I've got my all-star panel right here. We've got Dr. Shane Joseph from Harvard Medical, and we also have Dr. Jeff Jacobs, and we have Monia Day, who is going to be presenting virtually today. So I believe, Dr. Joseph, you're up. All right. Good afternoon. So I'm Shane Joseph. This is another part of our team. One person that's not mentioned here is David Stearns. He's a fellow resident with me at the Harvard School of Public Health. Fortunately, he was unable to make it here because now he's looking after a three-week-old daughter. So he does send his regards. Can you turn the volume up a little bit? Volume up? Anybody? We don't have the control of the volume here. It's back there. Good now? Good? All right. Thank you. All right. So just some disclosures. So we have no financial disclosures for this talk. Both David and I are active-duty service members in the United States Navy, so we are here representing us as civilians, and any opinions or positions in this talk do not reflect any government agency, the U.S. Navy, or the Department of Defense. All right. So here's a brief outline of what we're going to be talking about today. My focus will be the beginning of telemedicine, how we got here, and why it matters. So here's the brief timeline. So a lot of times when we think about telemedicine, we think of the COVID response of how we jumped on Zoom and started doing business. But in actuality, telemedicine has been around for a while, and as you can see at the far left of your slides with our timeline, with the beginning of the telephone, the medical community saw this as a great tool and started using the telephone as a triage device. Going into the early 1900s, we see the first tele-EKG, so we talk about now, which is a burgeoning field with remote physiological monitoring. We see that in the early 1900s when it first really started, so it's kind of fascinating when you look at the history of where telemedicine was, what it is now, and where it's coming. Then kind of moving on, you saw in the race to the moon, NASA started leveraging a lot of these RPM assets, those remote physiological monitoring, to monitor their astronauts as they did their missions, and so on and so forth, into the 90s, where you actually now get more recognition for telemedicine, with the American Telemedicine Association being established in 1993. And then in 1999, you have the Center for Medicare Services now providing reimbursement for telehealth services, specifically in this case was to underserved areas. And then as we saw in 2019, they started broadening reimbursement for telehealth services, which we'll get to later in this conversation. And then in the 2000s, with the explosion of technology, you saw the medical community start leveraging telemedicine services more and more frequently. So what, you know, when people speak about telemedicine or telehealth, it's kind of hard to define people, you know, how would you exactly define it? If I speak on the phone with a patient, would you consider that telehealth services? And then how you go from there. So we have two definitions that's provided, one by the American Telemedicine Association, where telehealth is used to connect individuals with their healthcare provider when an in-person service is not available or not possible. And that's where you have these virtual visits, they consider chat-based interactions or RPM, those are all telehealth or virtual services. But then you look at 42 CFR, how they define it, and probably more important since that, you know, has the front of law, is at a minimum, you need both audio and video, and it needs to be in real time, communication between a provider and their patient. And so then why does this matter? So the Kaiser Foundation did a study, and they looked at firms in the light blue is all firms with 50 or more employees, and the dark blue you see with 200 or more employees. And what we're seeing over the last few years is as part of their employee benefit package, they're now including telehealth services. And probably as a response to the demand from the employees, because as we see in this next slide, employees really like telehealth services. So when you look at the Likert scale of how important is having a telehealth practice or a benefit as part of their benefits package, if you look at the green, which marks very important, and the light blue, which is mostly important, about 75 to 80% of employees want telehealth services as part of their benefits package. So this is, and as they can know the convenience of it, we can only see this is going to grow further and further in popularity. So with that, I'm going to convert the next part of our talk to our virtual presenter, Monia Day. Hi. Can everyone hear me? Yes. We got you. Great. Okay. I wish I could be there with all of you. So do you have the supporting evidence slide? It is up. Okay. Oh, you know, I was seeing two of me and not the actual slide. So we, you know, as physicians, we, you know, we have concerns about telemedicine and despite the fact that it's convenient and easy for patients and cuts down on commutes, we worry, are we delivering the same standard of care? And you know, what does it actually do to the medical encounter, to the medical outcomes, to be delivering care in this way? So research around the outcomes and success of telemedicine and telehealth is emerging, as you might imagine. For this kind of thing, there aren't papers going back, you know, 40, 50 years that we can rely on. So everyone is effectively learning together. What we put together is pieces of information gleaned from recent studies that give us a little bit more confidence in using this modality of care. There are several studies that, one of which I've got the link on this slide, this might be an older slide, that's just an error, but we have more links that I can actually share with you all as well. The first thing I want to talk about is that there are studies showing that telehealth improves no-show rate, and that's even compared to what the general pre-pandemic rate was. So we can gather that patient compliance with appointments, you know, keeping the frequency of visits and keeping the care up to date is actually something that's potentially going to be helped by telehealth. We might be worried about patient satisfaction. And studies actually show that, you know, across a variety of specialties, that there is no difference in satisfaction with a healthcare professional when using telemedicine versus in-person visits. So that can be reassuring for, you know, someone who's worried about their PRESS gaining scores, but also like the, you know, the convenience of delivering care in this way. There was a study with a, with a rheumatology practice, and they were looking at patients who had arthritis, rheumatoid arthritis. And in this instance, telemedicine actually reduced the number of visits that the patients needed with their physicians in the sense that they were doing better overall clinically. The level of care and the quality of care was unchanged, and the patients actually perceived their quality of life as better. So this, I think, is something that we can, you know, extrapolate to the, you know, the frequency and the physical nature of your organs compensation injuries, for example, because sometimes we have to see those patients, you know, relatively frequently, and there's a focus on injury and disability. So that's reassuring that, you know, that in this similar situation where, you know, we're looking at joints, we're looking at, you know, a disabling situation, a physically disabling situation, that patients were actually able to benefit from telemedicine. Looking at a different kind of medicine, psychiatric patients, so one study recounted that eating disorder patients did better with telehealth, and this is something that's potentially relevant to the psychiatric patients that we see, you know, in the workers' compensation setting or in employee health, and not everyone's coming in for a bump or a cut or a bruise. Someone's coming, someone's potentially coming in for psychiatric issues or psychological issues, and in this study, you know, even though it's not exactly the same as the, you know, as the potential anxiety or depression that we might see in the workplace setting, these eating disorder patients demonstrated reduced outcomes of perfectionism and depression because they were using telehealth, so compared to the in-person visits. So that's also encouraging with those outcomes being improved in the eyes of those psychiatrists. You might be worried about increased insurance claims with telehealth. There is more, I think, to be found out about this as we move forward and see is there a difference in, you know, insurance claims, you know, with the greater use of telehealth because it's so new that it's been widely adopted, but one study that has been, I found out, has been sort of erroneously cited as, you know, as this is showing that there could be increased insurance claims. It was actually from 2008 and not really talking about meeting your patients over Zoom or over a face-to-face telemedicine meeting. It was about giving care over the telephone. So I think that actually illustrates that being able to give face-to-face care, you know, with, you know, patients having better internet connections and being able to facilitate that is really what makes the difference is being able to meet your patient as opposed to just speaking with them on the phone. Next slide. Okay. So what are the current best practices? Again, this is something that we're all figuring out together, but here are a few tips. One, keep abreast of the legal restrictions on telemedicine in your state in order to avoid, you know, risk, you know, exposure to liability. There is an insurance company called Beasley, and I have the name up here. They actually have an interactive U.S. map on their website that shows what are the legalities around telemedicine in each state. So that's really useful because, as we know, that's changing all the time and it can be intimidating to keep up with, so that's a resource for you. And as far as other best practices, you want to ensure that older patients can use video in particular and that patients in more remote areas or who may be income challenged can actually have reliable internet access because the last thing that you want is for the patient to miss something important that you're demonstrating or showing or that they misunderstand something because of a bad internet connection. Definitely get consent to substitute telehealth for their in-person visits. This was emphasized by the California Workers' Compensation Board during the pandemic. They said you can't just switch over to telehealth and say, okay, this is what we're doing now. You actually have to have their consent record. Of course, you know, use telemedicine when it's going to help reduce disease transmission. So making it a priority, for example, when, you know, when a worker is sick but can potentially zoom in or when, you know, a patient has an infectious disease, you know, aggressively using that would still be considered a best practice because you're keeping everyone in your office and the other patients safe. As far as guidelines for examining the patient, some guidelines came from a paper related to physical medicine and rehab medicine. And what they recommended was that for new patients that the patient have someone else in the room with them during the telehealth visit. And this allows that person to adjust the camera as you're examining the patient virtually. This examination should be performed in a comfortable and quiet setting for obvious reasons. The patient should be dressed in something like shorts and a t-shirt or tank top so that you can actually see, you know, how their body's moving, any difficulty they're having. We try to have that in the patient be in a reasonably large room so that there's sufficient space to capture a head-to-toe view of the patient. And they mentioned at least 10 feet of space is recommended. And the patient should have a standard height chair nearby with arms and a table for support. So again, a lot of our patients are undergoing rehabilitation and these, I think, can be extrapolated for us as well. If you're doing something like listening with a stethoscope, consider using a recording device with the person who is wielding the stethoscope so that you can make sure that you're hearing what you think you're hearing. Talk through your exam as you tell the patient to do certain movements, et cetera, and explain what you're doing so that communication stays open the whole time. As far as future best practices, this is something where I think we all have to be more proactive than in other areas that we try to keep up on. Keep checking for new articles, new reviews in your specialty, and just try to make sure that you're taking a look at the literature every once in a while because that can inform what you do in your office. So finally, prepare for telehealth, visualize your perfect exam scenarios, tweak it until you have the exam moving smoothly as you want it, which will ensure a better outcome and a better experience for you and your patient. Thank you. All right. Thank you, Monia. So next, I'm going to bring up Dr. Baranji back to talk about the regulation and reimbursement landscape. Great. Great. Thank you, Dr. Joseph. Let's see. So yeah, obviously, we want to get paid, right? So I feel like this is the most important topic, especially as we're still technically in the pandemic, but we're kind of getting into that endemic stage. And the rules and regulations around parity, around telehealth, this is still an ongoing discussion. I'm not sure if you folks know, but the American Telemedicine Association is actually happening as we speak in Boston, and these discussions are happening as well. So it's really important that we continue to engage with our respective colleagues in the telemedicine world. There are many different stakeholders that we need to engage with to understand this landscape. But clearly, we know that parity, making sure that these examinations are paid the same as in-person examinations, this is still a point of contention, and it does vary state by state. So in terms of what's happening at the federal level, I mean, this is still evolving as well. I just wanted to make sure that I was able to give you some up-to-date information, at least the last few months. Recently back in February, the Federal Telehealth Extension and Evaluation Act has been proposed by a few Congress folks. And really, again, the main basic gist of this is to ensure that patients have access to this type of service and that clinicians, providers are being paid for the respective service. So stay tuned. I think this is going to be an interesting development over the next few months. Many of us are utilizing telemedicine in our practices, whether it's full-time, a hybrid model. This is a very exciting space, and I feel that we in occupational medicine have a lot to contribute. I apologize. This might be a little too busy to read, but this is just mentioning the 2022 omnibus bill. So there are provisions for telehealth coverage, ensuring that folks on Medicare have access to telehealth services. This includes audio as well as audiovisual. There's been a lot of discussions about how folks are able to utilize these technologies. We've heard about the digital divide. Many folks in the rural communities don't have access to high broadband. So as we continue to see where trends go with the federal landscape, it's going to be important to see how that boils down to the clinician. The folks who practice in rural America, for instance. So stay tuned. So this is just, again, going through a couple of bills that are currently in discussion at the federal level. I mentioned the Telehealth Extension and Evaluation Act that's currently been proposed. And again, a lot of things are happening at state levels as well. I know in the state of California, there's been a lot of discussion about including telehealth as part of primary care packages. So in occupational health, I mean, this is, again, a very important topic when it comes to reimbursement. Let's see here. I think this is the most important slide because this has to do with parity and which states actually are paying pretty much the same as for an in-person visit as for a telemedicine visit. So right now, it's kind of a 50-50 split, roughly. Twenty-five or so states, you know, pay the equivalent for an in-person visit for a telehealth visit, and the rest of the states are currently not doing that. So as occupational medicine physicians, you know, we're going to kind of keep an eye on this. Clearly this is going to be something that we're going to communicate to our members. Many of us are interested in continuing telehealth practice, so we will continue to keep updated, working with our respective stakeholders across industry, as well as with the American Telemedicine Association. So this is looking into specifically occupational health and fee schedules related to telehealth services in the state of California workers' comp system. So there's been a lot of buzz about, you know, how should these types of visits be paid for. So again, this is what's happening in California. We're trying to ensure that there's certain parameters set for specific visit types. And I just wanted to outline a couple of telehealth rules that the California workers' comp system has devised. You can read them on the slide there, but really ensuring that there's adequate malpractice coverage for telehealth. I know this has been discussed, you know, managing risk, you know, how are you able to assess an individual's injury, for instance. So making sure that malpractice coverage is covering these types of situations. And then, you know, how are these visits comparing to current Medicare rules. Clearly a lot of the fee schedules are based on CMS guidance, so the California workers' comp folks have kind of understood that, and they've included that as part of their 10 rules. And then, again, looking at how telehealth can be a means of delivering care. You know, many specialties across the spectrum have, you know, developed best practices as to how they can incorporate telehealth into their day-to-day practices. And, you know, a combination of in-person and virtual seems to be, you know, the general trend at least for right now. A couple more rules here. I won't belabor this, but again, the state of California workers' comp, they're thinking about this in the short and long term, understanding that to be able to provide these types of services to injured workers, there needs to be certain parameters set. And I'm going to hand it over to Dr. Jacobs. Thank you. All right, so I have two disclosures. Being up here with my two colleagues and the two colleagues at home, I'm old. But the good news is that telemedicine has really rejuvenated the way I feel about my medical practice, so it's been a really, really great thing. And the second thing is, this is as dressed up as I've gotten in two and a half years. And my pants still fit. So, yeah, so anyway, so if you can, oh, do you have the, oh, that's all right. Back one, okay. So my path from Luddite to technological maven has been kind of slow, but it's been a good path. And one of my colleagues presented on telemedicine a few years ago, and she used the phrase crazy, crazy, crazy obvious. And I think the idea of doing something, an exam virtually, to me, at least initially was crazy. It really was. But as I went through the stages of this idea adoption, at some point in the last few years, it became very obvious that this is something that I could do, and I could do well. So we had a conference, a MarCom conference, regional Ahmed conference in Philly, and we had somebody come in who was a telemedicine doc for oil rig workers. And I listened to what he said, but I thought it would never apply to me. I mean, it makes sense. You're in a remote location and doing telemedicine in those situations, if you need to evacuate somebody, that's really reasonable. But I didn't really think it would apply to me. Then about a year later, I started with the company I'm currently at, WorkCare, and we had something called incident intervention. And that's basically where somebody gets hurt at work, or thinks they got hurt at work, or is having some kind of pain, and they call a number, and they speak to a nurse, and the nurse tries to triage them, and doctors get involved. If the person is requesting a clinic visit, or the nurse feels they need a clinic visit. And I started doing that, and after a while, I thought, well, maybe I should get pictures if there was a laceration. And I started my foray down that rabbit hole, to the point where I was doing one-offs of injury care, and I was having people with back pain bend, and turn, and stand on their toes, and things like that. So that kind of promoted my way further. And then the last couple of years, we've started doing remote fitness for duty exams for one client, their heavier industry. So they have potential for safety-sensitive work, so we're checking them for fitness for duty. And basically, we're doing musculoskeletal and neurologic exams, what you can do. Certainly you can't touch somebody doing it, so you can't check for hernias or anything like that. But that's been a really good experience, and an unusual experience as well, because sometimes you'll get people literally in their closets, their rooms are so small. So it's kind of difficult sometimes to do it, but I've also had people that were driving in their car, and I made them stop and pull over. So I've had them do things in parking lots and on the ground. But the important thing is that the clients are very satisfied, because we're reducing the turnaround time from the exam to getting them cleared to work. And now, this past year, because of the pandemic, it's almost like telemedicine has been supercharged, because there's really a limited number of clinics, and also real wait times for a lot of these clinics, and employers are really feeling the pain. So they're asking for a lot more virtual exams. So business-wise, it's been pretty good. So here are my not-so-random thoughts. I think a lot of people really make telemedicine out to be some mystical, futuristic thing, but truthfully, it's just another form of health delivery. And I've delivered health care in Winnebago's and clinics, and now virtually, and it's the same thing. You're basically doing a fitness for duty exam. And I think many people, just because of the pandemic, have experienced this, and you may not like it, and you may not want to continue it, and that's reasonable. It's definitely not for everybody. But you are practicing virtual medicine just by picking up the telephone and contacting the patient if they're asking for prescription renewals and things like that. So it's not that futuristic. You may not be in the same place, but you're doing the same exam. And I feel like you can perform almost any type of assessment that doesn't require your hands. So there's a lot of things that you really can do, and I've found over the years that the majority of the diagnosis for me comes from the history. So I'm already clued in as to what to expect. If somebody has a history of back pain, clearly I'm going to clue in on that. And my next statement that the value of the physical exam is overrated. The physical exam is a static exam. I'm looking more for functional abilities for fitness for duty. So I've tended to use a standard musculoskeletal exam or back fitness exam that asks people to move. So I'm checking range of motion, I'm doing strength with what I can, I'm having people stand on their toes, walk on their heels, they can get down and do a plank, all kinds of different things. In terms of balance, I'm going to embarrass myself because I have peripheral neuropathy, but I have them stand on one leg, and you can see I'm wobbling. But I have them do a walk the straight line test. There's a lot of things that you can do for the virtual exam that can give you clues as to whether somebody's fit for duty. So the other thing is, if you're uncertain, and we've had a few people like that, you just refer them to a clinic, and they can do an exam, or you order other tests. Things like a six-minute walk test, which I remember one time I was dumb enough to try to ask somebody to do it at home, and it didn't go very well, he just didn't understand what I needed him to do, but that was one thing that we did. Ultimately, we ended up sending them to a clinic. The last point is, employees really like it. They like the convenience of it. Clearly, they're much safer in their own home, infectious disease-wise, and pneumonia, talked about a lot of these things. The employers are happy because right now, they're really struggling to get their employees into clinics. There's really a backlog, so we're able to reduce the turnaround time in clearing people. I'm really happy because I can wear my sweatpants, and I can work from home. I think it's a win-win-win-win all around. The negatives are that you may get really poor connections sometimes, so it makes it impossible to do, and that oftentimes people may not be prepared. You can give them a list of the tests that you're going to ask them to do, but many times they haven't read it. Those are my two gripes about it. Finally, in terms of doing vital signs and vision and things like that, if you have an on-site clinic with a proctor, you can do an exam there quite easily. It doesn't translate as well to a remote exam done at home. The technology is improving. The apps are improving. I think as telemedicine becomes even more mainstream, those things will improve as well. So that's my thoughts. Great. Thank you, Dr. Jacobs, for your insights. Clearly, this man has been practicing occupational health virtually for a number of years. Getting testimonials from all of us, I think this is important. We have to set the standards for how we're going to capture the basic physical exam for a fitness for duty or for a work injury. Right now, we don't have standardization of these physical exam qualifications to be able to ensure that we're all kind of capturing those basic elements. So this is an area that I have personal interest in. I know AECOM has personal interest in. There's a presidential task force looking at this whole concept of the virtual occupational health clinic. So really, this is something that we all envision as being part of an occupational medicine practice in the future. How do we incorporate all these different elements? Looking at these complex patient inputs, how do we take into account remote patient monitoring, for instance? We can actually have patients be able to do their own blood pressure and take their own pulse ox, just having the special tools that they need to do that. So being able to capture those quantitative metrics and incorporating that into our physical exam findings, I think that's really going to be the future. And the future is already here. I mean, I'm not sure if you folks know, but there's hundreds of telemedicine providers out there. They're providing telemedicine services exclusively, whether it's to employers, whether it's to individual subscribers. This is here to stay, and most people like it, as Dr. Jacobs mentioned. They like being able to have their healthcare delivered in the comfort of their own home. So we all feel that this is something that's going to be here to stay. Working out how this is going to be paid for in the long term, this is something that's still being discussed nationally, at the state level. I encourage you all to take a look at your state policies regarding telehealth. I know the public health emergency was recently extended for another three months, I believe. So there's still going to be, at least reimbursement-wise, that's still going to continue, at least for the next six months or so. But really, we have a say in this. And if we feel that this is a media that we can use to practice occupational health safely, I think these are conversations that need to be had. Let's develop those guidance statements. Let's develop those position papers. Let's really put our input into this to make it worthwhile for the injured workers that we treat. All right. So we're going to have a quick little panel discussion, lessons from the pandemic. I can give a brief experience, at least from my standpoint, when I was at Boston Medical Center. So I worked at Boston Medical Center for approximately four years, from 2017 through 2021. And I know exactly where I was in March of 2020. I had a really successful occupational health practice. I actually worked within the Department of Orthopedic Surgery. It was a dream come true for me personally. I just thought it was a great clinical model, especially for work injury care. And then all of a sudden, our clinic shuts down. I'm redeployed. I'm actually having to work in an urgent care setting taking care of COVID patients. So that was an eye-opener for me, just seeing how people literally from one day to the next, we completely had to change the way we were practicing. And then our clinic finally did open back up in June, but we were offering a hybrid model of telemedicine as well as in-person visits. So I'm sure everyone has their own experience, at least those who were practicing clinically at the time. Initially, we were just doing audio. And I don't know how other folks feel about that, but that was really scary for me because you can't see people. And a lot of my patients were people of color who did not know English. So trying to understand what they're saying, even with an interpreter present, was just really difficult. Finally, our hospital was able to integrate a video platform with an Epic, which really kind of changed the game for me because I could actually see my patients virtually. So I actually was able to successfully have a hybrid practice for a good year for the rest of 2020 into 2021. And I thought it was working great because I was able to figure out what worked best for my clinical practice. For all the new patients, I would see them in person. For all the follow-ups, the pain management folks that I had to take care of their pain medicines, I felt I could use the virtual format because it was easier for the patients to connect with me. I could follow up with them with respect to test results. I could follow up with them with respect to their pain medications, doing refills. So I was able to make it work for me. Dr. Joseph and Dr. Jacobs, did you guys want to give a quick little rundown? I think Dr. Jacobs already provided his two cents, but Shane, you want to go ahead? Yeah, so I know at the start of the pandemic, I was preparing to move to Boston to start my residency at the Harvard School of Public Health. So I was with my unit in Southern California, and they just told the rest of the battalion to stay at home, but as the physician, I had to come in, which was weird because my full panel of patients turned to, I just had to start calling them because we weren't obviously set up for telehealth services. Then when it also reminded me of just about nine months prior to this, we were on deployment, and I had a lot of my guys spread out through the area of operations, when a lot of my physician assistants that I had kind of deployed about would contact me via FaceTime, Facebook Messenger, those types of things. We'd get a video, and I could actually evaluate a patient. And then click in my head about, oh, this is actually a really cool tool, until the pandemic really hit, everyone was at home, and I was like, wow, we leveraged that really quickly before I got to Boston, and then once I got to Boston, what we did similar to what Dr. Varangi was saying was a lot of the stuff we were doing at Cambridge Health Alliance or at the Harvard School of Public Health in terms of clinical care was a lot of our workers' comp injuries, that initial visit would be in person, and depending on the nature of the injury, we kind of make that determination whether a lot of the follow-up can go virtual, and as long as they're on the right trend that we expect them for the given injury, we can keep them on a virtual pathway until we are ready to return them to work. If they either are plateauing or getting worse and we can't have a good explanation, we bring them right back in. Same thing with a lot of the pre-placement exams or occupation exposures that we're trying to evaluate, a lot of the employees or the clients that were very enthused with having the virtual option because they could be in their sweatpants, they don't have to deal with traffic, they were great about that. And also for them, it gets their guard down. So you know, as many of you know, when you practice, there's always an agenda setting at like the first couple minutes of an appointment, whether it's a workers' confidential, an IME, or those types of things. Well, a lot of times when they're at home, it's more relaxed, you get a lot more good information, and that will help you make those clinical decisions. So we found that going forward. And a lot of people, we had a lot of our clients, they wanted to stay on that hybrid model where they only wanted to come in when they wanted to. And it actually worked out great from the provider standpoint, as well as a patient care standpoint. So I think it's a great tool to move forward with. Yeah, I just wanted to add, I know exactly where I was on March 12, 2020. I was seeing an Allman Brothers reunion concert in Madison Square Garden. And I was supposed to go two days later to the Big East tournament, and they canceled it. And our company pivoted almost immediately because a lot of business occupational medicine visits dried up. People weren't going to clinics, clinics weren't open, and we became a COVID company. And 75% of our business in the last two years has been COVID. And now we're having to pivot back to be a real occupational medicine company, and doing these virtual exams, which is what we did for COVID, is proving useful for traditional occupational medicine practice. Great. Thank you both very much. Let's see what's next here. I think it's a QR code. Okay. All right. So let's go ahead, and I'm just trying to kind of how we're going to do this. Go ahead. Oh yeah. So I'll kind of explain how we're doing these breakout sessions. For those in person, we're asking you just to scan this QR code. There will bring you to a Google Doc that has 12 different groups. You don't need to join the group. You could just select one, because all the questions for each group is the same. What we want you to do is within kind of like a local group, within about four to five of you around, I want you to discuss your experiences with telemedicine over the last few years. What you know, what you like, what you didn't have, what you're growing pains, and you know what you think you can learn from each other. Those in the virtual audience, we would ask you that you sign up for one of the groups with your, you know, and list your name so you don't all double up. And David Stearns is joining you in the Zoom world to moderate that discussion. Well, the panel here will be kind of walking around trying to spur some discussion, and it is, let's see what time is it now, 346. So we'll give you about 10 minutes just kind of to talk about yourselves, and then we'll kind of open it up to the floor to see what people's experience were with telehealth services, the growing pains, how you adapted, and where you see moving forward. So if you can just scan the QR code, and we'll give you that time to chat. All right, we'll give you guys a couple more minutes to finish out your discussion, and then we'll turn it back to everybody. That's why I was like, once I graduated, I was like, I need to start building that more, right? Yeah, the other ones that we know that have any trouble with it are, of course, the pods that are old, and they don't want to... No, everyone adapts really quickly, yeah. Yeah, no, the thing they miss is they do part of their life as same-sex occupations, and they don't like that they're suddenly completely split from that. Yeah, they like that connection. Yeah, but however, what we do is one-on-one, if you would, and then the other side is, if we need somebody in the room, you know, the primary doctors, we'll get a PT or something. Yeah, they can do a lot of stuff that you guys can't do. Yeah, I mean, so sorry. Oh, yeah, no worries. We're just trying to figure out, should we get the group back together? Yeah, okay, so hopefully you finished up your conversations, and you've nominated a point person in your group who's willing to share some of the experiences. Does anybody in here, this is just an anecdote, anyone here know what Navy stands for? Anybody? So, it's never again volunteer yourself. So, I'm just going to pick someone, because I know no one's ever going to volunteer. So, I see like a lively discussion now over here. Do we have a point person of what your discussions were with these breakout questions? All right. So, I think probably the easiest way to start is to explain. Oh, all right. All right, hold on. Can I get everyone back to Jessica? Hello, everyone. Sorry, guys. We're just trying to get everyone back together. Sorry. I know it's a good discussion. Hopefully, we'll get to everybody, and I think there's a few virtual questions we want to get to before this wraps up, and we've only got a few minutes. But can you please share your experiences of what you guys talked about? Yeah. I think when it comes to remote telemedicine, as you said, it's duh. We've got mining, oil and gas, oil and gas. We've been doing telemedicine since 2010, 2008, and that's not so much occupational health, but this is emergency medical care remotely. So, if you can do that remotely, then occupational medicine is pretty easy. I think I just quickly told the story in the UK. The company I work for, we do about 3 million consults a year, and overnight, we moved to telemedicine. So, 90% of those 3 million per year were being done remotely, either by telephone or video. 90% were done by telephone. We had no pushback from really any of the patients, certainly not the clients. The clients who didn't like it before absolutely loved it at the end. And we even started moving to doing mental health and musculoskeletal. So, our physios were doing, obviously, non-contact physio over the web. And we even did EMDR remotely. We didn't expect it to be effective, but our results, EMDR online, were just as good as they were physically. And there's certainly two of us here that have set up remote clinics, either using technicians or nurses, who do all the audiograms, the eye tests, all of that part, and then using the electronic stethoscope, which you can listen to the heart chest, 3-lead ECG, and you have your physician remotely anywhere you want. So, you can virtually do anything remotely. Thank you for sharing those experiences. Yeah, it seems like every day there's going to be new technologies come out. It will be the day where everything you can do remotely, if you so choose, because I know a lot of people don't want to do it that way. All right. It looks like these folks had some interesting conversations about licensing. Did you guys want to share with us? Maybe, maybe not. Just regarding when you're practicing in one state, but your patient population or employee population is across multiple states, what is the liability or concerns for privacy or other concerns that might crop up if they're in a different state? This is a very pertinent subject matter, because I ran into this firsthand when I was in Boston. During the public health emergency, we actually had the ability to practice not only within the state of Massachusetts, but Rhode Island, New Hampshire, as well as Vermont. So, right now, at least for all intents and purposes, I think it really depends on your state. I'm sure most of you folks have heard about Compaq. You could actually have multiple state licenses now, and I think 20-some states now subscribe to that. So, honestly, at this point in time, I would say check with your state licensing board and make sure you check on the malpractice side of things as well. Clearly, telemedicine, there's all these other risks that have to be accounted for, and the malpractice bit is still kind of, at least from my standpoint, still up in the air. But I wasn't sure if anyone had any additional thoughts or may know more about this. There was that Beasley site that Monia talked about. That may have information or a hyperlink that you can go to to find out about each state. I'll close it out with this one group over here. Who's our point person? All right, so we had a, basically, we're rolling what we use for COVID. We had a national virtual health group, a vendor that our employees could call into, either to access tests or now antivirals. And so that next step is to turn that into occupational health and potentially primary care. That's great. I mean, we see the pandemic gave everyone a trial to see if they wanted to do telemedicine or telehealth at all. And we probably have a lot of people here that says, I will never go back. I want that in-person because of that connection, or I would love to just see patients on my porch sipping lemonade or a hybrid schedule. That's what they kind of want to see. So we'll see how it goes. And we have the last one in the back. Looks like we have a comment from Dr. Bannister. Thanks. Really, I think that a lot of you guys may do corporate medicine or something along those lines. I'm in Minneapolis. I'm in Minneapolis. I'm in Minneapolis. I'm in Minneapolis. I'm in Minneapolis. I'm in Minneapolis. I'm in Minneapolis. I'm in Minneapolis. I'm in Minneapolis. I'm in Minneapolis. I'm in Minneapolis. I'm in Minneapolis. I'm in Minneapolis. I'm in Minneapolis. I'm in Minneapolis. 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telemedicine

virtual healthcare

occupational health

remote consultations

mental health services

musculoskeletal services

pandemic

licensing concerns

malpractice coverage