The Providence health system is conducting about 10,000 telehealth clinic visits daily.
There are several keys to building and sustaining successful telehealth programs at health systems, hospitals and physician practices, a top executive at Providence health system says.
Largely due to concern over the spread of the coronavirus in healthcare settings, many patients have avoided in-person visits and healthcare providers have expanded telemedicine programs. A recent research article published by JAMA Internal Medicine shows explosive growth of telehealth in the first half of the year. From the weeks of Jan. 1 to June 10, the rate of telemedicine visits increased 2,013%, rising from 0.8 to 17.8 visits per 1,000 health plan enrollees, the study found.
At Providence, the Renton, Washington-based health system has made nearly a decade worth of progress in expanding telehealth services in a matter of months, says Todd Czartoski, MD, chief medical technology officer.
"We are doing about 10,000 telehealth clinic visits per day across the health system. We are doing direct-to-consumer telehealth visits in the 500-to-1,000 visits per day range across multiple states. We have monitored more than 12,000 patients in their home with COVID-19 or symptoms of COVID-19 to help keep them safe and out of our facilities. We are way down the road compared to where we were a year ago in fulfilling the vision of telehealth being used across the care continuum to improve access, improve quality, and lower overall cost of care," he says.
Building telehealth programs
Whether a telemedicine initiative is based in a hospital, clinic, physician practice, skilled nursing facility, or patient homes, Providence asks four essential questions before building a program, Czartoski says.
1. Is the telehealth program safe for patients?
2. Is the telehealth program as good or better than an in-person visit?
3. Is the telehealth program reimbursable by government or commercial payers?
4. Is the telehealth program supported by a clinician champion?
Having a clinician champion for a telehealth program is often overlooked at other health systems, he says. "Whether it is an obstetrics program, primary care program, or any other telehealth program, you need to have a clinician champion to pull their partners and colleagues along."
With 15,000 clinicians who are now telehealth-enabled, Providence has many clinician champions for telemedicine programs, Czartoski says. "We still have some naysayers. Not surprisingly, there are still people who do not believe in telehealth and do not like it. But the wholesale change we have seen with most of our providers has been toward accepting telehealth. We are seeing most of them excited about how they can use telehealth to effectively and efficiently care for their patient panels."
Sustaining telehealth programs
There are three primary factors necessary to sustain a telehealth program, he says.
1. Financial return on investment
"We need to make sure that if we are going to operate a program there is a model to get paid, whether it is Medicare fee-for-service, commercial payers, or at-risk payment models," Czartoski says.
At-risk contracts such as accountable care organizations and Medicare Advantage have significant potential to sustain a telehealth program, he says. "Where you see risk being taken by the care delivery system, you will see providers pushing the envelope of what they can do safely and effectively with virtual care."
2. Patient and provider experience
"You need to consider both the patient and the provider journey. We need to make the telehealth experience more seamless, frictionless, and efficient for our providers and the patients who are using this technology," Czartoski says.
The biggest driver for patients in terms of telehealth experience is the ease of connecting to the service such as adequate bandwidth and having the device that they need, he says. "It should not require a bunch of apps or log ins—patients should be able to touch a button and the provider pops up."
Providence has tried to use existing tools to ease the way patients connect to telehealth services such as MyChart. "We have also used some secure texting to engage with patients and folks who are not as tech savvy—they do not want to download an app and they do not want to log in. They just want something that comes to their phone when they need it in a way that is easy to manage and use. How you engage patients is critically important," Czartoski says.
Clinicians also need to put patients at ease to generate a positive telehealth patient experience, he says. "We give basic training to our providers such as eye contact with the camera and putting people at ease. If it is a new visit, providers are trained to show their ID to assure patients that you are who you say you are. Simple things may not sound that important, but they are."
The ease of use and efficiency of telehealth platforms are crucial for provider experience, he says. "Clinicians want to be able to care for their patients efficiently. If they are running late, they want to be able to let a patient know through secure text that they will be five minutes late. Providers also want to have their telehealth visits embedded in their electronic health record. They do not want to open up another app. Almost all of our telehealth visits are conducted through Epic. Providers want telehealth visits to be seamless as part of their workflow."
3. Retooling the provider setting
The third primary factor for sustaining telehealth programs can be the most challenging, Czartoski says.
"You must re-envision what a practice is going to look like. Many practice groups have been reluctant to do that, mainly because there is no certainty that the shift to telehealth to see Medicare patients is going to be permanent. Without that reassurance or confidence, completely overhauling your practice such as changing the number of nurses and front office staff as well as changing the physical footprint that you need, the technology, and the scheduling of patients is daunting."
For example, several Providence physician practices and medical groups have launched an initiative to use a centralized team of medical assistants to conduct blood pressure monitoring and to call high-risk patients to check on them. The medical assistants have taken those responsibilities off the plate of primary care doctors, he says.
"This is an example of monitoring patients at the enterprise level through calls, texts, and Bluetooth-enabled home monitoring. It improves access and adds touchpoints to the patients who we are serving."
In the initiative, a team of about 50 medical assistants is supporting nearly 1,800 clinicians, Czartoski says.
Christopher Cheney is the senior clinical care editor at HealthLeaders.
Providence has made nearly a decade worth of progress in expanding telehealth services in a matter of months, the health system's chief medical technology officer says.
When building telehealth programs, Providence asks four key questions such as whether the program is safe for patients and whether the program is supported by a clinician champion.
The health system's CMTO says there are three essential factors to sustaining a telehealth program, including financial return on investment.