00:00:04:17 - 00:00:31:09 Adam Hocking Welcome to The Rounds, a podcast of Marshfield Clinic Health System. I'm your host, Adam Hocking. The Rounds brings together medical experts to discuss fresh, fascinating and important topics from the world of health care. In a time when technology connects us more than ever. Health care no longer takes place solely within the walls of the clinic or hospital. Today, we can connect a patient sitting on his couch at home with a provider in her office 100 miles away, just with the use of a smartphone. 00:00:32:00 - 00:00:53:11 Adam Hocking What does the explosion of so-called telehealth mean to the future of health care? And what is Marshfield Clinic doing right now to embrace this technology? Joining me to discuss these questions and more is Marshall Clinic Health System’s Director of Virtual Health, Chris Meyer. Chris is a longtime IT professional who also has a master's degree in behavioral economics from the Chicago School of Professional Psychology. 00:00:53:19 - 00:00:57:09 Adam Hocking He's also the former mayor of Marshfield. 00:01:00:05 - 00:01:02:00 Adam Hocking Chris Meyer thanks for joining us this morning. 00:01:02:08 - 00:01:03:10 Chris Meyer Thanks, Adam. Thanks for having me. 00:01:03:16 - 00:01:25:04 Adam Hocking When I talk about or think about telehealth, that that's a word that's being thrown around a lot in health care circles these days. And I think of telehealth, I think of calling the doctor, getting care over the phone. But telehealth as a field is really much broader than that. Can you sort of define terms for us as we start out and talk about what is telehealth and how broad is that definition? 00:01:25:06 - 00:01:25:14 Adam Hocking Well, you know. 00:01:25:14 - 00:01:42:20 Chris Meyer The concept of telehealth, obviously, we have the word tele, which oftentimes makes people think of telephone and health care can be delivered over the telephone. You can call our nurse line and get advice on how to take care of your colicky baby or whatever issue you may have 24 hours a day, 365 days a year, and that is telehealth. 00:01:43:02 - 00:02:02:18 Chris Meyer We are using technology to deliver to deliver health care, but it's obviously much broader than that today. It's been much broader than that for decades. If we think back to the 1960s, even if we weren't born yet, we know that in the 1960s we went to the moon. And while we were and had astronauts on the moon, we were able to see what their heart rate was while they were there. 00:02:03:05 - 00:02:25:20 Chris Meyer That was telemedicine. Telehealth has a long history in the military. Obviously on the battlefield you need people who can deliver care right there immediately. And over the last several decades that that level of health care has really improved with the use of technology alongside the soldiers in the battlefield. That same sort of technology can help us. Today. One of the most prolific uses of telehealth is the Veterans Administration. 00:02:26:09 - 00:02:44:22 Chris Meyer They use telehealth all over the country to deliver care to our veterans in veterans clinics and hospitals. And so it's not surprising that a lot of health care organizations have adopted telehealth over the last several decades, as well as a way to better reach the people they're serving. So when we talk about telehealth, we're not just talking about talking on the telephone. 00:02:44:22 - 00:03:10:12 Chris Meyer We're talking about streaming video. So a provider can be in one location on the other side of town or the other side of the world and interacting with a patient somewhere else, delivering that care remotely. Telehealth has got a lot of other applications as well. It may not be a live interactive, what we would call a synchronous encounter, and maybe an asynchronous encounter in which a patient who is chronically ill, maybe they have diabetes, and every several times per day they'll take their blood sugar. 00:03:11:02 - 00:03:36:07 Chris Meyer But because they need some help managing their diabetes, we set up a program in which those diabetic blood glucose levels can be communicated back to us automatically. And so all we're doing from that telehealth standpoint of telehealth in that case is looking at numbers as they come in. And of course, if something comes in that's out of the spec that it should be, we can reach out to that patient to adjust medication or console them or provide education, or at least help them try to figure out why their blood sugar is out of whack as one example. 00:03:36:19 - 00:04:04:05 Chris Meyer So telehealth is a pretty broad area. It's been around for a long time and it's not new, but it's certainly growing in the Marshal clinic. It's growing exponentially. We've been doing telehealth since about 1997, and today we offer over half of our specialty lines of medicine. We have about 86 of them, the Marshal Clinic, and 44 of them are offered via telehealth to our regional centers that allows patients in those communities to avoid missed time from work to travel to Marshfield to see a specialist and instead be able to see that specialist via telehealth right in their hometown. 00:04:04:11 - 00:04:31:11 Adam Hocking And you talked about the evolution of telehealth, specifically at Marshfield Clinic. We recently launched in partnership with American well, an app which you can essentially a patient can be at home or at school or at work pull out their smartphone with through the Care My Way app. I believe, loaded up and connect via FaceTime or call it. That's a familiar term for folks face to face right from your phone with with a nurse practitioner. 00:04:31:23 - 00:04:45:08 Adam Hocking Can you talk about the rollout of that program? And I think the convenience is fairly obvious to people. You can be at home and connect with a provider. That's great, but talk about how it helps with access to care and the cost of that care. 00:04:45:09 - 00:05:08:22 Chris Meyer Yeah, absolutely. So one of the things that became very prevalent in the United States over the last several years is are or rather are these programs that deliver what we would call low acuity, episodic care. So the kind of the routine things you would get. We all get a sinus infection. You know, most years, a urinary tract infection, pinkeye, things that are very, very treatable have a very straightforward diagnostic diagnosis process. 00:05:09:09 - 00:05:28:01 Chris Meyer And quite honestly, a doctor doesn't need to diagnose a nurse practitioner. In many cases, even a nurse can diagnose some of these things from the standpoint of care my way. We developed that service in 2014 as a telephone based telehealth service. The only option to talk to a nurse practitioner was via the telephone and they would diagnosis via an interview process. 00:05:29:08 - 00:05:50:01 Chris Meyer In 2017, we launched our virtual platform and added our app to one of the ways as one of the ways we can deliver care on the service. So now, in addition to being able to call, which you can still do, you can download the app and do an interactive video chat session with the nurse practitioner. Obviously, from a quality standpoint, this helps increase the ability of that nurse practitioner to diagnose you. 00:05:50:03 - 00:06:07:20 Chris Meyer They can certainly determine if you have pinkeye by asking you a list of questions and narrowing down what it is that's going on. They still do that via video chat, but they can also see the eye and they can say, Oh yeah, that certainly looks like pinkeye. Same thing for diagnosis, like ringworm, another another ailment that we treat on care my way. 00:06:08:12 - 00:06:27:20 Chris Meyer So that is certainly helped and it has been adopted quite quickly by our patients. Our goal was to have around five or 6% of our calls in the first year in care, and we moved to a virtual platform and we were actually a little over 10%. It's grown quite quickly. People really like it. It's a way to have that personal touch, so to speak. 00:06:28:03 - 00:06:44:23 Chris Meyer Even though you're not interacting with a doctor by being able to see them. And of course, it helps the provider be able to better see you and diagnose you as well. From the standpoint of what this particular service care, my way is, it's an easier way to access care. You don't need to come in to the doctor for a sinus infection. 00:06:45:11 - 00:07:08:20 Chris Meyer Quite honestly, it's it's not a good use of your time or the doctor's time. And it's certainly not a great use of health care resource dollars that you may have using a service like Care My way, which is a $40 flat fee, is oftentimes for almost everybody a far cheaper solution. These types of health care delivery services are one way that the Marshal clinic is trying to reduce the total cost of care. 00:07:08:20 - 00:07:29:23 Chris Meyer We all get sick throughout the year. We all have to go to the doctor. And if we're paying out of pocket or if we have a high deductible health plan, that trip to the doctor's office will probably cost you a couple of hundred dollars. If it's for something as simple as a sinus infection or a urinary tract infection or conjunctivitis, pinkeye that can be treated for $40 via the app or fee of the phone, same price, no difference in price. 00:07:30:07 - 00:07:49:03 Chris Meyer And so, again, it's one way that that people can access more affordable care. The other piece that's really important is that it's not just the cost from a financial standpoint, the cost of the care, it's the inconvenience of having to get the care. I've been living in Marshfield. I've never really been inconvenienced. I work in the Marshall Clinic. 00:07:49:03 - 00:08:05:23 Chris Meyer It's pretty easy to walk down the hall to see my doctor. But if you live in Philips or north of Philips, up in Mercer, in Presque Isle or someplace way up north, you may drive an hour or more to get to just the nearest Marshall Clinic. If you need specialty care, you may be driving all the way to Wausau or to Marshfield. 00:08:06:11 - 00:08:25:06 Chris Meyer That means that you are taking time off of work. If you don't have vacation, that means you're taking an unpaid day off of work off. If you're a senior, you may have an adult child that comes with you to your appointments that they have to take a day of of work off. Telehealth is one way we can help start delivering more and more medicine more conveniently in people's communities so that they can reduce their costs. 00:08:25:12 - 00:08:27:07 Chris Meyer And in receiving health care as well. 00:08:27:18 - 00:08:57:19 Adam Hocking You raise a really interesting point that I want to talk about is the rural aspect of providing virtual care. Telehealth services, obviously, Marshfield Clinic serves a rural population. It's it's not the same as a health system in New York City, where there's physical locations everywhere there's public transportation. The distances aren't as far. Is it particularly important? And do you see other rural health systems placing a focus on telehealth because of the distance people have to drive? 00:08:58:10 - 00:09:18:18 Chris Meyer Well, you know, you're right. It's absolutely, in my opinion, more critical in rural areas, but it's equally as important and valuable in urban areas. In fact, there's this prevailing mindset still with many of the payers, the insurance companies, especially the government, when it comes to Medicare, Medicaid, that when you're in an urban area like New York City, you won't need telehealth because, you know, as a dermatologist around every corner. 00:09:18:18 - 00:09:36:17 Chris Meyer And that may be true, but it's still showing promise, meaning that if you're in New York City, sitting in a big office building and you have a sinus infection, you can still get treatment for that from an app, from an online service and save yourself time, even if the doctor you would see is just down the street. Obviously, in rural areas we have a number of issues. 00:09:36:17 - 00:09:52:23 Chris Meyer One distance, we have two choices. We have the patients get in the car and drive to us or we have the doctors get in a car and drive out to them, neither of which is efficient. We can deliver more care via telehealth, which makes it more convenient for everybody. But I would also say that telehealth isn't an option for every type of health care delivery. 00:09:53:06 - 00:10:16:15 Chris Meyer Oftentimes that first visit with a doctor. I like to say that the visit where they have to poke and prod you still needs to happen in person. And it may be a matter of waiting for a doctor to be doing outreach in that community and beyond sight to be able to see them. Or it may be a trip to Marshfield, but at the same time follow up care, especially if you have a chronic illness that can be done via telehealth and be done much more conveniently. 00:10:17:01 - 00:10:31:00 Chris Meyer If it's done more conveniently and more cost effectively, that means that the patient is more likely to follow through on that care. It means that they're more likely to follow the directions of their doctor for follow up visits and and maintain that relationship with their doctor so that their chronic illness stays in check and doesn't exasperate. 00:10:31:10 - 00:10:51:09 Adam Hocking Another one of the challenges of being a rural health care system in terms of delivering telehealth services. Virtual care is Internet access. Is it right that disproportionately the rural population is affected by a lack of Internet access versus and a more connected urban population? Is that a unique challenge in serving rural areas? 00:10:51:10 - 00:11:06:04 Chris Meyer It is. And you know, the last question you asked me, I said there are two things and I told you, one, I didn't tell you the second. So I'm going to start by telling you the second. And it actually Segways really well into this question. The other issue, in addition to the traveling barrier is, of course, the income barrier. 00:11:06:18 - 00:11:33:02 Chris Meyer Rural populations tend to have a lower income in our service here in the Marshall District, we're somewhere just nearing $10,000 below the median income for families. The average in the in the in the nation. That makes it even harder to travel those distance to take time off from work or unpaid time off from work. So when we get to the point of delivering care to the patient in their home through a virtual visit, for example, one of the requirements obviously, is that you have that technology available to you. 00:11:33:02 - 00:11:55:01 Chris Meyer Now, we know that a lot of people have smartphones, a lot of people have computers at home and tablets and and obviously those people have that piece of equipment, but they also need the connectivity. They need the ability to connect to the Internet to use that device and for us to be able to deliver care. And if you live in a community, even a small community, you probably have fairly good access to Internet within the city or town limits. 00:11:55:17 - 00:12:11:21 Chris Meyer But if you get outside of those towns, get down a gravel road a mile or two, I feel like I'm singing a country music song here. But if you get down the gravel road a mile or two, you'll find that oftentimes your cell phone doesn't work. You don't have data service there. And if you call up your local Internet carriers, they may say, we can't get service to you. 00:12:12:17 - 00:12:36:18 Chris Meyer Oftentimes those patients are living in a home that maybe was a second home for them. They retired, you know, and grandma and grandpa moved up to their lake house and they live there now. And grandpa has passed away and grandma's still there. But grandma's getting older. And she could stay in that home longer if we could get services to her remote patient monitoring, for example, looking at those blood glucose levels or watching her height and weight ramps or other weight and and blood pressures for a heart failure patient. 00:12:37:13 - 00:12:57:01 Chris Meyer But we can't do that if we can't get Internet. So we recognize that there are a lot of places in the Marshall Clinic's service area that have barriers in getting Internet access. And it's not just a matter of getting Internet access. You have to have sufficient Internet access to do full streaming video. Generally speaking, from a technical standpoint, we would love to see people have a minimum of two meg of Internet connection in both directions. 00:12:58:00 - 00:13:13:13 Chris Meyer Most people will say I have broadband, but many people have broadband that doesn't meet those requirements. And so a video visit won't work. So one of the things that that I do in my role here in the Marshall Clinic is, is work with organizations, work with groups and advocate for the expansion of broadband in rural parts of the country. 00:13:14:08 - 00:13:48:18 Chris Meyer There's an organization, the University of Wisconsin Extension, that put together a group called the Connecting Aging Communities Program. And the idea with this program, it was funded through a philanthropy for a two year pilot to identify two communities that we could bring partners together, and those partners would be community leaders, city councils and mayors. It would be county board representatives, it would be the Internet service providers in the community, but also businesses, health care, especially education and other entities that would have a vested interest in seeing broadband expanded. 00:13:48:18 - 00:14:12:09 Chris Meyer The idea is that if we bring all these people together, we can create a case, a business case, and better explain to these inner service providers why it's worthwhile to make the investment to go down that gravel road two miles. Unfortunately, the economics aren't always there. And ultimately, in order to get broadband available to people universally across this country, not just in our service area, it's likely going to take an act of Congress. 00:14:12:09 - 00:14:31:13 Chris Meyer And we can kind of say that tongue in cheek and laugh about it. But back in the 1930s, the Rural Electrification Act allowed electricity to be delivered to very rural areas. And I think that at some point down the road we're going to see something very similar happen with broadband in this country. It's amazing when you think about the impact broadband can have outside of the health care issues we're talking about today. 00:14:32:01 - 00:14:47:03 Chris Meyer It opens up a world of education that people who are in a rural community and are place bound for whatever reason it may be, that they're older or unable to travel. But it could also be that they grew up on a family farm and mom and dad just can't have their kids leaving to go off to college because they need help on the farm. 00:14:48:09 - 00:15:10:03 Chris Meyer Internet access. Sufficient Internet access means that they have access to a world of of online education possibilities to continue to advance their education for businesses, business to business work and opening up an online storefront are economic development opportunities for businesses in the Northwoods of Wisconsin or any rural area in this country? And the other piece, obviously we all live in this area. 00:15:10:03 - 00:15:33:16 Chris Meyer We know that during the summer when it gets hot, we go up north, we go to the lake. Tourism is a big part of the economy in northern Wisconsin. When we go up north, we probably complain about all the Illinois license plates that we're following, our Minnesota license plates that are coming over. But those people are bringing their dollars with them and they're spending money going out to dinner and they're spending money at the grocery store and buy minnows or whatever it is they're doing while they're visiting. 00:15:34:06 - 00:15:50:20 Chris Meyer But oftentimes they come on Friday and leave on Sunday because they have to work. And if they had access to broadband, there is a portion of them that would be able to stay longer in these communities, keep their dollars in those communities longer, spend their dollars in those communities, and go home by having the ability to have to telecommute while at their cabin. 00:15:51:08 - 00:16:08:17 Chris Meyer And that may mean that somebody who can only come up on the weekend can now stay for a week or two or maybe all summer and work from their cabin remotely. But that is only possible if they have access to Internet. So the idea with the the Connecting Aging Communities program is to bring all these people together to start building the argument and the business case for why broadband should be expanded. 00:16:09:06 - 00:16:28:01 Chris Meyer And that generally is going to require more than just talking to a local ISP and deciding, yeah, of course we're going to do this. They generally agree that it's the right thing to do, but the economics aren't always there. So then we look at organizations like the Public Service Commission. They've got a grant program to help ISPs expand broadband and we work with them. 00:16:28:01 - 00:16:47:17 Chris Meyer I've written several letters of support for people who are applying for grants for broadband expansion in the Northwoods, and those dollars, when allocated and approved, come come into play to help expand that that Internet access, making it more cost effective to get it down that gravel road for two miles. And so we've got a long ways to go in that area, but it's something that is steadily improving. 00:16:48:06 - 00:17:09:14 Chris Meyer And regardless of political affiliations at the state level, there tends to be universal support for expansion of broadband. The governor's most recent budget included about $35 million for broadband expansion, which, you know, on one hand isn't nearly enough. On the other hand, it's a lot better than nothing. And so we're more appreciative of that in the continued efforts to to find ways to expand broadband broadband in the rural areas of our state. 00:17:09:22 - 00:17:34:14 Adam Hocking Setting aside the connectivity issues, the access issues, you mentioned remote patient monitoring, things like that that are important for maybe particularly elderly patients so that they can stay in their home, whether it's a 65 year old man with heart failure who needs to be in touch via telephone, talking about hear my symptoms, or whether it's a 75 year old woman who is vitals need to be monitored for a chronic disease. 00:17:35:19 - 00:18:05:02 Adam Hocking I think it would be easy to stereotype and to say the tools are great, but the elderly generation or the older generation is not going to want to use these tools. We've had conversations in the past about that, and you've told me really that's not the case, that if you equip people and teach them how to use this technology, they really take to it because it allows them freedom to stay in their home, to extend the time that they don't live in assisted living facilities or whatever it might be. 00:18:05:18 - 00:18:14:06 Adam Hocking Talk about the effort to teach both the patient and the provider how to effectively use these tools. 00:18:14:15 - 00:18:36:19 Chris Meyer You're right, Adam. You know, it's easy to say Grandma will never use this. You know, I have a grandma. Everybody's got a grandma. And they probably think, How would grandma do this? And you're generally right, there's an aversion for for seniors sometimes to using technology because it's something they're not familiar with. Many seniors are very familiar. We have lots of patients who say, well, this is just like when I Skype my grandkids. 00:18:36:22 - 00:19:05:18 Chris Meyer In California, seniors are using technology. But even for those who haven't used technology before, we're not talking about using the Internet like we may think of it in everyday terms. We're not talking about, you know, doing Boolean searches and Google and trying to explain and teach people how to use a tablet computer for for those types of things, the Internet of Things, the connectivity of devices in our homes via the Internet is really more in line with what we're talking about with remote patient monitoring. 00:19:06:05 - 00:19:28:21 Chris Meyer So let's walk through a scenario of what would be involved with remote patient monitoring. So let's say I have congestive heart failure and as a result, I'm enrolled in the Marshall Clinic, heart Failure Improvement Clinic. That means that I'm going to meet with a nurse practitioner in the heart Failure improvement clinic at least once a year. And one of the things I'm also going to do is every day I'm going to take my weight and I'm going to take my blood pressure and I'm going to call the phone number. 00:19:28:21 - 00:19:45:06 Chris Meyer I'm going to enter my weight and blood pressure and on my telephone. That's how we do it today. One of the things we're looking to do is update that technology so that we would give you a cellular enabled tablet computer, for example, a small tablet. And the first thing people may say, Oh, right there, you lost me. I don't want a tablet computer. 00:19:45:14 - 00:20:07:19 Chris Meyer It's a very self-contained and simple to use device. You turn it on and there are usually somewhere in the neighborhood of three or five different options. You can enter your weight, You can enter your your your, your blood pressure. You will probably have some questions to answer on a daily basis that help us determine whether or not your your chronic illness in this case, CHF is is exasperating. 00:20:07:19 - 00:20:23:06 Chris Meyer And then they'll be an option for video visits. So you really just have a few icons on a screen that are laid out in a way that's very intuitive. You don't have to do anything necessarily with that technology. You just have to turn it on. If you're taking your blood pressure and your weight. Now, it's the same as stepping on the scale in your bathroom. 00:20:23:06 - 00:20:53:09 Chris Meyer Now it'd be a scale you put in your bathroom. The only difference is it'll have a battery in it so that it can communicate that way back to the tablet and send it to the Marshall Clinic automatically. There's nothing you would have to do. Then when all those weights come in, whether it's in our current system or you're calling and entering on your phone, or whether it's coming in through the magic of the Internet with these remotely enabled devices, nurse nurses and nurse practitioners are watching this data and when numbers come in that set off an alert and they reach out to that patient to immediately interact with them to try and fix the problem. 00:20:54:03 - 00:21:18:08 Chris Meyer For example, CHF, one of the busiest days in that clinic is the day after Easter. If you have congestive heart failure, you need to be very careful with sodium. Well, who can say no to ham on Easter? So Monday, Tuesday, Wednesday, after Easter, we tend to see a little increase in volume in the heart failure improvement clinic. What we can do with remote patient monitoring is is see that you've gained 3 pounds overnight or that your blood pressure is starting to increase or decrease or whatever the case may be. 00:21:19:07 - 00:21:36:17 Chris Meyer And when you exceed certain parameters that are set for you in the computer, a nurse will get a prompt to call you and they'll call me and say, Chris, you gained £5 overnight. What's going on? And I'll say, Well, you know, I had six packages of ramen noodles for supper last night. That probably wasn't good. But I really wanted ramen noodles. 00:21:37:03 - 00:21:57:00 Chris Meyer The nurse would then talk to me about how I really shouldn't be eating high sodium foods like ramen noodles. And she may adjust my oral diuretics for a day or two to help reduce that congestion. The goal being that if we do nothing, I'm going to get worse. I'm going to end up in the emergency room Thursday night, Friday night, and that is going to be a very expensive health care service. 00:21:57:00 - 00:22:33:00 Chris Meyer For me, that was completely preventable by remotely monitoring the patient and intervening more quickly. So that is the benefit as far as seniors adopting the technology, here's what I can tell you from our experience with remote patient monitoring with the Heart Failure improvement Clinic. But even with virtual visits, even though we've just launched was a year ago and we've only used in our episodic care service care my way once seniors use it, or telehealth, having a telehealth appointment at a Marshfield Clinic center, once a senior or really any patient uses this, they understand how fantastic this can be for them and they tend to embrace it. 00:22:33:11 - 00:22:58:09 Chris Meyer I can tell you right now that we've got a number of telehealth patients who use telehealth fairly routinely. They're usually heart failure patients because they use telehealth and heart failure pretty prolifically who love telehealth. And I was over in Stevens Point one day with one of our tele presenters. This would be the nurse that is with the patient when they present at a Marshfield Clinic facility at a, you know, a small facility to do a telehealth encounter with the doctor at another facility. 00:22:59:09 - 00:23:15:09 Chris Meyer That particular nurse that that works at the center is actually an employee of mine. And I was there that day and the patient was talking to me and said, I make sure I make all my appointments on the day when Sunny is working because I like Sunny. And so the patients do develop that same sort of provider relationship with the nurse that takes care of in that telehealth encounter. 00:23:15:18 - 00:23:38:17 Chris Meyer It allows them to see their provider more frequently, far more conveniently for them and for their children or adult caregivers, and even for places like skilled nursing facilities. It's expensive to load a patient and transport them to even down the street to the Marshfield Clinic. You're taking staff with them that you have to replace. And so we do extend telehealth into some of our skilled nursing facilities in the areas that we can deliver more care directly into that facility, especially follow up care. 00:23:39:01 - 00:24:02:09 Adam Hocking So I understand monitoring a chronic disease, it's a great way to have constant and updated information on that type of patient. But let's take it maybe a little closer to just a basic visit. You're doing a virtual visit. You have your iPhone out and you're connected with a nurse practitioner and you have a sore throat. But that nurse practitioner, even though now they can see you as opposed to being over the phone, can't touch you. 00:24:04:03 - 00:24:23:03 Adam Hocking We have talked in the past about this. I believe it's called the title Care. Is that right? The title care device. Can you talk about that device and how things like that, innovations like that can help the virtual care process and give providers tools to do almost a more in-depth examination, Even virtually. 00:24:23:13 - 00:24:45:04 Chris Meyer You know, there's a whole array of new technology coming to the market. And I think we're going to see over the next few years, just like we have over the last ten years, the massive improvements in technology that consumers have available to them. On the device you mentioned, title care is one example. This is an all in one device that is FDA approved, which means it can be used for clinical diagnosis and it is not yet available. 00:24:45:09 - 00:25:04:23 Chris Meyer But the idea is that once it's through its quality reviews and it's in the mass manufacture, it would be available to consumers to purchase. The price point is around $300, which when I first heard that, I thought, boy, that's an expensive device to have in your medicine cabinet. But when I thought about it and started to do the math on what the return on investment would be for my family, it's pretty it's a pretty easy sell. 00:25:05:10 - 00:25:26:01 Chris Meyer So what the title care devices is a small, smaller than a Rubik's Cube, small handheld device. It's a Bluetooth device that connects to your iPhone. And for those of you who are not tech savvy and don't have smartphones, this may seem overwhelming. But for a young parent who uses a cell phone every day for just about everything they do, this is something very intuitive for them. 00:25:26:09 - 00:25:42:11 Chris Meyer They can connect this device via Bluetooth, which means wirelessly to their phone. And they now have, in addition to having our app where they can connect with the nurse practitioner, they will have the ability to have that nurse look at the camera through this device. So this device has a camera that allows them to see in your ears or down your throat or in your nose in order scope. 00:25:43:05 - 00:25:58:21 Chris Meyer It's a high resolution derm cam. So if you're calling about a tick bite or a rash or maybe a patch of skin you're not sure about, you'd be able to show them that it's a stethoscope so they can hear your heart and lung sounds. This type of device for $300. This is not an inexpensive device to have in your medicine cabinet. 00:25:58:21 - 00:26:19:07 Chris Meyer But when you consider that we could potentially look at treating an ear infection in children at some point in the future for $40 or $50 rather than for 150 or $200, it won't take many ear infections to repay the $3 cost that device. I know I had four children. I can I can guarantee you we probably would have paid for that in the first month or two that we had kids. 00:26:20:00 - 00:26:37:15 Chris Meyer So this particular device shows a lot of promise and we want to do more with it when it comes out. But there are devices like this out there now. You can go on Amazon and buy an older scope that allows me to clear your ear via your iPhone. A lot of these devices are not FDA approved. We wouldn't use them in a diagnostic environment for clinical practice. 00:26:37:15 - 00:27:01:19 Chris Meyer But at the same time, these tools are out there, they're being manufactured and people are starting to use them. Every one of us probably has something that is collecting what we call patient generated health data on them. Right now they're wearing a Fitbit. They've got an Apple Watch, they've got an iPhone in their pocket. All these devices are collecting information about our activity, how much we slept, what our pulses, what our and anything you can imagine. 00:27:02:21 - 00:27:23:21 Chris Meyer There are new devices coming to the market that are more medically focused. There's a patch few bucks that we can put on your back when you're discharged from the, let's say, a surgery. And for the next 48 hours, that device will work wirelessly and send your vitals and your basic vitals back to the clinic or the doctor so that they can stay connected with you virtually and monitor your health. 00:27:23:21 - 00:27:41:12 Chris Meyer They can see if your temperature is starting to rise, which they may May, which may prompt them to call you and say, we need you to come in. You could be developing sepsis, for example. It allows them to see all these things for just a few dollars. And most importantly, though, it allows that patient to go home sooner, which reduces their cost of health care. 00:27:42:05 - 00:27:59:19 Chris Meyer But again, when we talk about these technologies, what we're talking about is developing technologies that are very intuitive, that don't require the patient to have to know how to to use the technology. It's very simple. We certainly don't want to deploy something that requires grandma to call her her grandchild to come over and show her how to report her blood sugars to Marshall Clinic. 00:27:59:21 - 00:28:11:19 Chris Meyer We want this to be very straightforward, intuitive. And so that's the types of programs we're looking to develop. The tools like Title Care are going to be able to help us expand what we can do in an environment like the virtual visit. 00:28:12:01 - 00:28:33:08 Adam Hocking You mentioned Fitbit. Apple watches, iPhones, wearables broadly, we can call them that. And they're starting to be you know, a lot of people have a Fitbit. A lot of people, almost everybody has some sort of smartphone in their pocket. And they can track my steps, they can track my pulse. That's great. But where do you see the future going with wearables? 00:28:33:15 - 00:28:54:08 Adam Hocking Could we get to a point where wearables can track genetic variances in your body? I mean, you know, I like to think kind of big picture about it. Where could we go with wearables and how do we integrate some of the innovation that might be happening at Amazon or Apple into that health care community? 00:28:54:08 - 00:29:17:20 Chris Meyer Well, you know, Adam, that's a great question because there is so much technology out there and available and what is is being produced today is getting better and better. You're right, Most people do have a wearable device of some sort on there. Can they predict the future? I wouldn't say that they can predict the future, but they're getting better at giving us a good estimate of what that might be. 00:29:17:20 - 00:29:33:22 Chris Meyer I'll give you an example. There are contact lenses that you can get right now that are actively monitoring your blood sugar and they will actually change color. So as you're walking around and you start to see things are looking kind of red, that's your indication that your blood sugar is getting too high. Those devices, those contact lenses exist today. 00:29:34:11 - 00:30:01:19 Chris Meyer Those are a consumer product. You can get. There's a watch that you can get much like an Apple Watch. It's got a little cartridge in the back of it that actually does a very shallow needle prick periodically throughout the day to test your blood sugar. It would feel similar to maybe Velcro being rubbed on your skin and it's actually just testing the liquid that's right below the very surface, your skin for your blood sugar and reporting that blood sugar that can be connected to a tablet computer that reports that information back. 00:30:01:19 - 00:30:24:03 Chris Meyer So throughout the day, all you have to do is reach down and touch a button on your watch. Your blood sugar is taken as reported to the clinic and you go back to work. It took you one second. These are the technologies that that we're looking to to use. Predictive technologies are certainly something we're looking at. Artificial intelligence is going to be a huge part of our economy outside of just health care using big data. 00:30:24:15 - 00:30:40:03 Chris Meyer You know, there's some great research being done right now that talks about the new economy, where we talk about the new economy, which we really what is our economy turning into next is going to be very, very focused on and big data. We hear that term a lot. Now. We can learn an amazing amount by looking at population data. 00:30:40:03 - 00:31:01:00 Chris Meyer We can tell how many people in the population are overweight or underweight or have this disease or are more likely to have that disease. We can combine that with the information we know about our genetics to help start developing precision medicine services here in the Marshall Clinic. This is all an attempt to be proactive with health care rather than reactive. 00:31:01:09 - 00:31:20:13 Chris Meyer For too long. And in the United States in general, we've had really what is a sick care system. When you get sick, you come to the doctor and we fix you. What would be a better, more cost effective model is to have a long standing relationship with your doctor, see your doctor regularly and deal with issues that they come up proactively to keep you healthy so you don't get broken. 00:31:21:05 - 00:31:39:10 Chris Meyer Mt. Sinai is a health system in the East Coast who I thought had a pretty thought provoking advertisement that they printed in. I think it was in Time magazine. It was just a picture of a mountain, which is their their logo with one sentence. And the sentence says, if our hospital beds are filled, we're not doing our job. 00:31:39:17 - 00:31:56:15 Chris Meyer And I thought, you know, how true is that in health care, our goal is not to fill a hospital bed. Our goal is to keep those hospital beds empty. It costs a lot of money when you're in a hospital bed. Oftentimes more than that, we actually get reimbursement from Medicare or Medicaid or even commercial insurers. So it's important that we try to keep our patients healthy. 00:31:57:03 - 00:32:18:04 Chris Meyer And I do see a time coming where payers, whether that be a private insurance company or a medicare Medicaid, are more heavily focused on paying for quality, meaning we'll give you more money if the patient doesn't get sick rather than on the current fee for service model, which is what I like to call essentially factory widgets. Right? The more people you crank through your system, the more money you make that incentivizes sick care, not health care. 00:32:18:13 - 00:32:26:04 Chris Meyer Marshall Clinic has been very proactive historically in leading the way in proactive health care and keeping people healthy rather than just fixing them when they're broken. 00:32:26:08 - 00:32:54:01 Adam Hocking I want to close on a question that I think might be the most important one of all the topics that we've talked about today. You talk about the positives of telehealth, virtual care, this type of technology, the fact that it can keep grandma or grandpa in their home, living independently for longer, the fact that we may be able to better predict the onset of chronic disease, keep health care costs lower, keep people healthier, all that is tremendous. 00:32:54:15 - 00:33:16:18 Adam Hocking Is there any concern on your end about losing the human touch piece of health care, whether it's through a virtual visit, it's still that layer of separation through the phone or whether it's through remote patient monitoring. Do you worry at all about less time between the doctor and patient in a truly hands on setting? 00:33:17:01 - 00:33:36:07 Chris Meyer It's a great question, Adam. So there's two answers that one, No. One, our goal with telehealth is not to decrease the interactions you have with your doctors, to increase them. We want you to be our doctors, to be more accessible so it's easier to get in touch with them. We want to make it more convenient so people actually do come to the doctor when they need to. 00:33:36:13 - 00:33:55:00 Chris Meyer There's no reason that we need to sit at our desk for two weeks suffering through a sinus infection when we can help you via the phone. And so we certainly want to increase access through technologies like this. But you raise a great, great point, especially of people who very much value going and seeing their doctor, shaking their hand and talking to them face to face. 00:33:55:14 - 00:34:20:04 Chris Meyer And telehealth isn't a replacement for that. In fact, like I said in many cases, your first visit with a specialist to say you need to see a dermatologist will likely be face to face because they need to see it. They need to poke and prod you and then figure out what's going on. But if they then tell you that your care plan is going to be six follow visits over the next six months, one per month, and you are looking at a two hour drive to come back for each of those. 00:34:20:14 - 00:34:35:23 Chris Meyer You may choose not to come back for all those. You may cancel one or two or three or four of them and just not come to them because of the inconvenience and the barriers of travel. This is a way that we can still deliver that care and improve the quality that we're delivering and make it more convenient to the patient. 00:34:36:13 - 00:34:54:05 Chris Meyer It's always a patient's choice to use telehealth. If you would prefer to get in your car and drive to Marshfield or to Wausau or Clare, wherever that provider may be, that is absolutely your choice. We're happy to accommodate them. I don't see a time anywhere in the future where that is going to not be the norm for how we really receive health care. 00:34:55:01 - 00:35:17:19 Chris Meyer When we talk about the telehealth visits we do in the Marshall Clinic and we tend to be recognized nationally for the volumes we've used telehealth for over 20 years here. We do a lot with it. But when we look at the total number of patient encounters we have in the Marshall Clinic in a year, and it's somewhere between two and a half and three and a half million patient encounters, the number of patient encounters we have over just our telehealth network is just a little over 10,000. 00:35:17:19 - 00:35:37:14 Chris Meyer When we include virtual visits and some of the other telehealth visits we have, we do a lot of other things with telehealth tell a pharmacy does about 50,000 visits per year. But are generally between a pharmacist and a pharmacy tech at a remote site. Our Interpreter services group uses telehealth to connect to patients who have a language barrier and interpretation services. 00:35:37:14 - 00:35:53:15 Chris Meyer But holistically, when you look at that, we're talking about less than 100,000 visits by far probably around 65,000 visits per year via telehealth out of two and a half to three and a half million. So by no means is this a primary way to deliver medicine, but it is an option and it's a way that we can make health care more accessible. 00:35:54:04 - 00:36:12:21 Chris Meyer And if you've got a chronic illness, let's say you are that heart failure patient. It's really important that even if you're not being remotely monitoring that, we do have those follow up visits to make sure that you're staying healthy. The easiest way to keep you healthy is obviously to be proactive and catch those aspirations of a chronic illness before they become problematic for you. 00:36:13:15 - 00:36:29:01 Chris Meyer And so while telehealth will never replace a doctor, in fact, one of the things that we struggle with in almost every health care system struggles with is hiring enough doctors. There aren't enough doctors. And telehealth is another way we can help increase the efficiency of our doctors so that we can all have access to the care we need. 00:36:30:02 - 00:36:45:15 Chris Meyer But you're right. For some people, especially sometimes for seniors, it can be a highlight. If they're unable to get out of their house, they rely on somebody to give them a ride to the doctor's appointments. It can be as much of a social event, which for them as it is mentally, is valuable, maybe more valuable than the doctor's point itself. 00:36:45:15 - 00:36:52:21 Chris Meyer They get to get out and go and see people. We're not looking to take that away, but if that is a barrier, we have a solution. That's telehealth. 00:36:54:01 - 00:37:00:05 Adam Hocking Chris Meyer, the Director of Virtual Health for Marshfield Clinic Health System. Chris, it was a fascinating discussion. Thank you for joining us. 00:37:00:15 - 00:37:03:15 Chris Meyer Thank you, Adam. I appreciate it. 00:37:07:23 - 00:37:33:14 Adam Hocking The Rounds is produced by Ryan Maderic and supported by the Marketing and Communications department of Marshfield Clinic Health System. You can subscribe to The Rounds and download episodes via iTunes or by visiting Shine365.MarshfieldClinic.org. I'm Adam Hocking and I hope you'll join us next time on The Rounds.