Leveraging Telehospitalists in the Age of COVID-19

Telehealth offers a wide array of benefits, including the ability to care for patients outside the hospital and supplement inpatient care. But even within the four walls of a healthcare facility, telehealth can help extend the reach of certain providers, such as hospitalists.

Providence, a health system that spans five states, 52 hospitals, and 950 clinics, has experienced the benefits of a robust telehospitalist program, especially as COVID-19 cases ebbed and surged during the pandemic.

Last year, Providence's telehospitalists served more than 7,100 hospital patients and provided 19,000-plus virtual bedside consultations, a 45-percent volume jump year over year, according to a report released by the organization in April. This helped extend hospitalist coverage when hospitals needed it the most.

But expanding a telehospitalist program during a once-in-a-century public health crisis comes with its challenges, which for Providence included training for on-site nurses who help telehospitalists conduct remote physical examinations.

THE PROGRAM

The telehospitalist concept is not new to Providence. The health system launched pilots of its program a decade ago and deployed it as an enterprise offering across multiple sites in 2015, Todd Czartoski, MD, chief executive of telehealth and chief medical technology officer at Providence, told mHealthIntelligence.

The program helps the health system effectively spread out its clinician resources and ensure hospitalist coverage, day or night, at multiple sites.

"We have hospitalists that are on at night in some of our smaller facilities who maybe are underutilized and maybe don't even have to be in the hospital at night…And then we have other sites in our larger tertiary care centers where our hospitals may be overwhelmed at night," Czartoski said in a phone interview. "So how do you overcome that and prevent burnout and prevent stress and make sure that we're providing high-level, high-quality care? Well, we've developed telehospitalists to be able to have that [coverage] across multiple sites in a geographically unrestricted way."

Providence's telehospitalists are trained to admit patients to the hospital remotely. They first consult with an emergency care physician and then conduct a remote examination with the help of a nurse, both of whom are on-site.

The nurses, called tele-presenters, facilitate the hands-on parts of the physical exam.

"They also have a stethoscope so they can listen to the heart and the lungs, and as they're listening to it, the telehospitalist on the other end who is remote can actually hear breath sounds, heart sounds [and are] able to do a full exam that way," Czartoski said.

The telehospitalist then diagnoses the patient and admits them for in-person care.

"In addition to that, we've layered on cross cover capabilities," Czartoski said.

During a busy night at the hospital, hospitalists may struggle with juggling inpatient admissions and calls from nurses about cross-cover patients who, in many cases, the hospitalist has not seen before. These patients were hospitalized under the care of an attending physician, but if that physician is not available, then the hospitalist on call is paged if nurses have any questions. Telehospitalists can help ease the load on on-site hospitalists by remotely consulting with nurses on the cross-cover patients.

The telehospitalist program now extends to 16 sites across Providence's network. It includes 20 to 25 hospitalists who spend about half their time providing care via the telehospitalist program and the rest in person.

"It's gone from being kind of just an interesting idea to something that I think is fairly mainstream in our organization as a way to improve quality, decrease burnout, and help both on the nursing side and the physician side," Czartoski said.

BOLSTERING CLINICAL COVERAGE DURING COVID-19 CRISIS

When the COVID-19 pandemic hit, Providence ramped up its telehospitalist program.

"We added multiple sites, and then we increased that cross-coverage capability," Czartoski said. "That was probably a big one to really help sites deal with the volume of patients."

The health system also expanded the hours of the telehospitalist program. Pre-pandemic, it was a nighttime service. But as COVID-19 cases surged, the program added daytime coverage at certain facilities.

For example, Providence expanded telehospitalist daytime coverage at Providence St. Mary's Medical Center in Walla Walla, Washington, and St. Elias Specialty Hospital in Anchorage, Alaska.

"Some of our smaller sites needed help because they were having volume surges, and they wanted an extra set of hands, or in this case, I guess, an extra brain to help with caring for the surge in patients," Czartoski said.

This additional virtual support not only helped save the health system the high cost of having multiple doctors on call or in the hospital but also helped alleviate burnout as the public health crisis grew, he added.

Further, telehospitalists provided support for Providence's hospital-at-home and COVID-19 home monitoring programs.

"Essentially, we've been able to kind of use that [hospitalist] expertise across geographies for multiple different use cases to optimize efficiency and capacity," Czartoski said. "And frankly, they kind of like the diversity of the work. They can do some telehospital stuff, they can see a patient in hospital-at-home, and they can weigh in on COVID Home Monitoring when needed."

OPERATIONAL HURDLES AND STRATEGIES FOR SUCCESS

One of Providence's key challenges, as it expanded the telehospitalist program, was training the in-person nurse tele-presenters.

"Not only do we have a shortage of physicians who have burnout, but nursing is as bad or worse," Czartoski said. "And so, finding a nurse — particularly in one of these smaller hospitals in a rural location — who can go through the training to be the tele-presenter, who has the time and the interest and the capacity to do that. I think that has been a barrier at times."

Providence worked with local nurse managers and chief nursing officers to ensure they were identifying the right nurses for the program. They also streamlined the training process to be completed in a matter of hours rather than days. The training also involves technology and equipment education.

Another critical factor to consider when implementing or scaling a telehospitalist program is understanding the gaps in coverage and pain points specific to a location and then establishing the telehospitalist workflow, Czartoski said. For example, some facilities will need cross-cover capabilities or daytime coverage, while others won't.

Looking ahead, Czartoski expects the telehospitalist program to continue increasing daytime coverage and adding new capabilities.

Not only that, but there are also plans to further extend the program beyond critical access and rural hospitals.

"[We plan] to expand into some of our larger facilities where traditionally they were like, 'hey, we're a tertiary care center. We need to have people here physically, not remotely,'" Czartoski said. "I would say a lot of our growth will be tied to looking at ways to drive efficiency into the ecosystem, including at larger urban and suburban hospitals."