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Melanie Cole, MS (Host): UAB Medcast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s post-test.

UAB Medicine has partnered with Seamless MD, a patient engagement and care management platform in an effort to boost telemedicine capabilities. Here to tell us about that is Dr. Daniel Chu. He’s an assistant professor in the division of gastrointestinal surgery at UAB Medicine. Dr. Chu, welcome to the show. Tell us a little bit about the rationale, about the ERAS programs. And specifically, at UAB, how they got started and what did the health systems see as far as improvements in things like length of stay and pain scores for colorectal surgery patients.

Daniel Chu, MD (Guest): Well thank you very much for having me on the show. Enhance recovery programs is a multi-mobile pathway that was designed to recover patients better and faster after major surgery. And you're right, it really started in colorectal surgery because these patients had the longest length of stays, had the most complications. Just because you're dealing with the colon and small bowel and with lots of stool.

What was seen with enhanced recovery programs is major reductions in length of stay, as you have described, and also some other improvements such as the use of non-opioid medications. Enhanced recovery programs across the world, not just at our institutions, has really been shown to consistently improve this recovery and improve all of these metrics that patients love, and hospital systems love.

Where we’re at now at UAB is that we have had enhanced recovery for about four years now, in colorectal and multiple other surgical specialties. We’ve really looked at this at version 1.0. This is really our first go at this. We’ve had great results. Major reductions in length of stay, reductions in cost. All things that we love to see, but we actually think that we can do better than this. That we can even improve upon this version one to version 2.0. So that’s where patient centered technology, like Seamless, comes into play.

One of the things that we’ve known with enhanced recovery is that there’s about 15 to 20 different individual processes that happen within this recovery. If you are adherent or you follow each of these, the more that you follow the better the recovery. Out of 20, if you follow 20 of those instructions and procedures, you do really well. We’ve found that these technologies, like patient centered technology like Seamless, helps patients better understand the process and what it means to recover. It can therefore help improve the adherent to each of these kinds of processes. So that’s where we’re really hoping that this patient centered technology can go.

Essentially it further improves the patient’s experience after major surgery. Then, because of that, it will improve compliant with enhanced recovery processes. Then overall even further improvements in experiences and satisfaction for patients.

Host: So interesting. When you're speaking about adherence and compliance and how that really does work if they adhere to those things that ERAS dictates after surgery. Tell us a little bit, Dr. Chu. What is Seamless MD and how are you partnered with them?

Dr. Chu: Yeah. So, the way I describe Seamless is it falls under the umbrella of patient centered technology. So, this is the mobile technology that goes on your phone, it goes on the internet. You have your own login. It’s almost like a Map My Run, those exercise programs that are out there that you can follow. It does the same thing for your recovery after surgery. So, to be specific, patients once they're enrolled with Seamless—and we approach all of our patients for this possibility—they would install it, have their log in name from the day that we meet them in the clinic. Essentially it follows the patients all the way through the entire journey of surgery until the very end, and even until 30 days after they're discharged from the hospital. It basically helps educate patients, even before the operation day.

It educates them, teaches them about what to expect. I think instructions on what to do, such as taking your bowel prep and how to do it. It gets them to the operation. Even on the night of the operation, the program will help ask patients how they're doing. It can help remind patients on whether they’ve walked, what their pain control is like, how much opioids that they might be taking. It provides this real time feedback. Patients really feel like they're engaged with the whole recovery process and with all the providers that are involved.

We partnered with them about a year ago, with Seamless, in colorectal surgery in particular. Partly because thought we could take this to the next level. This platform is incredibly sophisticated. It’s very beautifully designed for patients. It’s a Toronto based program, invented in Toronto by an MD, Dr. Joshua Liu. They’ve had great results in Canada and some of the other institutions. We’re literally the first in the deep south here to have this program. We’ve expanded this now with a grant that was funded through the UAB Health Systems to help expand Seamless, not only in colorectal but also to other specialties including cardiac surgeries, thoracic surgery, and gynecology and oncology. These are all major service lines that I think could benefit from having this technology to help empower patients and get them more engaged in surgery, which is honestly very confusing to many people.

Host: Well it certainly is. So, is Seamless user friendly, Dr. Chu? Also, what about staff time? Does this help to save some of the staff time? Can you see what they’ve recording when they’re recording it in real time? Tell us a little bit about how that works with patient interface.

Dr. Chu: Absolutely. So, it’s extremely user friendly. That’s part of the reason why we partnered with them is that we really liked how it looked just from the very get-go. A lot of our work and health literacy really plays a role here too because we know the patients have the whole spectrum of literacy in their ability and capacity to understand information. Surgery is very, very confusing. The way we've presented the information to patients before hasn’t been very well. Seamless helps us do it better. It’s constantly engaged with patients. There’s an incredible education library that is there that’s very much picture based. Very visual instead of being text heavy. That patients can help understand how to take the bowel prep, how to change an ostomy. So that’s there, and that takes some of the load off of the nurses that we have in terms of education.

One of the things that seamless does too is it’s built real time. So literally we can log in and see all of our patients, almost like on a radar screen, who have Seamless installed. We can see what patients are saying in terms of how they feel, what their pain responses are like, if there’re any issues. It can literally be a red alert that’s set for patient’s that are having issues who are responding to questions saying I have an issue. That for now prompts basically a note to one of our nurses who can actually then get that red alert and then call the patient and follow up and help take care of the issue.

This actually happened last week where we had a patient respond to a Seamless question not doing well and my nurse was able to almost immediately respond within 10 minutes. The patient was so surprised, but it really got that patient out of trouble. That’s really where we see Seamless as playing a role here.

Host: So as far as what you’ve seen already, Dr. Chu. Obviously, this is, as you say, very user-friendly, but have you seen things like preventing readmissions or ER visits after surgery? Or even about preventing surgery cancellations. What are some of the patient reported outcomes?

Dr. Chu: Yeah, so that’s a great question. That’s an active part of the current project that we’re doing with this expansion and continued partnership with Seamless. We’ve seen it from a patient satisfaction standpoint with the use of the program and the use of the surgical services here at UAB over a 90%+ satisfaction. When patients get this program on their phone or have their login on the computer, they're incredibly engaged. Everyone uses it. Not just the patients, but their family members too in cases where patients themselves might have some difficulty using this technology. So, some of those patients reported outcomes of satisfaction is very good.

From a cancellation standpoint, I haven’t actually looked at that data quite yet. But that’s a great area to look at. I will say that all of our Seamless patients have had surgery. So, anyone who has Seamless has had an operation. So, I guess you could say it has a 100% there.

But some of the other technologies and outcomes that we’re looking at are things such as opioid use. Opioid crisis is huge in the United States. Surgeons are responsible for a lot of this. With Seamless, we’re actually able to chart the number of opioids that patients are using. The patients can even tell us through this application how many pills they're using. So, we actually have a map now that we can see across. We’ve had over 200 patients right now through colorectal in Seamless. We can kind of track globally what the common opioid utilization behaviors are. That can help us tailor our own opioid prescriptions that we give patients after colorectal. So, this app is really powerful, and it gives us this link to patients that patients really feel empowered to use. They can actually tell us things directly that we get immediately.

Host: That’s really cool. Technology is amazing. Dr. Chu as you wrap it up for us, tell us where you see telemedicine? And across all service lines and not just in colorectal surgery, where you see telemedicine and companies like Seamless MD and how they all fit together to make this cohesive multidisciplinary comprehensive care for patients so that it does reduce some of the complications we were discussing?

Dr. Chu: Yeah, absolutely. So, I think the future in medicine is going to hinge on technology. Telemedicine is, as you described, really nicely the umbrella term that will be used. Seamless is a part of that. How we envision this in the future here at UAB, Seamless takes care of the whole [inaudible] journey. It sort of is a foundation. It starts with the patient is in a clinic and it follows them to the operating day and then post-op. So, it’s a nice net and it engages patients throughout their whole journey.

What we can do with the other technology that’s out here, and UAB is really at the forefront with Dr. Eric Wallace and a lot of this technology. There are other technologies, applications that can build upon this. For example, besides Seamless UAB also has other programs that actually are more video based. So, if a red alert goes off on Seamless, for example, that can prompt the nurse’s attention. The nurses can then use some of these other technologies that’s almost like a virtual room. It can basically send a link through text messaging to the patient that they can click on that opens up within a program a HIPPA compliant and secure video communication channel where you can actually video with the providers or with a nurse and show each other hey my wound looks like this or my ostomy looks like this. What can we do? So many of our patients at UAB live far away, five hours/six hours away, and this is way more convenient.

What you're talking about right now, telemedicine, is something I think that we’re really just trialing right now. In fact, some of us had just gotten privileges within this world and we’re going to be test trialing it in the next couple of months. They're having remote visits where patients don’t physically come here, but I can see them in their home or at a facility that’s closer to them. I think telemedicine, such as a very accomplished technology like Seamless as kind of a platform and then building upon it with these other add-on pieces is where it’s gonna be going because of a coordinated care program for our surgical patients, especially taking account for all the distances that people have to travel.

Host: Well it certainly does. Fascinating Dr. Chu. An absolutely fascinating topic. Thank you so much for joining us today and explaining where you see the future of telemedicine going and how UAB medicine is using Seamless MD to really connect with their patients and increase compliance and help with ERAS. So, thank you again so much. A community physician can refer a patient to UAB by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You're listening to UAB Medcast. For more information on resources available at UAB Medicine, you can go to uabmedicine.org/physician. That’s uabmedicine.org/physician. This is Melanie Cole. Thanks so much for tuning in today.