Memorial Hermann Maps Out a Strategy for Primary Care via Telehealth

While the coronavirus pandemic may have changed the rules, health systems across the country are investing more time and energy in telehealth platforms that take primary care out of the hospital and into the home.

One such network is Houston’s Memorial Hermann Health System, which had a robust virtual care strategy in place well before COVID-19. The 17-hospital health system, which also touts eight cancer centers, three heart and vascular institutes and 27 sports medicine and rehab centers, is now looking to expand its connected health portfolio with new services.

Rakesh Mehta, RN, BSN, MBA, Memorial Hermann’s director of virtual health, recently spoke with mHealthIntelligence about the health system’s telehealth journey.

Q. Prior to the onset of the coronavirus pandemic, how did Memorial Hermann develop and launch a virtual care strategy?

A. Memorial Hermann was interested in providing increased access to its populations when and where the patients wanted such access to care. To that end, we already had a robust asynchronous direct-to-consumer offering for urgent conditions. We also had a scheduled virtual visit platform where patients could get near-real-time appointments for virtual visits with Memorial Hermann urgent care providers.

Beyond these offerings, the plan was to develop a primary care-focused virtual health service offering. To that end, they recruited a full-time leader focused on developing a full suite of enterprise-wide virtual care services prioritizing virtual primary care, remote patient monitoring (RPM) and mHealth applications.

We developed a strategic plan to enable a virtual care-augmented primary care (VCaP) model, where virtual health would be ubiquitous across primary care practices, and RPM and mHealth would be leveraged to manage the care of patients with chronic diseases. The focus was to leverage virtual care to manage co-morbidities in our ACO population - to prevent readmissions, provide access based on patient convenience, and have more asynchronous and digital care delivered while helping ambulatory practices to become more efficient in managing patient panels.

Q. How did COVID-19 change this strategy?

A. While the strategy did not change dramatically, the pace of implementation was significantly accelerated because of the momentum provided by the pandemic. There was reprioritization as well.

The intent at Memorial Hermann was always to strategically enable VCaP, and the pandemic helped enable early phases of that strategic plan almost in a span of a couple weeks. Since the people, process and technology factors were already primed and this expansion was aligned with our strategic roadmap, we kicked off virtual care in the Ambulatory space relatively quickly.

We also operationalized a 24/7, asynchronous and synchronous platform for virtual urgent care for our community at the time of need. The above service was plugged in to a 24/7 triage line established for the system support of the pandemic. We quickly surpassed 100,000 virtual visits in a few months, and continue to see higher than the pre-pandemic rate of utilization of these flagship offerings. 

In the acute settings, certain aspects of care were moved to virtual settings to create efficiencies for providers, avoid unnecessary staff exposure and provide patient-to-family virtual communication capabilities for patients in isolation.

Q. Were new technologies or tools introduced? How and why?

A. We had some tools and technologies before the pandemic: an asynchronous virtual urgent care service, an EMR-integrated virtual care platform for the ambulatory group, telemedicine carts in the acute settings and limited mHealth and RPM platforms in the population health model.

We introduced additional capabilities in anticipation of a patient surge, such as 24/7 synchronous capabilities for virtual urgent care, iPads for communication (between isolated patients) and care givers and family, and pulse oximeters for patients that we discharged with oxygen. We also procured additional devices for the Tele-ICU setting for remote patient monitoring.

We will soon be introducing a best-of-breed, EMR-integrated virtual care platform that will help improve the virtual care experience and bring in additional features and functionalities that consumers and patients deem critical, without losing the EMR-integrated nature of patient data that our physicians have been used to seeing. 

This platform is critical, as it brings to bear the seamless experience that patients are accustomed to in other sectors, such as shopping, financial transactions and entertainment. While virtual care has some distance to cover before becoming that seamless, many of the current platforms offer these capabilities and superior consumer experience. 

Finally, our organization strongly believes in the philosophy of providing a patient experience that is as frictionless as possible. To that end, we are implementing a true digital front door, with virtual care being one of the avenues available to consumers to access when and where they find it convenient.

Q. As we look toward a post-pandemic landscape, what lessons learned from COVID-19 will be integrated into a new virtual care strategy?

A. There are a few critical lessons coming out of this for us.

Evolving a Hybrid Model of Care. We are envisioning the new normal with a hybrid model of care, where vulnerable populations can continue to get the care they need in person and/or virtually as appropriate. We expect the vulnerability (of risk of exposure to COVID-19) for a significant portion of our population to be a threat for the long haul. As has been stated so often, we cannot afford to go back to the old models of care where virtual was in the shadows and nice-to-have.

The baseline from here on is going to include some aspect of virtual care - which will be a permanent  feature of care delivery - leaving the to the individual physicians and  health systems as to what, how and which aspects of care they decide to make virtual.

The Need for Clinically-led Change Management. Virtual care involves more than just the right tools and technology. While the pandemic provided an impetus for expanding virtual care, change management will remain a critical component of making this expansion meaningful and sustainable for both our patients and providers.

Creating a Closed Virtual Care Loop. Providing a virtual visit is just one aspect of the value proposition. We need to think through the entire value chain of virtual care delivery, from scheduling to filling forms to the intake process to the actual provider-patient interaction to the needed lab tests at home and, finally, medication management. There is a lot of innovation out there that we can leverage to complete this virtual care delivery loop. From that perspective, there are several to-dos in the new normal of healthcare, and we have just begun scratching the surface of the potential of providing comprehensive virtual care. 

(Virtual) Urgent to Primary Care. Before the pandemic, virtual care resided in niche areas that were considered opportune for a health system entering the space - behavioral health, acute telemedicine (especially teleneurology) and urgent care. Many health systems contracted with vendors to provide both the platform and provider services for virtual urgent care.

That has quickly changed. While still a strong focus area, the pandemic and the attendant (Centers for Medicare & Medicaid Services) waivers on reimbursement and platforms opened up primary care and other ambulatory settings to virtual care. There is no doubt that revenue substitution needs to happen quickly in these newer areas. 

This aligns neatly with our system’s strategic plan, and we are bullish that we can create stickiness in this (VCaP) area for the new normal of healthcare delivery.

Virtual Behavioral Health. While behavioral health has always been a great use case for virtual care, we expect this area to see ongoing innovation, especially as the nation deals with the widespread impact of isolation, depression and economic stressors.

Q. What are the biggest barriers to ongoing telehealth adoption?

A. There is a lack of healthcare equity for virtual care. We have to be creative in overcoming specific social determinants of health (SDOH) and other disparities to ensure that the impacted demographics are not being left out. Whether it is language, socio-economic factors, technology or disability (as a barrier), there are many reasons that patients are finding it difficult to adopt virtual care. Ironically, sometimes the patient population that could benefit most from virtual care faces the most barriers to access.

We are also living with the uncertainty of the reimbursement environment. While there is confidence that things are moving in the right direction, we are still not there yet. We have to wait and watch if all payers, not just CMS, deliver on the promise of a reimbursement environment that will support the unfettered growth of virtual care. We simply cannot go backwards in that regard.

We still lack enterprise platforms in the virtual care space, and that gap stems from differing views within the provider space. What physicians deem as a perfect platform may differ from what consumers want, as well as from what privacy, compliance, legal and revenue cycle stakeholders want from virtual care. And while regulations have improved for virtual care adoption, healthcare is not an intuitively frictionless sector for consumers.

In short, while there are platforms out there that provide a virtual experience comparable to banking or ordering pizza, it remains to be seen how secure these might be and if they will be permissible in the long term once the CMS waivers end. Virtual care seems to be the new focus of hackers and for identity theft, so patient privacy and security will continue to be of paramount importance, even if it’s at odds with a seamless experience.

Q. Will Memorial Hermann be looking more toward consumer-facing mHealth devices in the future to augment home-based care?

A. Since planning and managing for COVID-19 patients is our constant focus, mHealth and home-based care take a slightly reduced significance right at this moment. But hopefully as things normalize, we should be able to implement more mHealth and home-focused care with specific populations within our Accountable Care Organization. 

While there is some reimbursement in this space, there isn’t much momentum for virtual home health, hospital-at-home and other home-based models. With millions of virtual visits logged during the pandemic, this will allow payers to systematically evaluate the ROI, cost savings, quality, clinical and other metrics of virtual health and take a data-informed stand on whether virtual care truly reduces the cost of care and provides access. There will be some time lag, but those studies and inferences will happen, and they will create sustainability. Once that happens, reimbursement will be easier for payers to rationalize. 

Q. Will Memorial Hermann be developing more remote patient monitoring programs?

A. Yes. We have launched an at-home RPM program for patients post-COVID-19 discharge. To manage the surge volumes, patients who were medically stable and deemed safe to continue recovery at home were discharged with pulse oximeters and oxygen. A care advocate would get daily oxygen saturation readings from the patient and conduct virtual visits with the patient (and family) to ascertain that the patient stays on the right trajectory. We established escalation pathways with emergency department physicians in case of need.

From a preventive care perspective, there is robust interest in deploying RPM for patients with comorbidities to ensure that they stay safe and do not have the need to visit a physician when the health system’s capacity is tested. These programs are still being developed in anticipation of a fall surge.

For the acute setting, we have deployed tele-ICU nurse monitoring to provide our ICU bedside nurses with additional critical care-trained nursing support. This was to ensure that we create efficiencies for our bedside nursing staff and avoid staff burn-out and unnecessary exposure for providers. This also provide gives patients in isolation a means of communicating with providers, and it gives their families comfort in knowing their loved ones are being monitored 24/7 on video by a nurse.

Q. How do you look for a balance between virtual and in-person care as we move beyond the pandemic?

A. The mission statement of virtual care at Memorial Hermann is to provide a ubiquitous model that delivers care when, where and how the patient prefers it - and as clinically appropriate and efficient. 

With uncertainties surrounding the future of the pandemic, we have taken an agile mindset to virtual and in-person care. Supported by the physician, information services, consumer experience and marketing leadership, we will focus on a combination of in-person and virtual care. We have started enabling specific models of hybrid care especially for the populations have chronic disease needs. We have also very well-defined protocols for conditions that are episodic and those patient cohorts. 

We are also on a continuous learning and improvement path based on feedback from our patient, provider and staff stakeholders. We are learning about their pain points and aim to reduce the friction points for allowing seamless in-person to virtual transitions and vice versa. Finally, we are leveraging our EMR-integrated virtual care platforms where possible, always leading with that while allowing platforms that might better suit niche use cases and populations for virtual care.