Michael Reilly, MD, shares how he adapted to this new form of practice overnight, details the advantages it offers, and cites pitfalls other physicians can avoid.
Thanks to the COVID-19 pandemic, the transition from in-person care to telehealth happened suddenly for providers, many of whom had to learn a new way of working literally overnight.
What can be learned from this experience to improve telehealth moving forward?
HealthLeaders takes a deep dive into the experience of one physician, Michael Reilly, MD, associate professor of facial plastic and reconstructive surgery at MedStar Georgetown University Hospital. While MedStar Health, a 10-hospital nonprofit health system serving Maryland, Virginia, and Washington, DC, began forays into telehealth about a decade ago, there had been limited adoption of the technology among its physicians. In 2017 the health system chartered the MedStar Telehealth Innovation Center, part of the MedStar Institute for Innovation, which now centrally supports new and previously established telehealth initiatives—such as the MedStar eVisit for urgent care—with an eye toward system scale.
Before the pandemic, the MedStar's used telehealth for urgent care, and had a technology platform from Bluestream for its teletriage services. Within a matter of weeks, the platform was rolled out to 2,000 providers who conducted about 4,000 virtual visits daily within the first month.
Because of his profession, Reilly had never considered telehealth a viable practice option; he has since become a fan. His practice is complex, he says, involving cancer reconstruction, melanoma care, facial paralysis, and treatment of nose and sinus conditions.
Reilly takes HealthLeaders behind the scenes, offering insights into his own experience using telehealth, citing the advantages, pitfalls, and learnings. Following are excerpts from the mid-May interview, lighted edited for space and clarity.
HealthLeaders: What was your opinion of telehealth before you started using it?
Michael Reilly, MD: Very superficial. I'm a very practical person, and I probably considered telehealth only on a very theoretical basis. My feelings about telehealth were not deep. It was like, "Oh, that seems like it could be nice, but it's a pipe dream. Everything moves at a snail's pace, so there's no way this will ever happen in my professional career." I maybe disregarded it a little bit as a potential option.
HL: MedStar made telehealth services available to physicians in very short order once the pandemic hit. How did this occur?
Reilly: MedStar was pretty organized about rolling out. Very quickly after the elective cases and clinic visits were postponed, we got communication from the leadership about the intentions to roll out this telehealth platform that would be happening immediately in the primary care offices. I think they got up to speed within a week of elective cases and patients [visits] being postponed. Then the rest of us in specialties got up within two weeks.
HL: Tell me about your experience using telehealth.
Reilly: I've evolved to become an early adopter of technology. Through my role as associate chief medical information officer at Georgetown, I'm kind of the point person for the outpatient EMR at Georgetown Hospital. Through that, I've recognized the value that the electronic processes can add to patient care.
As soon as I saw that [telehealth] was rolling out [at MedStar], I was very interested in how it was going to work, and thinking about workflows. I began strategizing with our operations manager in our office about how we were going to educate the providers about it. I wanted to start testing it.
Basically the rollout was great. There were some issues that you would expect with any new thing like this. There aren't that many, but it still requires a little bit of expertise in areas that most of us were not previously so familiar with. For instance, what are the patient's security settings on their phone? Are they using a browser that isn't supported by this application? Do they have the security settings in their browser set to allow [access to] the camera? Which software do you have in your phone and which device are you using? And, sometimes, people just don't have a good signal.
The first week or two is spent being primarily productive but running into some of these glitches before we necessarily as individuals had the tools and understanding to help solve all the problems. But after we've gone through the necessary growing pains, I don't think I have had a single patient that I can't talk through how to get on the video call.
HL: What advantages does telehealth provide and what some of the barriers or challenges, particularly with your profession?
Reilly: There are a couple advantages. One of them is really seeing a person in their home. That has made me feel more connected to my patients than I honestly could have imagined. In some ways I actually feel more connected to my patients through telehealth than I do when I see them in person. In person, they're in your space. And there may be various aspects of discomfort or anxiety that come with that for them. But on telehealth, they're in their space. I found that to be a really cool augmentation to the other information that I get just from talking to the patient. So that's my favorite thing about telehealth.
It's also way more convenient for patients. Their waiting room is in their house. If I am running behind, which happens, they don't mind. They're not worried about parking. I also think they're on time, because they haven't had to deal with parking or other things that come up between the time that you leave your house and the time you actually get into the seat in the doctor's office. Those are all pretty strong advantages.
One thing I like about telehealth is the ability I've had to keep a closer eye on my patients. In the past if somebody had a problem, due to whatever scheduling constraints there are, it's hard to bring somebody back in on a weekly basis for three or four weeks if they have an acute problem to make sure they're getting better.
I'm thinking of one of my cancer patients right now who just had a really rough time. He's got all kinds of complications from radiation therapy and he's got open wounds and infections. I've seen him in the last two months on telehealth probably six times. He lives almost an hour away. I don't know that I could have gotten him in to my office six times in two months. But in part, because I've been able to see him on telehealth, I've been able to keep a really close eye on him and help him with each of these things way more easily.
Disadvantages mostly relate to physical exam findings that you just can't get a great sense of over a video image. And those would be things like maybe a lesion inside the ear or a nuanced part of the way their skin feels, or the way a lump might feel. So there are limitations. And then part of my practice as a rhinoplasty surgeon and sinus surgeon is that I do quite a bit of nasal endoscopies where I perform clinic procedures on patients routinely. So, obviously, I haven't been able to do those. I can't get the information about their internal anatomy like I would typically be able to obtain in an office visit. So those are understandable limitations.
HL: Do you think you'll continue to use telehealth and under what circumstances?
Reilly: Absolutely, assuming that it continues to be, um, allowable. Patients and providers should use all the information available to make the best decision for the patient. So for patients for whom it's an extreme burden to come into the office, or maybe they're immunocompromised and it's a risk them to come the office, or maybe they have a problem that can be sussed out purely over a video call [telehealth makes sense]. For those patients, if we give them the option of not coming to the office, we're doing them a service. For other patients, it's really not an option if they have a new lump or a new mass, or there's a cancer history that we need to see them in person and follow up. The hard part will be figuring out where to draw the line in that gray zone between those two examples.
HL: What implications does telehealth have for post-operative visits?
Reilly: There are some pretty strong implications for post-ops, especially for the visits that are routine and don't require any in-person intervention like suture removal or some sort of physical procedure. Certain providers at MedStar already have access to this virtual assistant called Amy, which is basically a postoperative surveillance system that allows patients to get their instructions at the time they need them. It also allows patients to do things like send photos to the provider to try to head off the need for any unnecessary trips to the ER or urgent care visits that could be alleviated with a better connection with the provider. The addition of this live call as a way to suss things out is certainly going to help. I personally like that call. I like that contact. I think that a photo is great, and a question can be good in a quick text, but I'm a conversationalist. I feel like some of the devil's in the details, which usually you can't get with just a picture, or a text, or an email thread. Sometimes, you just need that conversation.
HL: What about the personal convenience for you?
Reilly: I've been doing a hybrid approach [working from home and two office locations]. There is some convenience to providers when you can work from home. Right now it's limited by the fact that if you're at home, you have to figure out how to get the get on the network, which is just a few more steps. You also may not have like the latest applications on your desktop because it's not your work computer. So there are definitely some technical and logistical hurdles to working from home. But if this were to become the new normal, then I could see an investment in the equipment that would be required for providers to really have optimal technology set up at home to do it as smoothly as they'd be able to do it in the office.
HL: What about recording notes In the electronic medical record (EMR)? Is that more of a challenge?
Reilly: It's definitely more of a challenge. That has required some ingenuity and a learning curve. I need to have a good connection with the patient. Their full attention is on you, whereas you're talking, listening, and generating documentation. For the provider, it's important to have your screen set up in such a way that even when you're working on [a patient's note] they're still getting your frontal attention, and it doesn't [appear as if] you're looking off doing something else. [It involves] strategic arrangement of the camera and the windows that you're using to communicate with them.
HL: That's certainly a dynamic that happens in person anyway, right?
Reilly: It is, [but] it's still a unique challenge. I will just say it's not quite the same. In person because you're sitting in the same room and because it has been the norm for so long, the patients are used to you looking away from them when you're in the room with them. They know they have your attention because you're in the room with them. Whereas, when you're on a computer call with someone and you're looking away from them, I personally have felt a strong need to set my screens and cameras up in such a way that I'm still very much looking in their general direction when I'm working on their note.
I do this in three different locations. One is home and then my two different offices. So I have different set ups in both places. At home, my camera is in my computer, and I just toggle tabs between the patient's video image and the medical record documentation. At work I have a separate computer set up immediately below my work computer so that I'm able to look at the screen on my second computer, which is basically right behind the computer with the camera.
HL: What advice do you have for other physicians that are making this transition?
Reilly: Scheduling more time between visits is a smart idea. We have increased our slots by about a third. In other words, my 15-minutes slots are now 20-minutes slots. I used to do 15- and 30-minute [appointments]; now I do 20- and 40-minute appointments. It gives you time [to deal with technical issues]. It builds that cushion into your day so aren't behind the eightball, running late with every patient.
With our system, and we're working on building this out, we actually don't have a queue system for patients yet. The provider is the one that makes the contact. So if the provider is running 15 minutes late, the patient doesn't know that. Once we have the queue system set up, our staff can call and start the appointment and reassure the patient that the doctor will be with you as soon as he or she is available. I think that will greatly smooth things out. For anyone looking into this, I think that queuing system saves a lot of front- and backend work.
HL: Is there anything you want to say in closing?
Reilly: I'm grateful for the ability to connect with my patients and to provide care in a way that I didn't really think was realistic prior to this epidemic. I will restate my joy in seeing patients in their own environments to help inform me about what they're really dealing with. I think there's a holistic part of healthcare that can be aided by the ability to see someone in their home environment. And I think that because everyone's looking for connections right now, given our lack of ability to do it in person, telehealth visits actually provide a very intimate way to be able to connect to our patients. I'm really grateful for that.
Editor's note: This story has been updated to clarify the operational framework for telehealth within the MedStar system.
“In some ways I actually feel more connected to my patients through telehealth than I do when I see them in person.”
Michael Reilly, MD, associate professor of facial plastic and reconstructive surgery at MedStar Georgetown University Hospital
Mandy Roth is the innovations editor at HealthLeaders.
Seeing patients in their home environment increases the personal connection. Proper positioning of the computer screen and cameras enables better eye contact.
Expect a learning curve and initial technical issues. Consider increasing appointment times from 15 to 20 minutes.
A queuing system is advised so that patients can have an initial connection with office staff to work out issues and be reassured if the physician is running late.