With the coronavirus crisis, health systems catapulted the industry into the future by accelerating virtual care initiatives that will forever change the way healthcare is delivered in the U.S.
This article appears in the July/August 2020 edition of HealthLeaders magazine.
As 2020 launched, healthcare executives had no way of knowing the havoc a novel virus that had emerged in Wuhan, China, would wreak on the healthcare industry. By March 11, 2020, the World Health Organization acknowledged a pandemic was in progress, and COVID-19 began impacting the U.S. population. Hospitals and healthcare systems went into overdrive, brainstorming new ways to protect patients, and providers set out to devise new ways to deliver care.
Between mid-February and April, healthcare innovation was happening everywhere at a rate and scale never before experienced. New ideas were quickly greenlighted; funds were released to purchase new technology; and staff members were reassigned to deliver care in new ways. In this wellspring of ingenuity, one innovation that was already entrenched—yet mired in a bog of skepticism, regulations, and reimbursement restrictions—was ready to break loose: telehealth.
With the COVID-19 crisis, the stars aligned. The population was urged to stay at home, but the healthcare industry recognized people still needed access to care. The Centers for Medicare & Medicaid Services (CMS) waived many of the restrictions holding telehealth back, as did many commercial payers and states, and it soon became the go-to method of care delivery.
Hospitals ramped up their virtual care programs seemingly overnight, catapulting the industry into the future far sooner than expected. For years, advocates have touted virtual care as one of the best ways to transform the healthcare system, delivering care when and where people want it. The pandemic put that premise to the test.
HealthLeaders takes a deep look at three ways that COVID-19 transformed healthcare delivery through telehealth. Three health systems share their experiences about the processes and considerations they used to accelerate and refine telehealth for their patients during the coronavirus pandemic.
MedStar Health: Zero to 100 mph overnight
How do you take a telehealth program from zero to 100 miles per hour overnight? For an organization like MedStar Health, a 10-hospital nonprofit health system serving Maryland, Virginia, and Washington, D.C., the initial groundwork began nearly a decade ago.
Like many health systems experiencing the "instant" acceleration of virtual care, MedStar has been involved in telehealth initiatives for years. The health system, which partners with Georgetown University, experienced the same barriers to adoption that inhibited widespread use of the practice across the rest of the country: physician skepticism, minimal consumer awareness, lack of sufficient reimbursement, and licensing issues.
The key steps in MedStar's telehealth evolution include:
- An initial foray into virtual care began with a telestroke program almost 10 years ago.
- In 2015, the organization launched MedStar eVisit, an on-demand urgent care video visit platform.
- The health system then launched a teletriage program in its emergency departments, which logs about 60,000 encounters a year, using a platform from Bluestream.
- MedStar also provided a separate technology solution for physicians who wanted to provide virtual care direct to their patients. Usage was minimal, with about two scheduled visits conducted weekly.
- In 2017, the health system chartered the MedStar Telehealth Innovation Center and appointed Ethan Booker, MD, as medical director of the Center and of MedStar eVisit.
Then, in early 2020, the threat of COVID-19 came knocking at the door.
As the public health crisis heated up, urgent care visits immediately rose. Before the pandemic, MedStar eVisit managed 150 to 250 visits a month. During the first week of the pandemic response, daily volume sometimes exceeded 500 visits per day.
Ramping up the ability for physicians to provide direct-to-consumer care presented a more complex challenge. "Patients were canceling their primary care and specialist appointments," Booker says. "We knew that we needed a way to meet that community need to continue to deliver care."
"We had 10 years of pent-up expertise, knowledge, and systems already built into our revenue cycle, legal and compliance, and informatics groups in terms of being able to schedule, document, and bill [telehealth visits]," Booker says. To quickly scale virtual services for thousands of providers, "we needed a lightweight, agile technology."
The team decided the Bluestream platform used for emergency department teletriage services had the right capabilities and converted to it for rapid deployment and expansion of scheduled video visits.
About 10 days prior to the March 23 go-live date, the team marshaled the entire organization to prepare for the launch. "We created all of the structures within the health system that are necessary to be successful," Booker says.
The effort paid off. MedStar onboarded 2,000 providers, and during the first month, the peak daily volume hit nearly 4,000 visits a day, compared to the pre-pandemic volume of two a week.
"Our success, and certainly our speed, was related to actually not trying to put [scheduling, documentation, and revenue cycle solutions into] a complete package," Booker says. "Rather than reinventing the wheel, it made sense for us to execute down the same pathways we already knew, but kind of driving a different car."
The system is simple for patients to use, he says. "When a patient has an appointment, they get a ping on their phone with a link. You click on the link and you're in video appointment. There are no apps, no schedules to remember, or anything like that."
Training and education were essential to the process, Booker says. Because the eight-person telehealth team is affiliated with the MedStar Institute for Innovation, they were able to pull in 112 people from the Institute to supplement their efforts, including trainers and educators from the Medstar Health Simulation Training & Education Lab (SiTEL). In addition, 80 volunteers from Georgetown University offered to help.
"The challenge was about speed and scale and not so much about technology, and certainly not about the care delivery," says Booker. While the barriers to telehealth adoption are real, he says COVID-19 created a "massive set of incentives" for physicians and patients to try it, including stay-at-home orders and concerns about being exposed to the virus during a visit to the doctor.
Once physicians and patients try telehealth, they like it, Booker says, and "the genie is now out of the bottle."
Whether virtual care usage continues at the high rates it is experiencing during the pandemic de-pends on numerous factors, Booker says—namely, reimbursement. Commercial payers "have been using telehealth themselves for cost control for quite some time; so I don't think that they need convincing," says Booker. The primary question is whether reimbursement will continue from the Centers for Medicare & Medicaid Services, which waived many regulations during the crisis to enable access to care.
But the challenge to the successful future of telehealth goes even deeper. "It's very important for those of us who were doing this work to collect good data to demonstrate the quality, safety, and value of telehealth," Booker says. The equation goes beyond consumer value and convenience to demonstrating that "giving patients rapid access to care in their homes doesn't add new costs and it decreases later costs because you can get to preventative issues quickly." That means decreased hospitalizations, fewer emergency room visits, and improved outcomes for those with chronic diseases.
Because the coronavirus crisis is keeping patients away from ERs and physician's appointments, it's currently challenging to gather meaningful data, Booker says. "It's difficult to tell that story yet, but I think that we will be able to tell that story."
UW Health: Virtual rounding debuts
As UW Health prepared for the coronavirus pandemic, one of the health system's priorities was to protect caregivers from unnecessary exposure to the disease, says Tom Brazelton, MD, MPH, FAAP, medical director of the UW Health Telehealth Program and professor of pediatrics at the University of Wisconsin-Madison School of Medicine and Public Health. This concern eventually evolved into a method to conduct virtual rounds, a practice that has created numerous advantages for providers and for patients, he says, and will continue after the COVID-19 crisis abates.
Before the pandemic, the Madison, Wisconsin–based health system had employed a cloud-based, HIPAA-compliant platform from Vidyo for about eight years for a limited number of use cases. For example, the technology was used to conduct inpatient consultations between physicians and certain specialists and to communicate with physicians at community hospitals who were transporting patients to UW Health's pediatric or neonatal ICU.
To rapidly accelerate these capabilities, the health system decided to expand access to the Vidyo app. While CMS temporarily relaxed many rules that enabled healthcare providers to communicate with patients via consumer-facing apps like FaceTime, "I was very worried about the wild, wild West," Brazelton says. He explains that there can be unexpected downsides to using a familiar technology for a new purpose. Security and protecting patient privacy are paramount, he says, but they're only part of the issue.
"We are responsible for the patient's confidential information as much as we are for your health," says Brazelton. "We can't be irresponsible about it. When the dust settles, we do not want to be that exposed as an organization. If we told our providers to just go crazy, we would have ended up with … providers providing a lot of IT support to patients to get their devices functional," he says. "That is not the best use of their time. We had to be very conscious of what we could do quickly." Vidyo was HIPAA-compliant and encrypted, and it passed the health system's security tests. "The devil you know," he says, "is better than the devil you don't."
The ability to conduct bedside virtual visits involved providing Vidyo access points in all patient rooms and physicians' devices via an app. Because every patient at UW Health's University Hospital is assigned an Apple iPad® upon admission, the team simply added the app to each of the system's 600 bedside tablets.
Rolling the initiative out to the organization's 2,000 physicians was more complex. Initially, UW Health targeted infectious disease specialists, ICU doctors, and hospital-based physicians, Brazelton explains, because their services were considered most essential to address a surge of COVID-19 patients. Another concern was to mitigate the impact of a diminished workforce if these crucial providers became sick or had to quarantine.
"We wanted to provide physicians with the ability to spread their cognitive abilities as ICU or infectious disease docs," Brazelton says. "We know from our eICU programs that one doctor can command a whole [unit of] non-ICU physicians and run it virtually."
Once the priority physicians were armed with the app, UW Health loaded it onto secure devices for all physicians affiliated with the health system, as well as other personnel, including pharmacists, nutritionists, and the spiritual care team. The app is now available on 6,000 devices.
Part of the process included ensuring each device was secure. And, if a smartphone or tablet is lost, a mobile device management system can remotely wipe the missing device of all clinical applications.
Once the app was installed, the practice of virtual rounding evolved quickly. The technology allows the creation of virtual "rooms" where multiple providers can gather through their secure device while a nurse or other provider uses the iPad at the patient's bedside.
"In the peds ICU where I work, we could have up to 15 different providers," Brazelton says. "We would all gather at [a specified time] in this virtual room." Participants might include a cardiologist, a cardiac surgeon, the ICU physician, and residents, as well as a pharmacist, a nutritionist, a social worker, and a member of the spiritual care team.
"It's a very streamlined system where there's collective knowledge at one time on rounds about that patient," he says. "We also were conserving PPE (personal protective equipment) and reducing the chance of unnecessary exposures."
The process improves the patient experience, Brazelton says. "One of the problems being a patient [is that] providers don't coordinate their exams. You're woken up from 4:30 a.m. until 8:00 a.m. with people from different services coming in and doing the same exam on you. This way we could perform one exam, and everyone's witnessing it."
Virtual rounding delivers other benefits, he says. "We are now location-agnostic. With broad national adoption of telehealth, one of the lessons for all of us is that now it shouldn't matter where the patient is. It shouldn't matter where the provider is. If the standard of care can be met using video—and we know it can in many, many instances—then it should count. And by count, I mean that it's legitimate patient care. Video may not meet the standard of care in every instance, but in many cases it can."
UW Health physicians have embraced virtual rounding, Brazelton reports. "I have a lot of providers who say, ‘We're not going to ever end this; we're going to continue to use the system.' " They no longer have to travel to the hospital to see one patient, then rush to see a different patient in their office, he says. It frees up time and makes their workflow more efficient. "It provides access in a way that we've never had before—both for us and the patient," he says.
"Prior to the pandemic, we had several barriers to expanding and accelerating telemedicine," says Brazelton. "We had separate telemedicine programs that all started a dozen years ago but had not been aligned, making our work difficult to scale."
As the threat of the pandemic loomed, "our leadership moved extremely quickly and efficiently," says Brazelton. "I've been at UW Health for 20 years, and I've never seen us move like that. It is amazing how fast issues of alignment can be resolved when the mandate is there from leadership and so are the resources, both human and equipment."
Intermountain Healthcare: ER video handoffs ensure continuity of care
Like many large healthcare systems, Salt Lake City–based Intermountain Healthcare already had a solid telehealth program in place before the coronavirus pandemic. Yet the dynamics of the disease rapidly accelerated adoption of the technology.
According to Brian Wayling, MBA, assistant vice president of telehealth services, Intermountain had been using virtual care in three primary ways before the health crisis: for urgent care, for acute care consultations with other physicians, and, more recently, for scheduled visits between physicians and patients.
- Calls to Connect Care, the organization's urgent care telehealth service offered in partnership with Boston-based telehealth company Amwell since 2016, doubled after the disease began to spread, Wayling says.
- Before the pandemic, about 500 physicians in disciplines including critical care, neurology, oncology, infectious disease, newborn critical care, and pediatric trauma service, along with some advanced practice providers (APP) and nurses, employed telehealth on a regular basis for acute care, according to Wayling.
- In 2019, the 23-hospital nonprofit health system began using the Amwell platform for scheduled physician visits with patients. The organization was slowly deploying the service throughout the system, routinely logging a couple hundred such visits a week. "Once COVID hit, we suddenly had a lot more interest," Wayling says. By the end of May 2020, these visits hit the 100,000 mark.
To accelerate the practice of virtual care during the pandemic, Intermountain purchased 600 Microsoft Surface Pro® computer tablets and distributed them to the system's hospitals and clinics. Nurses and providers involved in bedside care began using telehealth to conduct rounding to reduce exposure to patients and save PPE. Specialists, nutritionists, interpreters, and cultural advisors could all be brought into the patient's room virtually. While the preference is to deliver in-person treatment, says Wayling, virtual visits "save a lot of time and are much more efficient and safer."
Altogether, by the beginning of June 2020, the health system surpassed a million telehealth interactions. Users include an estimated 2,000 physicians, 2,000 nurses, 1,000 APPs, 500 nursing assistants, and 300 behavioral health clinicians.
Onboarding and training was a "Herculean effort," says Wayling. Adding thousands of new users to the platform involved much more than creating usernames and passwords. With 23 hospitals in multiple states, there were complexities related to provisioning and credentialing to ensure providers only had access to facilities where they were authorized to provide care.
"A clinician might provide care in Wyoming on one call, and then in the next call they're providing care in Arizona," says Wayling. In a large health system like Intermountain, having to access a variety of EMRs creates "extra time and burden" for providers as they jump from "Cerner to Epic to athenahealth," each requiring unique usernames and passwords, as well as different approaches to navigation. To enhance interoperability, enabling clinicians to bypass these barriers and extract key points of information for faster treatment, Intermountain uses a platform from Redox, a Madison, Wisconsin, company the health system has invested in.
Training so many new users also presented a challenge to the 50-person telehealth department. "We basically stopped all our other projects and we redeployed everybody [to focus on] this effort," Wayling says. Additional people were brought in to help.
"As a result of COVID-19," says Wayling, "the biggest change was a much more rapid adoption of telehealth delivery by caregivers across a much broader spectrum on both acute and direct-to-consumer or direct-to-patient care management."
"The use cases and their creativity of integrating telehealth into their workflows has been very positive," says Wayling. One of these uses caught the telehealth team by surprise.
The emergency department had occasionally used video consults to communicate with care teams on the units where patients were being transferred. With access to new tablets, the practice flourished.
"Typically the patient would just be rolled out and taken up to that unit," Wayling says. "Then, that unit would have to prepare and catch up in the note." Telehealth helps bridge that gap and establishes direct communication between the ER and ICU or med-surg unit where the patient will be transported. "We now use telehealth to have that direct communication so the receiving unit can be better prepared and understand any of the nuances that might be more difficult to obtain strictly through the EMR."
During the video handoff, caregivers in the ER speak directly to providers in the receiving unit. "One of the advantages," Wayling says, "is that we can convey very quickly the condition of the patient, any nuances that the patient might be experiencing, or history of the patient and family members." The process enables practitioners to "really listen to each other," he says, and the ER physician can relay essential precautions. "Both parties understand what's going on with the patient and ensure that no misses [occur]."
This process accelerates care delivery to patients who are frequently in need of critical care, Wayling explains. The unit is better prepared to receive the patient, he says, and more immediately able to provide services.
The overall experience with telehealth in recent months has removed a lot of concerns providers had about using virtual care, "effectively validating that telehealth is a safe, effective way of delivering care," Wayling says.
As the industry moves into the next phase of telehealth, developing a one-touch connection and fully integrated model would be ideal, he says, along with payment models that support the use of telehealth after the pandemic ends. Also needed: a better way to handle interstate licensing, which is costly and time-consuming in many of the states where Intermountain
facilities are located.
"The investment has proven itself," Wayling says. "The challenge for us, and for the provider industry going forward, is to continue making it easier to use."
“It's very important for those of us who were doing this work to collect good data to demonstrate the quality, safety, and value of telehealth.”
Ethan Booker, MD, medical director, MedStar Telehealth Innovation Center and MedStar eVisit
Mandy Roth is the innovations editor at HealthLeaders.
Photo credit: Illustration by Dave Ember
The ability to rapidly scale solutions that were already in place was an essential component of telehealth success stories.
Massive training initiatives were necessary to deploy technology to thousands of new users.
With access to new tools, novel uses for virtual care evolved, such as virtual rounding and ER video handoffs.