Build and Deploy: How COVID-19 Accelerated Telemedicine

Build and Deploy with Liz Moy is a curiosity-driven technology podcast. This season, we’ll be talking to developers and technologists in healthcare about what they’re building to make the world a healthier place. Experts in the field of robotics, artificial intelligence, and telemedicine  will help me understand why it took so long to get here, and we’ll dive into what the future of telemedicine might look like.

Our first episode is a conversation with Jeff Lawson, CEO and Co-Founder of Twilio and Dr. Erica Lawson, pediatric rheumatologist at UCSF. Twilio Head of Global Healthcare Services, Susan Lucas Collins provides an expert point of view around the shifts that have happened. And Dr. Tim Peck of Curve Health and IDEO shares why there has never been a better time to be a founder working in healthcare technology.

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All of the music you hear in the podcast is made with code by artist Dan Gorelick using TidalCycles. You can see the composition on Github.

Liz Moy (00:03):

When we record this, we're just past the one year anniversary of COVID-19 shutting down workplaces, schools and hospitals. Where were you when you knew things were different?

Dr. Erica Lawson (00:14):

The moment that I realized that this was going to be a truly big deal, was when I was sitting in the workroom and my Friday afternoon clinic just wrapping up with my last patients, and I got an email from my kids' school that they were going to be shutting down for at least two weeks. And that was the moment I realized that our entire lives were going to have to be rearranged, that something really seismic was happening.

Liz Moy (00:39):

COVID-19 has changed the way we live and work. I'm a developer. And in the past year in my role at Twilio, I saw a huge influx of healthcare companies, who are ready for a digital transformation. Adapting to the pandemic, healthcare companies finally saw the need for reliable telehealth solutions, and are putting massive amounts of energy into making things happen. As a developer, it's easy to take these transformations for granted. Of course companies want to use powerful API's to rapidly build and innovate new products, and developers want to tackle big problems that affect us all.

Liz Moy (01:11):

However, the issues for developers building products and healthcare are complex. As soon as you think you understand a solution, you learn more about unique challenges and edge cases. At Twilio, we understand the complexities of the healthcare landscape, and have the opportunity to empower developers who are building systems that transform the way care is delivered. In this season of Build and Deploy, we're going to explore the world of healthcare software, and the opportunities that we're seeing in the space.

Liz Moy (01:39):

We'll look more closely at video for telemedicine, how underserved communities are benefiting from telemedicine, medical transcription for better patient outcomes, patient and provider experience design, startup solving for remote diagnosis. And we'll talk to experts in software and healthcare about the future of telemedicine.

Dr. Tim Peck (02:00):

Telemedicine has been around since the '60s, through NASA programs actually, it's not a new technology, it's just that the use cases for it, were not necessarily adopted, or had much political will behind it.

Liz Moy (02:20):

In this episode, we're exploring how COVID-19 accelerated telemedicine. My hope is that if you're a developer, or work in health care that these conversations inspire you to build the solutions we desperately need. Every time we talk to anyone in every conversation, with a friend, a co worker family, we talk about COVID-19. So, let's talk about it. In this episode, we'll be exploring the before picture of what the world was like before the pandemic. To learn how rapid and significant the changes in telemedicine have been over the past year. We'll be talking to five experts in software development and health care, including Jeff Lawson, the CEO of Twilio, Dr. Erica Lawson, pediatric rheumatologist at UCSF, Susan Lucas Collins, the Global Head of Healthcare Services at Twilio and Dr. Timothy Peck of Curve Health and IDEO.

Dr. Erica Lawson (03:14):

My name is Erica Lawson and I am a pediatric rheumatologist at UCSF. Pediatric rheumatologist is a pediatrician who takes care of kids with autoimmune diseases.

Jeff Lawson (03:23):

And I am Jeff Lawson. I'm the CEO and co founder of Twilio.

Liz Moy (03:27):

So, let's think back to a year ago, which isn't the most fun mental exercise to do. But, around this time last year, what was the moment when you realized that everything had changed?

Dr. Erica Lawson (03:38):

The moment that I realized that this was going to be a truly big deal was when I was sitting in the workroom in my Friday afternoon clinic just wrapping up with my last patients, and I got an email from my kids' school that they were going to be shutting down for at least two weeks. And that was the moment I realized that our entire lives were going to have to be rearranged, that something really seismic was happening.

Jeff Lawson (04:03):

I remember I was on a customer road trip basically, the week when a lot of the countries started shutting down. And I was in five cities in five days doing customer meetings with one of my board members, Jeff [inaudible 00:04:19]. And through the course of the week, it was just getting progressively more and more obvious that this was not okay, in a lot of senses, that the pandemic was real and it was going to impact our society in a major way. I also say this wasn't okay, meaning I should not be on a customer road trip right now. And I remember the beginning of the week, I started in New York, and we did a customer dinner with like 20 customers.

Jeff Lawson (04:49):

And at that point it was mostly you thought you wouldn't get COVID if you washed your hands and you bumped elbows with people. And it was still controversial. There were some people that were like, "No, we're shaking hands." Like, "I ... I don't know what to do I need an adult." But through the course of the week, I think people just ... it just became so real. On Wednesday, I think it was the NBA shut down. Tom Hanks had COVID in Australia and by the time it was Friday, we were just both ... Jeff [inaudible 00:05:16] and I were saying, "We have to get home."

Jeff Lawson (05:20):

This is now like ... it's clamping down. And that is when San Francisco, which is where we live, also locked down. And it was interesting though, I will say that was sort of though in the public sphere, it getting real. But, in the sense of Twilio and my role as CEO, it got real that weekend, because my inbox started filling up with so many customers and friends and investors and just people I come across throughout the years, and they were all building something with Twilio, to address the pandemic.

Jeff Lawson (05:57):

And they were all reaching out saying, "Hey, can we get some help? Can we get some credits? Is there anyone who knows anything about this?" And there were so many people reaching out because they were picking up their tools to go build the answers to society's problems in that moment, that was really amazing to see. And I can also see how the builders of the world, the developers of the world. And Twilio itself would actually be a part of helping society through the biggest challenge that we've had in probably a century. It was really amazing to have a front row seat to that energy getting activated in real time.

Liz Moy (06:33):

Absolutely. I think that it really lit a fire in people and made them realize the urgency to us sort of this term innovation, which we use a lot. And Jeff, you had a book that came out not that long ago, Ask Your Developer. And in it, you talk about how developers really stepped up and delivered in this time period, and that, in the course of a few weeks, we saw a faster digital transformation than in the entire previous decade. What are some of the ways that developers made an impact? And specifically, what did you see in healthcare?

Jeff Lawson (07:08):

Well, if you think about what Twilio provides, we provide digital communications, digital engagement. And in a moment, where nearly every face-to-face human interaction that we have as a society, needed to turn into one that was distanced and one that was not face-to-face. But that's exactly what digital communications provide. And so, organizations of every kind, so companies, nonprofits, governmental entities, pretty much every type of organization you can imagine, was trying to figure out how to rapidly digitize these workflows, these human interactions, in order to make them safer, in order to make them more efficient.

Jeff Lawson (07:47):

In a lot of cases in order to scale them up. Certain industries were scaling down like travel, but other ones were just bursting at the seams like healthcare. So I remember some really amazing use cases that really got kick started at that time, which was how do we use digital communications and digital workflows to triage patients easily? How do we keep them out of the hospital if they don't need to be in the hospital? How do we get them to the right provider over the right channel, without having them walk in the front door of the hospital.

Jeff Lawson (08:18):

That was really interesting. But it wasn't just healthcare, it was eCommerce. We saw so many retailers say, "Okay, the doors of our stores are closed." Okay, like people are going to need to come by and pick things up or we have to do contactless delivery, we're going to have to do curbside pickup. These are all brand new workflows, then you look at education and distance learning and how children had to be able to learn via digital channels as opposed to in-person learning.

Jeff Lawson (08:43):

You just see the number of use cases for digital communications just explode in a way that none of those stories were really like things that we didn't potentially need otherwise. They weren't coming down the innovation pipeline anyway. They just came faster, because necessity. Necessity is the mother of invention. And there was no necessity like a global pandemic. But these are things that got accelerated in the roadmaps. Most of the things weren't new ideas and they weren't out of left field, these were things that innovative organizations have been thinking about and planning and were on their roadmaps, they just got done in days and weeks instead of quarters and years.

Jeff Lawson (09:23):

And that was one of the most amazing things about this acceleration.

Liz Moy (09:25):

Absolutely. It was an all-hands-on-deck situation. And it really allowed a lot of developers to shine in those moments, I think. So Dr. Lawson, as a doctor, how did the ways that you provide care shift due to the pandemic?

Dr. Erica Lawson (09:40):

So there was definitely as Jeff referenced before, this process where in the beginning, we didn't have a good understanding of this disease. We didn't know how it was transmitted, we weren't sure quite how contagious it was. And so at first, the goal was really to try to keep everyone out of the hospital as much as possible. Including the providers. So I worked very closely with a lot of doctors in training, we were initially not allowing them to come in at all. And so immediately there was this need to figure out how we can engage them via these video technologies, to keep them participating in care and keep them learning, and keep the patients getting the best care that they could.

Dr. Erica Lawson (10:20):

What was interesting for me was to see how many ... previously what felt like insurmountable barriers just fell immediately. So we had been trying to figure out as a practice, how to do inpatient telehealth for a period of I think years. And there were always logistical barriers, and always ... just things that made it difficult or not feasible. And suddenly when you don't have a choice, these things get done. And that was really incredible to watch. So we went from this early period where we were really trying to keep everybody out of the hospital as much as possible, and then returned to coming into the office a little bit more.

Dr. Erica Lawson (10:58):

I'd say for me, starting around May, and then eventually hitting this really more stable equilibrium I'd say where I'm currently seeing about half of my patients via telehealth, and half of them in-person. And we did do in our practice some outpatient telehealth prior to the start of the pandemic. But this was really looked at more I'd say as a stopgap measure, rather than a way of actually providing the care that we give every day.

Dr. Erica Lawson (11:25):

It was reserved mostly for patients who live very far away, they would do maybe one telehealth visit for an urgent situation where they weren't able to get into the office in a timely manner, or for patients who live up to five hours away from the office, because as a pediatric specialist, I do see her patients from all over northern California, including some people who live quite far away. So, if it wasn't feasible to come down that often, say we do an in-person visit and then three months later do a video visit, and then three months later do an in-person, just to reduce that travel burden for the family.

Dr. Erica Lawson (12:01):

So the way that we utilize telehealth completely flipped on its head, where suddenly we were taking care of everyone via telehealth, and we had to ask questions like, "Can you do a physical exam over telehealth? What parts can you do? How can you make the most of it? What's useful? What's not useful? What information can you glean? How can we be creative in the way that we are using our screens and our cameras?"

Liz Moy (12:26):

Yeah, it is incredible as I've been chatting with more people that were providing care through this really challenging time, how creative people got right? Like how they just dove in and found ways to make it work. I would love to hear from you, what are some of the things that you feel worked really well in those experiences using telehealth for you?

Dr. Erica Lawson (12:48):

Absolutely. I think that without question, the thing that I most appreciate about telehealth is the flexibility it provides my patients to access care in the way that works for them. The amount of no shows to my clinic, especially my clinic in Oakland, which cares for a working class population with a lot of underprivileged folks, the number of no shows has just plummeted, because it's so much more feasible for a working family to do a 30 minute video visit, than to find childcare, take time off work, get gas money, and drive to the clinic. And so that without question is what I really love, is the way that I see my patients actually being able to access care in the way that they want to.

Dr. Erica Lawson (13:37):

In a way that works for them.

Liz Moy (13:39):

And then on the other side of that, what are some of the pain points of it or the things that you've seen that haven't worked?

Dr. Erica Lawson (13:45):

I think the biggest pain point remains, addressing people who are not comfortable with technology. Because, there is undoubtedly a contingent of people who are being left behind in the digital revolution, these people who do not have access to good internet, people who do not have access to good hardware, people who just have very low levels of digital literacy, people who are non English speaking. So what I found really fascinating about telehealth is that I feel like in the ways I just described, there are some aspects of it that actually reduce disparities and make it easier for less privileged families to access care.

Dr. Erica Lawson (14:26):

But then for families who have difficulties with technology, those families can be left behind, completely.

Liz Moy (14:33):

Yeah, absolutely. So Jeff, from a technology perspective, how do you think that developers can learn about these sort of barriers are these issues and build experiences that are accessible to people?

Jeff Lawson (14:50):

Well, I think one of the things that developers often do is they're sitting at their very modern computer with lots of RAM and huge screen and they're building these experiences, without really wearing the customer's shoes and recognizing that the actual users of the technology, are not sitting at a 35 inch screen with a 16 core CPU, it's like you've got a wide variety of different platforms you're supporting, you're supporting a lot of mobile handsets that you may not even have access to. And so really building a good regimen around building for and on and with the lowest common denominator that you think folks might be using.

Jeff Lawson (15:35):

So you really have a good sense of the experience. And oftentimes, when you take that point of view, the thing to do especially in the early days of building the product are not all the bells and whistles, but actually just getting the fundamentals right and simplicity, and optimizing for a good enough experience on the full set of platforms. And once you have that nailed, then you can start to think about bells and whistles. But I think that you hear developers periodically talk about how they always keep around some very old workstation or a collection of old phones, to be able to test the things that they're building.

Jeff Lawson (16:12):

And I think that really is important. And it's often a step in the development process that people forget, and they optimize for people with similar setups and ascribe similar value to modern technology that they have, when in fact there's such a diversity of different computing platforms that actual users are using, especially when we're thinking about maximum access for people when the stakes are people's healthcare. It's especially important.

Liz Moy (16:39):

Yeah, when I worked as a full time software engineer, we always joked about how annoying it was to get things to work on Internet Explorer. But the reality is, is there are people that still use IE, and you have to factor that in, and you do have to make it a priority when it is something as high stakes as health care.

Jeff Lawson (16:57):

Yeah. Imagine a world where your choice of your web browser dictates whether you get health care or not. Yeah, it's not something that we should be mandating.

Liz Moy (17:06):

That's a great point. Yeah. And access to internet as well.

Dr. Erica Lawson (17:10):

Yeah. And imagine how many patients are out there that don't know what a browser is, if you use that term, because there's a lot of those out there, too.

Liz Moy (17:16):

That's so true Erica, and like one thing or Dr. Lawson rather, that's one thing that as I've chatted with some other doctors, in preparation for the show, they've mentioned that a big part of what they had to do at the beginning of the pandemic was help their patients learn how to use a video platform, how to log in, how to do things like that. So I did want to ask another question around how developers can build better experiences. And ask your developer, Jeff, you said that the key to getting business people and developers to work well together, is for the business people to share problems, not solutions.

Liz Moy (17:55):

So, with COVID-19, there was clearly this enormous problem presented. But it doesn't always work that way, we're not always presented with a huge glaring issue. And what ways can developers do this on an ongoing basis in the context of health care?

Dr. Erica Lawson (18:14):

I think that it's important to keep in mind the experience of the patient. I think that where healthcare software though, often gets into trouble is that the patient isn't the customer. And so much of healthcare software is actually designed to optimize around billing, around the ability of the healthcare organization to document the work that was done, and charge for that work. And so there's a malalignment there of needs and priorities that echoes malalignments that exist throughout our healthcare system. And I think that's actually a big part of the reason why we end up with such challenges around healthcare software, because the person who is the customer, is not the patient and is not the provider often even either.

Jeff Lawson (19:01):

Yeah, the people actually use the software.

Dr. Erica Lawson (19:03):

Correct.

Jeff Lawson (19:05):

I think part of it, it's incumbent upon not just developers, but also the business folks at the companies, whether that's healthcare providers building software, whether it's an insurance company, an ISV who's building software. I think the key thing is for business people, to not think of developers as this black box where you hand specifications, documents in one side and mountain dew. And the other side, you get out code, because that treats developers like essentially little code machines, and all they know how to do is to write code given a specification. And then the reality, the developers that I have had the privilege of working with in my life, are really creative problem solvers.

Jeff Lawson (19:52):

Yes, they can use their creative problem solving skill, to write code and writing code in and of itself is a creative problem solving endeavor. But they can also apply that skill to solving business problems and customer problems. And I've seen developers do their best work, when they are brought in not to the solution they need to build, but to the problem they're trying to solve for that customer. And a bunch of things happen when the developer really understands that customer, and why they're writing code in the first place. First of all, they get to use intuition, about the problem and about the solution.

Jeff Lawson (20:28):

They get to think of new and interesting ways to go build solutions to that problem that maybe, the business person who wrote that specifications doc just didn't think of. And that intuition also comes to play into 1000 details for how the implementation gets written. Not everything is written in a specification doc, there's a lot of room for small improvements here and there that the developer can make, if they understand why they're building that thing in the first place. And the other thing is, when they are there to solve a problem, instead of write a prescribed solution, when you have a prescribed solution, the developer has to go build it in the way that the specifications doc says to write it.

Jeff Lawson (21:10):

And so oftentimes, you'll have to take a doc and give it to the developer and say, "Give us an estimate of how long this is going to take.' And they're like, "Well your specifications doc says, I have to go here, and then here, and then here, and then here, okay, well, if I map all that out and do an estimate of how long it takes, it might take me nine months." And then the business people often say, "What? That's not ... It's like nine months, how can it possibly take so long?" And the developers are like, "Well you tied my hands, you said it has to be done exactly this way."

Jeff Lawson (21:34):

But when you don't tie the developer's hands, when you say, "Here's the problem we're trying to solve, how would you think about the fastest and most efficient way to get there?" The developer might say, "Well, knowing what I know about the code base and the architecture of the solution and some new technologies that I know about, well I think we could do it like this. And this path only takes two weeks." And if you think about it, when you give the developer the freedom to propose those kinds of solutions, everybody wins. What business person, doesn't want to build digital solutions that are faster to build, that work better, because the developer has great intuitions around it, and tend to have less bugs?

Jeff Lawson (22:15):

Because the developer knows exactly essentially the problem they're trying to solve. Who doesn't want better software written faster in higher quality way? Everybody wants that, the developers, the business people, the patients, the providers, even the people who do the billing. So, my advice for companies who are trying to make this digital transformation happen, is to don't think of developers as just this digital factory who grinds out code. Think of developers as creative problem solvers, and bring them in to the big customer or business problems that you need to solve and when you do, amazing things happen.

Liz Moy (22:56):

One of the greatest privileges I've had in working on this podcast, is speaking with Susan Lucas Collins. Anytime I brought up the idea of doing a podcast about telemedicine, people would say, "Oh, have you talked to Susan yet?" Susan Lucas Collins is the Global Head of Healthcare Services at Twilio, with 35 years of experience in health and health technology. Thank you again so much for your time today. I'm so excited for our conversation. So I'd love to start out by asking you what is telemedicine?

Susan Lucas Collins (23:30):

Yeah, it's actually a really good question. Telemedicine is one of those terms that can mean different things to different people. These days because we have so many video visits, right? That is the generally accepted baseline for telemedicine, but telemedicine can also include things like remote patient monitoring and connections to devices that stream information back to providers or allow people to be monitored outside the walls of a traditional hospital or health system. Most typically though, we do think about it in terms of video visits.

Liz Moy (24:03):

A lot of us have had some sort of personal connections with using telemedicine over the last year but thinking about before the COVID-19 pandemic hit, what did telemedicine look like? What was the landscape before the pandemic?

Susan Lucas Collins (24:18):

Yeah, that's a good point as well. Telemedicine is not new, it's been around for quite a while, but it was much more infrequently used and not quite as ubiquitous as it is today. And maybe because of that, the technology was perhaps a bit more cumbersome than what we would expect at the current time when we think about things like having people need to download apps, possibly having to get special hardware and these kinds of things, that obviously would be a disaster in today's environment, but we accepted it, just because it was so infrequently deployed.

Liz Moy (24:50):

Yeah, I completely resonate with that. Then what happened when COVID-19 hit? What was the change that happened in telemedicine then?

Susan Lucas Collins (25:00):

Yeah, so all of a sudden, it became problematic to go to a hospital, unless you really, really needed to be there. And many of the basic health services that we would normally expect experiences to have in those kinds of environments became much more fraught, because of the fear of becoming infected with COVID and those kinds of things. And obviously, likewise, the provider organizations that were having to cope with COVID patients and this unbelievable influx of volume, were really, really stressed. And finding it very difficult to take care of all these other conditions that didn't just disappear because we were having to wrestle with COVID.

Susan Lucas Collins (25:39):

So we saw a lot of very fast deployment of telemedicine that allowed people to be assessed, to have conversations with their providers, to handle things that did not require face-to-face interaction, lots of screening, lots of check ins, you think about folks with maybe chronic conditions that have to have a regular check in with their healthcare providers, that don't really need to necessarily be face-to-face in order to do that effectively. And then you think about all the folks who are in locations where healthcare is not nearby, not convenient and the ability to access, even specialty care, and consults with specialists and things like that, really has driven an enormous increase in the use of telemedicine.

Susan Lucas Collins (26:26):

And of course, it's gotten easier to do and better, faster, cheaper if you like.

Liz Moy (26:30):

Is there any case in your own life where telemedicine has made an impact over the last year?

Susan Lucas Collins (26:37):

I am a huge fan of the rise of telemedicine and I am quite certain that it's here to stay. I think about the ability to join in at least in a virtual fashion, when my dad who's older, has a number of the typical health conditions you might have in your 80s, be able to join the discussions that he's having with his physicians and his care team, even though I'm sitting in Atlanta, and he's sitting down in West Palm Beach. And it really solved for some of the challenges that we had trying to help him manage some of his conditions. He'd go to the doctor and you'd call and say, "Well, how did it go dad? What did the doctor say?"

Susan Lucas Collins (27:13):

And he often couldn't really tell you in any detail. Maybe he got a new medication and you'd say, "Well, why did they change the medication dad?" And he'd say, "Well, they're the doctor, that's their job. That's what they do." And that was sort of an unsatisfactory answer. And it made it hard for us to support him effectively. Now we can literally be in that video conference with the physicians, we can ask questions, we can understand what's going on, and we can help him be compliant. And that leads to better outcomes for everybody.

Liz Moy (27:42):

I love that. I think that's one thing that I keep hearing people say, is that at the end of the day, hopefully, all of this will lead to better outcomes for everyone involved. Obviously the patient first, but also the provider and everyone else.

Susan Lucas Collins (27:57):

That's an important point. The provider experience is so critical. And I think sometimes, those of us who have spent decades chasing a better patient experience and for all the right reasons, perhaps have not been as thoughtful as we could have been, about making sure that the people who are delivering that care, are also considered when we think about things like workflow, when we think about things like access and not making their lives more burdensome with technology which unfortunately has sometimes been the case, when we deploy technology to do all sorts of things in healthcare, including necessary administrative things like billing, things like documentation.

Susan Lucas Collins (28:41):

But the provider experience is also central to making sure that outcomes are as good as they can be. And I think we've made tremendous strides as we've scaled this technology and deployed it much more widely. The improvements in workflow and access for providers has also improved and I think that's really important.

Liz Moy (29:01):

What barriers are there to the advancement of telemedicine and specifically, what sort of policies make that a challenge?

Susan Lucas Collins (29:10):

Yeah. So it's not news I think probably to most folks that we have communities with real infrastructure challenges, things like internet bandwidth and that can be a real barrier to making a technology like telemedicine effective. And those of us who work in technology know that there are also fixes for things like that and things that you can do to improve quality of resolution and those kinds of things to improve the telemedicine experience, but I think we still have quite a long way to go to ensure that the services that are available, that support services like telemedicine, are available to everyone, regardless of the socio economic status they may find themselves in.

Liz Moy (29:58):

Dr. Tim Peck sits at a unique intersection, as a doctor, founder and design leader. As a physician, Tim recognized the need for more advanced telemedicine solutions. So, he went and built one. And not only that, but he worked to enact policy to make telemedicine viable in the eyes of the healthcare system.

Dr. Tim Peck (30:19):

My name is Timothy Peck, I'm a emergency physician by training. But I'm also a serial technology entrepreneur in the telemedicine space, mostly for elder care and reaching patients with chronic comorbidities. I'm also a designer and come to design by way of product management and product design. And currently work at IDEO as executive portfolio director of health. On top of that, have a long history of telemedicine in entrepreneurship, forming an important company called Call9 that delivered telemedicine and data products to patients in nursing homes, with the intent of reducing hospitalizations and did so quite successfully.

Dr. Tim Peck (31:08):

And now I am founder and chair of Curve Health, which is a company that uses technology also to reach patients in nursing homes, but enables physicians and health systems to reach those patients and bring more quality care.

Liz Moy (31:26):

So you have this history of working specifically in emergent and in senior care. Can you tell me a little bit about, when it comes to telemedicine, what the landscape was like prior to the COVID-19 pandemic?

Dr. Tim Peck (31:43):

When I first started thinking about telemedicine, was back in maybe 2011 or so. And telemedicine has been around since the '60s, through NASA programs actually. It's not a new technology, it's just that the use cases for it, were not necessarily adopted, or had much political will behind it. And so telemedicine when I first started thinking about it and utilizing it, it was about two to 3% of doctors had ever used telemedicine back in the mid 20 teens. So, I worked at Harvard Medical School, was on the faculty there and was at Beth Israel Deaconess Medical Center, receiving lots of patients from the field.

Dr. Tim Peck (32:41):

Receiving lots of patients from nursing homes. And in fact, 19% of all ambulance visits to the emergency department come from nursing homes, there's lots of patients who I was wishing that I could be with them earlier, and really at their most vulnerable moments, those moments of emergency. But instead, I had to wait for those patients to get me, and said, "There must be a way to reach them." And telemedicine seemed to be a solution.

Dr. Tim Peck (33:09):

With that number around nursing homes that I was thinking I said, "Okay, so there's patients who are all consolidated in one place, who are all being on this conveyor belt coming to the emergency department so often, what if we can create a system in which we brought care to those patients from the hospital, rather than bring those patients to the care?" That seemed to be a much more humane way. And when I say humane I mean, a much more respectful way, a much more human-centered way, a much more user-centered way because, nursing home patients, chronically sick and elderly patients who come to the hospital, about 53% of them have dementia.

Dr. Tim Peck (33:56):

And most of them become delirious, which means they become confused. The rest of the 50% or so become confused upon the transfer from the lights and sirens and their pain and the fevers they have et cetera. So getting information for those patients, is almost non existent. And having time to call family members, is very difficult in a busy emergency room when there's a gunshot in the other room or heart attack. And the data transfer from nursing homes to hospitals, is also non existent. So you get patients, even though they have a wealth of information on them in their home, where they live in the nursing home, and people taking care of them there.

Dr. Tim Peck (34:41):

Once they change their location, there's no data on them. There's no way to get their history, and you have to start over new. And that just doesn't make sense. So, telemedicine is a way to bridge that gap of information. And so what I did is said, "Okay, how do we bridge that gap? How do I learn more about nursing homes? About the human experience there?" And I put my design hat on, and went and lived in a nursing home for three months. And in that nursing home, I started treating patients myself, was able to understand the patient experience, the family experience, shadowed nurses, rehab.

Dr. Tim Peck (35:24):

Learned all the economics and how money in terms of insurance money and payments flow through the system, and able to design a telemedicine company, in which I formed a physician group of palliative care docs, internist, emergency medicine docs who are able to be with these patients at their most vulnerable moments. When normally, especially nights, holidays, weekends, there wasn't doctor care there, or nursing homes, they're not doctor homes. And so, physicians will see their patients, maybe once or twice a month for the long term care patients, and patients who live there, maybe once or twice a week for the short term care that the patients who are after they're discharged from the hospital that are still going to go home after that.

Dr. Tim Peck (36:18):

And so that's the program we made. And that was really novel. There weren't programs that are that extensive and, what happened in Silicon Valley, got very excited about this. We were part of Y Combinator class of 2015, one of the first health companies to come out of that Y Combinator, the famed incubator, Dropbox an Airbnb Reddit, and we're able to raise a significant amount of money to put behind this technology in the service. And the idea was if we build this, people would obviously pay for it. And they did. Insurance companies paid for it, because they saw the intense and value that it created, because it decreased spending by decreasing unnecessary and avoidable hospitalizations.

Dr. Tim Peck (37:07):

And in fact, CMS says that two thirds of these trips to the emergency department are avoidable. And we saw that as well. In fact, our numbers were that we decreased hospitalizations, somewhere around 50% and avoidable hospitalizations by about 80%. But CMS, Congress, Medicare just didn't have the infrastructure to pay for our service and so many others for these vulnerable populations. Yes we'll talk about it but it took a pandemic to change those rules.

Liz Moy (37:41):

Those numbers are staggering, the adoption of telemedicine going from two to 3%. Really not that long ago, to now it's something that it seems like every provider is sort of scrambling to find a solution for. What did you see happen over the last year in terms of telemedicine adoption?

Dr. Tim Peck (38:01):

Yeah, so the story of Call9, that company that we made, is that we actually closed it in early 2019. A year before the pandemic hit. And the reason we closed it is because Medicare couldn't pay for it. Even though congress who had to change the role so that Medicare could pay for it, wanted to act on this, they saw the value of it, even though CMS was a huge supporter of telemedicine and couldn't get done. And I spent along with my colleagues a lot of time in Washington meeting over 200 senators and representatives, doing a lot of advocacy and working with patient groups and other policy and advisory groups.

Dr. Tim Peck (38:48):

And we even got a bill introduced to Congress called the RUSH Act, the Reducing Unnecessary Senior Hospitalizations Act. And this bill would have had a impact in terms of saving money if it were passed, and it had bipartisan support. There were a dozen or so Congress people who had their name on it from both sides of the aisle who rarely work together otherwise, the world wanted this. But in 2019 if you recall the government shutdown, and even though there were a number of telemedicine bills in 2018 that came through including telestroke and tele renal dialysis at home and some Medicare Advantage telemedicine bills.

Dr. Tim Peck (39:35):

Now this bill, which was set to go forward in 2019 didn't happen, and in fact, no telemedicine bills happened during that time. There was just an arresting of that progress. And so, even though it saved money, even though bipartisan support couldn't get it done, and then when the pandemic hit in March, the entire world changed overnight. And that RUSH Act got reintroduced, rules got changed, executive orders were made. And really in a matter of a week, telemedicine became flourishing. And so what happened it went for that two to 3% of doctors using telemedicine back in 2015 or so.

Dr. Tim Peck (40:13):

Before the pandemic was around, 17% of doctors had ever used telemedicine but weren't using it regularly. Now as you said, it's measurable, one way to say it is, Medicare beneficiaries, there's been an 11,000% increase in use of telemedicine of Medicare patients since March. It's almost infinity, it's hard to even imagine what that is. And the adoption happened because Congress was able to act. And we can talk more about why Congress was able to act because of the pandemic.

Liz Moy (40:49):

I personally feel like I need to thank you because, my grandmother just turned 95 this week and, she got very sick right at the beginning of the pandemic, not with COVID but with other issues. And, she was able to get telemedicine support, because of Medicare. So thank you, for all of the work that you've done in this area that has directly impacted my life.

Dr. Tim Peck (41:14):

Yeah.

Liz Moy (41:15):

Also, do you ever sleep? Because it seems like you do a lot of stuff.

Dr. Tim Peck (41:23):

I sleep well when I do sleep, because it's quite tiring. But it's also incredibly energizing to be able to make change, to be on the forefront of change. That's what is important to be in life and brings meaning is by being able to look at systems the way they're designed, put the patient at the center, and make solutions, just by waking up, talking to people like yourself, getting the message out there that this is not only possible, but needed and can make the healthcare system better than it already is. So yeah, it's actually energizing in the end of the day. And thank you for saying thank you to me, but there are 1000s of people who did the work to guess where we are.

Liz Moy (42:12):

Thanks for listening to the first episode of season two of Build and Deploy, How COVID-19 Accelerated Telemedicine. Thank you to Jeff and Dr. Erica Lawson, Susan Lucas Collins, and Dr. Tim Peck from Curve Health and IDEO, for taking the time to speak with us for this episode. In the next episode, we'll be exploring video for telemedicine. Make sure to subscribe to the podcast, and rate and review it to let us know what you think. If you're ready to start building a healthcare solution with the Twilio APIs, check out twil.io/buildanddeploy for everything you need to get started. See you next time.

Thanks for listening and subscribing! Want to talk about something you're building? Email me at lmoy [at] twilio [dot] com.