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Podcast Library > NextGen Advisors Podcasts > How Virtual Visits are Changing Care Team Roles

June 26, 2020

How Virtual Visits are Changing Care Team Roles

With the sudden emergence of virtual visits and the associated challenges, the NextGen Advisors continue to explore topics relevant to ambulatory care. In this episode, you will find out what all these changes may mean for the future of the medical practice team.

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Transcript

Dr. Betty Rabinowitz:

Hello, this is Dr. Betty Rabinowitz, NextGen Healthcare's Chief Medical Officer, and Principal with NextGen Advisors. Welcome to our podcast series. As we continue to explore topics relevant to ambulatory care, today, we're going to discuss the evolving healthcare team. With the sudden emergence of virtual visits, and challenges associated with maintaining safety for patients and staff in the context of the recent COVID-19 pandemic, practices have quickly and creatively reorganized workflows for practically everyone in the office. What do all of these changes mean for the future of the ambulatory practice team? I'm joined today by Graham Brown and Dr. Marty Lustick. Welcome, Graham and Marty.

Graham Brown:

Good morning, Betty. Good to be with you.

Dr. Martin Lustick:

Hi, Betty. It's great to be here.

Dr. Betty Rabinowitz:

We all carry a strong image of the doctor's office, with checking staff, the waiting room, medical assistant intake, nurse intake, the doctor visit itself, and check out at the front desk. While that model has evolved over the years to incorporate advanced practice practitioners, and in some cases, care managers, most practices had not seen dramatic shifts in the makeup and functions of their office teams before the current pandemic. What do you think are the biggest changes in the roles that have occurred in the last three months? Let's start with you, Marty.

Dr. Martin Lustick:

So, I guess I focus on two areas; one of them is because suddenly, a large portion of the visits weren't face-to-face. The whole idea of rooming patients, and the process in the office had to be adjusted for telephonic or virtual visits. And so, all of a sudden, medical assistants had to do things like help people figure out how to get a connection to whatever virtual platform the doctor was using. And on top of that, oftentimes, the staff wasn't together in the office, so they were working in disparate locations. So all the issues associated with that, to me, is one of the big things. The other one is, is that because things changed so quickly, patients didn't really know what to do. And so, for many practices, for the first time, they had to figure out ways to communicate globally with all their patients in real time; to get the word out to them, what to worry about, how to access care safely, where, when, how, all those things. And they kept changing on a day-to-day basis; and practices had to learn how to do that outreach both for their entire patient population. And then sometimes for certain subsets, they needed specialized messages; and that whole process really dramatically changed the needs of the practice.

Dr. Betty Rabinowitz:

Graham?

Graham Brown:

I think Marty really has covered a lot of the high points. What I would add on to that, is the need for practices now to really figure out a triage model. When they look at what face-to-face care they need to provide to patients in the clinic environment, and what services are appropriately delivered through virtual visits or telephonic care. So I think there's been a lot of focus in the last while, and a real clamoring for understanding how practices can adjust their workflows to offer those types of visits, and really inform staff and be consistent around triaging patients appropriately into different models of care, whether it's going to be face-to-face or virtual. The other related element that I think is, stay-at-home orders were initially put in place. There was a dramatic movement of nonclinical staff to work from home, if that was an availability where they could connect into the systems and tools of the practice to do billing, to do coordination, to do administrative, leadership tasks and backup work. So I think the movement of staff out of the clinic environment has also dramatically changed probably the interactions within the clinic, in the clinic team. And so that would be another big change that I've seen in the last several months.

Dr. Betty Rabinowitz:

Interesting that you mention that Graham. Do you think that that will provide an impetus of practices to re-evaluate whether those functions actually any longer need to be supported by the practice, or whether some of the back office functions can actually be in a cost-effective way outsourced completely?

Graham Brown:

I think you're exactly right, Betty, with the question. There's certainly the opportunity, depending on the practice themselves, and what kind of staff they have in place, how large and complex they're billing, their payers are, those elements. The ability to have staff work from home if they can access these tools, probably make sense, certainly through the period of the pandemic. I don't think we have a sense yet of what the horizon timeline is, for when that might ultimately allow staff go back into the workforce, directly co-situated. But if we assume that that's going to be a period of time until that can return, then there is the opportunity for practices to assess, "Is this a core function of ours? Is it something that we need to maintain with our own staffing? Or should we consider outsourcing this to a third party that might be more efficient? And then the staffing resources are really dedicated to patient-facing roles and functions."

Dr. Martin Lustick:

It actually, in some ways, indirectly relates to another big issue that we did mention of a change. And that's the need to focus on personal protective equipment for staff and patients, as well as the disinfection issue when people come and go; that the fewer people you have in the office for those face-to-face visits that do continue to occur, the easier it is to manage your inventory for PPE, as well as to minimize the need to do disinfection if you find out a staff member is sick or whatever. So, I think those issues kind of play off of each other, and kind of encourage practices to consider exactly what Graham would suggest.

Dr. Betty Rabinowitz:

What do you think will be the most enduring changes in the healthcare staffing model post-COVID? Let's assume we've found a vaccine, the COVID pandemic has subsided. What remains? What of these changes will be permanent, or go into the future? Graham?

Graham Brown:

As I think about some of the skill sets that probably need to increase, it makes me think about the bigger trends that are happening within healthcare. And we think about the movement into population management, connecting with other community services, the role of public health, and coordinating with public health in the community. I think the current pandemic has put a light on some of the fragility of the patient population. And we already knew that many individuals have chronic disease that needs to be managed over a long period of time. So those skill sets that are really focused around population management, managing over a longer period of time, and ensuring that patients are getting the care that they need, really over a multi-year instead of just an encounter-based model, will be important. So extending that population view, the role then of care managers, care coordinators, individuals that are really developing the care plans, and working with patients on adherence and education will be important to see. Because a lot of that care can indeed be coordinated and managed outside of the clinic environment. And so, it creates a level of sustainability and ongoing relationship with patients, that allows them to obviate the need to come into the clinic environment, and potentially, is therefore safer.

Dr. Martin Lustick:

I agree with what you're saying, Graham. I would add, I think another major change is because of the shift to virtual visits, the role of the medical assistant is going to change significantly. Obviously, they will still need to room patients that have to come in the office, but they're going to need skills, as I mentioned before, to help patients get connected on the front end of visits. The whole concept of rooming a patient virtually will require a new set of skills from the medical assistant. And I suspect that over time, that will require less and less manual interface with the medical assistant; a lot of that rooming will take place virtually. And so, the medical assistant's role may morph more into being a scribe, for example, for the provider. And we may very well see with the increase in virtual visits, a simultaneous increase in scribing, as part of the way that that is run.

Dr. Betty Rabinowitz:

You've both spoken a lot about the care team members surrounding the physician. How do you think that the physician's role will change, going forward? Marty.

Dr. Martin Lustick:

Yeah. In some ways, it relates back to the comments that Graham made in response to the last question. As there's increasing focus on population management, and understanding subsets of your patient panel and what their needs are and who's at risk, I think that doctors will likely spend more time analyzing issues related to their patient panel. They'll be looking at all their patients with heart failure, and trying to understand what are the critical factors that are making those who wind up in the emergency room end up there? And is there a need to change the way they manage that patient population? Is there something they can do, at the highest clinical level, to say, "There's a different way to manage these patients." Those who are getting daily phone calls from the care manager; I have a quarter of the ED visits of those who don't. And I think the doctors will play a major leadership role in analyzing those kinds of issues. On the other hand, I think they'll continue to see patients; but if it's done well, in the new world, I think that they will have fewer visits per day, and more time to take care of the most complex patients.

Dr. Betty Rabinowitz:

Mm-hmm (affirmative). Graham?

Graham Brown:

I think the other additional role, and I think we've heard this term out there before, where the physician acts as quarterback, as it were, with the care team. So, thinking about the tools, processes that are used in the practice, how different types of patient are managed, what is the care model that the organization is going to undertake for comorbid patients that might have different complex needs?? And how are they going to be managed? What are the different functional roles of the care team? I think that the physicians really have an important role to play, in defining what those processes and approaches will be for their team, and ensuring that they're accessible to their team for clinical decision-making; but at the same time, really can manage that entire panel, to Marty's point. And so, are wanting to ensure that other individuals of the care team have a clear understanding of what they need to accomplish, what role they have to play, and that really, all of the parties are working in synchronicity here, to manage panel effectively and really do everything they can, moving elements up the clinical decision-making ladder as needed. And so, that role of the physician quarterback, I think becomes more and more relevant as you think, a model going forward.

Dr. Martin Lustick:

Yeah. I'd like to make a comment on the quarterback issue, because I completely agree that that is a role for the physician to play. But oftentimes, I see practices where the physician is actually trying to be both the coach and the quarterback; and quarterback is a better analogy. They're the leader on the field, but it doesn't mean that they design all the processes, that they come up with the work plans of how the work flow should go, how the work processes should work smoothly together, how the different functions interface. There's a lot of expertise on the nonclinical management side that's really needed to build an efficient and effective team that way. And I don't think we need to depend on the physician to be able to do all of those different things as expertly as they need to be done.

Graham Brown:

It's a good point, because it's a different skillset. When you think about managing a team of individuals and defining what their roles are going to be, versus overseeing how care is provided, and ensuring that all of the parts of your team from a clinical perspective, are coordinating for both your own needs and for the patient's needs. And it's a good distinction, Marty.

Dr. Betty Rabinowitz:

So, other than the fact that I take issue with the gender specificity of the quarterback example, I agree that the physician's role as leader in a patient-centered medical home model, the physician leads the team.

Dr. Martin Lustick:

Au contraire; you'd make a great quarterback, Betty.

Dr. Betty Rabinowitz:

Oh, thank you. Along those lines, before, just as a last question, there have been some interesting shifts outside of the practice itself, with care team members in the broader sense, playing a role in care of patients, of varying and changing roles. So for example, the role of urgent care, or the role of the community pharmacist has evolved lately over the last few years, and accelerated so over the pandemic. How do you see those roles changing and impacting the care team, the core care team, as we know it? Marty.

Dr. Martin Lustick:

I wouldn't necessarily see a big change in the care team as a whole, in how they function. I actually think that the pandemic has created a big opportunity, particularly for primary care practices in this particular space. I think patients realize the value of having a really trusted provider. It's their provider, they know who to go to; and they're there for them, and they know them, and they care about them. And as they've implemented virtual visits, I think they've created for themselves an opportunity to be much more competitive when it comes to urgent care or pharmacies trying to create retail services for patients. If they can begin to offer those virtual visits and expanded hours, and make it easy for patients to get in. And I think patients will prefer to stick with their own doctor. And so, on some level, the urgent cares, the retail clinics, they're all competitors; but at the same time, I think if practices do well in managing through this transition, there'll be better positioned than they actually were before the pandemic.

Graham Brown:

The thought that comes to mind for me, is kind of the second half of your question, Betty, around how will practices have to adapt to those changes? So, if patients are going to access urgent care because of convenience or after-hours access; ensuring that the follow-up, the record, gets back into the medical practice's documentation system, they're aware of what services were occurring there, and what the need of the patient was, in doing the follow-up and outreach. It seems like an adaptation that is already, probably currently in place, but may be a continued focus going forward if folks continue to access urgent care at the rates that they have. From the pharmacy perspective, you can envision an opportunity for pharmacies to continue to do things like inoculations and vaccines, and provide counseling around complex medication regimens. I wouldn't necessarily see that changing; but again, how those access points are coordinated with the primary care practice, and the role that the pharmacy is playing, and how the patient sits really in their relationship with their primary care doctor, that role of managing the care being provided in other settings that the practice may not always be aware of, seems like an area of focus that might be a challenge, and that continued adaptations may need to focus upon.

Dr. Betty Rabinowitz:

Great. Thank you to our listeners for joining us today. I'd like to thank my colleagues, Dr. Marty Lustick and Graham Brown, for sharing their insights and perspectives on the healthcare team of the future. If you've enjoyed today's topic, consider subscribing to our podcast. This is Dr. Betty Rabinowitz, with NextGen Healthcare. Have a great day.