Using Telehealth in a Pandemic: Focus on Flexibility, Scalability

‘Take Care of the Patients First’

“There’s been a lot of spontaneous action,” says Alexa Boer Kimball, CEO of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, a network of roughly 2,900 physicians spread across eastern Massachusetts.

“The key is to take care of the patients first,” she says.

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Kimball remembers using telemedicine as far back as 1998, though more recently the network had focused on urgent on-demand care. Now her physicians are seeing thousands more patients each week via telehealth than they had seen just a few weeks ago.

While the traditional barriers – reimbursement, patient and provider buy-in, technology – “have always been there,” Kimball says the accelerated pace of the nation’s response to the emergency has allowed providers to jump in and try things out.

“The first thing we realized was that you can do a lot of things just on the phone,” she says.

Actions by state and federal officials have loosened a lot of those barriers, allowing providers to test new platforms and see more reimbursement. Kimball says her providers have long clashed with payers over coverage, and she’s hoping the success they’re seeing now will convince payers to maintain these new guidelines after the pandemic has eased.

“Right now we’re pretty confident we’ll be reimbursed for that business, but we’re still not sure,” she says. “This (rapid uptake) is kind of proof in the pudding. We need to make sure we have the data to prove our point.”

Kimball advises providers to “pay attention to all the guidance” right now, identifying both state and federal guidelines that have a direct effect and positioning telehealth and mHealth services to take advantage of those new rules. This includes developing a compliance and payer-specific billing plan, and massaging that plan to cover not just Coronavirus cases, but all cases.

“We need to be ready for a new (environment),” she says. “There’s no going back.”

‘We … Jumped Forward 10 Years on the Adoption Curve’

Out in Renton, WA, the Providence St. Joseph Health system was caught in the middle of the first wave of Coronavirus cases. But Aaron Martin, Executive Vice President and Chief Digital Officer for the six-state, 51-hospital health system, says leadership had recognized the value of virtual care six years ago and had the infrastructure in place to tackle the surge.

Still, he says, they were caught by surprise by a tenfold increase in telehealth visits and a sevenfold jump in care providers joining the platform.

“We had to move very quickly from feature-driven (virtual health offerings) to scale-driven,” he says. “We basically jumped forward 10 years on the adoption curve.”

Martin says PSJ has a large digital health innovation program, employing some 120 software engineers and producing more than a few tools and incubator spin-outs, like Xealth. The health system also partners with telehealth and mHealth companies to test out the latest in tools and services.

That helped the health system expand from its fast-growing ExpressCare Virtual telehealth platform to a stable of services that now includes remote patient monitoring for roughly 300 patients in the Seattle area. That program will soon be expanded throughout the enterprise to help other hospitals manage their populations at home.

Martin says the health system realized very quickly that it had to have a plan in place for expanding and evolving its virtual care services.

“Move fast, but make sure you’re being very, very diligent about things,” he says. “Understand all the processes in place, and make sure the technology is very fungible and easy to configure.”

In addition, make sure all telehealth and mHealth services are tested and fine-tuned not only by IT, but by the clinicians who will use them.

“And be prepared to learn,” he adds. “We will learn some things that work in virtual visits, and we will learn some things that absolutely don’t work.”

That includes addressing three specific goals: Make sure all online content is from a trusted source, be prepared to adopt all-digital transactions, and focus on engagement, both to get patients through the digital door and to keep them there for future care.

With regard to future care, Martin says “we’re already thinking of the new normal.” That means preparing to transition from Coronavirus triage and care to a platform that can take on elective procedures, chronic care management and specialty care.

Martin expects the healthcare industry, pushed by consumer demand and the successes of using technology during the pandemic, to pressure state and federal regulators to keep guidelines in place that expand telehealth coverage and reimbursement. But he also expects the industry will see an increase in fraud and abuse, as some look to take advantage of that new normal.

“There’s going to be some time to adjust,” he says. “Let’s just make sure we don’t back ourselves into a corner (with new legislation) that we can’t get out of.”

‘We Know It’s a Marathon’

At Houston Methodist, the health system has weathered the likes of Hurricanes Allison and Harvey, not to mention the surge of people displaced by Hurricane Katrina. Stephen Spielman, Senior Vice President of the Houston Methodist Physician Organization and President of the Methodist Primary Care Group, says the seven-hospital system has learned a lot from past disasters.

“We’ve been through this – we know how this feels,” he says. “We know it’s a marathon.”

Spielman says the health system has been expanding its platform since partnering with American Well some three years ago on its first virtual care service, and now has a broad network of services.

The Coronavirus pandemic, however, pushed the health system into uncharted territory.

He says Houston Methodist’s Virtual Urgent Care service worked well in the direct-to-consumer arena – handling the increase from 30-40 visits a day to 250-300 visits - but it didn’t mesh well with the network’s Epic electronic health record, giving providers fits as they tried to conduct telehealth visits with established patients. So the health system created a second telehealth network on the Epic MyChart platform, allowing providers to integrate primary and specialty care visits with each patient’s EMR.

“This gave us better flexibility, and our physicians loved it,” Spielman says, adding that the shift to a virtual platform took only 10 days. It’s also giving network executives the confidence to push ahead with their third connected health platform: E-visits.

Along the way, Spielman says he’s learned some interesting lessons.

While federal authorities loosened the guidelines for video visits through consumer-friendly platforms like Skype and FaceTime, “it’s been a little bit cumbersome to do that operationally,” he says. Those tools might be great for quick, one-off visits demanded by the epidemic, but they don’t integrate will with the health system’s telemedicine infrastructure – and likely won’t be an option when the emergency passes and some of the old rules and regulations come back into play.

On the other hand, Spielman says he’s had great success with the Press Gainey patient surveys sent out after every telehealth encounter, giving health system executives a good idea of what patients like and don’t like about virtual care. With so many people quarantined at home, more patients have time on their hand to complete those surveys.

At present, Spielman says Houston Methodist is ramping up its telehealth platforms to not only deal with an expected surge in Coronavirus cases, but to give patients with other needs – treatment for issues not related to the pandemic – the same access to virtual care as those with the virus. The health system is also looking to expand its telemental health offerings to help staff dealing with the stress of the pandemic.

Looking ahead, he says the health network will look to keep the momentum going after the emergency by expanding its telehealth services for chronic care management, health and wellness and other ancillary services that have been pushed to the side to tackle the virus.

“What we’re learning here will change healthcare permanently,” he says. “The genie is out of the bottle. Telehealth is our passion now.”