DRAGONBERRY: Welcome to The Vent room where respiratory therapists can come and get a little inspiration. I’m your host Dr. Tabatha Dragonberry. Our guest today is going to be Curt Merriman. He is the chief sales officer at rtNOW which is, essentially, the first turnkey respiratory therapy telehealth solution that I’m personally aware of. I think it’s an innovative way to bring respiratory therapy farther into the digital age. Curt, can you tell me a little bit about how the idea of rtNOW came about?
MERRIMAN: Oh, absolutely. Tabatha, thank you for having me today, I appreciate the opportunity and what you’re doing with The Vent Room. So back in 2016, as you mentioned, I’m a respiratory therapist. Myself and some of my other business colleagues were getting requests from our respiratory therapy staffing company to help staff rural hospitals and healthcare institutions when they’d have new admissions for COPDs going through an exacerbation. And, unfortunately, we did not have therapists just readily available to jump in their car and drive three and a half hours to go see those patients and then drive back home. So we came up with the idea, “Well, why can’t we utilize the respiratory therapists’ critical thinking skills and our unique skill set in a telehealth format to provide our knowledge in consultation remotely via our virtual video chat?”
So we initiated some of our planning in August of 2016. We opened up our first pilot in a small town in southwestern Minnesota, Sleepy Eye, and initiated with our critical access hospital there rtNOW telehealth. And we were there for about four and a half months, and during that pilot project we found success, and basically, acknowledged our concept was actually possible and achievable.
DRAGONBERRY: That sounds amazing. I know there’s several types of telehealth. You have provider to consumer, provider to provider, and remote monitoring solutions with that. Yours is more of a provider to provider, or also that, provider to patient?
MERRIMAN: Well, so we’re actually more of the live video conferencing synchronous mode. At this point in time, we’re primarily working directly with institutions whether they be small critical-access hospitals or skilled facilities that do not have respiratory therapists either available to them 24 hours a day and in some cases, they just do not have respiratory therapists available to them at all. We don’t intend nor do we think that we can replace the boots on the ground so to speak, of a respiratory therapist , but we have significant shortages. I think all of us are aware of respiratory therapy personnel across the country and, especially in rural America to recruit and retain individuals is a challenge.
So most of our work is done as live video conferencing. We’re communicating and working with the nurse or the provider at the bedside as well as speaking with the patient. At this point in time, we’re not in the home setting although there’re some new avenues coming about with remote patient monitoring that you had mentioned with some codes that may allow that to be a more successful advantage for telerespiratory to actually be seeing these patients in their homes to help eliminate hospital readmissions or, at least redu them.
So with the goal of using evidence-based practice, we’re always focused on those outcomes.
DRAGONBERRY: What have the outcomes been for the rtNOW services?
MERRIMAN: Actually, when we first got into this, we weren’t quite sure what we would come up with. And what we found is, even during that first pilot study of the four and a half months, that particular hospital identified– the nurses identified, themselves, three patients that they would have transferred out that they were able to keep because they utilized rtNOW, the telerespiratory therapist, to help them achieve successful non-invasive ventilation on patients and keep them there at the hospital and not having to transport them out.
DRAGONBERRY: Which is great for that small-world community because, then, they’re keeping the money within their organization not having to ship those patients out.
MERRIMAN: Exactly. And it’s not only just the money, but the community hospitals really play an integral part of that community. I mean, they’re typically one of the larger employers within that community, and they have family members that they’re taking care of. And one of the examples that we talk about in some of our studies happened over their Christmas holiday, and a COPD patient that exacerbated was able to be kept there on-site at their local hospital. The family was able to visit them without having to travel 60-plus miles to a larger tertiary care facility.
DRAGONBERRY: And that, again, goes to that holistic care of taking care of not just the patient, but the family and keeping them within their community because they feel safe.
DRAGONBERRY: With your services, are they being sought out by organizations now? Are there organizations saying, “Hey, we are needing to fill in these gaps.”
MERRIMAN: It is starting to occur that way because, as you had mentioned, we believe we’re the first very specific telerespiratory providers in the market place starting back in 2016. And it’s taken a few years just to get people aware of it, and we’re now actually getting some organic word of mouth growth with people hearing about the service and about telehealth being able to be provided for respiratory therapy patients and that. So it’s starting to come through, and we’re happy to see that. It’s been exciting.
DRAGONBERRY: So on your team, how many respiratory therapist do you have at a time or taking care of these remote patients?
MERRIMAN: Oh, great question, Tabatha. So we have 21 respiratory therapists that are providing services 24/7, 365, for our rtNOW. Those 21 therapists are typically working in point positions in various hospitals, and then, do extra above and beyond time working with rtNOW and the telehealth aspect of it. We do have a couple of people that are going to school, and rtNOW is their primary employment as well. At this point in time, with our call volumes, we typically have one therapist on at a time to cover the calls that may be coming in. But we do have redundancy and backup plans in place, so if there’s multiple calls occurring at once, that we have other therapists that we can make available to initiate and take those video chat calls.
DRAGONBERRY: In doing some research for the show, I found an American Academy of Ambulatory Nursing has a telehealth certification. I also found that there was a certification for telehealth coordinators. Just like any profession, there are different organizations, such as the American Telemedicine Association that also accredit courses. Do you believe that RTs could have their own telehealth certification one day.
MERRIMAN: I definitely think so. It does take a unique set of skills to successfully do telehealth as a respiratory therapist. It’s a different type of patient care, where we’re used to being the hands-on in the room, can see, talk to the patient, be able to assess what’s happening in the whole environment just by walking into the room. And it does take a little bit of additional training that we provide for our staff, heightening their awareness of being observant when they’re asking the nurse to move the technology, we’re using an iPad on a stand, and moving that around in the rooms. We have a good view of the patient environment, the patient, the monitoring, what’s going on in the surroundings there. And then heightening their communications skills to asking more in-depth discerning questions so that we can get a better picture. We’ll typically also have the ability to remote into the facilities EMR to get histories and that, but when we’re dealing with the emergency department where there’s not a lot of time involved and it’s more of a “just in time, we need your assistance right now,” we’re doing a lot of communication with the nurse and the provider and the patient right there in the room.
DRAGONBERRY: So with that experience and education, if there is a respiratory therapist that’s kind of looking at this as an option for their career tract, what do they need to be doing now? What education or any additional skills that they could be growing now, so that they can say, “You know what, in one or two years, maybe my old bones can’t do the floor care anymore,” or just people want to have that option of working from home because I know on social media I’ve seen questions about that, and people are always like, “I’m looking to transition, what can I do as an RT from home?” What skills do they need to start growing now?
MERRIMAN: Sure. There is information with– you had mentioned the American Telehealth Association and some others that have information about kind of enhancing your skill set. It’s still something that’s relatively new because telehealth is still a very new field in healthcare for us and specifically for respiratory therapists. One of the things that I can encourage is if you do go to our website we do have a section on there called the rtNOW Bullpen, and basically it’s a community where people can kind of talk with one another, learn a little bit more about telehealth. There’s also a LinkedIn and facebook area which is just under telerespiratory that, again, is not specific to rtNOW but is just for anybody interested for colleagues and peers to discuss amongst themselves and get ideas, share ideas. And hopefully as that community grows and people that are doing more of the telehealth themselves can be sharing their experiences also through that to get the backgrounds. And I do see that we’ll find more certifications coming available.
DRAGONBERRY: My aunt is a remote-nurse-case manager, and she holds licenses in 14 different states where she manages cases. How does the licensure work for the rtNOW therapists?
MERRIMAN: Very similarly. There’s really not at this point in time a telehealth reciprocity for a therapist to see patients in different states without requiring them to seek those licensees, so as I mentioned, we have a staff of about 21. The majority of our therapists have multiple-state licenses, and when we take on a new state will not only have our therapist gain a license for that state, but we’ll also do recruitment within that state itself of therapists that are currently working there. And that’s part of what the bullpen is all about, it’s just kind of prepping as things grow and expand. Right now, our company is Minnesota, Wisconsin, Missouri, soon to be Michigan. And as we gain more states, we’re actively recruiting and looking for therapists that have an interest and have the skill sets that we feel are important.
DRAGONBERRY: So I know that you were saying that in your education, you’re kind of focusing on that heightened communication and being able to observe differently because you’re not in that environment. What kind of education and training and hardware is supplied to somebody that is a new hire, as your company is expanding?
MERRIMAN: Great question. So we have online training that we’ve put together, that when we have a therapist that we’ve vetted and we feel that both they and our leadership team feels like it’s a good fit, they’re sent a link for some online training and education, which is just some basic information. It can be some things as simple as, what is the lighting like in the room that you’re going to be doing your video chatting, their Telehealth conferences? Making sure that it’s HIPAA compliant, PHI compliant. So that it’s a secluded area, at least an area that can be closed off so that people aren’t hearing information that they shouldn’t be hearing, or seeing it as well. Just kind of, I think I mentioned, the lighting, speaker sound, that type of thing. Just from a technical aspect, make sure that everything looks professional, sounds, and is professional from that standpoint. So they go through that training, some education on some of the communication skills to help heighten their questions that they might be asking. And then they do a one-on-one. Everything that we do is web-based, or browser-based, so they get our system set up on their computers and then we do some one-on-one training just to make sure that they’re comfortable, everything is functioning, they know how to navigate things through. One of the things that we do, because the therapists obviously have not set foot in any of these institutions, is when we on-board a customer, we’re seeking information from an internal champion at that facility to give us information on the respiratory equipment that they’re using, any of their respiratory medications, what’s in their formulary. So that when the therapist is seeing that patient, we’re making recommendations based on the equipment, the best practices that they have in place, any protocols they have in place, that type of thing. So we’re functioning just as if we were there on site.
DRAGONBERRY: I can imagine it in my head. I think it’s just the next step. I kind of think like Star Trek, you’re going where no respiratory therapist has ever gone before, right?
MERRIMAN: [laughter] That’s a great analogy. That’s fun.
DRAGONBERRY: Because I’m just imagine just having to work through that, and you’re seeing a patient and caring for them from however many, either thousands of miles away or hundreds of miles away, and that you’re impacting and affecting the care. And the facility’s happy to have you there and they’re wanting to have you there, even though you aren’t physically there.
MERRIMAN: Correct. There’s often times skepticism within the organization when they first start with our telerespiratory service. And many times, the nurses are wondering, well, how can you actually do this and really be of service to us via video chat? And after the nurses experience or providers experience the calls, the comments that we get are, “Wow. I didn’t realize how much you could actually do via a video chat and helping me at the bedside and just giving me the confidence that I needed to care for that patient in that crucial time when– oftentimes, their is an increase work of breathing and they’re dyspnic. They’re just having a terrible time and the amount of stress in that scenario is, oftentimes, quite high, and we can just help alleviate that with a therapist right there walking through with them.
DRAGONBERRY: Can you walk me through, like a consult, one of the RT-now-therapist may encounter?
MERRIMAN: Sure. So the two primary types of calls that we’ve experienced since we’ve started this is NIV or a new respiratory patient being admitted to the facility and the telerespiratory therapist performing an RCAT, a respiratory care assess and treat– or however you might term it. Each facility can name them a little bit differently, but. Basically, we’re viewing the medical record, looking what their histories are, what the medications they’ve been on, and their I’s and O’s, their current status, X-rays, all the type of information from a clinical standpoint just like you would be as a therapist in the facility, reviewing that before you go into the room. We’d ask the nurse, “Okay. Let’s go ahead and bring us to the room via our technology and arrange the iPad so that we can communicate easily with the patient and have a discussion with them,” to find out occupational exposures, just like you would if you were walking in the room.
Most of the time– at this point in time, we’re relying on the nurse’s auscultation techniques. And one of the things that our therapists are doing is asking, again, a lot of discerning questions. As many of us know, that one person’s definition of a wheeze is not the same as the next person sitting by them. So the therapists are asking some really discerning questions about what that wheeze or that particular breath sound actually sounded like to determine what it is that they’re looking for. There are technologies, Bluetooth stethoscopes that we’ve done some evaluation on and we’ll probably be deploying them soon, actually. But in the meantime, we’re just relying on the nurse’s communication with us and what they’re hearing. And we’ll then make the recommendations remotely in the medical record as if we were a therapist working right there at the bedside and make the recommendations for medications, treatment modalities, frequency, that type of thing, any airway clearance that may be required, supplemental oxygen, all those kind of things.
DRAGONBERRY: So we all know that advances in healthcare move faster than government legislation. Where you guys are working now and operating, is there any government regulations that it’s making it easier to provide this service or is it just such an untapped market that we’re kind of cowboys figuring it out as we go because there isn’t regulations?
MERRIMAN: Yeah. That’s a great question. So so far, there really has not been a lot of regulations that we can follow from a respiratory therapist standpoint and reimbursement there. There are currently a couple of different pieces of legislation in DC, the BREATHE Act and the CONNECT ACT, probably the two most prominent ones. Both of those acts, if they get forwarded on and pass, would allow and identify a respiratory therapist as being a telehealth provider. And that would open up something significant doors for us to be able to really take what we’re doing to the next level, and it also would identify the patient’s home as a location that we could be providing those services to those individuals. So again, by doing the virtual visits, we could help do that chronic disease management, education, self-management care, and just ensuring that the patient safety in their home surroundings and keep them out of the hospital and in their own environment, can truly learn better about their disease process and how to manage it better, and again help reduce the hospital readmission’s. There are some new things that have changed in this past year with remote patient monitoring, with some codes that I think are really going to play into the whole telehealth process. So it’s allowing respiratory therapists to be a part of that and seeking out in obtaining data from a patient that we can use those early indicators for them going into having some difficulties in trying to get them before, I mean, or contact them before they’re being rushed to the emergency room.
DRAGONBERRY: With some of those acts, I know previously that they required a bachelors degree. Do you know the ones that are currently pushing through with the CONNECT or BREATHE, is it saying that that respiratory therapist needs to have a bachelors degree to be considered for the reimbursement purposes?
MERRIMAN: Well, neither of those acts have a– because they haven’t been passed yet into law, those kinds of regulations and rules will be written after the fact. But what we do know is that typically, for any type of reimbursement from a healthcare professional, the standard practice is to have a Bachelors of Science degree, whether it’s specifically in respiratory therapy, or it may be just a Bachelor of Science in some other health-related degree along with a respiratory therapy diploma that they have and a degree as well. So those details have not been worked out, but it’s pretty much the standard practice that it would require a Bachelors of Science or greater. Masters, PhD, that type of thing.
DRAGONBERRY: So I know a while back, I actually took a telehealth course, and the professor mentioned a company that was in New Zealand, and they hired American doctors, relocated them overseas to provide telemedicine in the US. Because when it’s nighttime in the US, it’s daytime in New Zealand. So the whole thought process and their promotion was that, you’re always going to get that fresh doctor versus waking somebody up in the middle of the night. And we should be sleeping, naturally, I know that night shift has wreaked some havoc on my body. So what do you think on that whole aspect of that Innovative–? We’re taking telehealth, and now it’s an even totally different innovative thought.
MERRIMAN: Well, that’s actually quite interesting, and I’ve read about some of that as well, and it does make some good sense to be able to do that. A lot of it is really getting it to kind of come down to the logistics and the reimbursement and the fiscal ability to make that happen. Because we are a global world now, we could be providing those kinds of services with providers here in the United States for people on the other side of the world. Again, that would be the day shift there, the night shift here and vice versa. And it could work out quite well. So far, with our experiences with the therapists that are sometimes being woken up in the middle of the night, we have not had areas of concern with that. The vast majority of the calls seem to come in more on evenings and on day shifts and on weekends. Some of the night shifts, but not as many as I think we initially anticipated.
DRAGONBERRY: That’s interesting to know because I feel like– I don’t know, when I worked night shifts, 2:00 AM seems to be the magic hour.
MERRIMAN: Well, when we do get the nighttime calls, that’s about the time that they do come through, you are correct.
DRAGONBERRY: I think it’s interesting how those types of trends, you notice them when you’ve been working in the industry for a while.
MERRIMAN: Yes. Exactly.
DRAGONBERRY: Curt, thank you for joining us here at the vent room. It’s great to see RTs are making strides in telehealth and being successful and showing that they’re other opportunities, and that we can move to the bedside but in a digital perspective.
MERRIMAN: Well thank you. I’ve been a respiratory therapist for 40 years, and I still believe that this profession offers many opportunities in– the telehealth is now one of the newest forms that I think is certainly going to be in the forefront for many years to come. And I appreciate you reaching out to me and taking the time to chat about respiratory and how RT’s , and definitely take a part in the continuum of care.
DRAGONBERRY: Thank you, Curt