I'd like to just introduce our last speaker, Dr. Grace Su, who will be speaking on telehealth for high-value liver care. Thank you, everyone, for staying, and also I want to thank the organizers for inviting me to give this talk. I'm going to be talking about telehealth for high-value liver care. My disclosures are that I've received funding since 2011 for the ECHO program, which will be discussed here. I don't know how many of you in the audience could picture this, but in 1984, when I graduated from college, I took my first coding class, my one and only coding class. Back then, we had to have these little papers that just punched holes in it. I just wanted to tell you what it was like in 1984, as opposed to what it is like now. The iPhone 5 is considered a brick, practically, but the iPhone 5 actually had 1,300 times more computing processing power than the computer that landed at Apollo 11. We've come a long way, but what does this mean for us? I want to give you a story. Before that, I have another picture. What this means for us is that things that we would never have imagined in 1984, we are now doing things like Skyping with our families across the continents. We are FaceTiming with our friends. We are teleconferencing across the nation. These are just everyday events for us. I want to give you a story about what happened to me a number of years ago. I was skiing in my favorite ski resort, a beautiful morning. I like to go in the morning because I'm not a good skier, so I like everything groomed. I'm up there with my husband, who's a surgeon. He says to me, I think there's a problem, even though we just spent 15 minutes getting up there. There's a problem with my finger. It won't straighten out. As you can imagine, for a surgeon, that's a pretty big deal. It's our lifeline. I'm like, Beth, you need your fingers. I thought, oh my God, are we going to have to find a doctor in the box and go and wait three hours and figure out what to do? Thank goodness. He said, you know what? I'm going to take a picture and send it to my friend, the hand surgeon. What happened was he sent this. No physical exam, no blood pressure, no waiting. Within seconds, the text came back, you have a mallet finger. Just do this and you'll be fine. That was fantastic because we could have our vacation. You can imagine, this is incredible value for the patient. It's also actually incredible value for our insurer because they don't have to pay for an urgent care visit in Utah. I think that these are things that we take for granted because we have friends. Maybe we should be thinking about this for our patients. Was this telehealth? By the World Health Organization, telehealth is use of telecommunications and virtual technology to deliver healthcare outside of traditional healthcare facilities. I want to remind everyone that telehealth encompasses a lot, a broad range of services, some of which I won't be covering. The concept that we have for telehealth is a communication from a specialist to a patient. In that situation, that was a teleconsultation. Many of us do televisits where a hepatologist may see the patient. I also want to remind you that sometimes it's not a direct communication between the patient and the specialist, here the hepatologist. Different models like ECHO program, which is a tele-mentoring program, is an interaction between the hepatologist and primary care provider and then the primary care provider interacts with the patient. As Mina had also mentioned, this is similar to an e-consult where the hepatologist is basically telling primary care what to do and then the primary care does all the work with the patient. The first model I want to describe is back to the original model of the patient-specialist interaction. Now, this is happening all over the nation right now. It's happening in many different ways. Sometimes the traditional thing is the patient goes to the local clinic and at that point you get checked in. You can get your blood pressure. You can do an electronic stethoscope if that's really important to you. Some people have ultrasounds attached to them, blood pressure, weights, those kind of things. On top of that, there's other things happening. People are getting telehealth kiosks in retail stores all over the nation, including the VA, I understand. Of course, there's also the straight communication of a HIPAA-compliant link with your patient through their mobile phone. I think these are all happening. The question is, what about in liver disease? Telemedicine for hepatitis C treatment is actually very effective and it's broadly implemented. It reaches underserved areas, including rural areas and prison. It's widely implemented in multiple medical systems, federal, non-federal, and worldwide. What they've shown is there's many, many papers that have shown that this leads to equal efficacy in terms of sustained virological response, both in the non-DAA and in the DAA era. This has significant value for patients who then spend less time on transportation and costs of going to the doctor. It has improved access, actually, for people who perhaps can't get out, for example, in the prison system. What about the patient? How do they feel about this? This is a study about patient satisfaction with telemedicine visits. These are about post-transplant visits. As you can imagine, many of liver transplant is bundled care. This surveyed patients who had a tele-visit for their post-transplant care. It did propensity match samples of 22 patients. What is interesting in this study is that the patient showed equal satisfaction with interpersonal communication, even though they weren't actually there to touch their post-transplant caregiver provider. On top of that, there's significant decrease in travel and wait times. More importantly, 90% of the patients that were surveyed opted to use the service again. This is wonderful. I think it's great that we can do a lot of our visits. As you know, sometimes the physical exam is not needed, and so this works quite well. Another question brings to mind that this is a one-to-one. The hepatologist sees the patient, but it's really a one-to-one. We know that the burden of liver disease is rising. Even though we've cured hepatitis C, you know NAFLD is coming. The tsunami is coming, and we're going to have more patients with liver disease than we can possibly take care of. This is the tip of the iceberg, because the underestimation of chronic liver disease and cirrhosis is out there. Only 56% of patients with biopsy-proven hep C cirrhosis were coded as such. In the ANHASE data, there was double the prevalence of hepatitis C, and more than 50% of the patients were unaware that they had hep C or cirrhosis. As we all know, patients with NAFLD are definitely under-recognized by PCPs. Only 21% who had evidence of NAFLD actually ever got documentation in their charts, suggesting that no one is really paying attention to that. Are there hepatologists? Well, I don't know if you guys realize this, but in 2018, there are only 618 board-certified hepatologists, and the range is anywhere from 0 to 67 per state. California and Texas have the most. There are eight states that have no physician with active board certification in hepatology. Now, of course, you can say, well, how about the gastroenterologists? They can do hepatology. But even then, we only have 14,569 gastroenterologists. So do we have the capacity to address this increasing need to care for patients with liver disease? And I would be concerned that we have a lot more at the top of the funnel than can come through. The other question is, do liver patients really need to see specialists? So this is a study, a meta-analysis done by Amit Singhal, which showed that HEC surveillance rate are significantly higher in patients followed by specialists. I think you probably see this in your daily practice that, you know, HEC surveillance is close to our heart. But for primary care providers, perhaps it's one of, you know, many, many clinical reminders that they'd rather forget. And in this study that we published, we showed that, thank goodness, specialty care actually is important in liver disease. So we did a study where we looked at a cohort of 28,861 patients with a liver disease diagnosis within our VISN, which is in VA Talk, our region. 37% of them, even though they have a liver disease diagnosis, only 30% of them ever saw a GI doctor. Using propensity score matching, we found that those who had an ambitory GI visit actually had improved five years of survival with a hazard ratio of 0.81. And interestingly, there was a dose-dependent effect. So those who had two or more visits with their GI doctor did better than those who only had one to two visits. So you might ask, why didn't they go see their GI doctor? So patients were less likely to be seen if they were older, they had more comorbidities, they lived farther away from a tertiary care center. It was just inconvenient. So how do we solve this? One way would be electronic consultations. So this way, you would solve the patient having to actually go to see your specialist hepatologist. So this study was performed and is published in Hepatology Communications. It's a retrospective single tertiary care center study of 187 patients. I want to point out to you that an interesting thing about this paper was that in this program, the PCPs got 0.5 RVU for agreeing to an e-consult. Because I think they recognize that somebody's got to do the work, right? Somebody's got to call the patient, somebody's got to do whatever is recommended. And in this study, only 23% ever ended up with a face-to-face visit. So in other words, more than 70% of the patients never had to go see the hepatologist. And when they did see the hepatologist, they had most of their workup completed. So when they showed up, they pretty much had the workup and then the hepatologist could go the next way. The average response time was very quick and 10,599 miles were saved. So this e-consultation led to higher value visit and overall value to the patient and healthcare system. So in this model, we think that perhaps liver specialists can in part transfer their knowledge to primary care providers and only pick the highest risk patients in this innovative approach to specialty care. So a second model that takes this even one step further is, one, you're communicating with the primary care provider through electronic consultation. What if you actually talk to the primary care provider? So this model is a variation of electronic consultation. I hope that many of you have heard about Project ECHO, which is Extension of Community Health Care Outcome. It was funded by the Robert Wood Johnson and developed by the University of New Mexico by Dr. Arora. It was a new methodology to improve access for hep C treatment in geographically isolated areas. So this was first performed in the interferon era, so you can imagine that that did take teaching of primary care providers. It was an interaction between specialists and primary care. So for example, there was one specialist, multi-primary care, they did it through videoconferencing and they basically did case-based learning. So primary care providers brought their cases, they discussed it, and then there was a short didactic that was then associated with CME credit. And over time, the idea is that primary care providers, as they discussed their own cases, heard about cases from other providers, they learned and they learned how to treat hep C. And in fact, they did treat patients with hep C with interferon. The idea is that if you discuss it with them over time, you've now built little mini-specialists who knew about liver disease and could care, at least do the first-line care. ECHO has spread throughout the world. I talked to Dr. Arora. He says that it is in 128 countries and how I came involved in it was through the VA. The VA implemented the ECHO program and you can see on this map the multiple sites that we have and the multiple touch. So what are the outcomes? So Dr. Arora published in 2011 for the outcome. So at this time, this was interferon era and this was University of New Mexico specialists versus 21 ECHO sites. And what they found was equal efficacy, 57.5% versus 58.2%. It did not depend on whether you were treated by a specialist or a primary care provider. And the idea was that this really helped give people access who lived in rural areas. And this model, as I mentioned to you, has been implemented in multiple systems. This one is a publication from the Seattle VA and patients who were followed by primary care providers in the ECHO program had higher rates of hep C treatment with equivalent sustained virological rates. What about ECHO for other liver diseases? This is a study that we published about the kinds of patients we saw. So it's very similar perhaps to your clinic. So A is all the different reasons that primary care providers thought that they needed a consult. And of course, the most common is abnormal liver function tests, chronic hep C, management of cirrhosis or abnormal imaging. And as you can see, most of the B is the diagnosis that was at the end of the conference. And you know, it's your typical run-of-the-mill chronic hep C, NAFLD, alcoholic liver disease. So in our program, we looked at the first 511 patients. We had prospectively tracked them and then we matched them with our cohort that was in our region during the same period with a cohort of 62,237 patients. We did propensity score matching. And what we found was that those patients who came to ECHO actually lived longer. So the hazard ratio for patients who were in ECHO versus not was 0.54 and which was very significant. We were not sure as the reason why patients survived longer, but we thought that was likely due to primary care provider behavior and knowledge. In patients with cirrhosis, the HCC surveillance rate was much higher, 42% versus 25%. Variceal screening was higher at 25% versus 15%. In patients who had a scan ECHO visit, suggestion better adherence to clinical guidelines. Our overall experience is that there are some difficult to measure improvements, particularly in the specialist primary care communications. When you sit with them in a conference and discuss their patients, they actually know you and it decreases the silo effect so you can actually have better care coordination. If we want a CT scan, we tell them you need a CT scan, they know that we come from the heart and they do that. And people will call me when they have a problem because they know who I am. And overall, what we've noticed is the patients who end up seeing us in face to face are now much more complex. They tend to be decompensated. And actually, interestingly, those who come from primary care providers who were in scan ECHO, the workup is done. So you know, I think it's a higher value visit. So perhaps this could be a future model of hepatology care where primary care providers, we have some kind of knowledge transfer, either through e-consult or scan ECHO. And that way we can actually take the high risk patients to come and then convenience them and make them travel to us. So does it really work? Do the primary care providers actually learn? So at least they think so. We did a survey early on in the study and they said that basically the things they learned in scan ECHO, they were discussing with their colleagues and they even helped their colleagues with patients that have liver disease because they have become the local specialists. So what's the downside of all this? So there are still challenges in telehealth and liver disease. There are significant technological challenges. It seems like every other day some modality is not working. There are licensing issues, but really that's not the biggest issue. It's always comes down to money, right? So at the end of the day, it's about reimbursement models and recognition for the work that is done by specialists. I mean, it takes time. This is not, it's still work. You still have to take care of the patients. But I think also I want to recognize that there is going to be work on the primary care providers. What we hear is they'd rather just put the consult in and never hear about it again. So we need to think about that because we're putting a lot of burden on primary care as well. So the key takeaways. Many models of telehealth are being implemented in multiple different healthcare systems, showing clear feasibility in our specialty. And unlike traditional televisit and electronic consultation, the ECHO model has the potential to increase our workforce and knowledge. There's clear value for telehealth in the care of a liver patient and this has been demonstrated with increased access, higher value visits, patient satisfaction, and improved clinical outcome. Thank you.

telehealth

liver care

advancements

teleconsultation

ECHO program