The Operational Side of Great Care: Scalable Workflows and Technology for Telehealth Teams

# TextExpander Webinar: Clinical Workflows in Telehealth

**Featuring:** Amy Schwartz (Customer Marketing Manager, TextExpander) and Dr. James Rees (Founder, 20 Mile Medical)

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**Amy Schwartz:** Hello everyone. Welcome to our webinar. Thank you so much for joining us today. I'm going to go ahead and make sure that we are recording so that we have a recording to send to you guys after.

Thanks so much for joining us. My name is Amy Schwartz. I'm the customer marketing manager for TextExpander, and I am thrilled to have with me today Dr. James Rees.

**Dr. James Rees:** Hello.

**Amy:** Dr. Rees is a telehealth physician who has built a practice with a genuine philosophy around clinical workflow design, and he's here to share with us what he's learned, what he's built, and how other digital health operators can apply it.

Dr. Rees, welcome. Can you tell us a little bit about 20 Mile Medical and what you've built?

**Dr. Rees:** Thanks, Amy. Thanks for having me on today. I'm really happy to be here.

20 Mile Medical is a telehealth practice that I founded with one core belief: that quality of patient care really shouldn't depend on who happens to be on that day or what provider is on shift.

At 20 Mile Medical, we do everything from urgent care to mental health to overall wellness, including weight loss and peptides. We do it all exclusively with telehealth and, for the most part, with TextExpander.

After about eight years of working across lots of different platforms, I really needed to build a system that was quick and effective, but also compliant and maintained compassionate care, which is really hard when you're in the telehealth space. So I started using TextExpander early on, and I started building upon it over the years.

Our name actually comes from serving our local community. That's how we started. 20 Mile is our local street here, and we created a telehealth platform so that it was easy for people to access medicine. Since then, we've expanded to 37 states, so we're really up and going now. I still use those snippets, and I still use TextExpander, and over time, I just keep improving upon it.

I pass all that eight years of knowledge and experience with TextExpander onto my PAs and providers that I hire. It's become very robust, but I've also developed some strategies to address some of the deficiencies we find in telehealth.

**Amy:** Awesome. Well, it's so good to have you today. Thank you so much for joining us. It's a good thing that a lot of you are providers and are also in leadership, because today's content is really focused around something that may not sound exciting on the surface—clinical workflows and documentation. But as you know, it's one of the most powerful levers for patient safety, provider retention, and delivering consistent care at scale.

If you're running or building a telehealth organization, you know the landscape has changed fast. Providers are working across multiple platforms. Patients expect seamless, consistent experiences, and organizations are under enormous pressure to deliver quality care at scale without burning through their clinical teams to do it.

So Dr. Rees, you started 20 Mile Medical with a clear vision of how telehealth practices should be run. What did you see broken in the way that most organizations approach clinical workflows?

**Dr. Rees:** Thanks, Amy. The big thing is that we have really great clinicians, but they're just kind of left to figure it out on their own. You hire great PAs or nurse practitioners, and you hand them a login and a patient queue, and you assume that the brief clinical training that oriented them to the program was enough to provide an excellent, consistent, high-quality, compassionate encounter.

Clinically, the providers are excellent, but the documentation, communication, and all the follow-up was kind of improvised. That really needed to be fixed if we wanted to maintain our goals for patient care.

The result was that every provider had their own version. Some were really meticulous. Some were really fast, but they missed out on things—patient safety being a big one. The patients themselves experienced completely different interactions depending on who they saw, sometimes requesting one provider over the other, and that really broke the relationship for telehealth.

There was no minimum standard that every patient was guaranteed, other than some brief protocols you're given when you hire on. There was no floor, no minimum. Over time, providers start compensating for this. They start building their own systems and their own shortcuts, which is great, but that's not scalable and that's not teachable.

You might really appreciate one way a provider interacts or one snippet that they use, but they created it. You really needed a way for this to be more scalable, especially in the telehealth spectrum. When you bring on a new provider, you're starting from zero, you're starting from scratch again, and you don't really know what output you're going to get.

That's what I wanted to fix—not just to make the system more efficient, but because the variability you had became a patient safety issue, and it really needed to be addressed.

**Amy:** That's such an important reframe—that standardization isn't just for efficiency, but it's a patient safety issue. Dr. Rees, can you take us a little deeper into your insights into standardization as patient safety?

**Dr. Rees:** When we talk about standardized workflow, the knee-jerk reaction from a lot of clinicians is, "I don't want to be constrained. I went to school for years to make these clinical judgments." I completely respect that, but it's not about constraining your judgment. It's about protecting the patients from this vast variability.

We go through years of training, but we don't go through a rotation for empathy or compassion. We hope that we learn that along the way, but every practice is different, every specialty is different, and when you're on such a broad scale like telehealth, you really need to make sure you drive that home.

If you think about what actually drives errors in telehealth, most of the time it's not the wrong diagnosis—it's an omission error. The provider didn't document a key piece of information, forgot to send the patient education, or didn't include some critical follow-up or discharge instructions. That's usually when you get the most medical errors and bad outcomes. Those aren't clinical failures. They're documentation and communication failures, and that's where standardization works its best.

At 20 Mile, I equip my PAs with a shared snippet library in TextExpander, and I include it during any onboarding or training. Every provider has access to the same pre-built language, the same instructions, the same follow-up messaging, and the same documentation structure. When they use the snippets we review with them, they're not just saving time—they're ensuring that nothing gets left out and that the care is complete with every visit.

**Amy:** I've heard you talk about something that I find really compelling along this theme: the idea that great workflow design is actually a form of empathy protection for providers—that they can be the same provider with their 4:00 PM patient that they are with their 8:00 AM patient. Can you unpack that a little bit?

**Dr. Rees:** This is probably the most important but also overlooked piece, which is physician burnout. We can go into more depth as we go along. Telemedicine already makes the visit less personal—there's nothing we can do about that. You really need to do everything you possibly can to develop that relationship quickly and efficiently, and let the patient know that you're there to care for them.

The goal of workflow design isn't just speed—it's preserving your provider's mental energy. Every little decision a provider has to make, every field they have to type from scratch, every time they have to stop and say, "Okay, what was that snippet I needed to remember to put here?"—it's cognitive load, and it accumulates over a shift, and it doesn't have to be a long shift.

What I'm finding, at least on a personal level with the company, but also over the past eight years with other companies, is that a provider seeing your 8:00 AM patient is fresh—they're engaged, they're thorough, they're present with the patient. But by 4:00 PM, that exact same provider has a different version. They've made several hundred small decisions all day. They're tired in ways you can't really recognize or even appreciate as the provider, and the workflow requires them to generate everything from scratch every time. When that happens, you're going to get worn out.

My philosophy is that if you design a system where you're not searching and you're not typing and you're not doing those things, you eliminate the cognitive load pretty significantly, and it doesn't grind the provider down so much. When I armed my PAs and nurse practitioners with this strategy where you press one button and it pulls up the information that you need, it's more like having a conversation—but you're able to get more information out quickly and empathetically. So I've actually done a lot of snippets that are just based on one keystroke or one press.

**Amy:** The idea of a single press is very compelling. I know we're going to get into seeing how you do this, but can you describe a little bit what this actually looks like in practice for your team?

**Dr. Rees:** I'd love to, because it's definitely unique and it's super helpful. Even my own providers have reported back to me that they can work longer and see more patients, and they feel like they still have really high-quality care and relationships.

I call these "monster snippets." I'll show them live in a few minutes, but the concept is: instead of having dozens of little snippets you have to remember, there's just one button that's wired to one service you're interested in, one clinical scenario, or one type of patient communication—so it's easy access at all times. All the prescription options are in one place, there's a key press for patient instructions, there's documentation, and there's a key press for follow-up. Everything's in there, and the provider can select what applies, remove what doesn't, and then they're done. It's very quick.

They can have this cognitive flow, almost like they're having a conversation with the patient, even if sometimes it's typing. In asynchronous medicine, oftentimes we're just typing or doing a chat-based visit, and that's where it's really, really important.

I actually use shortcut remotes and a smart mouse that's modified from gaming, but it has multiple keys on it. There are also shortcut remotes—sometimes my PAs prefer those and hold them in their other hand while they're working, which makes it a little easier for them. I have each button mapped out to a different task, and with one press you can populate an entire note, as opposed to having to click one snippet and then click another snippet to create your note. You can create an entire encounter or note just by clicking one button and selecting a couple of things.

It really helps, and it adds up throughout the day, especially when you're doing a full day of patients. They're modifiable, so you're not just getting one option. There are dropdown menus, different empathetic comments you can make yourself, or you can use examples that have been successful and used over time. I like to share those comments. If I use some empathetic comments and I get feedback from the patient—a response that means it was effective—I save that. Then I use it again and again, and it really does drive home that empathy.

I've replicated the setup multiple times. I gave my PAs the same library, structure, and standards, and the quality of what they produce isn't dependent on how good they are at documentation. It's built into the tool.

**Amy:** That's awesome. Let's talk about the org leadership angle a little bit before we get in and demo this, because I think there's a change in mindset required here—from "I just need to hire great people" to "I need to design systems that my people can operate within." How do you think about your role as a clinical leader in managing the tools that your team uses?

**Dr. Rees:** That's a great question. Hiring great clinicians can be really difficult because of that variability—they all have their own way of caring. The real difference is what you're giving them to work with. That's the biggest difference.

I think about it this way: if I hired the best PA in the country and I gave them no documentation systems, no snippet library, no workflow structure, they'd still produce inconsistent output over time—especially that 8:00 AM to 4:00 PM variability you're trying to avoid—because they're human. They improvise. They get tired. Things vary.

My job as a clinical leader isn't to micromanage every patient interaction, because that doesn't scale. My job is to design an environment where doing things the right way is also doing things the easy way—path of least resistance. That's the ideal. When a snippet already has everything in it, it's also the path to the highest quality, and that's the goal. Something really easy to use that also gets you to the highest level of quality—it's a win-win for everyone. The providers love it. They hang onto it, and sometimes they don't want to work without it. So you definitely have to give them the tools.

At 20 Mile, I personally build and manage the snippet library. I control what language goes out. I review it, I update it when guidelines change, and I push those updates to the entire team. I also get feedback from the team—we're always communicating what works and what doesn't. I use that to implement changes. If there's a snippet they want to put into one of the monster snippets we already have, I'll add it, and then I'll star it so they know it's the new one I added. That empowers them to really want to use the system.

Overall, this is something that most leaders don't know they have access to, but they have to get involved.

**Amy:** Definitely. What would you say to the leaders who think that workflow standardization is an IT problem and not a clinical leadership problem?

**Dr. Rees:** That happens a lot. Sometimes it gets separated—they're severed altogether, and you're just having IT people make medical decisions, and we have to be really careful of that. It's probably the most expensive misconception in telehealth right now. Workflow standardization that's designed by IT without any clinical leadership driving it just produces tools that providers don't trust and don't use. They can usually recognize it right away—at least I did when I started using these things.

Clinical leaders need to get involved with IT directly. That's the only way. There's no way around it. As much as we want to see patients all day or help with our providers' education, it really has to be IT-driven if you're going to scale in the telehealth space. The clinical leadership has to own it.

The snippet library should be built by someone who understands the clinical context—what gets missed, what matters, what language serves the patient, what empathetic comments work the best. That's not an IT problem. I don't think IT would ever have any exposure to that. It's a clinical quality problem. When clinical leaders own it, they're not just building efficiency—they're building the quality of their patient experience right into the infrastructure of the organization. So they definitely need to be a part of the process.

**Amy:** Well, thank you so much for your insights. Now that we've conceptually talked through the importance of building solid workflows that ensure provider consistency, efficiency, and prevent burnout, we're going to get a walkthrough of how Dr. Rees does this in practice with TextExpander.

Dr. Rees, I'm going to stop sharing my screen, and then—

**Dr. Rees:** Mm-hmm.

**Amy:** —will you take us through how you've set up your workflows and show us some examples of how you use them?

**Dr. Rees:** Great. Finally, the fun stuff, right? Let me share my screen here. Perfect.

The first thing I wanted to show is my actual hardware tools, because this is pretty important—I didn't want to pass over it. My current mouse has 12 shortcut keys built into it, plus two on top. This is where I wire all my snippets. With one press, or just having a symbol mapped to it, the software comes with all the devices you choose.

Another example would be a shortcut remote. This is something you literally just hold in either hand. Some providers like to hold it in their off-hand, and each button can be programmed to anything you want. I find the mouse is a lot cleaner, but everyone's a little different, so you do want to provide options.

Right now I have a Google Doc open, and I'll show you what I mean by the monster snippet. What I'm doing is just pushing a key on my mouse—hands up here. By clicking the mouse button, I can pull up a snippet that has everything. This snippet is an example of a generic patient communication. When it's not service-specific, it doesn't have any medications, but it's a good example of what I can build with this.

Let's say I have a mental health patient coming back to see me, but they're still not feeling well. I can first paste something empathetic: "I'm sorry you're having those symptoms. We can continue your medication for now. Maybe we want to increase the medication." Then I sign it, and it instantly populates this note. All I did was click one button on my mouse.

It gives them empathy: "I know it's frustrating. We can continue, but if you want to change, let me know. If you're not having any severe side effects, we can do a more effective dose." We can give them titration instructions, some exclusions, or even something as small as, "Have you stopped your medication?" A lot of times people do that. As short as this sentence seems, after typing it 50 times in a day, it's much easier to do it this way.

Let me give you some more clinical examples. This is a psych note, and I'll give you an example of a refill. Let's say somebody's coming back. I click that they're going to do a refill, they're having minimal improvement but maybe looking to increase, they're having some sexual side effects, but their scores show depression is controlled while anxiety is still a little high. I'll click my medications that are built right in, and I'll say, "Maybe we'll increase to 100 milligrams here." And the entire note is written.

This is more about thinking about the patient and less about clinical documenting—hand-jamming everything in there. And you're not worn out, because it remembers to send them everything. It's based on past medications. We'll assess for check-in. We'll contact them internally, our follow-up plan, what handouts, suicide resources. Everything can be right here in your note.

You can also do quick snippets. I have one button that's just my signature, one button that's just my intro. Even typing ".intro" is just much easier when I'm doing it with one hand over here.

I wanted to go over two snippets that are going to be included for participants to have access to—at least for those with TextExpander—that I built out for this specifically. One is some basic notes I wanted to include. If I wanted to create a patient communication note, I could introduce myself. These are my PAs, and this is myself, so I could introduce as myself. Let's say they're coming in for a sinus infection, and then I sign. I create this entire note based on one snippet, and that snippet could be used for so many different things. It introduces myself, the empathy is built in—"We're sorry about your sinus infection"—and it has all the things you would want to comment about a sinus infection, plus a signature.

One click: I introduce myself, I give them the sinus protocol, and sign it. Done. That really makes things very easy.

Another snippet is medications. I built out a common urgent care medications snippet so people wouldn't have to worry about typing this out or how to take it. These are very common doses. There are a lot of medications built in here, but there are also some ED medications and how to take them. For example, if you click over-the-counter medications, it'll give you a little snippet that says, "Symptomatic therapy is mainstay," with some options.

If I wanted to prescribe something, I could click the prescription, and it actually has it written out for me—the number of refills, the tabs, how to take it. It's very useful to have one snippet for all your medications. You can build upon this over time, and that's the key. You find something you prescribe a lot, you add it to your monster snippet, and never type it again.

That's how those one-click monster snippets work in my day-to-day routine.

**Amy:** Thank you so much for walking us through that.

**Dr. Rees:** Mm-hmm.

**Amy:** I love seeing how you click through these monster snippets and end up with all of these instructions. If you're interested in trying out the snippets Dr. Rees showed, he's turned them into a public snippet group for us, so they can be added to any TextExpander account.

You can find them—it's called the Telehealth Starter Pack snippet group at snippets.textexpander.com. Once you're there, just click "Join Snippet Group," and that will add them to your TextExpander account under Public. If you don't yet have a TextExpander account, you can start a free trial on our website and then add the snippet group from there. Excited to hear feedback if anyone checks out these monster snippets that Dr. Rees uses.

Now we're going to get into some questions with our remaining time. I saw a couple come through the chat.

Dr. Rees, we have one from Jenny asking, "Have you thought of using a Stream Deck for triggering snippets? I'm wondering about that versus a gaming mouse."

**Dr. Rees:** That's an excellent question. Wow, we have some tech-savvy people out there.

The Stream Deck hardware she's talking about is interesting, but it's not as handheld as possible—that's the problem. It's pretty, and you can change its backgrounds and all those fun things, but having it incorporated into the mouse is useful because you can point with your hand and click with your thumb. That becomes very seamless over time, whereas the hardware deck can't.

The big question I have is that you can configure your hardware deck to have multiple layers. I think the default has eight buttons, but you can click a button and have eight more. Well, most of the mouse software does that too—so if I hold Shift, I'll have another 12 at my disposal that are different. I did test with that first, and I found it was a little clunky because I was taking my hands off the mouse to do it. The mouse is very seamless, and I forget I'm even using it.

Hopefully that answers your question.

**Amy:** Awesome, thank you for that. Another question—I think maybe we can't get to it live, but an anonymous attendee says, "Can you show us how to link them to the mouse?" Since it's hard to actually show with the mouse, could you explain a little bit—we don't have to go through a technical how-to, but just a couple—

**Dr. Rees:** Sure.

**Amy:** —steps of how you hooked up your smart mouse to TextExpander, what that looked like?

**Dr. Rees:** Yeah, exactly. I'll try not to nerd out without sharing the screen. In summary, most of the mice with 12 buttons will have their own software you can program. The key is the difference between a one-button press and what we call a macro. You don't want words typed out—you want to hotkey it to a single button, like the equal sign or some key you don't use very commonly. Then you put that one button into the one button on the mouse. I find that mapping using the mouse software is the easiest.

My snippets are all just symbols that I don't regularly use. All those wonderful symbols that hang above the numbers—you can use those at your disposal for snippets. When you create a snippet, instead of doing a dot phrase, just put the symbol in there—no dots, nothing else. When you hit that symbol, it automatically generates. If you can map that symbol to the mouse key, then you're done.

Almost all of the software that comes with the mouse or the shortcut remote I showed will incorporate that. So you stay away from macros.

**Amy:** Very cool. I don't know how it is that you know so much about the medical world and you're so good at tech. I'm impressed.

**Dr. Rees:** This is embarrassing. I just play a lot of video games, probably. Probably too many.

**Amy:** I've got another question: "For an organization leader who wants to start standardizing workflows but doesn't know where to begin, what is your advice? Where do you start?"

So the question is, where do you start with standardizing workflows? If you're a fellow leader who wants to set something up like this in their telehealth business, how did you get started?

**Dr. Rees:** The first thing is, you do have to find the minimum, and that's going to be very protocol-driven. When I started, a lot of companies would tell us what the minimum required is for a SOAP note, and then you want to build upon it. If you're the clinical leader or the owner and you want to try this, basically open up your SOAP, put in one line for each section, and start building things that are going to be medical-legally required in your note. Once you start doing that, you'll start to see the standardization build into itself.

Just use some very basic protocols, start from the bare minimum, and then add to it. The other thing that's helpful, as a clinical leader, is to get involved first. Instead of designing a snippet and then throwing it to the wolves and seeing what happens, use it yourself—because you'll find that most of the questions and feedback you get come just by interacting with patients. A lot of times, patient interaction was a really great way to help create the standardization I needed. If you find yourself typing on a keyboard, stop and see if it would be easier as a snippet added to that category.

**Amy:** That's great advice. I've got another question. People are loving this gaming mouse. The question is: "Is using a gaming mouse for shortcuts common in telehealth, or is it unique to 20 Mile Medical?"

**Dr. Rees:** I'm not sure. I think it's pretty unique. The providers I show it to look at it like, "What is this crazy monster of a mouse that you showed me?" I find that if you want a little more adoption, the other shortcut remote I showed is a little easier for people to stomach. Most of my providers will opt to use that in their off-hand. So if they're using the mouse in their right hand, they like to have that in their left.

I think the mouse setup is very unique. The shortcuts themselves are not unique—a lot of telehealth providers are using shortcuts. Getting it off the keyboard is what's unique. And I'll tell you—it sounds like that doesn't save you a lot, but it saves you a ton. If you're sitting back and you're not having to touch the keyboard, you're not worn out.

The nice thing about shortcut remotes is that you're not looking at them. When you're trying to find a shortcut on the keyboard, you have to look at the keyboard. But with the remote, it's just in your hand, so it's a real seamless thought process because you remember where all the keys are. They're usually close to your thumb. So I think it's unique, but I don't think it should be. I think this should be more of a standard way to utilize snippets.

**Amy:** One more question: "How do you keep the snippet library up to date as clinical guidelines or platform requirements change?"

**Dr. Rees:** As a clinical leader, you're going to have to get into the weeds a little bit to make sure you're up to date on these things. Also, being comfortable with changing and modifying the snippets regularly is a really good practice. Even if I'm not updating it in a really meaningful way, I'll go in and maybe change the syntax just to make sure I know how to do it—so that if something gets updated, I'm not spending a day trying to figure out how to program TextExpander. It's very easy, but if you're making the snippet more and more complicated, you do have to practice.

Also, just patient care. As you go through more encounters, even if you feel like you know the information, I always look it up to verify it's the most up to date. I try to do that just once or twice a day. It doesn't take very much, but I'll just say, "Let me check that medication interaction one more time and see if it's the same one it's been for the past year." A gentle reminder to yourself to check something once or twice is usually a really good way to keep up to date.

**Amy:** Awesome. I know I said that was the last question, but another one came in, and I think—

**Dr. Rees:** Yeah.

**Amy:** —it's a really good one, so since we have a few minutes: "Not sure if you're hiring or have hired with this setup. How do you train people on this monster snippet?"

**Dr. Rees:** It's very easy. Usually what I do is make sure they have TextExpander first, and then I share the snippet. I don't introduce any extra hardware at first—I'll show them where the shortcuts are on their keyboard. In TextExpander, there's a little down arrow where you can decompress everything and see the entire snippet. I go over the most common ones used first, get them comfortable with patient communication, have them demonstrate some of those, and then I'll go over the rest with them, usually a few times.

If they're typing, I can always stop and say, "Hey, there's a snippet on this button if you want to use that instead. It might help you."

So typically I walk through the snippets with them. It's one of those things where you invest a little bit of time now and you get a lot later. I spend a lot of time making sure they're very comfortable, because almost all the things they have to say are somewhere in a snippet, and they're already written empathetically and compassionately. If they want to change it, they just have to tell me, and I can change it.

**Amy:** That's awesome. Well, Dr. Rees, you've provided us with so much great insight today. For those of you listening in the audience, please feel free to stay connected with Dr. Rees on LinkedIn. He's provided his email—he's been generous enough to give us his direct contact info—so—

**Dr. Rees:** Yeah.

**Amy:** —would love to hear if you have any questions after the fact.

I think that's it for today. Thank you so much, Dr. Rees. We appreciate you sharing all of your insights with us. It's been really cool to watch you go through and see how you're actually using TextExpander. And thank you so much, everyone, for joining us. We appreciate it. Have a great rest of your day.

**Dr. Rees:** All right. Thanks, Amy.

**Amy:** All right. Bye.