By Mark Weisman, MD, MBA, Chief Medical Information Officer at Peninsula Regional Health System
For years telehealth has been this exciting, disruptive technology that the majority of health systems had minimal interest in pursuing. Adoption was slow due to regulatory burdens, payment issues, and provider resistance as the norm. Most systems had small pilots or partnerships with telehealth vendors so they can check the box that they were doing telehealth, but in normal times the commitment to fund and deploy on a wide scale was never a priority.
But these are not normal times.
Over the last two weeks, executive healthcare leaders have received hundreds, if not thousands, of requests across our country for tools clinicians can use to care for patients remotely. Providers want telehealth now. Practically overnight, the demand is for as many ambulatory visits as possible converted to video visits to prevent patients from infecting each other in waiting rooms or exposing healthcare workers to coronavirus. The mad dash to implement functional telehealth programs is happening across the country. In this article, I will highlight the pitfalls and early successes we experienced as we ventured into this new world.
At Peninsula Regional Health System, we went from having no direct to patient capabilities to seeing patients in a virtual environment in under a week. Barriers that were insurmountable for years were gone practically overnight. The federal government made the big moves by making telehealth visits reimbursed at the same rate as in-person visits. They removed the requirement for a patient to be at a healthcare facility to originate the video call. Then the OCR announced they would relax their enforcement of HIPAA so providers acting in good faith can use tools that patients are familiar with like FaceTime and Skype.
With the regulatory hurdles removed, we turned to the technology and people part of this initiative. From a technology standpoint, we were starting from scratch by not having an EMR integrated telehealth tool already in place. Trying to deploy an integrated solution was not practical for the speed at which we wanted to move, so we traded off the integrated user experience to gain momentum. We narrowed our choices down to Webex, FaceTime, Google Hangouts, or Doxy.me and decided to start with Webex since it was a tool clinicians and IT were familiar with and comfortable supporting. We encountered some difficulty with connecting on Webex during early use due to bandwidth issues, but that improved. We deployed the limited supply of video cameras we had to the first operational division that stepped forward, which for us was oncology. Clinically it made good sense to minimize the risk for these patients by keeping them at home and operations set out to document the workflows necessary to complete the visit. We have ordered more webcams, but doubt we will be able to get enough to support the operational demand, so providers have agreed to use their personal devices to overcome this obstacle.
Providers want telehealth now. Practically overnight, the demand is for as many ambulatory visits as possible converted to video visits to prevent patients from infecting each other in waiting rooms or exposing healthcare workers to coronavirus.
The strong demand from the ambulatory providers eliminated the most significant roadblock we ever faced to deploying telehealth, which was fierce resistance from the providers. Requests to start using the tools came in from all over the organization, which exposed a flaw in our plan. We recently completed an acquisition where the new hospital is not on our network yet; those providers are not able to use our Webex tools. We hoped to have all telehealth activities on a single platform to simplify support issues, but we recognized a limitation of our current infrastructure, and we decided to use a third-party standalone telehealth solution to serve those providers that cannot use Webex. There is a risk of providers going out on their own and using other platforms, but we recognized there is nothing we can do to stop that from happening. Through excellent communication and offering reliable platforms, we hope to minimize providers going rogue, but it may still occur and we will have no knowledge of it.
One hundred and twenty-two-year-old health systems tend to move very slowly. However, with laser-like focus due to extreme circumstances, we were able to deliver new services to meet the needs of our providers and community. It is unlikely that healthcare will return to “business as usual” anytime soon, and it appears the arrival of telehealth to the center of our care models will have lasting implications on healthcare IT.
- Build your team. Have a senior leader take charge of the telehealth initiatives and keep it connected to the larger incident response team. Centralize decision making quickly to avoid disjointed efforts. Have operational and IT leaders fully engaged; a successful initiative requires a tight IT/Operations partnership for mapping the workflows and matching the technology needs. Billing and coding leaders will want to be kept informed.
- Assign a project manager to keep the initiative organized.
- Communicate frequently and broadly to the organization, so those waiting for a solution do not go out on their own to find one.
- Identify the use cases; most will be pushed to you from the providers. Decide if you will use telehealth to serve existing patients already on the schedule for an office visit or use it for acutely ill patients seeking help. The workflows are slightly different.
- If you do not have an integrated solution with your EMR, do not let that stop you. Pick a free-standing vendor that you have a good relationship with and can move at the speed you need to help your frontline people. An integrated solution is not critical to start the program. For the longer-term approach, consider the benefits of EMR integration on the patient and provider experience versus the time and expense to make it happen.
- Think through the workflows well in advance of your first patient going through the platform. Identify who will make the connection to the patient, walk them through the connection process, perform “rooming tasks” such as medication reconciliation, and set the visit up for the provider. Consider how the workflow changes if the provider is using a personal smartphone versus a webcam. Consider the workflow if providers and staff are on self-quarantine offsite and not co-located.
- Have consent verbiage ready for your providers to use and have tools to assist them with documentation of that consent. We built a simple Smartphrase for them to use.
- Have specific telehealth visit types built so you can track these activities. Switching to telehealth can have an impact on your quality performance metrics. You will likely want to exclude telehealth visits from the denominator of quality programs where things like BMI are being tracked.
- Have documentation templates ready for the providers that are specific to telehealth. If existing office visit templates have vitals and a physical exam linked into the document, it will look silly in a telehealth visit.
- Be prepared for connectivity issues and problems where patients cannot figure out the connection process. Have support staff on hand for the initial visits.