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Ruchika Talwar: Hi everyone, and welcome back to UroToday's Health Policy Center of Excellence. Today, I'm excited to be joined by Dr. Kara Watts from Montefiore Medical Center and Dr. Jen Robles from Vanderbilt University Medical Center. They were both co-chairs of the AUA's 2023 Quality Improvement Summit, which was entitled Tackling Telehealth: Improving Quality and Access by Integrating Virtual Care in Urology. The AUA's Quality Improvement Summit is actually an annual event. And today, we're going to have them share highlights from the 2023 summit, their takeaways on important content that the broader urologic community should be aware of. And we'll hopefully provide you with the information to access Summit materials in case you weren't able to attend in person, but would like to catch up on some of the important findings. So first of all, to both of you, thank you so much for being here with us today. I really appreciate it.

Jennifer Robles: Absolutely. Thank you so much for the opportunity.

Kara Watts: Thank you for having me.

Ruchika Talwar: So let's talk about the summit more broadly before we tackle telehealth in detail. What is this event? Who organizes it? How did it come about? Dr. Robles, why don't we start with you?

Jennifer Robles: Sure. The summit is put on every one to two years by the AUA and specifically, it's led by the AUA's Quality Improvement and Patient Safety Committee. What happens is members of the committee come up with ideas every year, we go through a process to pick one, and we decided this year to focus on telehealth.

Ruchika Talwar: Dr. Watts. Why was telehealth the topic of choice this year? We've obviously seen a boom in telehealth utilization, but now the pandemic's over, is it still relevant? What are your thoughts there?

Kara Watts: Yeah, it is definitely still relevant. I mean, there was a huge boom in telehealth during the pandemic, but because of that, it actually allowed us a nice opportunity to study telehealth in urology in a way that we really hadn't been able to do before. And so, although the numbers in telehealth utilization have dropped off a bit compared to the height of the pandemic, there's a tremendous volume of research demonstrating not only the safety of telehealth, the efficacy, the equivalency to in-person care, but also the patient and provider satisfaction in a lot of different settings. It's a very effective modality of providing healthcare for our patients who are presenting to urologists with very sensitive needs or conditions that may feel nervous about coming in person or for patients with disabilities. And so, it's an opportunity to meet the needs of patients in a way that we have not traditionally been doing. So that was the genesis for this year's telehealth summit.

Ruchika Talwar: Awesome, awesome. And from what I understand, it's particularly relevant now because there were a lot of flexibilities around the way we could use telehealth during the pandemic and specifically during the public health emergency. But tell me a bit about where that stands. Are those flexibilities permanent? What's the future there?

Jennifer Robles: Yeah, so that's something that we talked about in the summit. Absolutely. The flexibilities, unfortunately, are set to expire this year, and so Congress is going to be battling it out. And there have been congressional hearings in which urologists have spoken on this issue. For example, Dr. Ellimoottil from the University of Michigan was one of our speakers. He testified in congress about this issue, and the big question is, number one, payment parity. So what that means is: should we be funding telehealth visits in video as the same as phone, as the same as in-person? And he highlighted this as an important issue because although it may seem like a minor thing, in actuality, anyone who's done telehealth knows that there's always a percentage of patients that are unable to complete video visits, and you have to be able to switch to telephone to be able to complete the visit.

And that can be for a lot of different reasons, but it always happens some percentage of your telehealth grid. And so, if you don't have payment parity, then he argues that will lead to essentially a slow death of telehealth, and that fewer and fewer people will want to do it if they're losing money on a 10th of their visits or maybe even up to a third of their visits whatever they have to convert from video to phone. And then, of course, if telehealth as a whole like video visits are not paid around the same rate as an in-person visit, then very few people will want to do telehealth in general at that point.

Ruchika Talwar: Yeah, so true. And even the implementation and rollout of telehealth, it does require some upfront investment from a practice perspective. So payment parity, I think, is really important to make sure that it's viable to continue providing telehealth care. So important point there. Dr. Watts, why don't we start by having you discuss some notable sessions that were covered in the summit. Perhaps you can summarize them for us and just give us your main takeaways.

Kara Watts: Sure. Dr. Robles already talked about Dr. Ellimoottil's session on telehealth policy and landscape. Dr. Lisa Finkelstein, who's director of telehealth services for a whole medical system in Wyoming, talked about innovative telehealth and talked about how we're basically in a digital revolution. And so, you basically, as she says, innovate or die. And so, she talked about the opportunity for delivering care through a number of mechanisms or sort of apps even that can be mobilized for urologists, so virtual uroflows, virtual bladder scanners, virtual cystoscopy, really thinking outside the box of just what we think of in terms of sitting in front of a computer screen and talking to a patient on the other end. Adam Gadzinski, who's in the Pacific Northwest, talked about rural care, and a really interesting point from his presentation is that 70% of counties in this country do not have a practicing urologist.

And so, telehealth is an opportunity to really bring care as it was originally designed to areas where people just don't get care, unless this is an option. One of them, actually, I think, highest yield sessions and panels that we put together was the tips and tricks for successfully incorporating telehealth into your practice. So we had representatives for men's health, pediatric urology, urologic oncology, endourology, general urology on the panel. And so, beyond talking about how to have the behind the scenes successful workforce to help patients behind the scenes engage with the platform and take a med rec and sort of a nursing triage the same way that you would have in the office, each urologist who presented talked about what conditions the telehealth has been effective for in their practice.

So just brief examples. In men's health, it's essentially effective for almost everything with the exception, at least for initial visits of Peyronie's and erectile dysfunction. In pediatric urology, those exams that require a genital exam. So testicular complaints and penile complaints were found to be more effective, at least for new patient visits in person, but a lot of followups were very amenable to telehealth. Urologic oncology, those that are imaging based, elevated PSAs, a lot of them very effective within telehealth. And endourology is similar. It's very much imaging based, which you don't necessarily need to have the person sitting in front of you to effectively engage. There were very helpful conversations about how to structure telehealth visits into your day, tail ends of your day, or very set blocks, which is a little bit more sustainable than sitting on your bottom and doing a full day of telehealth for some people.

I'll also add that Jeremy Shelton, who works within the National VA Healthcare System, talked a lot about the national telehealth program within the VA healthcare system. And some notable facts from his presentation are that a third of veterans are using telehealth despite older age with very high satisfaction, 50% of them prefer video use, and a third of all visits could be served by telehealth. And at the end of the summit, we had a panel that was focused on developing future resources within telehealth to help the urologic community as a whole. So whether it is tip sheets or updating a white paper, there's a number of really helpful ideas, some disease specific that are really awesome future energy for what to focus on for the next year or two as a deliverable.

Ruchika Talwar: Tons of really valuable information there. It looks like you guys really covered a lot spanning various aspects of telehealth care. Dr. Robles, any other sessions to add there?

Jennifer Robles: I think that we also talked about... So other things to touch on, we also talked about other policy considerations, particularly people's fears about doing telehealth and how that holds both people and policymakers back from embracing telehealth fully. But as Dr. Watts mentioned, the pandemic's given us an opportunity to really study telehealth and know now that telehealth doesn't increase fraudulent claims, it's not increasing costs, it has excellent satisfaction and really good efficacy, again for the properly chosen patient. And we'd argue for the properly chosen urologist too. It's not for everyone, that's totally okay, but I think it's for a lot more people than we ever realized pre-pandemic.

I think that people touched upon the flexibility that telehealth gives not only patients, which we understand patients not having to deal with a commute to the office and then having to wait in the waiting room for an hour and all of that and the time that takes out of their day, but also flexibility for providers. I found an interesting point that one of our panelists made, I think it was Dr. Gadzinski, is that if you're a provider that does telehealth, because sometimes it can be so flexible, you have to provide your own guardrails for how many visits you're going to do. It can make it too easy sometimes to keep adding on visits because you get patient portal messages and you can turn them into full telehealth visits to really improve patient care, but also that can then quickly eat away your evenings and potentially even weekend time. And that's sort of a negative consequence that not a lot of people had fully thought about before they started telehealth, but many people in the room realized, really spoke to them.

Ruchika Talwar: Yeah, that's a super important point to recognize and I think not something we talk about enough, but in the context of ensuring that we're doing all we can to minimize burnout, definitely something to consider during the implementation of telehealth. That's great. That's great.

Jennifer Robles: I just realized that one thing to also touch on is that we had a panel about legal considerations in telehealth, and we included Maureen Cones, who's one of the lawyers on AUA staff in that panel. And some things to mention with that, just so everyone is aware, is that there are laws governing telehealth nationally. Every state, except for six, I think, does require patients to do sort of a telehealth consent that has to be done prior to your visit. So that's something you have to sort of work into your workflow.

The good news is that there are so far to date zero lawsuits about quality of care or some issue that was missed on a telehealth visit. So that's another reason why a lot of people can be afraid of picking up telehealth that they're worried that they may miss something on exam or whatever and then get sued, but there's zero evidence that that happens. But that said, you do need to still be aware of the laws of your state, and it's important the laws govern what state you are in, but also what state your patient is in.

Ruchika Talwar: Yeah, definitely important to be aware of that and any other licensed considerations of where your patient may be physically located during the visit, and super important points there. You both have covered so many incredible topics that, I think, are all very relevant to the broader community. But if people are interested in doing a deeper dive in one of the sessions or panels that you've mentioned, are they able to access this information despite the fact that they weren't present during the summit in person?

Jennifer Robles: Currently, I don't think they are. I don't think it's currently online. As part of the process after the QI Summit, we've been working on what deliverables we want to do and creating essentially a toolkit online is one of the priorities, and then all of this information would be part of that. We wanted to try to summarize everything in more of a quick tips type of format rather than putting the long presentations online, which I don't think are going to be as helpful for folks. So I'd say that that's something that hopefully you'll see soon.

Ruchika Talwar: Awesome. Awesome. Well, be sure to send it to us and we'll make sure that we make it available on our site-

Jennifer Robles: Okay.

Ruchika Talwar: ... for our audience that's listening here today. And I think you all have already addressed so many important points of telehealth care that our viewership is certainly going to benefit from. But as we wrap up, Dr. Watts, what salient points about telehealth care are relevant to the entire urologic community?

Kara Watts: So I think the take home points are: there's a lot of data now showing that contrary to some of the misconceptions before, telehealth does not compromise care, it doesn't result in excessive spending, it's very effective for certain situations, for certain patients and for certain providers. And there's been tremendous evidence supporting satisfaction both on the parts of providers and patients in a lot of different settings and domains for this. There are still challenges that remain, and specifically that's for the back end implementation into the provider's workflow, having adequate staff to support a successful telehealth panel or successful telehealth practice to make it work within your schedule.

Payment parity is an ongoing issue as Dr. Roble said before, and we'll have to see how that rolls out toward the end of this year. But I will say this again, in the words of Dr. Lisa Finkelstein, we are in the start of a digital revolution. I mean, there are now full-time positions for full-time virtual urologists that are posted and hiring with the intention of expanding care, delivering care at the time when our workforce is continuing to be threatened. And although not every urologist needs to engage in telehealth, that's certainly not the point that we're trying to make. We do think that not offering this, at least within the context of your practice or your group is being shortsighted. There's a lot of great uses for this. It's beneficial for a lot of patients. And so, if you haven't taken the leap, go for it.

Ruchika Talwar: Awesome. Awesome. Important words to end with here. Thank you both for making time to chat with us. Again, I'm excited to be able to bring some of the content you covered to UroToday, so we really appreciate your time.

Jennifer Robles: Thank you so much.

Ruchika Talwar: And to our audience, thanks again for joining. We'll see you next time.