insights improve transitions of care and close the discharge gap. And we ve got a great discussion ahead of us. I had a little preview the other day and I think you re really going to enjoy what is discussed today. A few items of note before we get started. Today is a traditional webinar format, which means we can t see you or hear you. However, we do want to hear from you and we are going to have a time for some Q&A towards the end of the presentation. If you have a question at any point, feel free to drop that into your control module. There s a place specifically for questions. We re going to get to as many of them as we can today. If for some reason we aren t able to get to yours though, don t worry. Someone will reach out to make sure we get your question answered via email afterwards. Also the session today is being recorded. So what s going to happen is when we conclude maybe about an hour or so afterwards, you re going to receive an email and that email is going to have a link to the recording from today s session so that you can share that and rewatch it as, as you would like. And we hope that you do. And then also where the slides, we don t have a lot of slides today, but we have a few and they re meaningful. So you re going to want to download those as well. And there will be a link to do so. So without further ado, I wanted to briefly introduce our speakers today and then we ll turn it over to them. With us, we have Mr. Ryan Hess. He is the CEO and co-founder and founder. I m sorry of Connectivehealth. And then we have Dr. Mary Brackman. She is the chief medical officer with Illum ed. So welcome to you both. And I m going to turn it over to you at this time.
Dr. Mari Brackman: Thank you very much. I can go first. So I ll introduce myself. So I am Mari Brachman. I am a family doc. I am originally from Ohio. I did my undergrad at Notre Dame and then did med school in West Virginia. And then went on to do residency in Texas. After residency, I stayed on as resident faculty for a year and then moved to North Carolina, where I joined private practice. In private practice, I had about 3,000 patients. About 1500 medicare patients and we partnered with a value-based care company. Running the whole value-based care model, living, breathing, all of this stuff, taking care of patients. And shortly after about 18 months later, I went on to be a medical director at Agilenealth, where I then started teaching other providers, physicians and extenders about value-based care, documentation, coding accurate representation of what we are truly managing. I ve now been at UMED as the CMO for about the past 18 months. We are an ACO. We re both in both reach and MSSP and I will get to, oh, there it is. I was not going to quit don t do that, but yeah, but I ll do our little promo here for Ilyan. So we are, as I mentioned, we started in about 2021. We are then both reach and MSSP. We are currently in seven states with just under 50,000 patients. And we have about 35 different practices that we ve brought together under the ACO and some of what we re going to talk about today has really Connectivehealth has really helped enable us to be able to better serve the different cohorts and with how dispersed our partners are. And so looking forward to really getting into that and giving you all some more detail there. Ryan, I ll pass it over to you.
Ryan Hess: Awesome. Thank you, Dr. Brackman. So my name is Ryan Hess. I am the CEO of Connectivehealth. Thank you everyone for being here today. I m going to start in the opposite end of the spectrum, which is that I think my most pertinent background is that I have been a patient of the healthcare system many times. And what I have noticed and what I am passionate about fixing is that there s just not a lot of connectivity between different parts of the healthcare system. So if I go to one provider, oftentimes the next provider I see will ask me what the previous provider said, which is not a great way for our healthcare system to function. So our passion and really my passion at Connectivehealth is helping to source all that clinical data in real time. So as I show up next for my patient visit, what I want to have happened is I want all of that information from my hospital visit to my specialist visit to my pharmacy. I want all of that information sucked in. And then distilled down to something that a doctor will use. So they re not going to look at a 200 page binder that I bring in. But if there is one page that has popped into the EHR that says, hey, here s what s really important that happened to Ryan that s associated with this visit. That is what our mission is, is to bring down that one page of what s really important. That happens to Ryan. Just a little bit about Connectivealth. So we really focus on value based care and we focus on really specific encounters and value based care. So the way we talk about it is that image on the right of your screen, that changes based on is this a new patient coming in? Because what you need for a new patient establishment is different than if it s an existing patient and you re just trying to make sure that you have the most up-to-date, most updated problem was for that patient with an existing patient. So that image on the right changes. And we re really passionate about discharges. That is one of those points in the healthcare system from our perspective. Where you can improve both the quality of the experience of the patient. Improve the actual clinical quality being delivered. And at the same time reducing costs. A lot of readmissions are just unnecessary. It shouldn t have happened to begin. With. That is a great segue after our little railroad shows. That s a great segue. Garrett said we re going to do a few poll questions throughout the beginning here. So that s a good segue to hand it off to Garrett to introduce our first poll question.
Garrett Schmitt: Right, yes, you will see this on your screen. Our first question is this in your current workflow, what percentage of discharged patients are you able to meaningfully engage within the first 48 hours? And this is anonymous by the way. And this is just for fun. We re going to show the results here momentarily so you can see where you can stack among your colleagues. Which will give you a moment to respond here. So less than 25%. We struggle with the discharge gap. 25% to 50%. We catch some, but many slip through. 50 to 75%. Our process is strong. But it s not easily scalable. Or over 75%. We have a highly optimized real time workflow. We give folks about another 10 seconds to respond here and we ll close it down. And show you the results. Right. I think most people have. Well, there s still some results here coming in. We re going to shut it down another five. Four. Three. Two and one. All right Ryan, are you able to see those results? And if you wouldn t mind kind of if folks are calling in, kind of give them a sense of who answered what.
Ryan Hess: Of course. So I ll go top to bottom. So less than 25%. So the response to the question of what percentage of discharge patients are meaningfully engaged in 48 hours. 22 people said less than 25% of the patients are. 28 people said less than 50% of their patients are. So you have 50% of the respondents saying less than 50% of the patients are actually meaningfully engaged. 28% came in in the 50 to 75% bucket and 22% are performing really well on this. And these results I would say not terribly surprising. ADTs are really messy. EDTs are core piece of handling discharges. And you ll notice that in the, in the question, we said meaningfully engage, right? So meaningfully engage means two things. One, you were aware that the patient was discharged from the hospital. And then two, you have the data and you have the insights you need to engage that patient. And you really need the combination of both of those things. Know that they were discharged. And know why they were in the hospital and whether to engage them to meaningfully engage. And when we see is that if you have a, you know, if you have 100 patients and they all live in a, you know, single town in Florida and they don t go anywhere. You might be able to consistently find out if the patient was discharged. But as soon as those patients be snowbirds or soon as you start to cross state lines, the percentage of time that you can get even the ADT starts to fall. And then the analytics that we ve done, we found that ADTs alone only have the discharge, only have the diagnosis from the hospital, mission 75% of the time. So if you combine those two things, what percentage of the time that you know that somebody, an event even happened, and then do you have anything to go on? That s when you fall into what you see out of the survey, which is maybe 50% of the time. You know, in a good situation, 50% of the time, you ll know that your patient was discharged and you ll know how to engage them. So you ll have something out of that ADT. And that s what we found to be really the current state of the world today and I ll let Dr. Brackman talk a little bit about what she found to be the current state of alum. Prior to engaging with us.
Dr. Mari Brackman: Yeah, thanks. That’s, let me maybe a little bit more background too on what kind of what IlumED brings to our ACO. I mentioned that we have partners across all different states about seven different states. We also have different styles of partners. Some of our partners are solo providers that have been in private practice for 20 plus years. Some are still on paper charts. Some of them are kind of all the way up through hospital systems. And obviously depending on what your accessibility is, your resources are your staff ability also can potentially prohibit being able to continue to continue to collect that information. So at ILMED, one of the, one of the pieces that we bring from platform is a patient engagement team who will do the scheduling for our partners if necessary. And that includes watching these ADT feeds, pooling things in. The challenges that we don’t have EMR access everywhere. So we don t necessarily know what our partners are or aren’t getting from these discharges from these utilization utilization patterns. And that s really where we started to find, we were struggling. As an enablement partner, as wanting to really help support these Medicare patients and the workflows and processes that already existed with our partners, we realized we had and have this massive gap of, sure, I can see you were in the hospital, but I have no idea what happened. And if I m scheduling a visit for you or for a provider, being able to get some of that information and resource to them can be really valuable thing. Because when a patient is seen at that hospital discharge, having something in your hand at that point of care visit is the most valuable tool any provider can have in their hand upon discharge. For all of you providers out there, so much happens during a hospitalization. We all know this. And when you are the one seeing patient post discharge, if you have no visibility, you are flying blind. You have no idea what to do. Some patients can be very, very informative and very helpful. But even then there s confusion. Nobody knows what medicines they re on. And so just having this lack of availability of information for our partners is a big deal. We realize that when we kind of started this whole process probably about probably a little over a year ago now, maybe closer to 18 months ago when we really first started this conversation with Connective about how can we help this. We only were getting less than 50% of the ADT feeds coming into us. So if we were doing the scheduling, not only were we not scheduling nearly half of the patients to be seen from a utilization or helping to schedule that, we had even less visibility to what the providers were getting. And that s what one of our, some of our partners were kept saying to us is we can’tt improve our readmissions. We can t improve our ACR rates. We can t improve our utilization rates because we don t know what s happening. And we have this complete lack of visibility to that. So that s really what prompted us to go to Ryan and his team and say, hey, what can we do? How can you help us better equip our providers so that when they re seeing these patients, they can have the most meaningful highest quality post discharge visit to really impact the patient s overall quality of care, reducing readmissions, reducing medication errors, and really just trying to help smooth that process the best that we could. Lead us to the second poll question, Garrett, if you don’t mind putting that up.
Garrett Schmitt: Folks, we re working live here. Got it coming up. Right now. Okay, you should be able to see this on your screen. And this question is what part of the care transition process is currently the most time consuming for your care teams. And if you re joining us late, these are anonymous and just for fun, we re going to show the results here. Is it chasing down charts and discharge summaries? Identifying which patients are actually high risk? To reconciling medication changes without clear and helpful clinical context? Or is it attempting to reach the patient within 48 hours? You may be saying, well, all these are challenged. But if you had to choose which one was the most time consuming. Which one would it be? And it s like most folks have submitted their bonus, but we ll go ahead and shut it down in another 10 seconds here. And show the results. All right. Shut it down in five. Four. Three. Two and one. All right. Mari, Ryan, are you able to see the results here?
Dr. Mari Brackman: I got this. And no surprise here. Really kind of all the above is the answer. And I would imagine if you could pick multiple choice, you probably would have picked multiple choice here. But just to kind "of run through the answer. So just read the question again. What part of the care transition process is currently the most consuming for your care teams chasing down charts and discharge summaries about 27% said that. Identifying which patients are actually high risk about 19% Reconciling medication changes without clear clinical context about 22% and attempting to reach the patient within 48 hours about 32% So again, none of this is surprising to any of us. There are so many moving pieces. And if we just focus on an inpatient hospitalization discharge, this is so true. You know, it s so important to be able to try to catch that patient in the first 48 hours for a multitude of reasons. One, we know it s the time clock from the billing perspective for medicare to really get that high quality visit captured. But two, we also know that if someone s going to bounce back to the hospital, it s usually within those first 48 hours. And a lot of the times it s usually due to a medication issue. Get filled, wasn t followed up on, you know, any, any reason related to that. So no surprise at trying just to get in touch with the patient is challenging. And I would say maybe the most important thing to do within that first one to two days. And then you just kind of look at the other ones again, not knowing how high risk is this patient. Were they, if I don t know why they were admitted or I can t get a hold of them, were they admitted because they had a fall from their horse or, you know, did they have a simple UTI that just kind of got a lot of control. There s a lot of different things that that could mean. And then nobody has time to chase down a chart or discharge summaries unless you are fortunate enough to be in a system where either you are part of that healthcare system and it s automatically a part of your chart. Or as Ryan mentioned before, you have a really good feed coming in from your local hospital. I was really fortunate here where I was in private practice. We had a very strong connection. We only have one real local hospital. And so we got really good feed. So as long as my patients stayed local, I was getting all that information. That is not the case for our partners. And that s really what I started to learn as I got into this role, really started to dive into a lot of these things in these pieces of this. And then finally the, you know, medication reconciliation. I mentioned that s kind of full circle. Again, I still think it is the most important thing that happens when someone is discharged from the hospital is to make sure that patient is what they re on. Did they pick it up? What are they supposed to be holding versus how long do you hold it? And if you don t have that information as the PCP, you have a very, or even the person seeing the patient on discharge follow up. It s very challenging to know what to do and how to kind move from that. At Illumid, what we realized we had this gap. So we went to reached out to Ryan worked really closely with the Connective health team to basically take a discharge summary from the hospital. And condense it down into whatever we could condense it down into to make it be as user friendly. For a hospital discharge. And here s an example of kind of what you see when it comes to these discharge summaries. We worked really hard, as Ryan mentioned, to put together a one pager. Sometimes it s two, but a one page high level PDF of here is why your patient was in the hospital. Here was their discharge diagnosis. Here were the medications that they were discharged on. And here is anything that needs to be followed up when they re in the office seeing that first provider post discharge. On the back of that PDF is then all of the other information that was on during that hospitalization. And we really tried to tailor it so that we kept it to discharge summary. Maybe very important imaging studies that were done during the hospitalization. We didn t pull in 700 pages for someone that had been admitted for the last 30 days. It was really the pertinent things that you could kind "of double click into if you needed to. And when we did this, when we saw this, it allowed our providers to really start utilizing a tool that allowed them at their fingertips at the point of care to have what they needed. Again, many of them were getting feeds from other hospitals or from the system. And so that maybe wasn t where their focus was. But we got a lot of feedback really quickly from some of our partners, particularly down in the south florida area where they were having a lot of trouble getting discharged summaries that they now just had visibility as to why the patient was in the hospital and it was the most invaluable tool that they could have. And so that was really we worked together with connective to make sure we had the right product. And then we passed it on to the providers and got their feedback. Continue to make some tweaks or even still making some tweaks to it because we realized there s pieces that we could improve on based on feedback. And what we re really finding is it s just allowed again the for the PCP to be empowered or the provider on that discharge visit to be empowered to know what happened. And what they need to do. A lot of times, particularly myself as a family doc, there wasn t much I could do from that discharge, but it allowed me to help coordinate the care. Oh, you know, you had a, you were in abdominal pain and we did a CAT scan of your abdomen. And there was this little thing on the lungs that they said followed by an outpatient. A lot of times as the PCP or the post discharge provider, if you don t go dig into that discharge summary, you re not seeing that. So if you don t have the time to dig into a discharge summary, you ll miss it. If you never got the discharge summary to begin with, you re going to have no idea there was something on that lung. That is the goal of what we have here to really just enlighten and give our providers the ability to see all of the pieces that were available. And I think the interesting part about the collaboration that we have with Dr. Brackman is that to get down the one to two pages, we added a lot more to start with. Because what we found is ADTs themselves are probably actually, you know, you might get actually a page out of an ADT, but that wasn t really what you, that wasn t the entirety of what you needed. So the start of our collaboration was to say, let s go get more. And let s go get the discharge note like Dr. Bracket was talking about. Let s go make sure we get the pharmacy meds. So now it s happened to the pharmacy to see what meds that they had filled. Even prior to the visit, that may be Rome. Let s go get the labs. Really interesting aspect. Let s go into credit bureaus and get phone numbers. Cause you know what, as Dr. Backma was saying, sometimes the hardest thing is just getting in touch with the person. And you need, you may not have the phone number for them or they may have multiple phone numbers and they may have changed phone numbers. So even just going out there and getting phone numbers was a critical aspect. And you can even, it s far too small on the screen to see it. But on the left side of the screen, you can see all those little digits there. And all those are little alternate phone numbers for the patients that we found from some other data source that was out there. That we bring together for that one pager to say, hey, here is what you need to engage your patient. So at the very outset of our work together with the lumid and Connective, what we were looking for was what is all the possible realm of data? And that s what, as I said in the very beginning, that s what Connective is really good at, is we re really good at going, getting all of that outside data. Tapping in the pharmacies, hospitals, specialists. Credit bureaus, labs, everything you can name. Bringing that back in. And then distilling it down to that one to two pages in collaboration with the loom made in collaboration. And what Dr. Brackman said, yep, this is what a provider actually needs to engage their patient. And there s different parts on here, but, you know, we got it down to the point where it was really actionable and it really started to have an impact. And we actually got a chance to measure that impact. So we go to the next slide. I ll just touch briefly on. Some of the measurements that we did, which is that when you present that right information to the provider, when you actually can say, hey provider, you know, yes, your patient was in the hospital. Here s why they were in the hospital. Here s how to get in touch with them. And then here s a short synopsis of what happened in the hospital. It has a massive impact in terms of the readmission rate. And this is really just, I mean, this is really all credits due to aluminum on this. They have had a magnificent impact in terms of reducing readmissions across all of their different providers. So they reduce the remissions by 27.5% And what I will say is a very scalable way. When we ve seen these numbers before oftentimes there s just an army of people behind it. And you ve just added human resources to go gather, gather reports and human more humans do outreach. And it s just an enormous amount of capital. That s being deployed. But in this case, it wasn t. In this case, it was the existing, really the existing amount of human capital that was being deployed. It was just better technology, better processes, better information, better clinical guidance. That Illuminated to the provider groups so that they can have this impact, which is really a traumatic reduction in readmissions, which is really better for the patient. No patient wants to be remitted. And I can say that from experience, no patient wants to be readmitted. And no provider wants to see their patient being read them. And nobody wants to bear the cost of readmission. They re really expensive events. So this is really, really one of the, what we call the breakthrough in terms of a scalable and impactful readmission service.
Dr. Mari Brackman: Yeah, and I ll just add a little bit on to that just on the heels of anytime somebody is admitted to the hospital, they lose on average one ADO. Many times they come back, but it takes some time. Every subsequent readmission, there s the potential for another ADL to be lost. So very quickly patients that are in the hospital frequently, as you all very well know. Lose the ability to be independent. And so taking something just as simple as getting the right information in front of the right person in the right time frame is a pretty powerful tool that I don t think we even realized or I didn t because I mentioned I got discharged summary. So I rarely was flying blind when I was seeing patients on discharge. But that s not the case for everybody, like I mentioned. So really being able to get this to them, we saw this. Pretty impressive impact and reduction. And we ll, we ll kind of talk in a few minutes about just even some of the growing pains that we experienced to get to these numbers because that s, I think, something that I, I m very proud of that we do here at IllumEd is that we re not afraid to say, we can do better. So when we find something and we re like, yeah, this is working. We start to ask the questions, but how can we make it better? What can we improve upon? And that s what I mentioned, like even the PDFs from where they started a year ago to even some of our, our next levels that we re pressing them on to with some of our pharmacy data we re going to start pulling in in a different way. Like we continue to look at these tools and say, how can we make these tools better to impact these overall utilization events? As a PCP. Again, very is very near and dear to my heart. It is really hard to do your job as a PCP in particular. And when you layer on a very sick patient and our population is straight medicare, so you add on age. These are very vulnerable patients and you have a very small window in your schedule. To be able to devote to these patients. So really being able to get the right tool and the most easy way to use it when a patient is sitting in front of you is that constant thing that s in the back of my mind that I go to Ryan and his team for and I say, listen, we ve got to, we ve got to push on this. We ve got to push on this. And that is what has led along with our other programs that has led to this reduction and readmissions is just us being totally okay with saying we can continue to do better. Because it leads to better outcomes for our patients. I think we can probably jump to the next. Poll question. All right. You should see this like before on your screen. Here.
Garrett Schmitt: Okay, and this one is, how would you describe the actionability of notifications that your team currently receives? Is it passive? We get the alert without good or meaningful clinical context. Is it delayed? We get the information, but critical intervention window has already closed. It s an inconsistent. The quality of the information varies between hospital partners. And care teams. Where s it optimized? I get timely insights. We get timely insights that trigger immediate care. So we re going to give folks another minute here to respond and then we will look at these. Results here. And as before, if you re joining us a little bit later, these are anonymous and these are just for fun. So we re. Going to show the results of how folks voted here momentarily. I think most of the results have come in at this point. So I m going to go ahead and close it down in another five long seconds. Or three. Two and one. All right, Mari, are you able to see or Dr. Brachman, excuse me? Are you able to see the results here?
Dr. Mari Brackman: Yes, yes, yeah. And again, this is not surprising to me. So just to kind "of read through them real quick. How would you describe the actionability of the ADT notifications that your team currently receives? First of all, if there are any PCPs on here that aren t used to more of this administrative speak, if you know what these words mean, I highly applaud you. I had no idea what these words meant. Two years ago when I was seeing patients. Someone said ADT, if you would have been like, my patient is coming to see me. I have no idea what to talk about. So simply applaud you. But you understand what these words mean. But looking through the answer. So the passive, we get the alert, but without good clinical context, about 21% of voters delayed. We get the info, but critical intervention window is closed. About 14% inconsistent quality of info varies between hospital partners about 57% and then optimized, get timely insights that trigger immediate care about 7%. So again, nothing is surprising here. And I think it s really to highlight that over half said that it s that inconsistency that leads to kind "of the impact or the lack of impact that can be made. And that s something that we really tried to work with Connectivehealth was to keep these consistent provider by provider partner by provider or partner by partner. Hospital by hospital. And that was what we worked really hard on that kind "of front page, one page or one, two pager PDF is to make sure that was consistent regardless of what data was being fed into that every time a provider opened it. They knew what they were opening. I would say just kind "of a comment on that. When we kind "of piggybacked what I was saying earlier, when we were looking at some of our data around the utilization of these PDFs and around the readmissions. What we realized is that we had no understanding if they were actually being used. We could tell you how many were being produced. But we could not tell you how many were actually being used. So that is one of the things that we from an operations perspective started measuring. We started looking at when somebody clicks. And so let me kind "of walk you through a process for how it worked for us. And I will be very frank. There are some significant assumptions made with what I m about to say, but it s kind "of the best we have. So we have our ADT feeds that come into our kind "of internal system. Somebody has to click on that. Open it, and then they upload the PDF and it s our team to then upload it in our partners chart to where they want it to be uploaded. And if our team, so that it s readily available at that visit. If our team is not the one doing that, we ve made sure that we have educated all of our partners how to do that exact process because they all have the ability to access all the same workflow pieces. Just depends on who s doing the clicking and whatnot. So what we found is that in order for us to know if anything was happening, our first step was, well, what s our click rate? How many people are actually clicking on the PDF? And we realized not very many. So we started pushing that, hey, you actually have to click on that button that comes in. It gets, it flashes in and says there s a PDF available, click on it. That was our first step. So we made some assumptions again. We assumed a click. Meant that it was being inserted into the chart. Massive assumption again. But one of the pieces we did when we were measuring this and what the data is coming from, it was our team that was doing the clicking and the uploading. And because we had that process really well laid out, we feel very comfortable with that assumption. So that was one of the first things that we had to do was make sure back to that poll question that not just that the quality of product that we were pushing out, but the consistency in how we were getting the product and the information to the PCP partner by partner was also very consistent as well. Ryan, I want to jump in and kind "of share any other pieces around that process.
Ryan Hess: Yeah, I think what I ll augment is what Dr. Backman said at the beginning, which is inconsistency of data. Is then what leads to what she was just talking about, which is people won t use it. Like if it is not better than what they have today. There s no reason to change the habits that you have. So what we have found is that to get the consistency of data, you just, as I said before, like you have to get a lot of the data. And it ll toss a lot of it. But what we found is like the ADT will have a diamond and the discharge will have a diagnosis on it. And then if you get both of them almost every time you ll have a diagnosis associated with that visit. And then the same thing with phone numbers, right? I mean, phone numbers will come from everywhere. And it is just about going through and saying, okay, let let s make sure we have the most pertinent phone number. Let s make sure we have a backup every time. On that PDF. And that kind "of iteration of like, hey, what is missing? What is preventing somebody from saying this is a better workflow than I have before? What is preventing somebody from, as Dr. Braxton was saying, clicking on it and opening it and using it? You really have to be listening for what the providers are saying is what s preventing them from adopting it and using it. Inconsistency is a great example of it. We obviously have spent a lot of time making sure that the right information is on there, the information that is actionable for them. A lot of time condensing it down to one page. So, and we re happy to share. For both of us. We re happy to share some examples of what this looks like. So you can get an idea of like it s taken a lot of work to get where we are, but it really is better medical care, right? It is better care for the patients. If you re able to bring all those things in and condense them down to something. The providers that Dr. Backman was just saying, they will use them. And that leads to the better patient care and that leads to the lower readmission rates, which is what we were highlighting and celebrating before on a fireside.
Dr. Mari Brackman: And I ll add, we actually have some of our groups that are now using the Connectivehealth PDFs even when they get the hospital discharge summaries. They re choosing to go to this tool because it does give that higher level summary and then they can double click and go look in the chart or whatever they need to do to find it, but they get that really quick snapshot. And that s actually the partner where we had the big drop in reduction of readmissions by utilizing the tool. That was feedback from them is that they just really liked the product. They liked that it was the same no matter what hospital it was coming from, no matter who was the doctor that was doing the discharging. They got the same thing every time they knew exactly where to look. They knew exactly what to click on. And that flow, as we all know, just that natural kind "of muscle memory that when you are seeing a patient working in the EMR and trying to do both simultaneously, being able to just kind "of drag your finger the same way every single time when you re doing one of those visits is just a really, it s less brain space you have to use that you can focus on something else instead of where do I have to click and what do I have to do? Well said. Okay why don t we move to our last poll question. Garrett, do you want to introduce the last poll question?
Garrett Schmitt: All right. Here it goes. What is the primary barrier preventing your organization from scaling transitional care management relative to your baseline or benchmark? Is it an operational burden? This is too expensive and labor intensive. Is it data silos? There s not much integration between hospital systems and care teams. Is it provider engagement difficulty getting clinician buy in? Where s it resource allocation? Care teams are overwhelmed. By low or limited risk pat. Ients, I m sorry low risk patient data. That they are overwhelmed by low risk patient data. So what is the primary barrier preventing your organization from scaling transitional care management? Give folks another. Little bit to answer. And then we will show the results. This is our final polling question of the afternoon here. And again you may be saying well all these are a challenge but if you had to choose one that was the most. Of the thorn in your side, which would it be? All right looks like most folks have voted so we re going to go ahead and close it down in about 10 seconds. And we will show the results. And five, four, three, two and one. All right. Dr. Brachman, Ryan, are you able to see the results here? And I ll run through at a high level just what the results were. So the question was what is the primary barrier preventing your organization from scaling transitional care management? So the leading answer was data silos, low integration with hospital systems. That was the leading answer. Second answer is provider engagement difficulty getting question buy in third answer was operational burden too expensive labor intensive. And fourth ranked was resource allocation care teams overwhelmed. I ll state that obviously from my perspective not surprising. In part because data silos underlie everything else. Right. And I think you ve heard that through this conversation. Where if you don t have the data, if you don t know that that provider or that patient was discharged if you don t know the diagnosis, if you don t know, you don t know the discharge node. If you don t know the phone number, it is really hard for the provider to engage. So if you don t have that data getting provider buy ins really difficult and if you don t have that you re going to spend a lot of time calling around looking for a lot of that data. Which leads to operational burden. So really data silos lead to some of the other issues that are in there. And then I know Dr. Brock and you just talked about provider engagement. So I think I m going to you to talk about the other two.
Dr. Mari Brackman: Yeah, no and I think. Just kind "of thinking when I was seeing patients in hospital follow up knowing what I know now and thinking about having done it. I just kind "of assumed it was just, it just happened, you know, just suddenly I have a discharge summary sitting in front of me. And again like I said we had a really good flow from the hospital system to my clinic. But what I know now is that from the moment a patient steps foot into a hospital. To the moment the patient that steps foot in front of me. There is a lot of stuff that has to happen, a lot of pieces, a lot of flow, a lot of exchange, a lot of communication. And if any one piece of that breaks down, I will not have what I need to make sure that patient has the highest quality discharge visit to lead the best outcome for that patient. And I think that is what we have been able to very successfully work with Connective Health and Ryan and his team of making sure that kind "of the reverse of the Swiss cheese model where all the holes line up and ends up not in the right thing, right ending. We actually have as we created. We ve created a as best we can a Swiss cheese model so all the holes line up beautifully so that that data from patient admitting and or discharging to now seeing me can flow perfectly straight through. So I think just being able to have that resource and we don t have it for everybody like it s not like we have this readily available to all of our all of our partners for all of the patients on every single discharge. That s something we re actively working to try to continue to improve upon because we know when we have it and we get that flow working as well as we have over the past 18 months we get the outcomes that we re showing you. But that s just one of the things that we re continuing to focus on is how do we get even more and more of our partners and our patients able to have this flow because it s not just one tool. It s not just one person. It s not just one team member. All of these pieces have to work together to make it be so that it can flow as nicely as we ve made it flow for the places that we ve seen the improvements that we have.
Ryan Hess: Yeah, I ll follow on and say that s our commitment to collaboration to make sure that it s there for every patient at every discharge. That the provider has what they need to meaningfully engage with the patient. And that is the that is the collaborative journey that admitted and Connective Rowan. So maybe Garrett will stop here and open it up some Q&A. I know we ve only got 15 minutes left or so I know we wanted to leave some time for Q&A at the back end.
Garrett Schmitt: Yeah, no, this is great and we do have some audience questions. If you do have a question for either Dr. Brackman or Mr. Hess here go ahead and drop it into your control module. There s a place specifically for questions. But if we don t get to yours don t worry someone will make sure to answer your question via email afterwards. So first question is this. How real time is the data in these discharge summaries? Do you see the information as the patient is walking out the door or is there a significant delay while the hospital finalizes the billing and coding?
Ryan Hess: Yeah, I ll take the first step which is it s a mix. So you oftentimes will get things as they walk out of the hospital realistically you know you ll probably wait 12 hours to make sure that you are getting getting the discharge note because oftentimes that ll take a few hours for it to close out. But it is I mean it says real time as it needs to be to make sure that you engage the patient is the way that I would frame it. We can pull the way that we connected work is we reach right back out into the EHR of the hospital to pull the information out so we re not waiting for something to load into an HIE or anything like that. We re actually reaching back into the HR pulling the information out. And then pairing that with the ADT which oftentimes is also real time. And bringing that together. And then same thing with all the other data sources we re doing. We re doing all of that in real time. So as soon as we can. We reach back out to the source itself pull the information back in and then do the processing. That we ve talked about with Dr. Breckman.
Dr. Mari Brackman: Yeah and I would just add so ultimately our goal is that every patient that discharges from the hospital is seen within two days. That is the most unrealistic expectation anybody could have for anybody that has a panel of any patients you know that getting somebody in 48 hours is very, very, very challenging. So our goal at Illum ed is to try to get all these post discharge visits within seven days of discharge that allows for and many happen within five. Many of our partners have set an expectation of we want them within five. We usually have all of this ready to go clicked on visit scheduled and uploaded within about 24 to 48 hours post discharge. So it s a Ryan s point it s very real time and it s very it s very helpful. We have some other care teams at our platform level that utilize the tool and they are calling prior to that post discharge visit with the PCP. And this is very often very available within that call. So within 48 to 72 hours we ve got something that we can you know physically touch and look at.
Garrett Schmitt: Thank you. Next question is this how does this system help with managing a patient s medication adherence and or reconciliation with what the hospital just prescribed and what the patient currently has at home.
Dr. Mari Brackman: Yeah I can talk kind "of from what we see on the PDF and sort of how we put the PDF together. So within the PDF again we have that kind "of lead page that s very just pertinent to what happened during the hospitalization. But within kind "of the details page behind it and that can be anywhere from two to 27 like that s where you can get some of that beaten potatoes. We have an active medication list and we have last fill date on that. And so if you really want to kind "of dive into that really level of detail you can see as long as the hospital did it the way that they re supposed to. Again that s a big assumption. I understand that but we re pulling in that information. And then there s also pharmacy data pulling in as well to try to really make it as the most up to date as we can. One of the things I mentioned that we re working on kind "of the next iteration of our PDF is how do we better highlight using like sure scripts data what the patient picked up post discharge. So much can be known. If you know nothing else if we if all I can know if all I can know is the PCP is what the medicines the patient was discharged with. I can make some really educated guesses about why they were there, what we re trying to do to continue the, you know prevent that readmission. And so being able to get that real time pharmacy pickup data is also something that s going to be really, really helpful once we kind "of get that up and running a little bit more intensely. But Ryan, I ll pick it to kind "of add some more content.
Ryan Hess: Yeah, so I ll just give you a little bit of how this works underneath. So as Dr. Brackman was saying there s a few different pieces of medication data right so the first is going to be what was prescribed in the hospital. So that s going to repoll that out of the hospital itself. So what did the patient have in the hospital? What did the patient have as orders leaving the hospital? And then we pair that Dr. Bracker said sure scripts which is just kind "of code for reaching back into the pharmacies itself. So that s what we re doing to get the what have they picked up since? So did they walk out of the hospital and did they pick up the heart medication that they had been prescribed before because they had a refill waiting for them. You want to know that and that you get directly from the pharmacy. You also want to know what s in their medicine cabinet right so you do also want to know typically what you know what have they been picking up for the two months prior to the hospital visit? And that s also pharmacy feed data. It actually tells you what they ve picked up from the hospital or from the pharmacy itself. So those are a few different data sources that we pull together to say hey this is what you need for the medication reconciliation. This is like a kind "of the medicine cabinet. Is what they were prescribed in the hospital. And then this is what they picked up since they were discharged from the hospital and that gives you a pretty good starting point to do the medication reconciliation to make sure that they re not taking something conflicting. Make sure they re not taking something that was in the medicine cabinet before that might conflict with what they just were given in order for coming out of the hospital. Because from a patient s perspective I don t know. I assume that my doctor who prescribed me something at the hospital knew it was in my medicine cabinet. I know the throng assumption. But in general that s the assumption folks make. And that s what we all have to address.
Dr. Mari Brackman: Yeah, and I would say I always used to joke that I think probably one of the most incorrect things in the medical record is what a patient, the active medicines a patient is actually taking. And so being able to have all of those pieces together because it requires somebody going in and updating it. And so being able to have all those pieces come together when you re looking at this particular dish, particularly on the discharge, you can have a really good understanding as to where those discrepancies were. I know they re not on this and this my EMR says this. So you can kind "of make some clean some things up that way. But I think it also just gives as the PCP knowing that you re getting or the provider even seeing the follow up getting all of these details. You can really start to put together like things like, oh, I see the hospital had you hold this medicine not stop it. So now that you re seeing me seven days later and you re doing a little better, we re going to go ahead and restart that now. I think that s one of the biggest things especially when I was mentioning medications typically in my opinion being the reason people bounce back to the hospital. It s because things get stopped and don t get restarted or they get started and they don t get stopped. So having that visibility into all of the pieces of what was happening and the outpatient world versus the inpatient world versus discharge an all in one spot allows for a little less of that inability to be able to kind "of keep that active management happening. All right.
Garrett Schmitt: Yeah, thank you. Next question is this for a low med do you anticipate any challenges in scaling this program across more of your provider partners going forward?
Dr. Mari Brackman: Yeah, no. So as Ryan mentioned because of the way the data comes in. We I mentioned we have a patient engagement team that does this for our partners that want or need us to. And so for them it s just part of their process flow. So it s a quite easy thing for each discharge. And then we re educating our partners as well even if we re the ones doing the scheduling we re educating our partners for how to go access this or if they re the ones doing their own scheduling and uploading having them know how to do this. And because everybody s getting those feeds and kind "of living in there anyway with it just being a simple click and upload. It s really not a challenging process. Our leader of our patient engagement team usually gives me a role of an eye when I ask our team to do one more thing for me because I think it s just you know it helps if the PCP can have this. This is one of the areas where she says we don t mind doing this because it s really, really easy. It s a click and an upload. We know exactly where in the EMR our each of our partners wants it dropped or at least sent to and then they can move it where they want. So the ability to scale this is not challenging because it is just part of the natural workflow. It s just getting a document into the EMR. That s all we ve done. We ve just created a consistent document that s going to allow there to be that constant same each discharge that gets dropped in the EMR and the natural flow for each of each of our partners.
Ryan Hess: And I ll add this works in every state. Every area of the United States. So the connections that we ve established is to support just to support Lumid. It works everywhere. So it s scalable across all states. I know aluminum is saying they re in seven states earlier. But we ve done this in all 50 states and I think all three territories and there s a couple other definitions out there as well. We ve done this everywhere. It works really well. So scalable across states it s scalable volume wise from a data gathering and synthesizing perspective.
Garrett Schmitt: All right wonderful. We ve got another question here. For a care team with limited personnel. How do you prevent care managers from being overwhelmed by the patient information? Is there like a filtering mechanism that tells us who to call first?
Dr. Mari Brackman: That s a really great question. It s actually something that we re actively working on. And it s still it s still in the process so but we are working through some of that prioritization. One of the pieces that we use to help prioritize that flow are these Connective health. Discharge summaries like who are we getting them from? Where are we getting them? Who can we get them to? And then we have a couple other tools that we use at Illum ed to kind "of prioritize order of attack and that prioritization. And so. I think the question that you re asking is something that we all ask a lot of times is who can t I miss on? If I have five patients which one can I not miss on getting that connection with? If somebody knows how to do that and has figured that out please send it my way my email will be up at the end like let me know because we re looking for help there too. But I think that real answer is that it s not it s it s not just one thing. You have to look at a multitude of different things. Some of the things that we currently are doing we re cutting our data now in a little different way. We re looking to see you know when somebody discharges from the hospital. And they see their PCP. They may have a PDF. How many days later did that patient readmit? And we re kind "of going to Z state by disease state to say hey like our highest risk patient from our illum ed population probably not surprising is our highest readmission. Within 30 days when they see their PCP within seven so I m discharged see my PCP by day seven within three days posting that PCP visit our highest readmission to someone that was discharged with sepsis. So now that we ve kind "of cut that data it s going to allow us to put some different processes in place. One of the things we re looking to do is do we now schedule someone that discharges with sepsis two visits. Do they now get a post discharge visit scheduled within seven days another one schedule within 14 days. And how are we going to use a tool like Connectivehealth is are we going you know we have that first PDF like what happens if that blood culture comes in three or four days later because it was now the final result five days later like how are we going to up you know kind "of get that that data to flow in? These are all the things that we re thinking about the kind "of the process that we re in and that s what I said one of the things I really have appreciated about us here at IllumEd and with Connectivehealth is that we keep saying what s next? How do we make this better? How do we improve? How do we get better information to our partner so that they can care for their patients the best way they can and starting to look at that kind "of stuff is really what we re trying to do next.
Ryan Hess: And then what we re doing in support of that is gathering and structuring and cleaning all the data that Dr. Brachman needs for the different algorithms that can be applied. So if you re looking for sepsis, if you re looking for how many medications have this patient picked up prior to the 30 days prior to a mission. You re looking for those structured data to be able to say I want to create my own prioritization algorithm. Great. Our role is making sure we gather that data will do the computation for you. You design your own clinical algorithms, but we ll design the computation for you and say hey this patient had six medications picked up prior to admission. There s a sepsis mentioned in the discharge note. Those combination of two things that s your highest score. That s what we re here to support you with. Going out gathering the data making sure it s clean complete structure and then we can run analytics on it and then we support you all in terms of creating the algorithms to say, yep this is. This is the person that s got to be at the top of the stock to make sure that I engage and then Dr. Breakfast point and make sure you have the program in place to say, yep this is what we re going to do if that high risk patient comes through and these things are true. This is what we re going to take as a next step to try and reduce readmissions.
Garrett Schmitt: Very good. Well unfortunately we are out of time so if if you had a question that didn t get answered again don t worry someone will make sure to reach out to you via email but if you have one and even if it s right now go ahead and drop it in and someone will make sure to get that question answered. I wanted to say a special thank you to you Dr. Brachman to you Ryan. This was a fantastic presentation. I know we covered a lot of material here. And as we close out I wanted to encourage you all to head over to vbc exhibit hall.com and there will be a link here in the slides that we send out or that we make available. That you can check this out and I would encourage you to do that because there s a lot of great material there on them. You can really read up on Connectivehealth what they re doing in the space. There s some resources that they provide and really educate yourself on those services. And of course be able to reach out to them from there. And I think you ve heard today that there s a lot of great things going on and hopefully this testimony will encourage you to go ahead and reach out. And then finally if you would like to reach out either to Dr. Brachman or to the Connective health team you can reach out to Shane s information Shane Callahan who s the VP of sales who s on here. And again Dr. Brackman s information is on here as well. Or if you would like to reach out to me. I m happy to facilitate an introduction if that s easier and put you in touch. But again I wanted to thank you all for spending your afternoon with us and hope you will join us on the next one. So thank you so much and have a great rest of your afternoon. Bye bye now.