Text your patients | Ajay Haryani, MD

[00:00:00] Danielle: All right. Um, Ajay, it's so awesome to have you here. Thanks for joining us. We, uh, spent a lot of time trying to understand what, what your company does and what you do and, uh, come to some realizations that it's, it's very unique. And in talking to you, We got to jam out on one very small, but very big part of your business, which is the role of SMS in how you deliver care at Galileo.

So I'm stoked to get into the weeds with that with you today. I also just want to preface it that. I did some crowdsourcing of questions from other value based care operators throughout this, and we'll be peppering those in. So be ready for some hard hitting ops questions from the universe.

[00:00:43] Ajay: Let's do it.

I'm here to prevent

[00:00:45] Nikhil: more people from sending me bad

[00:00:46] Ajay: SMS texts.

[00:00:50] Danielle: Amazing. Well, Ade, maybe you can start us off here by giving us like a thousand foot view explaining what Galileo does.

Then maybe like a 500 foot view and [00:01:00] then a hundred foot view and then your role and give us an understanding of all these moving parts.

[00:01:05] Ajay: Yeah, yeah, yeah, yeah, absolutely. So, um, you know, like pie in the sky, Galileo is a full stack primary care practice. We provide primary care services across the entire patient population, uh, through a variety of clinical touch points, both virtually.

And in person across the full spectrum, and then bringing that down to the next level, we've got 2 sides of the organization. We have a kind of digital 1st virtual only side of the organization that serves, you know, you can think of kind of a 80 percent healthier side of the population. And then the side of the company that I do most of my work on.

Which is the complex care delivery organization that partners through value based care contracts with Medicare and Medicaid organizations. Um, and then zooming into my specific role here is I am a regional medical director. I oversee our four complex care markets. So I have four, uh, four clinical [00:02:00] leaders under me and then all of our frontline providers under them.

Um, and, um, yeah, I'm responsible for market performance and making sure we're, we're delivering on the excellent care that we promise.

[00:02:11] Danielle: Let's stay on the whole field based side of your business and your role. Maybe maybe you can share a little bit more about kind of what you've learned on how to build a very successful, efficient, high functioning field based team.

[00:02:26] Ajay: Yeah, also like what do the field based teams do, like for my context?

Yeah,

[00:02:30] Nikhil: sure. Are they going every day or like what do they actually do? Are they doing like complex visits? Are they doing wellness visits? Like I'm curious like what, what, what, like what do the

[00:02:40] Ajay: field teams actually

[00:02:40] Danielle: do? They do everything.

[00:02:42] Ajay: Other than everything. That's the answer to everything. We do, uh, we do a little bit of everything.

I know we've got a, we've got a variety of folks out in the field, right? So we've got kind of purely, you know, like classic primary care clinician types, um, that are [00:03:00] out doing home visits. We also see patients out of mobile clinics that we drive around in the patient communities. Uh, and then, you know, they're also doing virtual care stuff, which is It's technically not field based, but we also have a kind of community health worker phenotype called a health advocate that we pair with each of those providers that are out in the field together.

Sometimes those health advocates are deployed into homes alone or bringing in the provider through a virtual visit. Um, we have also kind of field based behavioral health resources and social work resources that are out there kind of tackling those problems as well. So they're the variety of services is pretty wide.

Um, and then they are, they're doing, you know, they're seeing patients on the cadence that's needed to keep these folks healthy and keep them at home. So higher acuity patients might be seen, you know. Every month, maybe every two months, lower acuity patients a bit wider out than that. Um, and we try to kind of provide the right provider type and resource for, for, for a given moment.

Um, so they're, they're doing that variety and they're, they're also [00:04:00] doing a mix of different types of care. So they're doing kind of primary care. what we call proactive care, thinking about, you know, routine chronic disease management, preventative health services, making sure folks are getting their colonoscopies, you know, flu shots, COVID shots, things like that.

Um, and then we also have a field component to our urgent care and reactive care that are, you know, responding to acute, um, acute incidents, acute exacerbations of chronic disease. Things that, um, if not stabilized, we'll end up with, with, with folks in the hospital. Um, so the care model kind of serves, serves both sides of that.

And like how far, like if

[00:04:37] Nikhil: you're, if I'm a physician working for Galileo, like

[00:04:40] Ajay: how much of my time in a given week do I know in advance

[00:04:44] Nikhil: versus things that like change and come up on the fly? Because I assume the urgent stuff, obviously you can't plan for, but you need some slack to like handle that, right?

So like how much is like pre planned versus like

[00:04:56] Ajay: Sort of ad hoc. It's pretty [00:05:00] templated, I would say. And like, this is one of the key components I would say in, in managing a field based team, especially a field based team that is doing, um, a number of different activities is that you really have to provide.

them a fair amount of structure to feel comfortable doing this type of work, right? If you are kind of out in the field every day, um, running around between patient homes, there has to be some level of consistency week to week and what you're doing. Otherwise this quickly becomes a very exhausting activity.

So most of our providers have a pretty good sense of the days that they're going to be in the field. Seeing patients, um, have pretty good sense of what areas they will be in on different days. Although there's a little bit of flexibility there. Um, and what days they're going to be at home doing care coordination work and or, you know, at home doing virtual visits while that that health advocates in the field.

Um, so there's, there's some slack built in, uh, there's a little more slack built into the health advocate role because they're more of the deployable resource when we think about kind of urgent care [00:06:00] activities. Um, but, but it's, you know, as far as field teams go, it's, it's, um, it's an important part of maintaining that, I would say, and that to answer your, the kind of first answer to that question, um, Danielle is like, I think one of the things I learned up front was that you have to really respect the emotional weight and the physical weight of this work.

It is, is one of the most exhausting types of kind of direct service. And work that exists is kind of being on the road for entire days at a time, seeing patients in our more rural markets, right? That's like hours of drive time. And in more urban markets, it might be, you know, public transport or ride share or things like that, or driving as well.

And ignoring that and acting like that's not a part of what's weighing on people only increases burnout. So being able to just support that mentally and physically and talk about it and bring it into the conversations come number one, um, number two, I would say. Is you [00:07:00] have to get your whole team out into the field, um, which is that like your ops folks have to get into the field and do shadowing even, you know, your providers are obviously going to be out there, but even folks who I consider kind of virtual care providers who are not typically in the field, I really try to get those folks out into the field.

Um, you know, folks that are doing more clerical clerical work at Galileo, still trying to get them out into the field. It's a very unique feeling. Um, and. It is a very difficult thing to describe without just getting folks out there to actually see what it what it feels like. So one of the examples is like, you know, we got our scheduling team out to go shadow visits for like a couple of weeks because they're the ones mapping folks on a map and trying to optimize for geo efficiency.

Also trying to get new folks in acute visits in. Um, and so having them be out there so they can really feel what it likes to, to, like, you know, take two or three trains or be on the road for hours a day, uh, was, was a super helpful thing and something that [00:08:00] we try to keep up throughout the organization.

Um, yeah, those are, those are probably the main things that, that come to mind as far as what I've learned over the past couple of years in managing field teams.

[00:08:10] Danielle: Any other core parts of managing the team that are really essential for, for making it high functioning and for folks out there that are also trying to build a field based team?

Any, any, uh, secret sauce or learnings you can share to make it

[00:08:24] Ajay: better? Yeah, I guess, you know, the last thing I'll say is that you have to be, and we can get a little more granular about what this means. Um, cause it's a, it's a floaty word I'm about to use, but you have to be really extra intentional about culture.

In a decentralized team like this, because a lot of providers are used to working in a clinic based setting, where actually the like sitting in the charting room together, typing your notes is kind of a natural, um, you know, instigator of building camaraderie and supporting each other so they can bounce clinical things off each other.

And it helps share the weight of the work that you're doing. But when you've got field teams who are in the [00:09:00] field most days of the week, um, you have to be a lot more intentional and structured about what you're doing. What in person time you're going to spend. So we have built in weekly in person time for each of our markets to spend together.

And that's a whole morning dedicated towards Team meetings, you know, we'll do lunch together, we'll do interdisciplinary case review together. So we're talking about our most difficult patients in person together and not necessarily all spread, you know, spread apart on, on, you know, virtual or, or phone.

Um, and then just, you know, a, a lot of intention towards making sure we have those like social events on the calendar and, and keeping an extra eye on folks to make sure that they're doing okay. 'cause a lot of those signals that you pick up when you work in the same office as somebody. Um, you know, you don't, you, you kind of miss, um, so that's, you know, that of course is prevalent in like the virtual, more remote world that we live in now, but just a little bit of weight added when it's care teams, uh, I think, given, given the work.

Yeah.

[00:09:57] Danielle: You, one thing I was just personally curious [00:10:00] around in that those long drives that you have through maybe more rural parts, like what do you do on those car rides? Like. What's your, what's your go to activity on a three hour car ride?

[00:10:11] Ajay: Yeah, I, um, I try to do as many patient calls as I can during those times, especially if it's folks that I know want to chat a lot, then I'll, I'll like work those in during, during the car rides.

Um, The best that I can, you know, and sometimes we may have two folks driving together, in which case one can kind of, you know, crush notes on the side on their hot spot at the same time. Or as a backup to that, it's like good decompression time between visits, kind of reflect on the visits I've had that day.

Um, and, and, you know, what, what decisions I want to make. So, so it's a whole mix of things and, and depends on the day. You need, you need

[00:10:47] Nikhil: carsick, uh, carsick avoidant doctors basically

[00:10:51] Ajay: to do that. I would just

[00:10:54] Nikhil: upchuck trying to look at a screen for three hours in the car.

[00:10:59] Ajay: And

[00:10:59] Nikhil: it's the [00:11:00] best way, like for you to reach those patients, is it like you're calling them and you already have a relationship with them? Is it like, this is sort of segue, I think, to the stuff. Which is like, when you need to, like, how do you think about, cause it sounds like you're calling patients in the car ride sometimes.

You're texting them about certain things at other times. Like, how do you choose which medium you're picking to communicate which

[00:11:23] Ajay: type of information? Yeah, it's, um, you know, during our initial visit with the patient, we have a really explicit conversation around communication preferences, and that's not only preferences of the patient, but especially in the geriatric population, it's getting a hold of, like, who are the main stakeholders in their life, right?

It's like, who's the caregiver? who's the son that makes the decisions or like the daughter that's really involved and getting their phone numbers as well and getting their, their preferences for, for communication down. Um, and then we use those to guide a lot of our care, right? So if it's, um, and I guess the other layer on top of that, or [00:12:00] the other access is the type of conversation that I'm looking to have with that patient, right?

So if I'm calling a patient to give them, And update and they have abnormal lab results and I'm going to have to prescribe a medication, right? That's a synchronous conversation. That's a phone call. That's not something I'm going to disclose over text message because there's going to be questions. You don't know what that patient is doing at the moment that you text them.

Um, and it requires like a little bit of Yeah. Emotional holding and discomfort there to work through that moment. Sometimes if I'm using that, though, as just a check in to say, like, Hey, you missed your appointment. Is everything okay? That's great for SMS because it's you can get that anytime you can respond to it anytime.

Um, you know, it's it unlocks and we'll talk more about what I think the like benefits of SMS are. Um, but I think those two things together communication preferences and then the content of the conversation that we're looking to have in that moment. Really determine, um, what route we're going to take for for a given patient.

[00:12:57] Danielle: Yeah. And in those, those two [00:13:00] examples that you gave are more outbound side of SMS, where you're kind of the one determining whether or not you'd reach out the SMS or a call, it's not the inbound side. And we'll get into that too, but you alluded to, to a point there, which was what makes SMS so impactful.

So maybe you could unpack that a bit for us and tell us your take on why you think it's so, so

[00:13:20] Ajay: great. Yeah, I think that, um, There's there's a few things that are really special about kind of unlocking both async care, but specifically SMS. In this case, um,

number one, and the kind of baseline that I think everybody knows, and we'll call out is that SMS is just very prevalent today, right?

Lots and lots of folks have access to it. More senior citizens than anybody would ever guess, like pretty effectively use SMS and also their caregivers, as I mentioned, are heavily on it all day. It is if you ask patients, especially younger patients, if you ask them or caregivers, what is your number one communication [00:14:00] preference?

SMS is almost always at the top of that list. So ignoring that is to ignore, you know, patient centric care in one of its most core ways, right? How would you like to talk to me is such a basic fundamental question. That's number one. Number two, though, is that I think it really reverses this power dynamic that we've set up in the healthcare system.

If you think about traditional care, um, it is. Built around the question of, you know, when can the provider see you and we're going to give you a 15 minute slot for you to be in one very specific location for that amount of time and they're probably going to be late and that's the only slot that you get to have, you know, a conversation with your provider.

And if you can't make it there, you don't deserve care. Is what we're telling those folks and SMS is the entire opposite of that, right? Which is I'm giving you the opportunity to text me whenever you have time to and I'm saying that I will be responsible [00:15:00] for maintaining and monitoring and being there and kind of responsive in that way when you do reach out to me.

And I think that just unlocks so much ability to move care forward. Um, you know, I give the example of when I, when I was working at the county hospital in SF, uh, this was like the number one ask of all of the residents in the clinic. It was like, why can't we just text our patients when we know that this is how they want to communicate?

Um, and then the, the, the last thing I'll say that I think is really powerful. is that it unlocks time in the care relationship. Um, in that one of the, like, constraints of visit based medicine is that you have these very short time intervals to discuss, to give information, to get information, to process, and then make decisions.

Right? These are like four independent forms of communication that each need space and time. And when you don't... When you see a pay, you know, a provider for 15 minutes every three months, [00:16:00] this happens in these hyper small chunks, and it's not really good decision making. It's, um, and it's just, it can just be really tough.

And this again, kind of flips that on its head which is if you unlock care outside of the visits and do this asynchronously. You know, you have time to process in between the patient can come back to you with a question 20 minutes after the visit ends right where typically they leave before and they they're in the parking lot and they're like, Oh, I meant to ask about this and this.

And now they can just send that text message, right? Or they can send it whenever it comes to their mind, whenever they get off work, you know, thinking especially about marginalized populations where there's, they might be working multiple jobs, um, and, or they may not have transportation access, things that are, you know, really obvious barriers to them being able to kind of step into care in this way.

Um, This, this is both that kind of convenience play of the first patient and a pure access play for that second patient, um, to be able to, to provide them care.

[00:16:57] Nikhil: It's pretty interesting also thinking about, you know, in [00:17:00] other countries. WhatsApp is such a common communication channel between docs and patients.

And, you know, just anecdotally, it's just a totally different means, first of all, means of running

your business too, right? Because if you're a doc communicating your problem through SMS,

there are like lines you got to figure out between like, when do you need to come in for a visit?

When do you need to pay for a visit?

When do you not, you know,

who's

answering the message?

Blah, blah, blah. Um, so it's, you know, you can kind of like see

analogs in other countries for what this looks like.

[00:17:33] Ajay: So one question I wanted to just follow up

[00:17:35] Nikhil: with, there's like.

There's this debate

[00:17:38] Ajay: right now, sort of flowing out of that because, uh, hospitals are charging for my chart messaging

[00:17:45] Nikhil: now, right? Which I think of as flowing out of this a little bit, right? You, you guys are in value based care arrangements for the most part. So I'm curious, like how, first of all, like [00:18:00] what your

[00:18:00] Ajay: thoughts are on billing for MyChart messaging?

Cause I can

[00:18:04] Nikhil: actually see both sides of this coin. And then also on the flip side,

[00:18:08] Ajay: like how you think about, you know, the

[00:18:11] Nikhil: value, like what you should be quote unquote, like charging or like staffing resources to answering

[00:18:17] Ajay: texts. Versus in person messages. Yeah, you know, it's the charging for my chart messages thing is like a perfect example of incentives playing out in like a pretty rigid system that does not do any new service design.

And when you put all that together, this is what you get, right? So you've got a, the health system who, um, has really no service built to manage inbound in a, in a pretty effective way, right? Horrible phone trees. That like everybody gets lost in and hangs up in and we have got in inbound epic messages that are mostly falling on provider shoulders, but sometimes getting filtered [00:19:00] by like medical assistance and things like that.

But really no intentional service design around. How do we manage the inbound? How do we float the real bigger problems to providers and the smaller problems to front desk and scheduling when you don't do any of that work? All of the work falls on the providers. And then you end up with this kind of conclusion of, well, if I'm taking up my provider's time, I need a bill for it because the opportunity cost there is a fee for service visit.

Uh, and so it's, it is understandable why people got there. Um, but it's, you know, in my mind, kind of philosophically the wrong answer to the question, which is that I think that you can still think about. Um, staffing models within health systems, even within a fee for service environment where you're actually attacking all of this inbound a little bit more, more effectively, it's easy to say from the value based care world right where I get to kind of live in a world where I can [00:20:00] choose my touch points and and like my incentives are aligned in those ways.

Um, but, uh, but yeah, I think, I think it's tough and then I think you end up increasing activation energy for folks to reach out to their providers. And like, you know, if anything is the last thing I'll say about this for a second, I, one of the things I think the most about as a primary care provider is will my patient reach out to me in a type of need.

And that is one of the most important questions. It's so much more important than, like, even them showing up for their routine visit, because, like, the moments of vulnerability and the moments of acute sickness are some of the most dangerous moments. And these are also the moments that demonstrate the highest degree of trust.

And you're taking the easiest, the low, the easiest way they could reach out to you and they could express their need to you, and then putting a fee on it. And I, that feels so wrong to me. Um, and which is why which is why I think [00:21:00] it's tough. But again, you know, I understand the mechanics behind it and and why they go there.

Um, and essentially, it's kind of as just like a behavioral stick to try to get people to do it less. Uh, but, you know, that's The wrong, wrong philosophy from my side.

just like

[00:21:15] Nikhil: Riffing on something you said earlier around the triaging trees, right?

[00:21:19] Ajay: Yeah. That, um,

[00:21:21] Nikhil: you know, hospitals don't have, I mean, I was just talking to a friend who works at Kaiser, and her biggest complaint is that there aren't Good systems of triage in the inbox for severity.

Right. Um, and I think that, I think what you said totally

[00:21:37] Ajay: resonates curious, like

[00:21:39] Nikhil: how either like the tech stack or the process that you guys have implemented to deal with inbound messaging, to figure out. triaging

[00:21:49] Ajay: and all that kind of stuff. Yeah. Yeah. No, this is one of the most important parts about, of being, of running a service like this, right?

Because if you are [00:22:00] opening up this channel of inbound and saying, you can text me, um, then like, I think that it's your, your duty at that point to both be responsive, but also be monitoring for acuity and for issues that come up. Um, and you know, I'll say of all the texts we get. Probably, you know, 20 to 30 percent of them are acute clinical symptoms.

A lot of folks will end up calling, but folks will text in with with issues. So it's, you know, how do you correctly identify those 30 percent and get them floated up to the right person? So we've built triage protocols that, you know, the staff that manage that monitor our inbound text 24 7. Follow. And we've had to kind of coach and, you know, like run workshops on this and make sure everyone feels really comfortable with it on how to identify this question of what is clinical.

Um, and taking those moments out of their hands and handing them off to either, you know, a triage RN is somebody who can then make [00:23:00] it another step and or a provider if it's something that needs to actually be addressed or, you know, digging a little bit deeper into, um, and so we've built protocols around the different types of things that can come through and most things do fall into the, you know, four or five buckets.

It's, you know, a new symptom, sometimes a value. Someone might send in like a glucose reading. Um, And be like, Hey, doc, my glucose is like 54. Should I do something about that? That needs to be escalated emergently, right? Um, you know, medication refills, which is what are urgent and what are not urgent? What could just go documented in the chart for the provider to address with like a 24 hour SLA?

Versus what is like a four hour SLA around that, that medication refill. And so we've, we've had to create trees here and then kind of coach around them to make sure that we're getting the right information floated to the, to the right folks. If a patient

[00:23:48] Nikhil: sends a meme in, which of the five does it, does it fall in?

There's just a sixth that breaks the whole process. Or do you send them for an assessment?

[00:23:57] Ajay: There's a sixth one that goes to you, Nicole. And [00:24:00] then you get to give the meme assessment on how much trouble that patient is in, and then let us know what got laid. We'll take it from there. Perfect. End of my role.

[00:24:11] Danielle: It's, uh, the ops in me is already imagining lots of different trees in the background that I'm following on some sort of flowchart software, and it's It's terrifying to think of, but at a very high level, what I'm gathering from your explanation is that SLAs are tied towards the the bucket that that person has diagnosed, maybe diagnosing is not the right word, but categorized that within those master buckets, this one.

Um, so is that, is that kind of a fair assessment? SLAs are relative to the thing that they're identifying.

[00:24:44] Nikhil: Just to rip off that point for a second. This seems like why having a longitudinal record and history with this person matters, right? Cause if you're. environment and keep switching the person you're talking to, then you don't have the context of knowing how important this [00:25:00] singular message is.

[00:25:01] Ajay: Right. Yeah. I think that's, that is right. Although, you know, there is a large aspect of triage that is like relatively commoditized, I would say. And like once, once you've been practicing as a clinician for some time, um, you know, like this is this. Function has existed for years, right? There's like triage R.

R. N. Lines. The V. A. Has had a pretty good one for many, many years. So this has has existed. There's the Briggs book is a classic book that folks by you can google it and it gives like classic triage pathways for different symptoms that come in. So the function has existed and is relatively robust and easy to follow.

Um, but you do, I think, you know, in going back to your question, Danielle, there's an S. L. A. Around laying eyes on the text, which needs to be really fast for everybody because you have to figure out what's important and not. Um, and then from there, yes, then the next round of kind of S. L. A. S. Is determined by the content of the message.

And then if that goes down the [00:26:00] clinical path, they have their own set of getting back to the patient. And, you know, how quick follow up needs to be and things like that. And then if it's a non clinical issue, you know, when that's going to be reviewed next kind of by the care team for, for action. Is this like in

[00:26:13] Nikhil: software somewhere?

Or is this like people just are trained and they

[00:26:18] Ajay: just, you know, know this? Yeah, it's a bit of both. We've got some of it built into the software, but you know, a lot of it is still like human process, you know, and kind of coaching and training around this. Just because, you know, there's some... Some aspects of the software that can help identify things that are might be symptom focused.

Um, and, you know, so there's like a little bit of, of, um, light automation there. Um, But there's enough nuance here that, like, you've, uh, it still ends up being a lot of kind of, you know, human process driven, uh, work.

[00:26:48] Danielle: So you have some sort of software that can help mildly identify potentially some of it. And then you've got training.

One thing that I would be curious around is if you have a really rigorous [00:27:00] QA process. And if you can touch on that

[00:27:03] Ajay: at all. Yeah. Yeah, absolutely. Right. Because in this case, we do, we, we've got to take this, this like aspect of patient safety very seriously. Um, you know, and, and that's, it's, the bar has to be really high there for, for kind of no, no like near miss events here.

So we, um, we do have a pretty rigorous QA process. We've, and we have weekly meetings that are just reviewing. Issues that we've had in this escalation process, and we're kind of constantly going back through constantly giving feedback to frontline staff and to the clinical teams on on what we need to do there, and we have to create a culture of, like, everybody being able to escalate these these issues because they touch everybody, right?

You can imagine that the workforce that answers that monitors the text messages is a pretty large workforce because it's monitoring 24 7 Um, and so we've got all of those different folks and we've got all the clinical folks that [00:28:00] might be getting the, uh, triage on one side. And then if something gets mistriage and goes in the wrong direction and ends up in somebody else's lap, we've got to empower that person to be like, Hey, in case this happens, this is how you get it to the right person.

And this is how you escalate that that case. So yeah, pretty, pretty rigorous, like internal processes, both culturally and tactically on a weekly basis to make sure that we are. Holding up high kind of quality standard there.

[00:28:26] Danielle: How many hands would you say, like, let's take an example of a text that comes in.

Can you maybe walk us through the different teams that are all touching that one text

[00:28:35] Ajay: message? Yeah. So it, you know, the first team that touches the text messages is the. We call them patient support associates or PSAs. Uh, they do a variety of tasks for Galileo. They're like a bit of a virtual workforce, um, that support kind of a lot of, you know, cloud based care coordination work, you could call it.

And one of the things that they do is [00:29:00] monitor our inbound text. So they're the first person to lay eyes on it. And to make that kind of initial triage decision, and if they have questions about that decision, they've got folks to escalate to that, that we can kind of pull in if it gets determined to be a clinical decision.

It'll get handed off to somebody who can do a more effective clinical triage. This is usually a triage nurse who can then kind of do the next pass and determine if this is something that truly needs to be addressed by a provider who's who's on call right now. Or whether, um, this can be wait for the primary care team to, to address it kind of, you know, within 24 hours about, uh, the nonclinical stuff usually gets documented and handed back off to the care team, um, directly from there.

So not too many, uh, different teams, although, you know, there can be different people playing that role, um, at, at, at different times, given that some of these teams are, are kind of quite large there.

[00:29:52] Danielle: Well, I wanted to, it sounds like you've got this pretty down pat now. Maybe you could give us a sense for [00:30:00] how it used to look and the story arc of how it got here, especially for folks who are trying to build a V1 of their SMS or just trying to get this off the ground that don't have several layers of triage or specialties even within there.

I think it could be helpful to kind of rewind and give us a sense for how it started.

[00:30:20] Ajay: Yeah. Yeah. You know, it followed kind of a classic art that I think happens in a lot of startups. Um, with regards to services is the kind of transition from being more decentralized and owned by the particular market or field team.

And then over time as needing to scale that getting centralized and needing to build a bit more of kind of robust process around it. Um, and there's like interesting trade offs that kind of come, come around there. So initially these would be monitored By, uh, the, the, either the care teams or the kind of local operations folks.

For a particular market, and so they would keep an eye on text messages, [00:31:00] especially throughout the day, throughout business hours. Um, and you know, they would be the ones to kind of route and escalate as needed, and you can imagine a really tight feedback loop right between the local ops and the local care teams and local care teams being very in tune with everything that's happening with their patients, uh, in a way that's like extraordinary and kind of unheard of.

In in a lot of the health care system. Um, and those care teams being really involved in, you know, Oh, I can just hop in and respond here. Um, it develops a really kind of intimate human connection with that patient, uh, through SMS, which I think is like not, I don't know, 10 years ago. I'm not sure I would be lecturing and being like the way to intimacy is through SMS.

It unlocks this sense of really being taken care of. That's, that's pretty special. So I would say that's, you know, that's how this started off and That's probably the easiest way, I would say, to get something like this off the ground, at least small scale, is thinking about, um, folks who are close to the care also kind of monitoring and being able [00:32:00] to keep track of things.

Um, But then, you know, over time, you those care teams need to be focusing on the field based work that they're doing right, and they can't be being pulled away into other tasks that are coming up. And similarly, those local ops folks have to be supporting those care team members that are out in the field and may not be best utilized by monitoring something that could be monitored by a virtual team that is not locally tied.

And so over time, then now we've kind of more robustly, um. Establish this now is being monitored by that central team and then, of course, the challenges there are you've now put another layer of communication between the patient and the care team. And how do you ensure that there's like, really good communication and those handoffs go well.

[00:32:46] Danielle: Is there something that as you look back on, Um, Some symptoms or signs that you knew it was time to move to a more, uh, centralized model.

[00:32:55] Ajay: you know, I think one of the symptoms that you start to hear in that is that like everyone [00:33:00] feels really busy all the time, but they can't totally pinpoint what's keeping them busy.

And it's like, oh, you're spread across way too many different activities and you're in reactive mode all day putting things out and we need to streamline this work a little bit more. So it's one of the things that we had kind of picked up on and one of the reasons why we centralized it. Um, you know, similar happens with scheduling often, I think in a lot of organizations where.

Scheduling starts in the field and it starts with the care team, especially when panels are small, but as you get bigger and scale, like you, you have to become kind of a centralized process that you, um, you know, scale across the org. When you do outreach to patients

[00:33:36] Nikhil: like from your end How do you decide when it's coming from the doc who has the direct relationship with the patient?

From maybe a more centralized patient assistance team. How do you like figure out what level of personalization also just like, if you've seen different response rates with different levels of personalization, like how do you pick and choose which ones, like how

[00:33:56] Ajay: to do it? Yeah, it's a tricky balance, right?

Because you [00:34:00] know, that patients and people in general, like. Will feel more connected to if they feel like they are speaking to a particular person, whether that's a particular provider or their primary care provider, but at the same time, wanting to build trust with the entire organization and with the brand of your organization, right, which is that, you know, you have a care team at Galileo or at any, you know, kind of virtual care based company who I think thinks about this a lot, especially doing async care.

Um, and so I think, you know, a good amount of communication we try to word as kind of from the from your Galileo care team from like the folks that are looking out for you is kind of the energy behind that we do. In the cases where, you know, there's a particular thing you might be following up on or a particular thing you might be asking, um, even in those [00:35:00] cases, I would say we try to keep it coming from a centralized source and kind of reference that provider to be like, Oh, hey, Dr.

Ariane. was like curious about this thing. Can you send this over? Can you send this form over whenever you have a chance to? So there's a personalization aspect to it, but you don't want to be kind of duping patients into thinking they're texting somebody back who they're not. So I think there's a level of honesty there, which is that there, and this is something we explain in all of our initial visits, which is like, there's a whole care team.

There's a whole bunch of folks who all know about you because they can see your medical record and you know, they know the things that matter to you. Um, and they want to help you. Uh, so if I'm out seeing patients, they're there to help you, right? There, there's a way to frame this that I think feels good to patients.

Um, then, then kind of instilling that, that team mindset throughout and leaning on that, I think is, is most of the time.

[00:35:57] Danielle: I have a bit of a question around that specific example that [00:36:00] you mentioned, which was, um, there's, look, we, we needed like follow up from you basically like, Hey, can you give us a call at the, when your earliest convenience in my head that translates to a ticket or some sort of open interaction or an open thing that needs to be closed out?

Who's responsible for chasing that, right? Chasing down that patient and closing the loop on something you've opened up that then you need something done from their, their end. Does that make sense?

[00:36:31] Ajay: I think that the way that we mostly approach this is that. You only really open up tickets or text somebody about something that you're comfortable receiving their response within the SLAs that we described, right?

Oh, got it. Right? So if you are like, Hey, can you send us this form? We just need to get this filled out, take a picture of it and send it to me, [00:37:00] or send me a picture of, you know, You're the medication you had a question on, but you know, it's not an urgent issue. You're cool with that coming back in through the flow that I mentioned, right?

Which is that that comes in, that patient support associate will see it, will document it in the chart, and then you can get back to it there. Um, so, you, if you were texting, if you needed information back with that level of kind of acuity and concern, you're calling a patient, is what I would say, is really how that ends up.

And your text, or you're calling them and if they don't pick up, you're texting them to say, Hey, I really need you to call me. Do you have five minutes to call me back? And then they'll call back and get transferred to you. It can kind of have that conversation. So, so there is, there is some bounds around, you know, the amount of acuity that you might be wanting to address over text message before moving to, to synchronous.

And that's the math that I would say most people do.

[00:37:57] Danielle: Yeah. And that, that tracks with your earlier [00:38:00] framework of content and communication preferences. The different content warrants different ways of, of addressing them. Um, and communication preferences obviously play a role in how, how they might respond better.

Do you have like internal data on what communication channels are most used? Out of

[00:38:20] Ajay: curiosity? Oh, that's a good question. I don't have this actual number off the top of my head. I would probably say the majority of our below 65 population is comfortable and prefers SMS, I would say. Um, and Let's say if I was just guessing, you know, 40 to 50 percent of our, uh, seniors might be comfortable with, I don't know if it would be their number one, but they would see it and respond to it, you know, as needed.

Um, especially if they aren't able to kind of make it to the phone at, at a given time. Those are guesses though. [00:39:00] Yeah. One thing

[00:39:01] Nikhil: I'll, I'll just say, this is not really a question, but we're just like idle thought

[00:39:05] Ajay: from my side. The thing that I

[00:39:08] Nikhil: always. Wish existed more in health care. Was group chats in some capacity, right?

Like group chats with all of your care team at once or a group chats with, you

[00:39:21] Ajay: know, my doctor and my insurance provider are fighting and I want to just get

[00:39:26] Nikhil: a group chat going with them to

[00:39:27] Ajay: hash this out. And

[00:39:29] Nikhil: one of the things that always has annoyed me, especially with the SMS channel, is that it is nearly impossible to do group chats versus.

It is, uh, you know, if within your app or within your EMR ecosystem, you, you can set up group chats and all this kind of stuff. Um, so this is not really a question. It's more just like an observation

[00:39:50] Ajay: that, like, I wish there were more group chats in this kind of

[00:39:53] Nikhil: industry. That's, that's my, that's my

[00:39:56] Ajay: rant in my soapbox.

Yeah, but you can, [00:40:00] we, I do this in email all the time. And it's like, we can take everything we just had about SMS and what that unlocks, and you can transfer it to the email world where, you know, most specialists. Most providers, most care managers at insurance companies are on email and I will wrangle wrangle people down and be like, Hey, I'll call the specialist office and get people on an email thread, especially for my sicker patients.

And I will put their four specialists and the care manager on that thread. And then every time they hit the hospital, I'm like, Hey, what's going on. Let's get post discharge appointments. And like, who has, who has their eyes on this person, you know, um, for some of our sickest patients, like that level of coordination is necessary.

Uh, so there, there's, I think like a bit of a larger thread there around what async can unlock in different environments, even on the care coordination side. Um, but I agree. I wish it was a lot easier on, on the SMS side across the board.

[00:40:53] Danielle: Yeah. I also think there's probably some behind the scenes group chats going on.

That aren't visible to the patient [00:41:00] where all folks are all triaging and trying to put pieces together and then one person's just like giving you that really synthesized response, but you're missing all the context behind the scenes of what they've talked about. That would be helpful.

[00:41:12] Ajay: This is imbalanced.

I want to group chat

[00:41:13] Nikhil: with all the patients that the doctor sees so I can grow steps.

[00:41:22] Danielle: When it comes to the actual SMS, I think we've skirted around the actual text content and so much of SMS can feel so automated and like 90 percent of my interactions with healthcare systems and SMS are reminders or really generic things. Do you have any tips around like small nuanced ways you can actually sound like a human when you're writing an

[00:41:43] Ajay: SMS? I think like Funny little things that make a really big difference are like a greeting, like a hi or hello, or like a hi, you know, ideally person name, if possible, um, and just making things a little more [00:42:00] conversational, right? Yeah, it's

[00:42:01] Danielle: very Swiss army knife of a tool here of ever. It checks off a lot of boxes and then there's a lot of just. Good practices and tooling internally that you've built to make sure that you're not missing anything and that you're handling it with the right level of clinical or non clinical observation and so on.

So it sounds like much more of an operations challenge than I was anticipating, honestly, because you're, you've opened up the floodgates here. Towards anything under the sun and you have to be somewhat reactive all the time towards what what's going to come inside your inbox. Yeah. Were you always 24 seven?

[00:42:42] Ajay: Yeah. So we actually, um, I mentioned the, the virtual care arm of Galileo that kind of operates. Adjacent to the complex care work that we do. Um, the care that they deliver is primarily through the Galileo app. And they do 24 7 async care through the app. [00:43:00] So that part of Galileo was actually built before we launched the complex care arm.

So we're really, I like to think of our complex care delivery org. That's kind of built on the bones of 24 7 virtual basic care and then deploying, you know, high intensity resources on top of that for the folks. Got

[00:43:18] Danielle: it. Got it. So you had that infrastructure in place,

[00:43:21] Ajay: right? That's the infrastructure and, and yeah, and the kind of the mentality around that, um, and, and things like that.

Exactly.

[00:43:28] Danielle: We're coming up on on our time here. One thing that folks really craved some information around and data points around was how you measure success and how you define value in the SMS domain. You shed light on that.

[00:43:45] Ajay: So, I think that of three different kind of buckets of value when it comes to SMS and kind of thinking about measuring that within Galileo. Number one, and most importantly, is, you know, [00:44:00] The patient safety component and making sure that we're living up to our kind of promise of high clinical care quality.

Number 2 is patient experience. And then number 3 is a bit of an internal kind of utilization metric around, you know, do we think that we're utilizing SMS as much as we should be within within our care model? On number one on the patient safety side is a lot of that triage protocol that we talked about, which is we need to feel really confident that clinical issues are not going to fall through the cracks when they're when they're coming through the doors and that they're getting to the right folks within the right amount.

Um, and so that's we and we do we do measure that we measure, you know. As far as the amount of time it takes for folks to respond to a message, how long it takes for the clinical team to get involved, and then how long it takes to be able to kind of resolve that issue. And then, in addition to that, you know, we measure, are we avoiding ED visits by that those interactions as well on the patient experience side?

I think the main thing to measure there is responsiveness, [00:45:00] which is, you know, how fast are you looking at the message and getting back to the patient? With a meaningful kind of response there, right? So you can think about the first tier of that, which is acknowledging the message, which needs to happen very, very quickly.

And then the second tier of that, which is providing kind of meaningful information, whether it is that clinical triage or an answer to the question that they have, you know, if they're asking when their next appointment is something like that, right? Did we actually answer the question? Um, and then the third aspect is, you know, I mentioned the idea of utilization here because process.

Sms is a new form of care to live, and anytime you're implementing something that your team members haven't necessarily been trained on, um, there in my mind is kind of an expectation that it's going to be underutilized for the amount that a value that it can provide. So I think about, you know, how many.

Outbound texts. Are we sending over the number of patients that we think are text capable that want to [00:46:00] text? I think about inbound outbound ratio of text messages. And, you know, because that's a good sense of are we replying to our patients on time? And are we kind of matching them in our ability to provide these these conversations?

Um. And are we texting patients who want to be texted, right? We're sending a ton of outbound that's not getting any response to it, then I think we should think a bit about whether we're using that channel kind of accurately. Um, but those are some of the main things I think about when it comes to value of SMS here.

[00:46:28] Danielle: It reminds me a lot, there's some analogies here to the chat functionality that It's I think pretty underutilized in, in healthcare because you're not always, it's not always a web based experience, but if you look at how you were to build up chat, um, on any other kind of maybe consumer based company, the speed and the speed and quality of response are two of the biggest reasons why people will jump off of chat, but SMS to me feels like a very unique way [00:47:00] to kind of take away some of what doesn't work in chat, which is that.

It's web based, or it's very easy to X out of a browser, whereas SMS kind of follows you throughout the day, but still has that sense of immediacy. So I think folks that are, are leveraging chat are trying to, this, this for me has been a new way to look at how we can bring, uh, almost like that chat like mentality, but into the SMS framework and look at SMS as an immediate.

Response, not just this async answer, whenever thing like, no, you got to be fast and you got to be accurate in the way you respond. That was a big takeaway for me in this conversation.

[00:47:36] Ajay: Yeah, I think it is really interesting, right? It takes down barriers that are existing in chat. It puts it like, you know from the platform into the pocket.

In that way, where, where they can respond when they need to, but it is like you said, it's a, it's a lot of onus to carry as an organization to, to kind of open that up, especially when you are claiming to be a clinical provider and, you know, there to support them in those ways. It's, it [00:48:00] can be a lot.

[00:48:01] Danielle: I, um, I'm very, very impressed with what you all have built.

It's, it's no small feat operationally. And, um, yeah, it's, it's really

[00:48:09] Ajay: amazing. You got any SMS hot takes? Me? SMS hot takes? When to send

[00:48:16] Nikhil: messages, what kind of messages to send, bad builds, good build. Have you seen any, like, particularly bad SMS flows without naming other companies or other industries that have used

[00:48:27] Ajay: it?

Um, I think that one of the ways to immediately recognize a bad flow, and I, it's so obvious on the patient side when this happens, I think, is when you get multiple folks that are jumping in on the, on the organization side at the same time that are saying kind of conflicting things. I think it is like the biggest buzzkill when it comes to building a relationship where like somebody says, like, thank you so much.

We're going to get that back to your care team. And at the same time, somebody asks you a question about the thing that you guys answered. And so it's one of those patient experience things [00:49:00] that like immediately any human touch that was created is out the window. It feels kind of uncanny and strange, like who am I talking to?

Is it a robot? Is it multiple people? Is it my doctor? I have no idea. And I think it makes people want to immediately disengage because it starts to really lose that touch. So that's one of the things that I, I think it's really important to kind of protect against when you're scaling SMS from within an organization.

Um, and, and outside of that, no, I just think it's a, it's like a really, really powerful, wonderful tool that, that can, can have a lot of impact. Uh, yeah, I guess my hot take is what I said earlier, which is that you can build a lot of intimacy through SMS. And, and I think that that's, I stand by it. I stand by that, that higher frequency of check ins being really important.

That's going

[00:49:49] Nikhil: to be the show episode, how to build intimacy, intimacy with SMS with

[00:49:54] Ajay: Ajay.

[00:49:56] Danielle: I have one other, one other question around just like this [00:50:00] idea of building relationships because You have an advantage when it comes to relationship building, which is obviously you being a very empathetic and easy to get along with person, but also that your company is so field based.

So you have the real human to human connection that many virtual care companies don't have right now. And so introducing SMS actually seems a lot more impersonal from the get go. So if you were to magically advise. Folks that want to bring SMS, want to bring more relationship building, but don't have that initial touchpoint to set the ground rules, understand, like, what would you do in that case to help set the right

[00:50:45] Ajay: foundation?

Right. I think to answer that. Right. You have to ask the question, what do patients actually care about? And they want their problems solved, and they want them solved quickly. And if you can do that, and you can be [00:51:00] responsive, and you can provide high quality information like we were talking about, right?

That is providing value to that patient. In a much greater way than seeing them multiple weeks later for an in person visit a lot of the time and of course you have to separate things a bit here and there right certain conversations are not appropriate for async at all and and you've got to know what needs to go where but I think the hesitation there um assumes in some environments that patient wants you Patient's priorities may not be as they actually are, which is, you know, in person care and human centric care is extremely important, but there's a lot of moments in which access convenience.

And acuity or time to, to problem being fixed, I think would, would outweigh that. And so thinking about the populations you're serving, I think is important there too.

[00:51:56] Danielle: You know, I've tried to bring SMS in my companies and one of the [00:52:00] biggest challenges is like people just don't remember your phone number or just forget your existence entirely. Do you have like a, uh, something that you do in the initial visit to like make sure that's locked in and like any, any good best practices around

[00:52:15] Ajay: that?

Yeah, we will create the contact with the patient. On their phone, and we will save it together as Galileo, your primary care office, and we will show them how to text us, or I will send them a text just from, you know, from our app real quick. So to see it go through. And so there's a little bit of coaching there, which is you're not used to reaching out to your primary care office this way, but look at what you can do.

You have to show them a bit because you're right. They won't just naturally start texting you. Even when I say that to patients, they look at me kind of skeptically, like, why would I do that? Um, and so there's absolutely a little bit of coaching there and it's from our side, you know, making sure [00:53:00] our texts are coming from the same number across markets, making sure it's a local number, right?

Thinking about things like that to make sure that. It feels trustworthy and, and, and makes sense, but using that initial in person visit as an opportunity to build the trust and kind of connect all those dots, I think is super powerful.

[00:53:17] Danielle: Yeah. That that's been something, uh, from, from multiple folks that I've talked to who focus a lot on onboarding processes and virtual care, one of the biggest tips that they, they say is don't ever leave an onboarding call.

Don't ever leave an onboarding interaction without checking off. Every single one of those details. So if there's an app involved, make sure that they've downloaded the app before you hang up on the call. If texting is a core part of your business, make sure you create that contact. Um, so I think that that framework and that, uh, checkpoint can be applied also virtually as well.

And it's just a really good reminder of those small details help extend that relationship beyond what, what goes on in your head. Cause in startups, you know, you're [00:54:00] like, Oh, you can text us, you can do all those things, but you just like. Forget that there's an actual activation moment that needs to happen.

And being super explicit is such a good lesson.

[00:54:09] Ajay: Yeah, and you know you're entering a world of noise, right? If you start entering it to SMS, and you have to be really careful to not fall into that noise. And this little creating contact showing them is just a little bit of Creating signal within that noise, uh, in that way.

And it's, I think it's worked pretty well.

[00:54:26] Danielle: Nicole, are you taking notes on that for when you want to pick up peeps?

[00:54:31] Ajay: I'm

[00:54:32] Nikhil: taking notes on how to triage my inbox.

[00:54:35] Danielle: Yeah, we'll need

[00:54:36] Ajay: it. Need someone else to

[00:54:38] Nikhil: do it. I'm

[00:54:39] Danielle: sure there's a lot of lessons on that that we could take personally. Um, any other, any thoughts here?

Last, uh, things about SMS that you feel strongly about that we didn't get to?

[00:54:51] Ajay: Um, no, I think we covered, we covered all the main things. I mean, I'm always happy to chat about this. I'm super passionate about it. And I think it's. [00:55:00] Uh, I think it's like one of the biggest care delivery unlocks of our time. So as folks are interested in it or excited about it and want to learn more, um, just like, oh, always happy to kind of nerd out on this together.

[00:55:12] Danielle: What is the best way for folks to get in touch with you should they want

[00:55:14] Ajay: to? Um, they can, uh, obviously, come on,

[00:55:22] Nikhil: geez, this is a layup.

[00:55:23] Ajay: Uh, we can, we can include a little like Mike Jones moment where I drop my cell phone number at the end of your podcast. Um, uh, yeah, easiest way you can like always hit me up on Twitter at Ajay Haryani or LinkedIn email address as well.

A Haryani.

All our great ways to, to get in touch and we'd love to chat. Yep.

[00:55:51] Danielle: Okay. Amazing. Um, that's, that's it on my end. Nikhil, do you got anything else you want to weave in and edit post production?

[00:56:00] Ajay: No, that's great.

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