Ep. 9: Tashfeen Ekram, MD, Co-founder and Chief Medical Officer, Luma Health. Topic: Telehealth and technology innovation

Kathy: Hello, and welcome to Episode 9 of the Smarter Healthcare Podcast! Today we are taking a look at healthcare technology and how the COVID-19 pandemic has changed care delivery and the technology that supports that.

Our guest today is Tashfeen Ekram, co-founder and chief medical officer of Luma Health, a San Francisco-based startup that helps improve patient engagement and communications. Tashfeen and I talked about the shift to telehealth over the last several months, other key technology breakthroughs that will emerge due to the pandemic, and how healthcare providers can use technology to recover some of their lost revenue over the last several months.

I hope you enjoy our conversation.

Kathy: Hi Tashfeen, welcome to the podcast. Could you start off by telling us just a little bit about Luma Health?

Tashfeen: Yeah, I would love to. So, Luma Health, we are a San Francisco-based startup, about five years old, and our core product is about automating communication to patients for providers and practices. So as you know, as we have seen as patients and both providers, healthcare is very difficult to navigate so what we do is we help automate a lot of the communication that happens to make sure that the patient is moving along the patient journey. So you can imagine when a patient starts off with a particular disease there are many steps that need to happen for them to get from Point A to Point B. So what Luma helps does is it allows providers not to have to take that manual communication that needs to happen to make sure they get from Point A to Point B, but we automate a lot of communication making sure that they get to the next step of getting their lab drawn, getting their referrals done, whatever it is. So we sit on top of their EMR and be able to automate a lot of that communication so that we make sure the patient is guided along the patient journey from their state to getting to a healthier state.

Kathy: Now, several months ago COVID-19 kind of turned the world upside down. Do you think healthcare providers could have ever foreseen such a radical shift in the way that care is delivered?

Tashfeen: I think if someone told me that I would say they were not telling the truth. It’s, I’d say, COVID has obviously been a very significant challenge not only for the healthcare world but the world as a whole, but I’d say that one of the amazing silver linings in the COVID, is it has accelerated certain things, not only in healthcare but also outside of healthcare. But one of the things that we’ve been really challenged with over the last several years is just adopting telehealth, and I think just we were, we’ve been just put to the fire, both as patients and providers, and suddenly I think we’ve been asked to, out of necessity, use it. And it’s really interesting because I think if you asked just six months ago before this COVID hit, if you had done a survey of both patients and providers and asked them, what’s their comfort level with telehealth and how many telehealth visits they’ve done, they would have quite few and their comfort level would have been very low. Now, let’s fast forward, six months later or whatever it’s been to today, and the comfort level and I think both from patients and providers, I think we’ve come a really long way. And it wasn’t out of choice, we were kind of forced into that, but I think a lot of us are more comfortable. And I always like to tell this one anecdote, so one of our clients, who…because of this a lot of our clients have been asking to jump on the telehealth need, and so one of our clients, they’re ear nose and throat, one of the providers in their practice has been practicing for quite some time when I was talking to him, I asked him, “Did you ever think you were ever going to do telehealth?” And he said, “No, why would I ever do that?” I think as physicians we’re very comfortable in treating patients with our hands and seeing the patient in front of us because it gives a comfort level, and I think there’s a part of medicine that’s very personable and you just can’t do that in a telehealth visit. But that said, when COVID hit he needed to close his practice down and start doing a lot of stuff over telehealth so he was evaluating a patient that had a growth in his mouth, so that’s concerning, could be cancer, could be something bad. So like he said, “I never would have imagined” - this visit was actually scheduled prior to his office being closed down, and so then he just kind of had to out of necessity, hey we’re going to do this over telehealth, so the patient got on, turned the camera on, angled the camera so they could see this area in the mouth, and he made the diagnosis over the telehealth visit. And what this shows us, if you had asked him before if he’d do that he would be like no way in heck am I ever going to do that, because that just doesn’t make any sense, why would I ever risk missing something. But I think suddenly he felt a lot more comfortable and so did the patient. So I think this anecdote just speaks to a lot of how we as a nation have become a lot more comfortable with telehealth. I think that’s what that radical shift is, I think…if there’s a silver lining in COVID I think it’s that it has given us the courage, I guess maybe is the right word, to be able to jump in and really embrace telehealth and give us the opportunity to take advantage of a lot of healthcare that can happen over telehealth.

Kathy: Right, and I heard someone say at one point that the healthcare industry accomplished in about three to four weeks what it would have taken them a decade to do before, so it really has been an amazing shift. And I know that like Boston Children’s Hospital, they went from 20 telehealth calls per day to 2,000 per day during the pandemic, and this is kind of our new normal. But as things hopefully settle down and as we move into the next phase of COVID-19, whenever that is, where do you see telehealth going? Do you think it will go away as quickly as it came or does it really have a future that’s going to stick?

Tashfeen: No, I think there will be a significant amount of it that will stick, and I think some of it will be, unfortunately, driven by reimbursement models. Because currently physicians aren’t shying away from doing telehealth visits, in part it’s out of necessity they’re doing it, but also their insurance companies are still, and payers in general are still paying on par, so there isn’t necessarily a big loss, or loss in opportunity for physicians. But I think what will happen is right now a lot of the visits, whether they should or should not be happening over telehealth, are happening over telehealth because it just is a lot more comfortable for the patients and for the provider. But I think what will happen is once the COVID pandemic passes, physicians will learn to understand what are the type of visits I’m comfortable in doing over telehealth and what are ones that I want to do in person? And I think this is a great way to test it because you end up, physicians ended up conducting a majority of their visits over telehealth right now, and they’ll learn through that process to say OK, well this type of visit or this type of patient, it would have been better actually if I had seen him or her in person or this person with such and such disease type, it would have been better if I had seen him or her in person. Whereas previously I would have thought I would have never wanted to see this kind of patient in telehealth but actually I’m comfortable and I can rely on a patient. So I think we’re kind of on the extreme side right now of pushing a lot of stuff to telehealth, but I think it will swing back in the middle where it won’t be 20 and it won’t be 2,000, it will be somewhere in between. But I think certainly there will be a lot more comfort level both for patients and providers saying that, hey, there’s no reason for you to really come in. And I think what’s really the amazing part about this is that patients have – a typical physician visit could last anywhere from 15 minutes to 45 minutes, depending on the complexity of it. But I think what we as providers often forget is that that 15 minutes to 45 minutes, for a patient actually often times, and especially for patients in the lower socio-economic status, it actually means that they’re often taking a large portion of their day and dedicating that 15-minute block to 45-minute block, and so I think it really opens up the door for a lot of other things that previously we couldn’t accomplish as physicians. So I think we will learn that now here’s a whole group of patients that we had a really tough time connecting with before, and the reason was – and as a provider I never perceived it – was because they had to take the whole day off. And it just wasn’t economically possible for them – or feasible for them - to take the whole day off because they may live paycheck to paycheck or whatever it is. But suddenly I see these patients now on my telehealth visits. So I think we will understand who are the patients, not only based on their disease states but also their social status and their economic status and the demographics of – who are patients that can really benefit from this and where I can really expand my reach and so I think for sure, I think telehealth is going to stay and I think as I mentioned before we as a nation have become a lot more comfortable with it we just have to figure out where that delicate balance is of when a visit should be done in person and when it can be done over telehealth. And unfortunately again some of that will be dictated by the payers and what they’re willing to pay and then what’s our comfort level in spending that time and kind of balancing that too. So I think there will be kind of a few different things that will play into it but I think eventually there will be, I think we will be doing…I don’t want to throw a number, but I think a certain number-fold over what we are doing. So if we’re doing 20 before, I would say there should be at least 3x or 4x more than what we were doing before COVID hit.

Kathy: In addition to telehealth, what do you see as some of the key technology breakthroughs in healthcare that will emerge as a result of this pandemic?

Tashfeen: I think that’s a good question. I think when we talk about telehealth, I think it’s important to maybe broaden the definition a little bit. I think generically when we say telehealth, the type of visit that comes to people’s minds is the actual kind of video, real-time interaction, kind of synchronous way of I’m seeing the patient, the patient seeing me, and then there’s a real-time exchange of audio. I think that’s where telehealth starts, but I think really what this has broadened our scope is that we should really think about what we could really maybe call telemedicine. So there’s a lot of ways for us to be able to conduct or deliver healthcare outside of that real-time interaction. And CMS, I kind of like how CMS has done this where they basically have defined three types of, and they’re both broader telemedicine billing codes so they have what they call telehealth, and they have something called an e-visit, and – I’m blanking on the third word. But the other two are basically asynchronous ways to check in with the patient. So these are ways where a provider or someone on behalf of the provider can communicate with the patient through secure messaging, it could also be a voice call, but it doesn’t actually completely have to be an actual telehealth visit where there’s a video exchange. And I think as we become more comfortable with doing telehealth visits, I think we also become more comfortable in managing healthcare issues for patients asynchronously, using messaging protocols. So for example using the patient portal, which was heavily pushed 10 to 15 years ago which hasn’t gotten the adoption and the excitement that it originally came out with. But I think as physicians and patients become more comfortable with even receiving and delivering healthcare from a distance over telehealth visits, I think they’ll also become more comfortable in saying when I have an issue I don’t actually have to synchronously connect with my provider, I don’t actually have to physically go into the clinic and talk to him or her, and I don’t have to even go onto a video call to talk to him or her. I can actually try to deal with the issue or manage the issue just by messaging. And what’s really great about the way CMS is doing this is, they are actually reimbursing from this. So you could as a provider have an interaction, have an exchange of messages that occurs, over the course of, for example, seven days, and then you can actually bill for that interaction. And it obviously won’t pay as much as an actual synchronous kind of visit, whether it’s in person or over telehealth, but it does get reimbursed. And I think there’s a lot of healthcare that can happen there because again, talking about when a patient comes in I think as providers we don’t appreciate how much time it takes to go see a doctor. Whereas sometimes it’s a simple question as like, “I’m on this medication and I’m having this issue. Are they related or not?” Or, “What should I do? Do I need to up my dose? My labs just came back, do I need to decrease my dose?” Rather than me taking my whole day out for a 15-minute visit where the provider is going to tell me hey, look, your cholesterol is not well-controlled, we need to up your dose, I can have this exchange over secure text messaging, and then I can adjust the dose for the patient, and then we can move on. And the whole interaction both for me and for the patient may only require five minutes, and it’s much more seamless. So I think the breakthrough technology that’s really going to start coming is being able to facilitate the interaction out of these synchronous kind of interactions where we can, the providers can communicate with patients in a secure way and be able to address a lot of the questions that otherwise would have required more of a time-consuming way. And I think again we’re going to become more comfortable in doing this, both as patients and providers.

Kathy: Now it seems like with the introduction of some of these asynchronous ways of communicating it might also be a good time to move to some of these more value-based models that we’ve talked about for so long but maybe haven’t fully implemented.

Tashfeen: Yeah, and I think that hits it on the…I think that’s exactly where we’re going to be headed. Because unfortunately right now a lot of these other interactions…and physicians are, we’re obviously trying to deliver care, but a part of us is driven by the finances of the interaction. So there needs to be – the question that always comes up to physicians is OK, I’m going to spend this time, but am I being reimbursed for this time, am I being rewarded for this time, and so I think certainly changing the reimbursement model to a value-based model certainly facilitates because physicians will then become innovative, and trying to figure out, hey how do I address this same problem in a much more cost-effective way but also in that health-effective way which actually drives better outcomes for the patient. Makes it easier. And I think, for example, CMS has bundled payments for joint replacements. And I think that was a good example where the hospital and all of, the whole provider staff, they’re given a bundled payment for delivering a quote-unquote “product” to the patient, just basically replacing a joint. And then they’ve been figuring out innovative ways, and I think this is perfect, where the patient gets discharged to home and then you can have the patient deliver asynchronous ways – messages – to check on the patient. It’s not necessary 24 hours later once the patient’s been discharged home that he or she physically has to come into your clinic to be seen. The patient just was discharged from the hospital and it’s not going to be easy for them to be able to transport from their house to the clinic. So is there an asynchronous way? And I think this is definitely a way for them because previously what would happen is that the patient would come and then that would block off another 15 minutes from the physician’s time whereas now if you can deliver messages to the patient just to check on them to make sure that they’re doing OK, and if you’re able to check and make sure that they are progressing in the right direction, there’s no reason for you to dedicate 15 minutes of your day to check on the patient in a synchronous way. So certainly I think some of the reimbursement models will help physicians to reassess ways to be able to interact with the patients, deliver care in a more virtual world, which will be not only more cost-effective, but I think also it will drive better health outcomes, and I think it will also drive patient satisfaction.

Kathy: Now a lot of what we’ve just been talking about are some of those finances and one major impact from the pandemic has been the decrease in physician and hospital revenue. What are some of the ways that providers can harness technology to recover some of that revenue?

Tashfeen: Yeah, this is one of the things that we’ve seen – a common request we’ve seen with some of our clients. And unfortunately what has happened is that when the pandemic was first hitting providers, and patients too but a lot more providers, just the mass canceling of their schedules. They said you know what we’re closed for two weeks, three weeks, four weeks, and going forward. And now as we’re kind of, depending on what state, we’re going up and down in terms of the impact of COVID and clinics are starting to open or they’re running a hybrid model where they’re seeing some patients in the clinic, they’re seeing some patients in telehealth…But I think one of the things, one of the challenges that the providers are facing is that they know, so they’ve canceled, let’s just say two months of appointments. But they have this backlog, they need to see these patients, so figuring out a streamlined way of getting them back in. And of course in the process of this they’ve either had to let go unfortunately some of their scheduling staff, just because the finances just couldn’t make it work, or they haven’t actually, they haven’t had the opportunity to actually hire further staff. But now suddenly as they’re opening up there is this strong need to meet, to schedule, two months’ worth of patients. So how would you do that with the same staff or less staff. So some of the things that we’ve seen, and I think this is probably the other aspect of medicine that we’ve been trying to get up to speed on but hasn’t happened as fast is on-line scheduling. Really allowing patients to be more self-serve. And this is – we see this in other industries where patients want to be able to take more control of their experience when they’re engaging with that industry, whatever, retail industry. And I think similarly patients are asking for that in the healthcare world and a manifestation of that is on-line scheduling, so what we’ve seen is a relatively rapid adoption of on-line scheduling where we, a lot of our clinics what they’re doing is they’re saying sorry we had to cancel your appointment two months ago. You can call in to schedule your appointment or here is a convenient way for you to find a time that works for you, and just go to our website and schedule online. And so one of the ways we’ve seen is that what our clients are doing is that they’re identifying, they’re going through their two months or whatever months of cancellations or backlog that they have, identifying who are those patients who are candidates to be scheduled for telehealth visits or if it’s candidates to be scheduled for in-person visits, and doing mass messaging to those patients to allow them to be able to reschedule themselves, and particularly those patients who are going to be doing telehealth visits so that the phone lines don’t get inundated they’re referring them to their on-line capabilities where they can do self-scheduling. So they can have a streamlined way where they can start re-populating their schedule, but not having that excessive burden on their staff to be able to reach out and do a lot of the manual effort to schedule, because as you can imagine, these – the front desk staff, I don’t know if you’ve ever seen them, they’re quite – they’re overworked as it is and to ask them to be like hey look here is a list of two months of patients, please go schedule them, that’s just an insurmountable task. So that’s kind of one of the ways we’ve seen. And the other thing we’ve seen is interesting is that a lot of our clients have adopted ways to kind of be able to take the ebbs and waves that are coming with COVID in terms of turning up their in-person volume and turning down their telehealth volume, being able to shuffle the schedule kind of very easily because if a mandate comes tomorrow that says from the governor of your given state that says all clinics must be shut down, our clients have learned to be able to adapt, to say OK, we were planning on seeing 40% of our patients in person, we have now, because we’ve kind of gone through this, we can quickly shift them to a telehealth visit or back and forth. And so I think one advice we’ve been giving to a lot of our clients is that we don’t have a clear sight to where COVID is going, and it’s going to come and go and come and go probably for the near foreseeable future, so what we have recommended is that you come up with a game plan of how you can shift patients from an in-person visit to a telehealth visit and back and forth such that you have a more steady volume of patients and more steady revenue coming. And so that way you can kind of be able to prosper regardless of what practice model you’re doing. If you’re doing a more heavy telehealth model or doing an in-person model.

Kathy: Now how can technology such as AI or machine learning be used in the care setting?

Tashfeen: There’s a very interesting play for AI, and I think, again, this is one of those things, one of those technologies that we’ve been talking about for ages, and it slowly is coming and taking place, root in medicine but it’s probably slower than we probably would like to see it, and again that has a lot to do with both provider and patient comfort level. But I think one of the interesting things is, and I think this sort of goes back to the asynchronous communication that we were talking about, is that as patients become more comfortable in communicating with their providers in an asynchronous way, I think what will happen is that it will be important for providers and healthcare systems to be able to kind of filter through a lot of those messages and a lot of that data that’s coming in. I think one of the challenges that physicians have in general, just from the devices that generate, like the Fitbits and the Apple Watches, all this, there’s a lot of data that comes in but it’s hard to filter the noise, filter the sound from the noise. Sorry. Filter the signal from the noise. And I think similarly here as we allow for asynchronous ways there’s going to be a lot of data there and so really identifying and helping providers kind of filter where they need to focus their attention. And so what I think will happen is that there will be a lot of interesting ways. So for example, patients are messaging in, saying I need a prescription refilled, I need to reschedule my appointment, or I need my lab results, and having a system that can kind of understand what the patient is actually getting at and then put them in the right workflow so that way it can be streamlined. For example, a clinic will have dedicated staff that are responsible for, for example, doing rescheduling. So when a patient messages and says I need to reschedule, that will be routed to that person. So that way it streamlines, so nobody is sitting there trying to figure out, who should be taking care of this message? Who should be taking care of this message? So that way the whole workflow can be streamlined, so for example, like prescription refill. The three most common reasons that patients call in into a clinic are prescription refills, getting my lab results, and scheduling issue. And now – the way most clinics do prescription refills is that they will often tell them to either call and leave a voicemail and then you will get back to the patient later, or you try to kind of directly connect with the provider, but then there’s a whole disruption in the schedule and things of that nature. And so imagine if when the patient messages in, all of the information is properly captured, and then we can facilitate the next step that needs to happen to be able to deliver that, if the patient is ready for the prescription. So I think being able to have workflows, and allowing the system to be able to understand the intent of a patient and be able to facilitate the workflows I think is really important and which will be really fulfilling both for patients and providers because again taking 15 minutes out just to see your provider to get a prescription refill doesn’t necessarily make a lot of sense if there’s a much more facile way of doing it.

Kathy: Let’s jump ahead five years: where do you see care delivery in 2025?

Tashfeen: I think in, it will be very interesting to see where we do end up in five years, but I think it will have a lot of components of what we’ve been talking about so far. So I think there will be, I’d say, it’s hard to put numbers on this but if, for example, we were doing, let’s say, 2 to 3% of our telehealth business – 2 to 3% of our current business was done on a telehealth visit, I’d say we should be at 10x that. So I would say that at least 20-30% of the healthcare that’s going to be delivered will be delivered in some sort of virtual way. And I think one form of that will be the what we’ve been talking about, the more traditional way of delivering telehealth, which is the synchronous kind of communication, but I think a lot of the visits will also be happening over an asynchronous way. And I think a lot of the reimbursement models will shift to do that, such that you will see a significant percentage of the healthcare delivery being done over a, sort of a digital format. And I think what will be really interesting to see from that is how that actually drives some of the core things that we as a nation have been struggling with around rising healthcare costs, with kind of subpar health outcomes, and poor patient satisfaction. And I think a lot of those things will be addressed as we become more of a digitized healthcare nation, so to say. So to put it kind of more bluntly I think really what COVID has done is I think it has put to light the potential of what telehealth and digital healthcare can do for us, and I think it can really address some of those core problems that we’ve been struggling with as a healthcare nation for the last several years which the Institute of Medicine back in the early 2000s had said that in order for us to solve the healthcare problems we need to address patient satisfaction, patient outcomes, and costs. And I think really us leaping forward with what COVID has put us through in terms of adopting digital healthcare, is really going to help us solve these things and push us forward. And I really think that what will happen in the next five years, what we will be able to accomplish in the next five years, we have not been able to accomplish in the last 25 years.

Kathy: Well thank you so much Tashfeen, this was a great conversation.

Kathy: Thank you for joining me for this episode of the Smarter Healthcare Podcast.

To learn more about Luma Health, follow the company on Twitter @lumahealthhq.

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