Season 1: Episode 9 – Telehealth: Pioneers in the Future of Healthcare Technology

Dear Healthcare It’s You: Episode 9

Elisha Yaghmai

Finally, I'm able to do what I wanted to do, which is why am I in medicine? I wanted to solve problems Right now you actually give me something that enables me to use my mind to solve something that means something rather than to figure out how to classically document the right thing that you want and for whatever totally meaningless outcome.

Elisha Yaghmai

This was right.

Jo O’Hanlon

For the 18th time today, for.

Elisha Yaghmai

The time today day, I'm instead solving a real problem that affects real people in what I hope is a positive way.

Jo O’Hanlon

Welcome back to your health care. It's you. Welcome back to do health care. It's you. I'm here with Dr. like you and I am Joe O'Hanlon. We are continuing to dive into the crux of the failing American health care system. So it's a bleak it's a bleak topic. We know last time we're talking about a lot of the bleak parts of it, the rigamarole that goes into coding and things like that that you discovered in Seattle and ultimately, I mean, really insightful episode.

Jo O’Hanlon

Actually, if you haven't catch that, please go back and watch it because it's really illuminating for anyone, whether you're medical or not. But ultimately it left you in a state of burnout. Yes. Where we were going with that.

Elisha Yaghmai

And before before we move to our next topic, I just I want to throw in one more thing, which I think physicians should relate to, but the public should know about. So one other thing that contributed to burnout. I mentioned some of the coding dishonesty that goes on, but there was also there is a second form of dishonesty which went on, which was hiding death.

Elisha Yaghmai

Right? So this was another thing that when I was first time I had seen it was when I went there. It's now I've seen it in multiple places. So once again, whether they were trailblazers or not, it's now common.

Jo O’Hanlon

So what does that mean? Hiding deaths.

Elisha Yaghmai

So essentially patients come in hospitals and some of them die, Right? Right. Yeah, it's right. Something terrible happens and they die. But what is supposed to happen is there is some measurement of what the death rate is. Right. And you would be concerned if a hospital had an unusually high death rate or an unusually high death rate for a particular condition.

Elisha Yaghmai

Right. Right. Everyone that comes in with something, they die at a higher rate than they do at all the surrounding hospitals, for example, you would question what's going on. Right?

Jo O’Hanlon

Right.

Elisha Yaghmai

So one and this again goes back to payment, right? It goes back to payment. So one of the strategies that was used in this facility or the series of facilities was if a patient came in and it looked like they were going to die, we would switch them over to a different service, effectively a hospice service.

Jo O’Hanlon

Right.

Elisha Yaghmai

And the reason we did that was because if they died on that service, then the death didn't count against the official death statistics for the regular service.

Jo O’Hanlon

For the hospital that.

Elisha Yaghmai

So, it was a kin, I think. What was it, what it was meant to be was if you had a patient, for example, that was on hospice that for some reason had ended up in the hospital or something and they were going to die. So it was a planned death, right? It was like we already knew they had a terminal disease.

Elisha Yaghmai

We've already all agreed we're not doing anything here. We're just hospitalizing them for social reasons, for logistical reasons, for some other thing. Right. To be hospitalized. But we're not trying to save their lives like we acknowledge. No one here is trying to save their life. We're just trying to make them comfortable as they pass on. Right? Right. That's what that was meant to be for.

Elisha Yaghmai

But at some point, somebody realized what you could do was change your acute care patient to hospice status, even though they came in there intending for you to save their life.

Jo O’Hanlon

Right.

Elisha Yaghmai

And then their death doesn't count against your official death statistics. So here again, you're a patient. You're trying to find out how good is my hospital right. And you look at things like, well, how frequently do people die in that facility? Is it in line with everybody else? Is it out of line? Is it really good? Is it really.

Jo O’Hanlon

Bad? Yeah.

Elisha Yaghmai

Sorry. There's no way for you to actually accurately know what the death rate is because those rates are gamed. Now, again, when we were doing this in Seattle, that was new to me. Yeah. Now it's everywhere. It's done here in Kansas and it's done in a variety of other places. Also, people may have seen standardized practice. Yeah, it's a pretty standard practice.

Elisha Yaghmai

Certainly in large health care centers, it's a standardized practice. You may have seen a news report recently from, I think Florida or something where some physicians were alleging that this was done right by a corporation that owns hospitals down there. You know, it was denied by their spokesman. But now this stuff goes on and it goes on not infrequently, and it goes on for the reasons that I have just stated.

Elisha Yaghmai

And so once again, you can say, well, there's insurance games and there's payment games and things that go on. But the question for the public should still be, don't I want to have an accurate record of deaths and who's dying and what they're dying from? And if the death rate is either better or or worse than what can be expected.

Elisha Yaghmai

Yeah, it would be. Wouldn't I want to know that? Is that not in my personal interest and in the public's general interest to know right. Sorry.

Jo O’Hanlon

Are these not so? These are patients that would not have previously or in other settings they would not have had hospice assigned to.

Elisha Yaghmai

That, correct? Yeah. What would have happened in the past was they would have come in for whatever their condition was. They got sicker and they died, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And the point of looking at death right here again, people die in hospitals, right. And it doesn't mean anybody did anything wrong. Right. Right. Nothing wrong there.

Jo O’Hanlon

They're coming there because there's something wrong.

Elisha Yaghmai

There's something wrong. Right. And you're trying to solve the situation. Right. But the question you do want to ask from a from a scientific perspective is it once again, are the people trying to save their life for this particular condition? Are they doing an average job, a better than average job or a worse than average job? Right. And if they're either better or worse, that is a place I would want to investigate to find out why are outcomes so bad or why are your outcomes so good.

Elisha Yaghmai

Right. Right. There's probably something in there worth learning, but instead we've opted for is let's just make the numbers look good, right? So that once again we look like we have good death rates. So then again, whatever our payment bonuses or whatever else it is we get rid of, our incentive is to do that. Is there what what's lost in that is honesty, truth, accuracy.

Jo O’Hanlon

Yeah, right.

Elisha Yaghmai

And ultimately the ability for the public to make an informed decision.

Jo O’Hanlon

Is it also an additional charge to the patient then to get hospital? That is an excellent question.

Elisha Yaghmai

Actually, I didn't think about that. But you are changing their service and that may be true, but I'm not going to I'm not going to swear to that one because I just don't know the dynamics. Yeah. Yeah.

Jo O’Hanlon

Okay. Well, and so let's talk about your burnout. Like at the end of the last episode, we're trying to kind of talking about that and just, you know, it's this mill that just churns through patients and just I mean, works physicians and I'm sure the other health care workers in the facility.

Elisha Yaghmai

Everybody.

Jo O’Hanlon

To the bone in a way that's just it's not sustainable. It's not life giving. It's not I would imagine, like it's not fulfilling your passion that you wanted to get into. And so was it through your notes and noticing those differences that you referenced in the last episode of like you were taking notes on the on your journey about your patient or not just your patients, but just about your cases and your your general demeanor?

Jo O’Hanlon

Was it through those that you started to realize how burnt out you were getting, or how was it apparent to you that you needed a change?

Elisha Yaghmai

It was an introspection, self analysis. It was in the realization that that I was coming home angry every so I was working night shifts. At that point, I was coming home angry every night, every every day, rather, when I would come along, I was just angry and I would, you know, and this is Seattle, so it's heavy traffic, right?

Elisha Yaghmai

So I sit there for an hour on the road, commuting back the, you know, ten miles to my house right. Mom and I and I would say, okay, I'm angry. What am I why?

Jo O’Hanlon

That's what I was just going to ask. Like, who did you articulate? Who you were angry at or what you were angry at?

Elisha Yaghmai

I was. I was. I mean, at the time. Yes. At the time I knew the job was making you angry. So I knew that what I can say in retrospect was it again? Was it was it was running into these persistent conflicts. It was this persistent conflict. I mean, what had preceded that. So at that episode, I was working one of the nights, one of the facilities.

Elisha Yaghmai

What they had done at the facility was to save money. Here again, right there was reimbursements, cutting reimbursements. Right. Hospitals are always screaming about this. Not necessarily incorrectly.

Jo O’Hanlon

Right. Right.

Elisha Yaghmai

So to save money, what they had done was they cut the janitorial staff. You're going to talk about a conflict. They cut the janitorial staff and you think, it's janitorial stuff. Maybe that's not a big deal. It's a huge deal. Yeah, right. So the problem is, here I am on the night guy, I'm being called and all these admissions, I'm trying to take care of these patients and they're all getting stuck in the emergency room.

Elisha Yaghmai

Why? Because there are no janitors and because there are no janitors, No rooms can be cleaned. Yeah, right. So the patient ends up stuck down in the emergency room for 12 hours, 16 hours, whatever it is, because there's one house cleaning person trying to go around and turn over every single room right now. How does that affect the patient?

Elisha Yaghmai

This just really happened. My patient is sitting in the emergency room, right. I have accepted them, but I haven't taken over their care yet. They go into shock. Right here are nurses busy year nurse has other patients to care for and in her mind the patient has been admitted. So the patient is now gone, right? E.R. doctor is not paying any attention whatsoever.

Elisha Yaghmai

Why? Because they've got 15 other people that they're also trying to see. Right.

Jo O’Hanlon

So they've checked them after they.

Elisha Yaghmai

Checked them off. In their mind, they're gone, right? They're not paying any attention to them here. Again, that's not unique to Seattle. That is common. That's common. Right. So the patient is not boarding in the emergency room. Nobody exactly is watching. Right. So what happened in this particular case was the patient went into shock, right. 2 hours or so into it, I'm like, hey, you know, the patient don't know what's going on.

Elisha Yaghmai

Let me just check down there. I happened to just log in and check the vital signs and see, wow, We've been recording, you know, shaky blood pressures for a couple of hours now, right? There's been no call to me. There's been no notification of into anybody about this. Right. So here again, a real harm to the patient caused by the fact that we cut the housekeeping staff, which we did to save money while that was happening.

Elisha Yaghmai

I think the CEO is being paid $9 million a year. Right. And so, you know, I go back a bit. I did some math on it and I was like, you know, we could have paid the CEO like eight and a half million dollars a year and probably kept all the housekeeping.

Jo O’Hanlon

Yeah, but we.

Elisha Yaghmai

Don't do that here, right?

Jo O’Hanlon

We'll do it backwards too, because, I mean, just a few episodes ago, you were talking about like how the whole system is predicated on needing the hospital to be full, right to work. Yes. Like to work out, you know, in this broken system. But this.

Elisha Yaghmai

So you got a bed, right? Yeah. Don't have a housekeeper, right. You cut them to save money. But at the same time, we are paying an enormous amount of money to the to the putative leader of the organization. While the organization is failing in its mission. Does that make sense? Yeah, Failing on a fundamental mission.

Jo O’Hanlon

Is to.

Elisha Yaghmai

Keep the patient safe.

Jo O’Hanlon

It sounds like it's adding a very heavy load of stress to the physicians, too, because like, you know, you're doing the extra work of keeping in your mind that you have those patients that you can't see that's not on your floor yet, that you just got told that is coming. And, you know, when you're overworked would be easy to just put them out of your mind until then.

Jo O’Hanlon

And you're doing the due diligence, as you remember, as you can to look at them and then finding out that they've been just pushed off to the side and they're in shock for like I mean, that's just an increased yeah, an increased stress load on your already overworked and misdirected whole schematic at that point. Like so what did it I mean, did you want to quit medicine?

Elisha Yaghmai

Not yet. Not at that point. I just wanted to change. I thought at the time I wanted to just change settings, right? So I sat down, I went home after, you know, several of these, and I sat down and I thought, like, I'm just I'm either going to lose my mind doing this or I'm going to have to lose my soul.

Elisha Yaghmai

I can't.

Jo O’Hanlon

Keep I can't.

Elisha Yaghmai

Keep both of these things because they're just the conflicts, the perpetual conflict between what I believe is right and what and my obligation to the patient. Right.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

This the thing like a lot of physicians actually take that seriously, right? It's not just the oath. It's like people come in and they entrust you with their life right? It's like the most valuable thing they have. Yeah. And so you're trying to if you take that responsibility seriously, right? Because the tradeoffs society's main physician's right is that we're going to give you some social respect for whatever that's worth.

Elisha Yaghmai

We're going to pay you a lot of money. Right. And the tradeoff is you're the stewards of our lives. Like that's a really serious obligation.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Not everybody in medicine takes it seriously by any means, but it is it is a real obligations and serious obligations. So you have this constant conflict between your sense of that obligation and then all this other madness that you see going on. It's just chaos. It's usually not at all centered around what's good for the patient, right? It's just it's got a lot of other incentives, but the patient's good is not one of them.

Elisha Yaghmai

Right. So your choice in that situation is you can either you can either go along with it and become apathetic or you find a way to live.

Jo O’Hanlon

Right, become apathetic and probably have your like your level of care that you're providing would have to just decrease.

Elisha Yaghmai

It goes down like stay there. It goes down. Yeah it does. No, it very much does. And you see it, you see it, you see people make the concession. They say, I cannot do this anymore, so I'm just going to deal. I'm just I can't. I'm just going to do what I can do. Right. Yeah. Within the constraints of this system and all these tools you've given me, they're just garbage.

Elisha Yaghmai

Tools are worthless that don't make my work any better. I'm just going do what I can do. And when I hit the limit of what I can do, that's where I stop, Right? And whatever happens after, that's not my problem.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And the doctors that don't adopt that either leave.

Jo O’Hanlon

Or to.

Elisha Yaghmai

Some degree just kind of lose their minds. It's the best way I can describe it, because there's not a way to resolve that tension. Right. Constructive.

Jo O’Hanlon

Well, I mean, through COVID, we've seen just droves of people leaving the health care field because it's been just even exacerbated more so. But so you were feeling like it was more that it was that sort of a high profile center that had so much traffic and so much like opportunity to get burnout in the ways that you were, that you were thinking maybe a different environment would solve that.

Elisha Yaghmai

Yes.

Jo O’Hanlon

And so what was the environment that you had hoped would do that initially?

Elisha Yaghmai

Initial my initial intent, you know, I mentioned a few episodes ago when I initially got into medicine, I thought I was going to do international medicine, right? So I go overseas and I was going to work in a developing country, this kind of thing. So that was my initial. My thought was, let me just go somewhere. This is the fantasy All doctors have.

Elisha Yaghmai

Let me just go somewhere. They just let me do medicine, right? Like I could just focus on trying to be a good physician, right? Focus on the science and the outcomes and these kinds of things. So I thought, okay, maybe internationally I can do this, right? So I tried I tried a variety of different things and tried to get in touch with people.

Elisha Yaghmai

You know, I think at one point I tracked down and were like at that time there were probably, I don't know, 40 doctors in Liberia or something, Right? I tried to find an email on the Internet, you know, and just send a cold email and never got a response to that. I tried things like that. I tried try to go through organizations and certain situations and just none of it none of it worked out right?

Elisha Yaghmai

It did for various reasons. None of it worked out. So then I thought, okay, well, what's what's the closest we get to international work in the United States? Well, rural, I thought rural health care. Right. There's always shortages.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So maybe rural health care is where I should go to find the place where I'm going to be able to. To practice in the way that I feel is appropriate.

Jo O’Hanlon

Yeah. You know.

Elisha Yaghmai

And maybe the rural hospitals don't have the same imperatives that the urban hospitals have. That was that was not correct. Right. But this is what I was thinking.

Jo O’Hanlon

As you say, we've heard heard here that that's not been the case. But at the time you didn't have that knowledge. I didn't.

Elisha Yaghmai

Know that. Right. So this is this is kind of what I thought. So so I thought, okay, I'm going to do that. And then then the thought process from there was relatively simple. I knew that at that time I had a child, right? My son was, you know, three or four years old.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And I was like, I can't just go. And my wife is still in fellowship, right? So she went crazy, right? And I'm like, I can't just go flying around all over the place, right? And leave my my son here. What am I going to do?

Jo O’Hanlon

And she's in the midst of a.

Elisha Yaghmai

Decision not to relocate is not an option. Right? So I was like, what? What to do? And I thought, well, okay, I had heard about and seen a little bit of kind of virtual care going on, video conferencing and stuff. And I thought, well, you know, maybe we could use this as a solution to the problems in rural health.

Elisha Yaghmai

And I kind of here again, a few episodes back, we talked about, you know, kind of the locum tenens system, right? Bringing in temporary doctors. Right? And you're paying a company, you know, $300 an hour or $400 or whatever, some enormous number. Yeah, right. To bring a doctor in. And this is how rural health care has done work for decades, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So you, you try to hire and get someone into your community, right. Or multiple people in. Right. But if you're not successful in doing that, you have holes in your schedule and to get things covered, you go to a locum tenens company and they charge you a premium to try to find new people that they slot in for however long that is right.

Elisha Yaghmai

Yeah. And the problem with that long term is that the prices are very high, right? And the volume of patients in many rural communities is so low that it's not financially sustainable long term.

Jo O’Hanlon

Right. This is the plan, right? Yeah.

Elisha Yaghmai

And so at that time we already had dozens of rural hospitals that are already gone bankrupt. Right. And they're just the revolving doors. Yeah, they're just shutting down. Right. And so then what would happen is the community would lose its hospital depending on the size of the community. Sometimes that meant, you know, people could be going in 100 miles, you know, 80 miles, whatever it was for a single hospital.

Elisha Yaghmai

Right. So so you look at that situation and say, okay, well, what are we going to do about this? Right? And so my thought was, you know, you know, why don't I use this virtual stuff? And I can.

Jo O’Hanlon

See it being used somewhere or just.

Elisha Yaghmai

Yeah, we use a tiny bit of it actually, in Seattle, just a little bit. They had big carts right in this kind of thing. And so we done a little bit of it. And the time I did it did a few cases that way and I was like, you know, stuff like, it's okay, it's not, not too bad.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

But I had pretty limited experience with it.

Jo O’Hanlon

So you guys were using it there in terms of treating people that were elsewhere in a different campus?

Elisha Yaghmai

Yeah, different camps in the system. Right. So I'd seen enough of it too to know it was a thing. Yeah, right. But not but know it wasn't, it wasn't very developed and it wasn't very heavily used at the time. Right.

Jo O’Hanlon

And the way that you're speaking about it, just to clarify for our audience, it's not like we experience now, like talk to your doctor on the phone for a regular appointment. This would be for like hospital visits.

Elisha Yaghmai

That's right. Yeah. This would be a hospital. You get in the hospital, right? And you instead of having a doctor walk into your room, you're instead seeing them on a computer screen, right? They're communicating with you over the Internet and then putting it.

Jo O’Hanlon

So you still would go to the facility that you're used to going to. But they would need to have a local locum tandems that would work.

Elisha Yaghmai

Yeah. Rather than having attendance positions gone.

Jo O’Hanlon

And they would just.

Elisha Yaghmai

They would be.

Jo O’Hanlon

Able to see you over the Internet.

Elisha Yaghmai

That's correct. Yeah. This was this is how this works.

Jo O’Hanlon

And you still have the nurses and everything. The normal staffing, normal testing available.

Elisha Yaghmai

All that stuff is the same.

Jo O’Hanlon

Yeah. Okay.

Elisha Yaghmai

So all that happens in this kind of theoretical system that I came up with in my head was we're just saving them a bunch of money right on the price of staffing. And the logic was very simple. You know, a lot of the smaller rural hospitals, they've got one or two inpatients, right? I mean, bear in mind, right in my normal day, I'm doing probably 15, 16.

Elisha Yaghmai

Very complicated, right? That's right. These are one or two patients, often not as complicated. That's why they're in the small hospital and not the bigger one.

Jo O’Hanlon

Right. Right.

Elisha Yaghmai

So I was like, So hey, look, I could do you know, if they all have an average of one patient a day, Right? I cover ten of these places simultaneously. It's still not a full day for me, right? I charge everybody 1/10 of the price of the normal service or my normal service, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So they get a 90% discount, right? You know, and then I can be because it's virtual. I don't have to travel and have to fly or drive there. Right. I can be readily available like all the time.

Jo O’Hanlon

Right. Right.

Elisha Yaghmai

Because I can just be I just sit where I'm sitting and I just I just beam in on the Internet when I need to see a patient.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So that was the basic idea, right? I was like, This makes sense. It's simple. It's easy, right? Seems like it solves a problem. And then the other piece is so there is a but the other piece to solve that was the quality issue, right? Because because using virtual care, my logic was the problem that rural communities have besides the price, right.

Elisha Yaghmai

Is that look, I mean, how many people how many people in the country are like, you know what I want to do? Like, I want to go out to a, you know, far rural town that's 4 hours from the nearest city, right? That's what I want. That's where I want to spend my time. It's not that many people, right.

Jo O’Hanlon

For doctors or for doctors.

Elisha Yaghmai

Right. And how many on top of that are like, you know, you need this in two weeks, right? I'm you know, I'm available. Let me do that right now. Right. I mean, it's a tiny number, right? So what that leads to is variations in quality, right? Yeah. You may get a great doctor. You may get a really bad one.

Elisha Yaghmai

Right? You have no means to know this, but what you can do with virtual is you get extended contacts because, again, you take the travel out, right? Yeah. So the same doctors, one can be available. So you begin to understand who you have and you can recruit much more broadly because now I don't care where the doctor is, right?

Elisha Yaghmai

And they don't travel so I can recruit from anywhere in the country. Right? Theory at least I should be able to bring in higher caliber physicians who can be consistently available to a small community for a tiny fraction of the total price.

Jo O’Hanlon

Right. Or are you thinking of like building a locum Dunham's alternative or like going through that system and being staffed like through the same age? It was meant.

Elisha Yaghmai

It was meant to be an alternative. It was like, Hey, you don't need to pay these people in dollars an hour anymore. Yeah, yeah.

Jo O’Hanlon

But it would take each of those hospitals that you were serving, having the technology.

Elisha Yaghmai

Correct the place that was. And that was the original barrier. Right. It was the technology because at that time video conferencing was obviously already a thing, right. Yeah. But at that time, the way it was done.

Jo O’Hanlon

What year are we in here?

Elisha Yaghmai

This is now 2014.

Jo O’Hanlon

yeah.

Elisha Yaghmai

Yeah. So there's, you know, it's there and people are somewhat familiar with Skype.

Jo O’Hanlon

At least.

Elisha Yaghmai

Skype is being used, Right? You could do it. I think there's some iPhone iPad stuff, right? Yeah. Based on.

Jo O’Hanlon

Whatever this.

Elisha Yaghmai

These kinds of things were were in some use but but in health care, the way this was most commonly done was by a company called Polycom. Right. And you had to put these Polycom terminals and each side at the time, they were about $150,000 per year for one hour. So you had to put that on both sides of whatever the equation was.

Elisha Yaghmai

Right. The doctor and then the patient side, they were large and they were fixed. So you put it in a room, for example. Right. But it wasn't like it rolled around or something. Right. So if you wanted to do a roll around, there was a so-called robot, which is basically a computer on wheels. It wasn't really a robot at the time made by a different company that that was pricing out, If you wanted one that would run by itself was about $60,000.

Elisha Yaghmai

I think if you wanted one that you would push around is about £110 card, if I recall correctly, in that neighborhood. Yeah, it was like $35,000, 40,000 something in that range. And then if you wanted to go to kind of a bare minimum card.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

It's about $25,000 to push one of these cards. So you had to push it all around. Again, all of these are just computers on wheels for the most part. Right? And then on top of that, if you wanted to actually do an exam, like if you wanted to do a hard exam, like listen to their heart, look in their ears, these were extra attachments, right.

Elisha Yaghmai

Which were cost of time, like 3 to $5000 each.

Jo O’Hanlon

Right. Okay.

Elisha Yaghmai

So, so to realistically set this up right, you needed a couple hundred thousand dollars. Yeah. You know, bare minimum. You probably need 25, 30,000 bucks, right, to do this. So the first problem when I kind of began to broach this idea with the rural communities was how do we afford it?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Right. Yeah. Interesting idea. You know, we're we're interested in exploring it further, but how would we afford it?

Jo O’Hanlon

Was it not going to save them enough in terms of.

Elisha Yaghmai

They weren't.

Jo O’Hanlon

Even side of things.

Elisha Yaghmai

This was so long ago in technological terms, not in life terms that for one, many people didn't even understand what I was talking about. interesting. I would talk to them about it for an hour and.

Jo O’Hanlon

They couldn't wrap their mind or.

Elisha Yaghmai

They couldn't get their money because the idea that you didn't have to have a physician walk into a room to examine, to see a patient was like, just not commonly known. Right?

Jo O’Hanlon

I mean, until like 2020.

Elisha Yaghmai

Yeah, exactly. Yeah. That's that's when it became much more commonly known, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So this was kind of the scenario. So one was just getting people to even comprehend that this was possible, right? We didn't even get to what are you going to save on this versus, you know, the cost of the equipment?

Jo O’Hanlon

They just saw it as this huge you know, they.

Elisha Yaghmai

Saw like it's a weird new thing and then you want me to spend a whole bunch of money right on this stuff. And I don't have it. I don't have this cash around. Right. I have these hospitals were struggling in the first place. Right. That's part of the issue. So so what I did was I went back and said, well, okay, I mean, if I can like face time on an iPad or Skype or whatever, why do we need the 25,000 on a cart?

Elisha Yaghmai

Right. It didn't make obvious sense. I was like, well, let's let's try to use a, you know, an iPad and.

Jo O’Hanlon

That was sufficient for you.

Elisha Yaghmai

Yeah. Yeah. To to interview the patient. It was right. And then and then at the time, there were these stethoscopes that the company called Littman made. They make regular stethoscopes at the time. I think we're about $750. And you had to buy two of them to get to get the connection to work so you could examine their heart.

Elisha Yaghmai

You could do that. Right. So that was the that was the initial initial model.

Jo O’Hanlon

Is that the same stethoscope that was used at the like with the packaging that you had experienced in Seattle?

Elisha Yaghmai

I can't know if it was Lipitor. It might have been. It might have actually been. Yeah, I think it was similar. So there's the maybe the biggest variation was let's just use an iPad. And on this $25,000 stuff. Right, Right. And then pair it with a stethoscope and, you know, and there were rules. You had to have it.

Elisha Yaghmai

You had to use a computer with the stethoscope. So I was like, okay, we'll need to have a computer nearby, but we can make this work, right? So it was kind of clunky, but it was like it would do the job in a in a clunky form. Yeah, right. So then so that was step one. So the step two was actually I recruited in the second guy in who was another physician.

Elisha Yaghmai

Right. To look at this. Right. And he began to look at the technology and came up with another solution which is again premade right. That you could plug in to the.

Jo O’Hanlon

iPad and other stethoscope.

Elisha Yaghmai

It was different stethoscope that you could plug into the app. So you solve the clunkiness problem by phone. And the thing about it was here again, this technology was all out there. Yeah, it's all stuff you do. You just need to piece it together. So in the.

Jo O’Hanlon

End, nobody else was using it like.

Elisha Yaghmai

That if they were.

Jo O’Hanlon

Not.

Elisha Yaghmai

Yeah, not to our knowledge, I put it that.

Jo O’Hanlon

Way.

Elisha Yaghmai

Because almost nobody was even trying to do this. Right. This is the thing. Like no one, it wasn't that somebody could have thought of this. It was that no one was trying to do this right. There just wasn't wasn't a demand.

Jo O’Hanlon

So then how did you proceed from there to get doctors and hospital doctors to perform this remote stuff and then like the hospitals to actually agree to it? How did that.

Elisha Yaghmai

Go? So it was a lengthy, lengthy process. The recruiting of physicians was actually very easy. So they're kind of, again, kind of going back to what we discussed before, Right? Yeah, I wasn't the only person feeling that.

Jo O’Hanlon

Sort of burnout, burnout.

Elisha Yaghmai

And angst. Right. So when I went to just physicians that I met over the years, right, they said, Hey, you want to help me with this project? The answer was almost always yes. Really enthusiastic. Yes. Yeah, People loved it. They were like, Absolutely, I want to help rural areas. And I by this time I knew Kansas because I'd been there before.

Elisha Yaghmai

So, I thought rural Kansas is, you know, as rural as it gets, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

So let me take this back to Kansas. I know the ground. I kind of know how things work there and people were absolutely on board with it. So that was the initial the initial concept that we had tried to roll out a bunch of doctor on board with that while we were doing that. Also, different subspecialty docs had also expressed interest in this.

Elisha Yaghmai

So people that did mental health, dermatology, various other things, but they were also interested in doing this. So then what happened was a series of reaching out to hospitals, making contact, and I was flying back to Kansas twice a month at that point. So I was flying from Seattle back there. I was driving all over the state. Right.

Jo O’Hanlon

Because you you're focusing here?

Elisha Yaghmai

Yeah, I was focused.

Jo O’Hanlon

Just because you had familiarity with.

Elisha Yaghmai

This. I knew the place in Kansas was very rural. Kansas also had at that time the most critical access, critical access hospitals or hospitals with less than 25 beds. They're paid a little differently than than regular hospitals. But generally speaking, critical access is kind of code for rural, small rural hospital. And that's not universally true. But this was it's often true, Yeah.

Elisha Yaghmai

So I thought, who better write? Critical samples are often in small communities. They're often struggling for staffing, often struggling to make money. Right? They're under stress. Yeah. And a lot of them are closing. So I thought in Kansas there's a bunch of them. So a great place.

Jo O’Hanlon

Right? And you were already licensed and.

Elisha Yaghmai

I was the I was still licensed in Kansas. I'd kept my license from before, so it was very easy from my perspective. So I went around. So I flew in. I drive all over the place, right? Go through that process, and I would sit down and pitch these hospital CEOs about what we were doing. I started bringing tech demos with me, you know, do this.

Elisha Yaghmai

So all of us as.

Jo O’Hanlon

Air travel salesmen.

Elisha Yaghmai

Yes. I mean, really what I'm doing travel sales, that's exactly what's going on. And the hook on this is that there are two things. So one was recruiting all these doctors, putting the structure together, getting everything licensed in the state of Kansas, getting everybody credentialed with these hospitals, with a bunch of back in paperwork again, goes into this.

Elisha Yaghmai

So we did all that. The second ingredient of that was the technology piece, which I mentioned. Right. So by this time we had some third party software, an iPad, also third party and a stethoscope also.

Jo O’Hanlon

How much did all that? And then I want to say.

Elisha Yaghmai

It was about 1300 dollars. Okay.

Jo O’Hanlon

So we had super affordable. Yes.

Elisha Yaghmai

With the price had dropped compared.

Jo O’Hanlon

To 35,000 or 20.

Elisha Yaghmai

Five, 35, 60, 150 to 3000.

Jo O’Hanlon

Bucks. Yeah.

Elisha Yaghmai

So, you know, kind of a story I've told before in other contexts was I can't sort of overemphasize the how significant that was. Right. Because we initially thought, you know, we're working with visual equipment and then we went down that consumer electronic route. And, you know, the the other doc that I brought in put a lot of time into this.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

An aside to that and I'll I'll get back to that but you put a lot of work into into trying to find these pieces right. To to get to get everything prepared out properly done right. So because at one point I remember he'd ask you know hey you know, you also do pediatrics, right? You know, you look in ears.

Elisha Yaghmai

And I was like, yeah, ideally I would like to look in there right? How are we going to do that? So here again, he found an attachment that you could put an iPhone or you could look in somebody's ear. So but the point of it was all this technology comes together and and the first time we realize it worked, you know, we sat there and said, wow, like this is we have we have solved access to care.

Jo O’Hanlon

Yeah, that's a huge breakthrough.

Elisha Yaghmai

And we were like, we can we can we can interview the patient. We can listen their heart and lungs. We can look in their ears or their throat or their nose or whatever. We have the ability do all of this using third party consumer electronics. Yeah. So we're like, we have access to care is now solved. You can see a doctor anywhere in the world that you want that as long as they've got a cell signal.

Elisha Yaghmai

Right. We can, we can do this, which.

Jo O’Hanlon

Is huge for underserved communities.

Elisha Yaghmai

And massive thing. Yeah. So we thought.

Jo O’Hanlon

That you were the saviors of health.

Elisha Yaghmai

Here. Again, the analogy I'll give is it was kind of like George Bush on the battleship where we thought we'd be greeted as liberators. Right? And so what we did was we went around and we were like, look, rural communities, we will pay for the technology, will give it to you.

Jo O’Hanlon

So, you're just trying to sell them on the concept of.

Elisha Yaghmai

Just let us let us in here, let us relieve you, let us provide care in your community. We will give you the technology for free, will pay for it out of our own pocket.

Jo O’Hanlon

And how many work agreed to that initially?

Elisha Yaghmai

Over time, over the first two years, there's about 30, 30 communities, I think. 30? 33. Yeah. Agreed to do this right. So lots of travel and work go into this, you know, all kinds of time. So we kind of set the set all that up, start rolling out the technology, you know, and then we and then we ran into kind of miles all that was going on, the realities of sort of how health care actually works.

Elisha Yaghmai

Right?

Jo O’Hanlon

So back to insurance.

Elisha Yaghmai

It's back to insurance, right? This is this is where this goes. And so, you know, the first issue that we ran into was Medicare had set up a rule where this is from years before the telemedicine physician could not be the admitting physician because of the admitting or attending physician. Basically, they couldn't be the person with primary responsibility.

Elisha Yaghmai

This was buried in the Medicare manual. So this one line in Medicare meant you don't know what to do about a case. You can call somebody and they can suggest to you we do. Right. But they're not going to step in. They're not going to take over the case doing these things that you might need, which is the opposite.

Elisha Yaghmai

We had proposed to do exactly those things.

Jo O’Hanlon

Right.

Elisha Yaghmai

So we find out that Medicare has this rule where they won't allow us to do this. So we then said, all right, well, if we can't do that right now, then we'll start with just offering subspecialties because we also have these, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And so our first subspecialty we rolled out actually was endocrinology with a doctor here in Wichita. Right. Who did that and started seeing patients. Right. And just began to gain just a little bit of traction showing, okay, this can actually be done and done properly on this very limited ambulatory outpatient care model.

Jo O’Hanlon

Right. Right.

Elisha Yaghmai

While we continue to go around and try to work with insurance and the regulations and then find somebody to allow us to trial the kind of hospitalist thing which we ended up getting over time.

Jo O’Hanlon

You did get something. We did.

Elisha Yaghmai

It took a long time, like it took me another year or something like that before we were actually given the opportunity to launch it right.

Jo O’Hanlon

And then it was being covered by Medicare at that point.

Elisha Yaghmai

No, no, it wasn't actually. And so then we had to what we did was we figured out a workaround. The workaround was the the local physician when when admission would come in, the local physician would consult us. Right. And so we would consult as the consultant. And this is true anywhere you go as a consultant, we had the ability to do anything right, orders or whatever.

Elisha Yaghmai

So as a consultant, we've come in and effectively we would admit the patient we would do all the work, we would interview them in the morning, they would come back in and readmit the patient. They would see them right and do this. Obviously, this is here again, redundant, wasteful, silly system.

Jo O’Hanlon

But it still did allow them to not have to be there. It did.

Elisha Yaghmai

But at least it accomplished the basic goal of getting some rest right while we cover the place. Yeah, but this was but because of the silliness and redundancy in it. Right. Again, it was a tough sell, right? Because we were like, Well, I already have somebody here, so I need to have them do whatever they do. So initially, actually we started off, we did it for free.

Elisha Yaghmai

Actually, I did the vast majority of it, right? Really? Yeah, for free. So I would just be on and I would take calls all night and I would do whatever I was doing and try to see the patients and just be like, We're just going to donate our time. One of the other docs, I think was working initially at pretty reduced rate, right for his, but it was a lot of free work and it was a lot of just spending Spending saved money.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Personal savings, right. To try to try to get these things launched and going the whole time though, the rationale for it, it wasn't just martyrdom. Right? The idea was, hey, this will work. Right. And so all we got to do is show proof of concept that was trying to buy time.

Jo O’Hanlon

We're like.

Elisha Yaghmai

Let's just show proof of concept to show that this works. And then when we show that this is a better way to do real health care, it's more cost effective, it's higher quality, it's more sustainable, etc., then surely. Right? All the gates will open, right? And you know, and then we'll be able to finally do what we want to do.

Elisha Yaghmai

Yeah, that was wrong. That was totally, totally wrong.

Jo O’Hanlon

Which how do you keep to be how do you keep being so optimistic in the face of you have two sides. Were you very jaded? If you're willing to create an entirely new system and yet you continue to be like, well, they'll they'll, they'll figure it out. Like I'll see this for believing in at some point, like, I mean, do you have an answer for that?

Jo O’Hanlon

I mean, that's an interesting piece of you, too.

Elisha Yaghmai

Yeah. It's so I think two things were going on, right? One is this year we talked about working on the wrong things, right? So this was an opportunity, just personally speaking, this was an opportunity to work on a project that I felt was meaningful. I thought it could make a positive impact in the lives of a lot of people.

Elisha Yaghmai

And I thought it was just and how we have to look first, which is we have to solve the technology. Then we got to figure out the logistics and then we got to figure out the licensure and the credentialing and we got to do right. And we're doing all these things and all that work, some of it busywork, some of it real, required a different kind of thinking than medicine, some creativity.

Elisha Yaghmai

Right. And working on problems. Interestingly enough, actually, my my colleague that was working on me, there was a process which I still to this day called intellectual reconstitution syndrome like this what is so there's something called immune reconstitution syndromes. When somebody has HIV, either their immune system gets really knocked down, when HIV is out of control, when you control the HIV, their immune system kind of comes back.

Elisha Yaghmai

It comes back and has a lot of effects, which sometimes can be negative on the body is scary. The technical jargon. The point was it was kind of intellectual reconstitution. So what I mean by this is that I watched this process as he got involved and began to research these things and begin to get engaged again in solving a problem right.

Elisha Yaghmai

That he felt was meaningful. Yeah, it was really fascinating to watch his mind switch back on as the best way I can describe it. Right. And I observe the same process with myself. I was like, okay, finally I'm able to do what I wanted to do, which is why am I in medicine, right? I wanted to solve problems Right now you've actually give me something that enables me to use my mind to solve something that means something, right?

Jo O’Hanlon

Yeah.

Elisha Yaghmai

Rather than to figure out how to, you know, classically document the right thing that you want and for whatever totally meaningless outcome. This was right.

Jo O’Hanlon

For the 18th time today.

Elisha Yaghmai

For the 80, the day, I'm instead solving a real problem that affects real people in what I hope is a positive.

Jo O’Hanlon

Way. Yeah.

Elisha Yaghmai

So that's where a lot of the initial optimism came from because it's like finally I am able to do something that I feel has some kind of value.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

And that attitude, that optimism is really what spread through. So on the one hand there's a cynicism. On the other hand, you know, the other thing is it's like you have hope, right?

Jo O’Hanlon

Right. You saw a glimpse of a solution. Yes. With that, like I'm sure it must have felt like a clouds opening. Yes. Of like maybe medicine can get better.

Elisha Yaghmai

Yes, we can solve we can solve this rural health conundrum. Right. That's existed has been getting worse and worse and worse for decades. Like we can fix this.

Jo O’Hanlon

Yeah.

Elisha Yaghmai

We can fix this. And so that that initial optimism is what floated us through a lot of those early periods.

Jo O’Hanlon

Yeah. Which I'm sure we'll talk more in depth about some of the struggle of that at some point. But you mentioned with Medicare that there was the problem, then the workaround and then eventually getting solved. But what about on the private side of health care?

Elisha Yaghmai

The private side.

Jo O’Hanlon

For health insurance.

Elisha Yaghmai

Was so much worse. It was so much worse. They Medicare, I would describe their they were bureaucratic but not malignant. Private insurance was much more malignant in their approach. So, there we went through this very lengthy process, which we can probably detail more next time, but a lengthy process like a like an ongoing battle for years, trying to get recognized, first of all, trying to get conversation being rejected.

Jo O’Hanlon

Like not even being able to get a seat at the.

Elisha Yaghmai

Table. So, yeah, no, no ability to no ability to do anything, despite the fact that we were checking all of the alleged boxes that were supposed to meet to do this right. And even after they rolled out some additional checkbox. So they added some requirements that weren't in there. Written publications.

Jo O’Hanlon

Gotcha.

Elisha Yaghmai

All that, all this stuff kept going. So so that was that is when I think the kind of the bloom began to come off, right, Because we're like, okay, we solved all the other issues. To some degree, it isn't perfect, but it was good enough to do the job right. We solved all.

Jo O’Hanlon

These things, stonewalled by.

Elisha Yaghmai

And then here we are, right? The the people that really control this. Yeah I it I'm not interested in having us do it.

Jo O’Hanlon

Or even the conversation.

Elisha Yaghmai

Or the conversation about it. And we are we are stymied. We can't do anything.

Jo O’Hanlon

Gotcha. Well, that definitely put a damper on the plans, I would imagine, because you can't really run a health care business just footing the bill for years. Yes. So. Well, we'll pick up with that. I know that there is more to that story. I'm curious to hear from you all the the details of that battle with insurance. But ultimately, I mean, it's it's a thread that's run through our whole story as far as insurance being such a factor, the billing being such a factor, but insurance, especially Titan, not that they're the villain in the story necessarily, but, you know, it's just one of those arms of this dilemma and health care of that.

Jo O’Hanlon

If insurance won't pay for it, then we're not doing it sort of thing. So we'll pick up there next time. Thanks. Election.