Brandon: Welcome everybody and welcome to another episode of Get’n Down with Digital Health. I'm your host, Brandon Worley. Joining me today as co-host is my fellow co founder and Mend CEO, Matt McBride. Matt, what's up man? How are you doing? Matt: Doing great Brandon, great to be here. This should be an awesome episode. Brandon: Yeah, we're very much looking forward to it. We are very honored and excited for our guest today. We have Dr. Matthew Sakumoto who is a virtualist and clinical informatics physician champion based out of San Francisco. Dr. Sakumoto, thank you so much for joining us today. We’re very excited to hear what you have to say. Matthew: Thanks so much. Happy to be here. I'm happy to be Matt number two here. Brandon: Dr. Sakumoto, I just gave a very brief introduction of who you are. I know you have just a tremendous amount of experience. For the audience, if you wouldn't mind, please just give yourself a little introduction. Matthew: I think you encapsulated most of what I do. I'm a virtual primary care physician in San Francisco but it's a hybrid model, so I also care for patients in the office as well. I get to actually meet my patients. The other part of my life is really around the informatics piece. How do you help both clinicians and patients use digital health most effectively and efficiently? Those are kind of the main areas that I focus on and continue to work on throughout my day-to-day. Brandon: I know for us, one of the really exciting things why we were excited to talk to you is that you do so much virtual care. And you are a virtual-first primary care physician and a physician champion towards virtual care. Would you mind sharing, when did you first start caring for patients via telehealth? Matthew: I've always been super interested in care beyond the clinic walls, even during medical school. I think telehealth in terms of specifically video visits, I started doing that during my clinical informatics training at UCSF. Again, I always liked the idea of sharing beyond clinic walls and reaching out to patients. Then I really realized you can meet them in their homes. You can kind of meet them where they're at and meeting patients where they're at through a video visit. I did telehealth before it was cool, but in 2019, not much before the pandemic, but set up a pilot project through UCSF. Basically, doing video visit urgent care, just to improve access. Physically to get a spot in our clinic took a while, but if we can meet patients at home and offload the patients that were coming in, it was safe to do so. I started doing some of that in 2019 and we were doing maybe about five visits a week. Then the pandemic hit and that pilot project of mine actually became UCSF’s Covid video visit screening clinic. It went from five visits to (I think) doing—it was a high number—80–120 visits a day, running 12 hours a day. I think we ramped up close to 40 physicians at one point to really help with that Covid video visit screening. I got to see telehealth at scale and be part of that scaling. Since then, it just was all in on virtual care. Since then, I've worked at a bunch of different startups and currently I'm in another community practice doing (again) primarily virtual care and telehealth. Brandon: Thank you for sharing that. You brought up the pandemic and that you were doing telehealth pre pandemic. Then obviously you've been doing it since then. What was it like as a physician? I know you're one of many, but you're really kind of at the forefront within your organization of doing this. What was that like for you during the pandemic? Matthew: I think for me—because particularly I'm an internal medicine primary care physician, so mostly outpatient-based—it was a way to really help (I think for me). That was actually my first time. I have a lot of colleagues that work in the ICU, emergency rooms in the hospitals, and they were just getting destroyed by the amount of patients that are coming through. The [...] are empty, so how can we help? I think that was my first thought. It's also that you just kind of start doing it, help on. It’s different. A lot of it felt like medical school where I'm re-learning how to do the physical exam, re-learning how to do diagnosis via video. There was a learning curve to it, but also kind of this level of just like again, really just wanting to pitch in and help while my colleagues are actually physically there on the frontlines. Matt: What was different about the physical exam? How did you adapt that part? Matthew: I call it the virtual physical exam. You can't do a stethoscope for most of the time, you can't listen to the lungs, but there are a lot of things. And you really have vitals as well. You don't have a pulse oximeter to check oxygen levels, but there's a lot more functional testing. I would ask the patient, can you stand up and take a lap around your apartment or to take a lap around the room and come back? Do you feel short of breath? Yes. Okay, I'm concerned. Let's send you in. Or, do you feel short of breath? No. I think you're okay. We can watch you for a day and then we’ll check in tomorrow. I think, rather than just taking a number and kind of treating patients, all the e-patients based on just the numbers in the chart and things like that, you start to rely on just the art of observation and really, really trusting patient reports. I think trusting the patient to say like, how are you feeling, let me know, incorporate it in the patient and the decision making a lot more than I did when they were physically with me in the exam room. Matt: Would you get much self-reported vitals? Did people have a blood pressure cuff or anything like that? Or maybe on their smart watch? Matthew: Fair question. All of the above. I think the number of people with home blood pressure cuffs is increasing. They're pretty cheap, you can get them at a pharmacy. For decision-making, particularly around Covid things, that was last important. Same thing. There's a number. Is your blood pressure 120/80 or when you're standing up, do you feel dizzy? To me, that's a symptom correlated with relatively low blood pressure. Again, it's the same thing, that it's functional testing for patients and they can self-report their symptoms. I guess that's the difference I would say. Instead of treating to numbers, instead of treating to a specific oxygen level or treating to a specific blood pressure number, it's like, do you feel dizzy, do you feel short of breath, and in my head, I was trying to recalibrate these with okay, that usually correlates to a lower oxygen saturation or correlates to lower blood pressure. Briefly some of the other things, particularly at the height of pandemic—mid-2020s, late-2020s—you would get creative. I remember specifically there was one kid. I was like, you might have Covid. He says he feels hot. He didn’t have a home thermometer, but he had a home meat thermometer and I was like okay, [...] based on that. You're good to go. There's a fair amount of creativity that happens there as well, the first year of the pandemic. Brandon: You just brought it up and it just triggered a question that’s interesting, because you have to kind of be like a Swiss army knife, what tools are available just try to diagnose these people. Since you operate a hybrid model of both virtual and in-person, how do you feel your ability to diagnose people virtually during the pandemic when you just weren't seeing anybody in-person and then once they were able to come back and you could care for them in-person, how do you feel your accuracy was in terms of diagnosing folks? Matthew: Great question. I think one, it’s a learning skill. The ability to do virtual and diagnosis at a distance, I felt that learning curve. I was not as good at doing it in March of 2020 as I was even in December 2020. I think you learned how to do it. The two axioms that I tend to use are both around times. One time makes up for touch. The physical physical exam where you're able to listen to the heart and put hands on it and do that, you can't do that through a screen, but the nice thing and that's the other half of this axiom is like the greatest diagnostic test is time. If I see you today and you say you feel kind of run down, not so great, maybe a little short of breath, I was like, okay. We can check in tomorrow or we can check in two days from now or three days from now, and you kind of have time as a test. It’s like, okay, are you overall getting better, or worse, or about the same? You don't really have that luxury as much when you're in a urgent care or regular clinic. You kind of see the patient and by the end of your 15-minute patient visit, you have to make a decision—treat with antibiotics, don’t treat with antibiotics, send to the urgent care, don’t send to the urgent care. The luxury of being able to say, I'm not sure, let's watch it, and actually come back in one day, or two days, or three days, helps me make the diagnosis better, because I have more data points. I have 24 hours, 48 hours, 72 hours of time to say like, are you getting better, or worse, or the same, and this is more likely to be a viral illness, or a bacterial illness. Brandon: It’s just fascinating how the pandemic has moved just digital health and digital tools forward. You mentioned that you're doing maybe 5-ish virtual visits pre pandemic and then it went up to 80-100 sometimes per day, how has your practice changed in kind of the mix of virtual and in-person? Matthew: My current practice is 80/20. Four days a week, I'm practicing care virtually with my team, it's not just me. It’s myself, a nurse practitioner and a nurse all caring for a patient panel. It's a mixture of video visits and a lot of just messaging. A lot of messaging with patients online to help them walk through their different symptoms, and then one day a week I'm in clinic. We reserve those for things that truly need to be seen. Vaccines, pap smears, things that have to be done in-person that can't be done through a screen. Brandon: I guess one last follow up question at least for me on this. Now that you're operating kind of 80/20, four virtual, and one in-person. Within your organization, are you the only one that's operating in that kind of schedule or are there others? Matthew: Great question. Actually, we're a franchise model of startups. I'm the fourth pod of these different kind of a team-based virtual-first primary care group. There are four of us, each of us with our own primary care panel with our own team scattered geographically throughout the Bay Area. The reason that kind of works geographically is because we have that in-person part where it’s kind of hub and spoke of sorts. That's the hub, so we tend to have patients that are in that geographic driving-ish catchment area for that few times that you have to come in. Brandon: We have these conversations with folks all over the country every day. It seems like many providers who offer virtual care, they're starting to get more appointments on their calendar than some of the in-person folks because it's just so convenient. Would you say that that's holding true for you guys? Are you noticing any kind of difference in terms of your schedule because of the way you're offering service? Matthew: Yeah, 100%. I think you get rid of a friction point which is driving and parking. I think even to fill a slot on a virtual schedule, you can do within minutes. If you have a quick cancellation, there's a patient that can easily fill that spot versus in a traditional brick and mortar practice. If someone cancels with 20 minutes notice, the chance of you getting someone else to come in and take time off of work, drive, park, and come in to fill that slot is low. I think the no show rate is lower and then just the slot utilization is also better, because the barrier to starting an appointment is, do you have a phone, do you have internet, and can we get in touch with you? Brandon: My take away from that is that patients who are seeking care, there's a higher probability of them actually getting that care virtually than if it was in-person just due to parking, due to all these other types of circumstances and events that could happen that may prevent them. Matthew: I’ll actually take that one step further. I kind of use the, ‘this meeting could have been an email’ analogy. Think of the meetings that you [...] and you're like, this is a waste of time, this could have been an email. There are a lot of even video visits that patients have that or for a blood pressure check in, or for a medication refill, those can just be messages. Like I said, I mentioned a lot of my team's time is spent triaging messaging. That's kind of the other part, too, that we tend to tell patients is like, hey, just message us first if you need something and we can probably take care of it without even having to do a video visit. Brandon: That's a great point. It makes total sense. We try to operate within our organization, too. We kind of minimize meetings and use other modes to make things more efficient. Switching gears just a little bit because you are unique and that you are very forward-thinking, you're trying new ways of caring for patients, kind of being a leader within your organization of other physicians and the way that you care for folks, but you're also involved with some startups and different things. I know you're a mentor at MATTER and you have a background in startups. We know you're obviously passionate about medicine, healthcare, and caring for patients, but what else are you passionate about? How does that all play together? Matthew: I think I love marrying the two. It’s that idea of being, I call it a boundary spanner. I use descriptions for myself and like-minded physicians like myself where you're able to take knowledge of one just like medicine—how does medicine work, how do you treat patients, but also medical systems. I've trained in large hospital systems both in academic setting, community setting. Understanding that piece and then marrying that with all the really cool things that are possible out in the startup community like who's really pushing the envelope of ambient listening devices, a lot of the machine learning AI hype. Some of it is hype, most of it is hype, some of it is actually legitimately cool and you're able to put into, ready for primetime and ready for practice. I think for me, I like being able to (again) take my understanding of medicine and healthcare systems and then say like, what are the broken pins, what are the needs, what are these different startups that are doing things to fix that, and kind of marrying the two and being that, the go between. Matt: I know we spent quite a bit of time talking about kind of current state, what you were doing before the pandemic, how things are operating today. What do you think the future holds for telehealth? What might the next two, three, four, or five years look like? What do you think is on the horizon? Matthew: I think right now, a lot of people are looking at telehealth—again particularly video visits—as a way to substitute stuff that we do in urgent care or in a clinic office. I want to flip that in two ways. One, I actually push it both from a higher acuity and a lower acuity. I think there are a lot of things that we can just do out of the office. Being able to promote wellness, promote preventative care, and less reactive, like I have a runny nose, I want to have a video visit. I think we can increase that and move up the timeline. Again, go from reactive to proactive care, to being able to do a lot of preventive counseling wellness promotion. Again, through telehealth, meeting patients where they're at, you kind of catch them at work, or at home, and not have them (again) take time off of work, park, and come to a clinic that's more focused on sick care, and again, meet them where they're at, and provide care in the home, and promote wellness actually in the home. That's one half of it, it is kind of moving upstream, moving more preventative. The other area that I think is really, really exciting is kind of being able to do higher level of acuity things in the home. That’s the hospital at home, tele-ICU kind of idea where we take patients out of the hospital safely, obviously, that you're able to do that monitoring. When you're in a home environment with family, not eating hospital food, the ability to just heal faster, feel better, and have a better experience I think is so much better. I see it moving on the two opposite ends of the spectrum, kind of out of the clinic and then more back into the home and taking some hospital stuff and moving it into the home as well. Matt: I also think, just going back to some of the messaging you were talking about and sort of triage you're doing there, I think there are just a lot of opportunities just like you said, this meeting could have been an email. I think there are a lot of opportunities there. Is your organization operating in a value-based care model that allows you to do that or is it just some sort of extra service that you're offering patients? Matthew: Excellent question. It's interesting. The answer is yes and no. I'd say overall, the organization that I currently work with is largely legacy fee-for-service. There are hospitals in the system, the goal is to generate revenue per visit per encounter. I’m slightly actually completely protected from that in as much as our current panel. We actually only take patients that have HMO insurance. By design, we are value-based. Our goal is to actually prevent hospitalizations and ER visits and we have a lot of data and processes that help us do that with our patients. I'd say, my specific clinic that we work in, functions in a value-based mindset. I think that's really close to the only way that telehealth will thrive is to put it in that mindset, because again the goal is to not have billable video visits. The goal is to have decreased total cost of care and improve total patient wellness. Matt: It's probably going to take a really long time for these organizations to transition from fee-for-service to value-based care, but it does seem like there's a whole world of possibilities that open up because I rarely hear physicians that are doing any kind of messaging. Usually maybe the staff is looking to do some messaging because they've got an exchange of information, or forms, or book an appointment, or whatever. Obviously I think therapists that have a clientele on a regular repeat basis, they're usually texting and whatnot. But you rarely hear about care being delivered in that format. I think that is going to be a big part of the future but who knows how long that will take to move to value-based care. I think that is something extremely exciting that you're able to offer people. Matthew: One caveat that I’ll put on that is actually, I would not be able to do message-based care by myself. It's by design. We’re a team-based, value-based, virtual-first primary practice, and that team-based part is so important. I split my inbox with our nurse and our nurse practitioner. It's a team and I think that’s what makes it fun, too. I truly get to practice at the top of my license because a lot of the things that are like, can I refill this medicine? Sure. The nurse [...] it up and it goes through. Then it’s like, I have this complex question about two medication interactions, and a possibly medication side effect, and a symptom. All right, we're going to forward that to Dr. Sakumoto, you can start that one out. It's definitely a team-based thing. The patient doesn't know what level of care that they need and that's on the medical team and the care team to help sort that out. Matt: Very cool stuff. A lot of our audience is going to be decision makers, health leaders, managers, so on and so forth. You're out on the frontlines, you've been on the frontlines, you are an early adopter, a pioneer before the pandemic, and I would say still very much a pioneer with four days of virtual, one day of in-person, and the messaging, and this value-based care that you're doing. What types of things would you want to share with the leaders to help shape and guide the future of healthcare? Matthew: I appreciate that. I think the message I have is, video visits and virtual care can actually just be, I can say it's less sexy than it sounds. In the way that you have a stock portfolio and you have your stocks and bonds. Virtual care—particularly value-based virtual care—can just be your bond market. You can still make money on fee-for-service, but invest in the infrastructure to have a strong base. The reason that this resonated with me so much was the person that hired me in my current role, she had been doing it for maybe about three years prior. I was like, hey, this peak of the pandemic, how is that the virtual practice going? I told her, every other system I've seen is just getting killed during Covid because all of their surgical volumes are down financially. It's really tough. She goes, nothing's changed. In 2018, 2019, to 2020, everything has been exactly the same because we're providing virtual care and we're getting paid per patient per month. When times are good, you focus on the fee-for-service, but invest in your bond market so to speak, and I think that value-based virtual care can be that provider. Brandon: That was a great analogy. Thank you for sharing that with the group. You were quoted in a recent AMA article titled, To excel with virtual care, listen closely and with empathy. You had said that telehealth really brought back the home visit. What is missing from a virtual visit that you wish you had? Matthew: I really want to shout-out my co-presenter with that, Sarah Krug. She’s a fierce patient advocate. I think for me, I see a lot of patients, but I think that they hear a lot of patients, if that makes sense. I think getting to hear kind of her thoughts on how she perceives telehealth just from the patient's side was super, super helpful. We co-wrote a paper and we co-presented this idea of digital empathy particularly on this AMA webinar. I think pieces that we have missing from the virtual visit, one more time with the patient, I think is always nice. I think that's the biggest thing and that's just something that we wish for in medicine in general. There's so much medical stuff/administrative stuff to get to, that there isn't time to build on that personal relationship. I think that's the piece that I think particularly in primary care, makes such a big difference, being able to build that doctor-patient relationship. Brandon: That's an interesting point. Again, since you're a hybrid, do you notice any difference in the kind of relationship building or the efficiency of a visit, virtual versus in-person? Matthew: Virtual is by far and away more efficient. I think there are levels of, and I don't know if that’s just because people in their work life started doing more Zoom calls and video visit calls. But I will repeatedly get through my video visits faster than equivalent complexity patient in-person. I think it’s the patient mindset. Transactional is a little strong, but I'm sure with a couple of tasks that I want to get done versus the clinics a lot of times is both a medical encounter, but also sort of a social check-in, if that makes sense. I think it will be reflecting back and that's the difference I've seen in efficiencies. But I think working harder to make the video visit is both a social visit and a completely medical task. Balancing that is going to be important to moving forward. Brandon: We hear that often about just how efficient virtual visits are, how they can just care for more patients in a given time period than in-person. I wonder if it has anything to do with, it could take 30–60 minutes to drive to your provider's office for a 5-minute visit, and then have to drive back. I'm wondering like, I spent all this time in my car, I want to spend a little bit more time with my provider just to feel like it was really worth it versus clicking on your calendar from one appointment to the next, to the next, and you could kind of get right back to what you were doing. Matthew: I 100% think that's part of it, too. Getting your money's worth, so to speak. I worked at a couple of other startups prior to my current role. What really helped me talk with patients was the idea that, like in an office, both the patient and I knew that I needed to make my decision again by the end of that 15-minute encounter. There's that safety blanket of both myself and the patient to say like, hey, I'm not sure if you need antibiotics for this cough, but you can check in tomorrow. Again, that barrier to checking in tomorrow is so much lower that they're like, okay, yeah, that's fine. We’ll check in tomorrow. Versus if they were in the clinic with me—I’ll take you back to my in-person urgent care days—you might haggle over starting antibiotics yes or no for an extra 5–10 minutes because you have to make a decision by the time the encounter ended. Brandon: It makes a lot of sense. With all the time that you're spending caring for patients, I'm curious to know how you have so much time to spend being as active as you are on social media and really putting out valuable content for folks? I would love for you to just share with the audience because we have had the opportunity to take a glimpse at some of the stuff that you're putting out there. Could you just talk a little bit more about your passion for doing that and also how they can find you? Matthew: For sure. Social media handle is easy to find, @mattsakumoto for both Twitter and LinkedIn. Those are the main parts that I tend to, my main [...] I guess. I think for me, I owe it to social media prior to the pandemic, but I was just being so bored during the pandemic. It just got me more on to Twitter, I wanted to connect with people just because we were stuck at our houses. I think that's what got me into it. The other part, particularly Twitter, is a very vibrant community both from a medical standpoint and from a digital health innovation standpoint that I think so many people are doing cool things, sharing what they're doing. For me, that was a really good way to just keep my finger on the pulse of what's going on out there. For me, I love learning from other people and I think the other reason why I'm so active on it is in the same way I like to share things I find cool and interesting, again, particularly in the digital health realm. Brandon: I'm sure people really appreciate the time effort you put into it so thank you very much for that. I think now comes competition time. Matt: We got a little bit of fun in the store here. We've got an optical illusion today. This is from The New York Post. I'm going to bring up an image and you're going to count the number of tigers or the number of cats. I'll give you a little hint. The number’s probably a lot higher than you think. We’ll go ahead and bring it up and the audience can play along, too. I'll give you guys maybe a minute or so and you tell me how many you think you saw. Now, some of them are baked in the background. I see a lot of intensity through the cameras. Matthew: I will say the art of observation was brought back by the [...], I feel a little bit on the spot here. Brandon: I spotted a couple that are incredibly hard to see. I have to believe there's more that I'm missing. I see eight. Matt: All right we got our first answer. Matthew: I had 11. Brandon: Oh gosh. Good thing you're caring for patients and I am. Matt: Eleven is a strong answer. I think the answer is actually 12, but 11 is impressive. I’ll see if I can point them out. There are one, two in the rocks, then you've got the family of four, so that’s six. Seven in this bush over here. Eight next to the parrot, really hard to see. I think this one is suspect. You can see the eye of the tiger here, so that's nine, blurred into to the top of the trees, on the top center there. Then you get 10. There is a ghost one, another ghost one and then two more here. Is that 13? They just keep appearing. Brandon: Yeah, I'll take my whooping on that one. Matt: It was through the screen share. We'll cut you some slack. Brandon: I appreciate you throwing me a bone because I consistently lose at these things. Well, Dr. Sakumoto, thank you so much for joining us today. I know Matt and I have learned a lot from you. as I'm sure our audiences will as well. For anybody who's doing this, please feel free to hit us up with any questions or comments. In the next episode, we're going to have another great digital health thought leader for you. Please make sure to like and subscribe to this, and thank you all for watching, very much. Dr. Sakumoto, have a great rest of your day. Thank you again on behalf of all of us here at Mend and everyone watching. Matthew: Thank you. Thanks everybody. Brandon: Take care.