AH013 - Redefining Virtual Care: A Blueprint for Effective RPM with Robert Longyear

Transcript

Lightly edited for clarity.

Justin Venneri: Hello and thank you for joining us for this episode of the Astonishing Healthcare podcast. This is Justin Venneri, your host and director of communications at Capital Rx, and today I'm excited to have Robert Longyear with us. Robert is Co-Founder and President of Avenue Health, a remote patient monitoring and telehealth company, author of a virtual care Blueprint, and board member of the Commission for Nurse Reimbursement. Robert and I met a while back, and that was all around the employment challenges in the healthcare industry and everything going on post pandemic, and we've stayed in touch. So, it's great to have you on the show today. Robert, thanks for joining.

Robert Longyear: Yeah, thanks, Justin. Glad to be back. I haven't done as many podcasts as I used to, so we'll see if I can get this done properly.

[01:10] Justin Venneri: So how about we just start off with a softball for you, maybe? Can you give us a little bit more about your background, how you got into healthcare, the world of virtual care, just to help frame the discussion?

Robert Longyear: Yeah, absolutely. So, I studied healthcare management and policy at Georgetown, and I really got into healthcare there. I was into healthcare prior to that, but I lost my mom to chronic myeloid leukemia when I was 20. And I was a caregiver during that entire episode of Care over the course of about eight years. And I learned a lot about how our health system cares for patients, in a lot of circumstances very well, and in some circumstances not so well.  

So, I kind of took this academic passion for healthcare, and medical care, and health policy and had a personal experience that sort of solidified my personal mission in healthcare over the subsequent years -- and currently. I got really interested in how we can change the patient's experience of care on a daily basis. And I knew that technology, and some of these emerging remote patient monitoring based care models, would be particularly helpful for patients with chronic disease, particularly helpful for patients who are going through a more acute episode of care.  

And so, I left college. I went to work in research briefly at the Institute for Medicaid Innovation. I studied high-risk care coordination models and social determinants of health programs and got into tech a little bit after that, and then met my two co-founders in a coffee shop off Farragut Square in Washington, DC. We decided to launch Avenue health a couple months after that.  

Avenue Health is a full-service nurse led chronic disease management, remote patient monitoring, and telehealth company. And those are a lot of buzzwords, but what we do is we work with medical practices and health systems to launch remote patient monitoring programs and episode of care programs for particular patient populations.  

So, in the outpatient setting, that might be hypertension, diabetes, COPD, congestive heart failure, where we're working on helping patients over the course of several years, prevent hospitalizations, emergency department visits through using connected medical devices and nursing care to reduce their risk. And then, we do work on the post-discharge from hospitals as well.  We have a stroke readmission reduction program, quality metric program, at George Washington University Hospital that we operate in partnership with them, and that's really focused on collecting and following up with patients after they get discharged from the hospital to ensure that we're monitoring their condition and to track outcomes over time.  

So that's sort of what we do at Avenue. I'm involved with the Commission for Nurse Reimbursement, where I work on policy and payment policy innovations related to the nursing workforce. We can talk a little bit more about that later. And then, just generally, I would say student of healthcare, particularly health policy and health services research. So, I spend a good amount of time reading and writing about healthcare as well.

[04:24] Justin Venneri: Got it. So, what are you currently seeing out there in the healthcare staffing space generally? Maybe you can share a little bit more specifically about any trends you're observing in and around the pharmacy segment of the market, if you have visibility into that? We do hear a lot about the strain on clinicians of all kinds, nurses, burnout, etc. We'd love to hear just kind of a quick update on what's going on.

Robert Longyear: Yeah, absolutely. So that's probably been, I don't know, 25% of my focus over the past, let's say, four years since the pandemic. We launched Avenue out of our sister company called Wanderly, which is a digital staffing marketplace for nurses and allied health professionals like pharmacists. It really supported a lot of facilities during the peak of the pandemic, where they were looking to hire more contingent staff. And so, what's beautiful about Wanderly is there's just an immense amount of employment, wage, and job posting data that was available for research purposes.  

So, I've spent the past several years working on our analytics product, which helps hospitals and healthcare organizations figure out what wages they should be paying for contingent or travel healthcare providers or healthcare staff. But that data has also resulted in a number of academic publications as well, related to contingent labor and workforce in the United States during the pandemic and in the years afterwards.  

What's really interesting is the burnout trend that we hear a lot about -- which sort of affects nurses, physicians, other clinicians, pharmacists, and we've been sort of reading about this academically, this phenomenon over the last 20, 30 years, if you go back in the sort of nursing and clinician literature -- what's really interesting is that not much has changed. It's been a problem since the early 2000s, and then COVID came along, and it added acute stress to the situation.  

So we've all seen those headlines and reports about how 30% to 40% of nurses are planning to quit their job. We've probably seen some of that in pharmacists as well -- how pharmacists are overworked. We've seen a lot of pharmacists discontent around retail pharmacy jobs. So, pharmacists in pharmacies not having time for lunch, not having time to really spend time with patients just because they're understaffed. And we've seen that in hospitals with nurses being understaffed and feeling like they're not able to offer the level of care they need to for their patients. And we've seen that in retail pharmacies as well, in recent years. I believe CVS recently set a mandatory lunch period where the pharmacy is going to close in response to some of these issues. But really it comes down to overwork, and moral injury are really the two things we hear from clinicians across different specialties.  

Overwork is just related to having to do too many care activities or too much patient care, too many tasks that need to be completed. And that's very much related to burnout and desire to quit or to turn over. And then we have moral injury, which is, I became a clinician to help patients, and my current work environment and the current management structure does not allow me to offer the highest quality of care that I would like to offer. And so that's also a contributor to burnout. It's also a contributor to people dropping out of roles or dropping out of the workforce entirely. So, there's two big areas of focus for clinician discontent.  

Now, what we also know is that there's underlying labor market drivers of clinicians leaving work or coming back to work, for example. So, during the pandemic, there were some acute situations that occurred where elective procedures were delayed or canceled for a period of time, or patients were doing it, or facilities were shutting them down. And so there were certain types of clinicians and staff that were put on hold or that were let go or that ended up finding new roles.  

So there's has been a big sort of shift in what's going on in the clinical labor market, both sort of on these long-term trends, but also with sort of the acute effects of stress and risk and injury during COVID.

Pharmacists, if I recall correctly -- I don't spend too much time looking at pharmacists but I did spend some time looking at it during the pandemic because of the pharmacist's role, or the proposed role of pharmacists in delivering vaccines. We had a number of engagements at Wanderley that were related to hiring pharmacists and pharmacy techs to work in either drive through vaccination sites or mass vaccination sites, as well as in some pharmacies across the country. And so I did spend some time looking at pharmacists, and there was a period of time prior to the pandemic where pharmacists were, there was sort of an undersupply of pharmacists. And then I believe during the pandemic, we were sort of in an oversupply of pharmacists, and we may still be in sort of an oversupply of pharmacists, but the issue is a mismatch between roles that allow pharmacists to practice at the high end of their license and what they want to be doing, or if they're just sort of putting drugs into bags and handing them over the counter. Right?  

Pharmacists are highly trained clinicians, and they have a particular skill set around medications which are critical to our healthcare systems functioning. And so, I think there's a bit of a mismatch around the actual day to day work after pharmacy school that causes some discontent among pharmacists. But we ended up having a pretty easy time hiring pharmacists for these roles that were more, more clinical. They were administering vaccines, they were engaged in patient care, and they weren't sort of sat behind a counter as much, just kind of delivering medications and answering phones.

[10:30] Justin Venneri: That's interesting.

Robert Longyear: Yeah. So that was very interesting.  

Nurses, on the other hand, are fleeing the hospital environment because of burnout trends, overwork and moral injury, so that's been a larger part of where I've been focused. But the overall issue that we're seeing is, you know, sort of a need to sort of rethink the role of the nurse or the pharmacist or the clinician when we're identifying 1) moral injury and they don't feel like they're delivering safe care, and 2) from just a workplace satisfaction perspective, what can we do as healthcare organizations to create new types of jobs that allow nurses, pharmacists and other providers to have a good satisfaction with their workplace and also deliver a needed care service to patients?  

That's what we do at Avenue. We do have a nursing led care model that provides virtual care to patients. So, it's an opportunity for nurses who have not worked in virtual care before to not be in a hospital environment or a clinic environment and be able to still deliver high value, high quality care services to patients. I think what we're going to see going forward is new workplaces and new organizations and new types of delivery models that leverage the expertise from clinicians that are kind of dissatisfied with these legacy operating models.

[11:57] Justin Venneri: That's a pretty good segue to my next comment question. We're excited about the future and the potential to deploy an enterprise system that enables better communication and better information exchange between providers of all kinds. Can you share what you're seeing as it relates to new models for providing chronic or whole person care? We've obviously seen some skepticism of some of the employer focused RPM or virtual care models recently, so I'd love to hear your take.

Robert Longyear: Yeah, absolutely. So, information exchange is something that is an infrastructure that underlies everything that goes on in healthcare services -- and anything else that happens in healthcare. My book, A Virtual Care Blueprint, is really about collecting real-time patient data through remote patient monitoring programs to enhance chronic disease care models, to make telemedicine and virtual care more effective, and to just generally improve the experience of care for patients who receive a lot of services, in particular for a high cost, high need condition.  

I'll get a little bit more into that a little bit later, but we leverage a cloud-based software that collects data from patients in the home using connected medical devices. I believe this model is going to become standard of care for certain conditions over the next five, six years, and we can talk a little bit more about remote patient monitoring later. But to answer your question about, I think, information exchange, it's about getting the right information about the right patients at the right time. I'm on the board of Washington, DC's health Information Exchange Policy board at the DC Medicaid agency. I was appointed to that in October. And that health information exchange infrastructure is critical to reducing unnecessary services in particular.  

So, if the patient is already had labs done recently or imaging done recently, we don't need to duplicate that, just maybe in a different provider's electronic health record or a different system. So, if we can increase connectivity there and ease of data transmission and data access, then we can reduce unnecessary services, which reduces costs to everybody -- the patient and the payer.  

The other benefit is ensuring that rich clinical data or operational data is available to people who need it, when they need it. And I think that has two implications for our conversation here. One, it can just make sort of operations and clinical effectiveness better, right, if you're able to ensure that the right clinical information is available for the right clinician at the right time. But two, I think that it can make the experience of the clinician in their workplace better, or the experience of any healthcare worker better, if they're able to get the information they need from a system that is working for them, that's designed for their processes, and that helps them deliver better services. And so that's something that I think we're going to be talking about more frequently going forward.  

There was, after the Affordable Care Act, that first wave of electronic medical records, we know that electronic medical records produce more work for clinicians in some circumstances. We know that it's a driver of burnout among physicians in particular. And so can we design software and information systems to actually support and enhance the workplace and the operations that people go through on a daily basis.  

Healthcare is inherently a product that needs to be extremely tailored to the individual, because each patient is unique. But at the same time, it needs to be scalable because we have lots of patients, and it's important that our software and our information systems reflect that as we look at what the next wave, or the next phase, of digital innovation is in healthcare services, in particular. And that sort of clinician well-being, that design component for how you can make that system actually helpful for clinicians and not just a burden, is something that I think will be increasingly critical going forward as a strategic advantage for companies and as a sort of decision point for organizations that may adopt new software for their care processes.

[16:24] Justin Venneri: So, it seems like you're more focused on providing a solution that works with the clinician's workflow, as opposed to a point solution that would kind of be layered on a benefit program.

Robert Longyear: Yes. So, I think that I was speaking more generally -- what we do at Avenue is really, one leverage the skills and expertise of nurses to provide value to patients and to clinics that want to provide better, more connected care models for their patients. For example, we're leveraging information technology and connected medical devices, as I mentioned, to enhance chronic disease care for patients with hypertension, diabetes, COPD, congestive heart failure. And we're partnering with physicians and clinics to bring in additional clinical staff that can support them in doing a high-volume virtual care program to give nurses the opportunity to try and prevent acute care utilization when they're often kind of relegated to this sort of revolving door of hospital care. They can't necessarily keep the patient out of the hospital, but they have to kind of fix them up when they come back in.  

Nurses, like many other healthcare providers, get into the space to help people and improve quality of life. That's something that wears on your acute care bedside nurses over time. So, we're really providing a new avenue, hence the name, for patients and nurses to provide and think about care differently, even though we're using very well established, evidence-based care programs and interventions that we're delivering.

[18:03] Justin Venneri: Do you work with pharmacists at Avenue as part of the RPM program or the care teams, so to speak? If so, how?

Robert Longyear: We do not currently, but we have it in our plan to leverage pharmacists. So I've wanted to bring pharmacists in for a number of years. We just haven't quite gotten to the point where it makes sense just yet. But the pharmacist being able to look at medication lists and be able to do a comprehensive review, comprehensive medication education, and to work with physicians to actually re-engineer that med list when there's side effects or interactions or issues that may be affecting patient outcomes and patient quality of life.  

So, we definitely see pharmacists as a core part of a team-based care approach. We're currently very focused on registered nurses, but we do intend to bring in social workers, dietitians, and pharmacists over the next several years because we believe that the complementary expertise can really add extra value for patients. And the way that we operate, our care model, the way that we leverage reimbursement, allows us to have that type of flexibility. And so, that's something we see as a big part of our clinical vision going forward.  

I've seen firsthand the value of clinical pharmacists. One of the biggest drivers of my interest in providing these types of support services for patients while they're going through care is I reviewed med lists for my mom when she was on 12 to 15 drugs and looked for interactions. I went on to PubMed and searched the studies and the adverse events that occurred during them. And I, a couple times, identified interactions that may ultimately reduce the effectiveness of very important medications that she was on.  

So there were two examples where I called the pharmacist at the clinic, and I said, “Hey, this was just prescribed by this other doctor that we were seeing because, you know, she had some, some other symptoms that needed to be managed by a different specialist than her oncologist.” And the pharmacist was like, “Oh, yeah, don't administer that drug that was just prescribed. It'll keep the cancer drugs from working.” And so that was something that I knew to do because of my background in healthcare and spent a lot of time doing it. But your average patient in the United States doesn't have that type of support.  

So, I think pharmacists, particularly for critically ill patients, are critical parts of an effective care team, particularly for, for those patients that are often, as I mentioned, on 5 different drugs, 6 different drugs, 10 different drugs, where that can be better optimized for patients. So that's one of the main reasons why we have a vision of adding pharmacists clinically to our remote patient monitoring and chronic care programs.

[21:01] Justin Venneri: Your book, A Virtual Care Blueprint. So, what led you to write that?

Robert Longyear: Yep, absolutely. So, one thing that I wrote it in 2020, 2021. The quick story is I was writing my first book. This is my second book. My first book. I sent it over to the publisher at Routledge and the editor at Routledge, and she came back a little bit later than I expected, and she was like, sure, we'll publish your book, but I had already made plans with another publisher at that point in time. But I really wanted to work with the publisher that published a virtual care blueprint. And so, we agreed on the phone that I would just write another one, which was an interesting decision.  

But A Virtual Care Blueprint is about the evidence for remote patient monitoring and how it can help us sort of make telemedicine more effective for certain conditions. So, I talked a lot about the operational components of launching a program. I talk a lot about what we know about how they work and some outcomes that have been demonstrated from clinical research. And then I talk about some of the policy implications for remote patient monitoring.  

Now, I'll tell you, there's been a lot of research that has come out in the past two years since that book was published, and it's probably due for a refresh. So, I've been paying close attention to some of the cost effectiveness research for remote patient monitoring programs and some of the effectiveness research for it. And it's probably time to do a little bit of a refresh for the second edition.

[22:31] Justin Venneri: And we'll include a couple of links in the show notes to one of the studies and your book, of course. But what makes your take on virtual care or telehealth different from what's commonly discussed?

Robert Longyear: Yeah, so one of the things that I really focus on in the book is telemedicine, where you're really just Zooming with the doctor or any other healthcare provider is really just a different modality to deliver the existing standard of care and to sort of make the existing care model effective -- where you go to a doctor's office, you walk in there, they run some tests, they talk to you about your symptoms, they document in the electronic medical record, and then they sort of provide you with a diagnosis and a treatment plan.  

It does come with the added benefit of increased access for people who don't have access to certain specialists or to any physician or care provider near them, particularly for rural areas. That's usually, I think, what most people think of when they think of telehealth or telemedicine. For some people who may live in an area where they do have clinicians closer, some people will then also think about it in sort of a convenience perspective. So, you know, oh, it's just convenient for me to be able to do this from the comfort of my living room as opposed to having to drive and wait in the waiting room.  

Now, what I talk about is the addition of remote patient monitoring, the collection of data on a daily basis from patients in the home, to supplement what's going on in telemedicine. So, there's a limit to what can be delivered via telehealth or telemedicine in its traditional video chat format.  

While we still don't have permanent telemedicine or telehealth, from Medicare's perspective -- it's been sort of delayed since the flexibilities of the pandemic, and it's set to expire in December 2024 -- we still need Congress to allow Medicare, for example, to continue paying for certain services via telemedicine in the home. And so that still hasn't been made permanent.  

So we're still sort of at this phase where it's like, okay, you know, we've got all these advanced concepts and technologies and these sort of remote patient monitoring care models we can add in to make telemedicine more effective, or to think differently about how we deliver it, but we're still not permanent with sort of that telemedicine 1.0 model of the video conferencing.  

And so, what I talk about is, hey, if we start collecting blood pressure data from a patient with hypertension long term, we teach that patient what that means, we're going to provide better care, and we're going to potentially see better patient outcomes. For patients that have really high-cost conditions, like congestive heart failure, if we can build care models once that patient gets discharged from the hospital or they get first diagnosed, that carefully track and collect data from patients that are very relevant to preventing hospitalizations and emergency department visits, then we're going to save the system money, we're going to save the patient money, and we're going to prevent significant acute conditions or acute care.  

That’s really the promise of additions to traditional telemedicine. And my book kind of walks through what we know about the history of general telemedicine and then the standard of evidence for remote patient monitoring and what this means for the country and for our health system. That's sort of the summary there, if you will. It also briefly discusses digital therapeutics and the difference between remote patient monitoring and digital therapeutics, which were very popular over the past three or four years. But we've seen some very high-profile failures, which is a whole other topic we could get into.

[26:11] Justin Venneri: Oh, yeah, we definitely don't have time for that one today. But thank you for that overview summary. You've really described nicely how you see RPM playing into the larger scope of care for chronic diseases and the different ways, you know, different clinicians can participate, whether it's, you know, pharmacists or the nurse or primary care physician, etc. I think we can see pretty clearly how this adds value to their toolkit for caring for patients. The last question I ask everybody, it's a standard exit here at the Astonishing Healthcare podcast. What is the most astonishing thing you've seen that you can share with the audience, of course, over your career, good or bad? Just is one of those things that sticks out and is a good story.

Robert Longyear: I don't think I have a good story so much, but I will tell you the most shocking thing to me, and it, it's something that continues to surprise me since the first time I really experienced it. It's this culture of stagnation that exists in healthcare, and it's partially due to the fact that there's just a higher bar for change in healthcare and innovation in healthcare. You really have to demonstrate that something is better than what's being done currently.  

But the most surprising thing to me that I run into frequently is how resistant people in healthcare are to change in a lot of circumstances. And there's been a number of situations where there's something that's just demonstrably better, that has been demonstrated as better, and that works very well., but there's people who either don't want to go through the challenge and the struggle to make the change, or that don't believe you and believe that what's been done for 20 years is still the best way we can deliver things.  

So what's really interesting is there's a paradox that I've observed over the past, let's say 8 to 10 years in healthcare, which is, oh, you want to change to this new, innovative care model? Okay, prove to me that it works better than what I'm doing. But we know that the way that care is delivered right now isn't always all that good. So there's this false sense of belief that, oh, what we’ve been doing is the best we know how to do right now. So I have to add extra scrutiny or resistance to this new concept that, again, may have proved that its more effective, but it hasn't quite convinced me just yet.  

That’s something that always comes up. It's a very interesting phenomenon, because if you ask any given person who works in healthcare -- a clinician, an administrator, a business person -- or you ask any given patient on the street, you say, hey, how does US healthcare work for you? They're going to say, oh, it's pretty bad. Right? But if you get into those organizations and maybe you're trying to sell a new technology, maybe you're trying to push a new care model. That belief that it's not all that good doesn't translate all the time. There are still people who will sit there and resist that change, even though they may know that it's not all that good or that they could do better. That's always what continues to surprise me.  

I get lulled sometimes into this false sense of innovation where I work with people who are innovative, want to do something new and believe in this culture of change and continuous improvement. And so, once you surround yourself with that group, you get confronted with the stagnation and the “resistance to change” group every once in a while. And you're just bewildered by it.

[29:51] Justin Venneri: Like, why are you still here?

Robert Longyear: Yeah, why are you still here? And so, I work in healthcare because I believe that it's the moral good to try and make care better for patients, whether they're experiencing a minor health condition or whether they're in a really bad spot. And not everybody shares that urgency. And that's something that I don't quite understand.

ustin Venneri: Well, great, Robert, thanks so much for joining us today. Like I said, I'll share some of the links in the show notes to this, and I look forward to staying in touch with you and seeing how things evolve with Avenue over time.

Robert Longyear: Awesome. Thanks, Justin. Great to be here.

For more information about Robert's book and to get in touch:

• A Virtual Care Blueprint - How Digital Health Technologies Can Improve Health Outcomes, Patient Experience, and Cost
• Travel ICU Nurse Concerns Across Covid-19 Hot Spots (NEJM)
• Robert's LinkedIn Profile

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