Hi, I'm Joshua Elder. I'm an emergency physician and Medical Director for direct-to-consumer telemedicine at UC Davis Health. Over the past decade, I've had a variety of experiences in telemedicine which have allowed for me to understand the importance of creating institutional culture and achieving the patient outcomes we strive for. We have four main objectives today. We're going to talk about understanding culture and its role in telemedicine, to create expectations in your organization, to discuss cultural framework for your organization, and one that I have used and I think is important to understanding how to create successful culture in your telemedicine efforts and discuss feedback and how to drive it, cultural competency. Let's start with creating culture. I think culture is one of those things that we understand when it's not there. We often underestimate how much time it takes to create. I'd like to discuss an example of when there's a lack of cultural expectations and how that can have significance. You might be in a position where your health system is figuring out whether you'd like to start a telemedicine program. Many are expanding their efforts. Obviously with recent COVID, obviously the wave of telemedicine and being a very important additional framework of care that our patients both need and desire. Let's say you're starting this program, and let's say that you have the providers identified, you've identify the technology, you've defined the operations and administrative teams, and you're ready to go. Chances are you might have forgotten culture somewhere in that initial launch. Culture can be education, it can be expectations, it can be quality, it can be oversight. There's a lot of ways to create culture, but a provider showing up to their shift and expecting things to just work out because they're a great provider, IT expecting IT to just work out because they're great at what they do. It takes some practice runs and it takes feedback, and it takes a intent to create culture in the space. At the end of the day, I think one of the pillars of telemedicine I've learned and I want to share with everyone listening today, is that one of the pillars of telemedicine is the pillar of medicine, is that you need great clinical care. This is a clinical care space and we need to achieve that end. Culture is a big piece of how we drive great care in organizations. We need to be striving for it in telemedicine. An example of where I think cultural expectations do occur is where that provider shows up to their shift understanding not just how to provide care in that clinical space or in a different setting, not just how to route care and how to engage in care in an IT framework, but also the culture of, how to be prepared, how to communicate, how to move as a provider in this space. Being able to create that takes time, takes energy, but it is so well worth the investment. When that's not in place, often the initial iterations of whatever telemedicine program you're creating, are around really creating culture. I'd say taking time to think through this now is going to pay dividends long-term. How do we do that? I think there's five main pillars of creating expectations and by default, creating institutional culture. One is education. Education can be in the form of onboarding, it can be in the form of bringing people together, understanding their backgrounds, playing off different people's strengths, educating to people's weaknesses. But oftentimes we don't fully understand what education is needed until we start. A lot of telemedicine programs that are starting, I always say, put patients first, business second. In the beginning of a telemedicine program, you want to go slow out of the gates to get experience even when you directed great on-boarding and great education to your providers. Because there's going to be some unknowns, both with the technology, both with the provider and also with the patient experience. Education is a two-dimensional pathway. Some is giving feedback to the providers and the staff and the IT teams of what we hope to achieve. But then it's also getting feedback back and being educated on what service we're really providing. Not just press gaming, but reaching out to providers and reaching out to our team to understand how we can improve as we go. Creating a culture of openness, transparency and feedback is really at the forefront. I think all of this falls within the framework of education. Now, outreach. A lot of time setting expectations for our health system and for the patients we're serving is really important to creating culture. Oftentimes, patients, providers, staff, may come at this with a certain lens with how they see this and certain expectations that might come with it. The more outreach that's done to educate and both in form and create those expectations, create those boundaries, if you will, there's a better appreciation of what you can and cannot achieve in this space. A better allowance for a real authentic relationship to emerge in a virtual care platform. Marketing. Obviously, as we market, we need to market what we're creating and not what we're not. Speaking the truth as to what we can provide, and also just stating the basics of what the service does, can often help providers and the IT teams and support staff to really figure out how to achieve what the ends of the goal are. Sometimes it starts with creating a vision statement. Sometimes it starts with creating some feedback from the team, not just those leading the team, but from the team around what is being marketed to make sure that the two are [inaudible] policies and procedures is often something that comes after an iteration or a cycle of starting things up. I'd say you can start often with policies and procedures that already exist. Often institutions don't have policies and procedures created specifically for telemedicine. But I think that word policies of procedures brings up an important point I mentioned earlier, which is that, the expectation and the outcomes we're trying to achieve in telemedicine need to be on par with the expectations and outcomes we try to achieve in brick and mortar healthcare and person health care. Policies and procedures are a certain way to create a legitimacy and an expectation that is shared culturally and institutional. Quality improvement efforts, no matter your best intent and your best set-up and all the energy you spend, there will always be curved balls in the space. The hidden spaces that you are not yet aware of, of patients that are being seen in a virtual space that you may come to find out that something isn't getting done the way you want. Quality improvement and having a mechanism for that very important and having a diverse set of stakeholders that are a part of your team as part of that quality improvement effort. Often I have found that the majority of conversations come around efficiency, around coordination, around how to improve technology. Very rarely do you see a major quality issue from a medical standpoint. But how to foster those conversations, quality improvement space can start that process.