COVID-19 Impact

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PSNet: Patient Safety Network

 Perspectives on Safety

Special Edition Perspective: Technology Responses to COVID-19

Editor’s note: This Perspective differs from the typical Perspective in that it compiles findings and insights into a series of case studies from interviews and written responses from leaders at three different health systems who had to increase their telehealth capacities in response to the COVID-19 pandemic. Please note that there is no separate interview transcript accompanying this Perspective; rather, the interview transcripts are integrated throughout.

Executive Summary

Since the emergence of the COVID-19 pandemic and resulting social distancing safety precautions, telehealth utilization has greatly increased. Hospitals, specialists, and ambulatory care clinics have quickly scaled up their telehealth efforts in response to an immediate need to enhance safety by reducing direct physical contact and interactions between patients and between patients and caregivers. For example, the University of California, Davis (UC Davis) Medical Center estimates that outpatient telehealth encounters have increased from 1% pre-COVID-19 to more than 50% of all visits currently. Between March 14th and April 1st 2020, daily ICD-10 telehealth claims for upper respiratory infections from private insurers increased approximate 12 times from the daily average when compared to the previous month.[1] Based on an April industry outlook and market forecast, by the end of 2020, the telehealth market size is expected to reach $9.5 billion, an 80% increase over 2019.[2]

While the majority of US hospitals and nearly half of all physicians now connect with patients remotely for outpatient and office-based appointments,2,[3] telehealth capabilities can vary substantially between health systems and experiences ramping up telehealth offerings have differed. This can be partially explained by variation in institutional infrastructure and telehealth utilization pre-COVID-19; systems with more established telemedicine systems were positioned to leverage this existing infrastructure in response to the sudden demand at the onset of the pandemic.[4]

The three case studies presented below from UC Davis Medical Center, University of Arkansas for Medical Science (UAMS), and Greater Baltimore Medical Center (GBMC) provide three different examples of how healthcare systems have expanded their telehealth capabilities, augmented patient safety considerations, and generated lessons learned. Despite their differences, several key themes are emerging from the field:

  • As with other efforts to improve patient safety, the rapid and successful implementation of telehealth requires a culture that supports new technology. Staff must understand the value of change and innovation and be willing to modify practice to support it.[5],[6]
  • Telehealth may be better suited for certain patient populations than others and some specialties are going to incorporate its use more readily than others. Whether telehealth is appropriate will likely vary by institution and individual provider. 
  • It is challenging to establish protocols that definitively state which patients and which visits are appropriate for telehealth services. Written escalation protocols can facilitate those decisions, but ultimately providers need to trust their clinical judgement.

Telehealth provider training has been greatly expanded and expedited to meet the acute needs of the COVID-19 response; more structured approaches to training will be necessary once recovery begins. Many hospitals and practices are already planning to invest more resources in telehealth solutions and physician education.2

  • While telehealth and video visits have been critically important means of receiving medical care safely during the pandemic for many patients, alternative approaches must be available for individuals who have limited access to telemedicine to ensure they do not experience gaps in care.
  • Patients are seeing the benefit of receiving telehealth services and will likely drive the demand for increased utilization after the immediate crisis.[7],[8] This will create a need for remote monitoring technologies and procedures around implementation in a safe and effective way.

Case Studies

To develop these case studies, the sites responded to a series of questions that gathered basic information on their telehealth activities in response to COVID-19. We then conducted follow-up interviews with the individual or teams supporting these activities.

UC Davis Medical Center

Based in Sacramento, California, The UC Davis Medical Center is a 625-bed multi-specialty academic medical center serving 33 counties spanning north to the Oregon border and east to Nevada, including underserved rural populations. Prior to the COVID-19 crisis, the telehealth program operated by UC Davis was recognized for connecting remote communities to academic specialty and sub-specialty care.  

While UC Davis had invested in the infrastructure to provide outpatient telehealth services, particularly for specialty consultations in rural areas, only 1% of outpatient encounters occurred via telehealth prior to the COVID-19 pandemic. In response to the pandemic, UC Davis found themselves well positioned to change the model of care from onsite visits to video visits with patients in their homes within in a few weeks. Outpatient video visits now account for more than 50% of their outpatient volume.

UC Davis has also implemented provisions specifically related to the management of patients with suspected COVID-19 infection, notably online screening measures and the use of some at-home technologies, such as pulse oximetry, to monitor patients remotely. Video visit use has also been incorporated into new settings, such as in the emergency department and the inpatient hospital setting. Allowing patients to be seen over video, as opposed to in clinics and hospital settings, is considered a safety measure for both patients and the staff at UC Davis. 

However, not all care can be easily transitioned to telehealth.  For example, emergency department care typically involves "forward triage," where the patient is evaluated before they present to an urgent care or emergency department. UC Davis has attempted to address this by having patients connect first either by phone or video to a provider who can perform the triage function and, if need be, schedule an in-person visit. For outpatient encounters, the urgent care and same day appointment lines offered same day video visits; for emergency department encounters, an “influenza like illness” tent was established to screen and offer same day video visits if patients’ conditions did not warrant admission to the emergency department.

UC Davis’ Center for Health and Technology leaders hope that greater use of telehealth and remote patient monitoring is the future for patients with special healthcare needs, multiple comorbidities, and/or high-risk conditions. They think there is an opportunity for a recalibration, or restructuring, of UCD’s healthcare delivery that builds on the lessons learned and changes made during the COVID-19 pandemic. Rather than the model where people make a physical visit to the doctor for all types of questions, technologies can be used to offer such services as electronic consultations, video visits to the home, and telemedicine visits to the local primary care provider office. Depending upon the condition and specialty, concerns that are typically referred to an in-person visit have the potential to be handled more efficiently, safely, effectively, and in a more patient-centric way using telehealth technologies.

AHRQ PSNet Co-Chief Editor Dr. Hall spoke with Dr. James Marcin, Pediatric Critical Care Physician and Director of the Center for Health and Technology at UC Davis. In this role, Dr. Marcin oversees telemedicine and eHealth initiatives across the health system.

Dr. Kendall Hall: In our initial email communications to prepare for this interview, you had noted that UC Davis was well positioned to rapidly change your model of care to predominantly include telehealth visits. Is your patient population used to this type of interaction? How did you expedite that transition and what were some of the lessons learned?

Dr. James Marcin: I think there are certain segments of the population that are familiar with and use the type of telehealth that has exploded through the COVID-19 epidemic, what is referred to as “direct-to-patient” or “direct-to-consumer” telehealth interaction. This is when a provider or physician is using video directly with a patient in their own environment or home. There has been a lot of investment into making these technologies available to patients, but it hadn’t really taken off. I think the utilization across the country, for the most part, had been very low. We at UC Davis had made the investment to do our outpatient encounters via telehealth, so we had the technology already integrated into our electronic health records, the operations guidance, the workflows, and the education for the clinic staff; all of it was already readily available. So, thankfully, when we had to quickly transition everything from in-person to video and/or phone we had everything in place to be able to do that. However, one thing to keep in mind is that we had some long-standing relationships with our rural area clinics where we would provide specialty consultations provider-to-provider, but that has also had to change. When the pandemic hit, patients and providers didn’t want the patient to come into their local clinic to receive specialty consultation anymore. As a result, a lot of our specialists have had to transition from a provider-to-provider telemedicine consultations to a provider-to-patient consultation model, engaging directly with the patient in their home.

KH: With that huge increase in telehealth encounters and your specialists having to change their model to one where they're directly interacting with the patients, are you all using platforms that support or can be HIPAA-compliant? How do you handle that kind of surge in equipment needs? Or now that we have our cell phones and our tablets, does everybody already have the infrastructure in some way?

JM: Well, I actually don’t think it’s an infrastructure issue as much as an operational issue. I think that many physicians could use a HIPAA-compliant platforms, such as Zoom, WebEx or Doxy.me, all these different platforms out there. Or, even now, given the relaxation of the HIPAA enforcement due to the pandemic, other platforms like FaceTime or Skype became usable. The technology is kind of the easy part, I think. It is the incorporation of video visits into the clinical operations, I would say that is more challenging. We're on Epic here and we had the integration of video visits in Epic already set up. Scheduling occurs the same way as in-person visits, and the doctor is then able to go into their Epic page to start the video visit, document the visit, and submit their notes for coding and billing. Anyone can FaceTime or send a Zoom link or a WebEx link, but having that operational infrastructure makes the difference. The Center for Health and Technology had to work very closely with clinic operations, our health information management people, our coders, our billing team, our legal and compliance and regulatory teams, as well as telecommunications and security people, and of course our electronic medical record or Epic teams. You have to involve everybody to be able to do it – we call ourselves a “matrix team.” 

KH: How do you prepare your patients for this transition? Going from 1% to 50% of outpatient encounters in a relatively short period is a huge increase.

JM: For some of our specialists the number of telehealth encounters is well over 50%. For example, our Psychiatry Department went to 100% telehealth and we are doing no in-person visits for scheduled ambulatory care now. For our system to be able to do this, because we were conducting video visits using our EHR, the patients need the Epic “MyChart” app either on their mobile device or tablet for the video. Prior to COVID-19, about one in five of our patients even had this application. We had already created a telephone help-line for patients to install the app and to test it, but after COVID-19, we had to quadruple the staff that were manning these lines. There are still instances, of course, where patients may not have video capabilities, cellular phones, access to Wi-Fi or may not be physically able to complete the process of a video visit. These visits were converted to simple telephone visits. We also had our clinic staff calling patients to let them know we could safely convert in-person appointments to a video visit or phone visit. We heard anecdotally that patients were more receptive if these calls came from their physicians versus clinic staff or phone bank staff. I think in general, once we got over the hurdle of making sure the patients understood the process, both the patients and providers have appreciated how easy and convenient it can be. But again, it's always case dependent. For example, our outpatient cancer visits, in general, have not all been converted to video visits. It's just common sense, right? Psychiatry yes, cancer care, no.

KH:  That's interesting, but what sort of concerns do you have for immunocompromised patients like that? Of course, if you need an infusion you're going to have to go in to a facility to have that done, but what about just regular visits for those folks?

JM: Yeah, so there's going to be variation here. Of course, if you need something like an infusion or things of that nature, you are going to come into the clinic or hospital. But there’s also a lot of testing involved in oncology and a lot of anxiety around that process which is best handled in-person, so we had to set up our Cancer Center to handle this safely and ensure everyone wears a mask and maintains social distancing. However, if you have an immunocompromised patient that is just getting post-chemotherapy follow-up, those visits could be converted to video pretty safely. So that's a great point that there is a patient population that you want to minimize exposure and have their visit conducted over video.

KH: As we come out of this pandemic, will immunocompromised patients, like oncology patients default to video visits for post-treatment follow-up? 

JM: I'm actually meeting with the leadership of the Cancer Center next week because they recognize that some of their patients don't need to be coming in. Let's say, if you need a blood count and things like that, can we have patients go to their local lab or local provider instead of requiring they be drawn here at UC Davis? I don't know if it's infrastructure or frame of mind, but there is variability in how amenable people are to telemedicine. People think there are limitations to what specialties can safely do. For example, endocrinology or something similar where you look at a lot of labs is very amenable to telemedicine, versus sports medicine which is very hands-on, examining joints and testing strength, so they are less amenable. But you know what, at the same time, we've got sports medicine docs here that are really into the possibilities of remote care, who have taken the time to coach their patients, and they have successful telehealth services.

KH: In terms of training, how are you advising your docs when to do telehealth vs. bringing patients in? Is there any standardization across your practices around those criteria? For example, if it’s a post-chemo visit they can be seen via telehealth, but if you have a fever in a dialysis patient with belly pain, they need to come in?

JM: This is very good question and one that has frequently come up for many years. I'm going to have a really disappointing answer for you. When we’ve looked at this nationally, some health systems have a provider privileging process where performing telehealth services is actually a qualified procedure. Then on the other end of the spectrum, other health systems just assume that providing telemedicine is just part of being a doctor – you can see some patients in-person and some over video. Lots of protocols have been suggested or talked about, and it’s one thing when it’s at the thirty-thousand foot level, but once you start going down into the weeds of what should be required to conduct telemedicine visits and which patients it will work for, it's just a mess. The academic societies, including the American Telemedicine Association, have some guidelines for some specialties, but they ultimately don't go into the details of which specific conditions or all of the nuances of care should be done in-person versus over video. I tend to agree with the less regulated approach because, ultimately, it should be left up to the physician’s perspective for the unique patient whether or not telemedicine is acceptable or preferable to in-person visits. At UC Davis, we trust that physician perspective.

KH: One more question, what does the horizon look like after the COVID-19 response. Do you think your telehealth outpatient encounters will stick at the 50% number? Do you think it will change? 

JM: I think this is an opportunity to reimagine how we deliver care. I have been talking to medical staff and CEOs across the country about how we can make electronic consults, video visits, and provider-to-provider visits as efficient, effective, patient-centered, and cost-effective as they can be. This will hopefully allow us to wipe the slate clean on how we currently deliver care, and enable us to think about implementing more efficient, patient-centered models of care. You know the IOM quality of care domains, we absolutely see this as an opportunity to reimagine how we deliver care to better accomplish them. Right now, much of telemedicine has been considered experimental, an innovation, or a care model that needs more research. But now, and ultimately, it’s going to end up being a normal part of operations.

GBMC HealthCare - Greater Baltimore Medical Center

Based in Towson, Maryland, GBMC is a 231-bed medical center with primary care, elder care, and hospice practices throughout the state of Maryland. GBMC began to invest in a preliminary telehealth infrastructure in 2018, with a focus on demonstrating how telehealth services can be used to conduct remote patient monitoring and focused interventions within specific patient populations. Upon the emergence of the COVID-19 pandemic, GBMC already had a rudimentary telehealth architecture built into its Epic medical record software. Based on their data from January 2020, only one or two video visits were conducted a week across the entire network, and this was largely attributed to the organizational mandate that all primary care physicians execute at least one video visit by the end of February as a proof of concept for the Epic telehealth architecture.

In response to COVID-19, their primary care offices began providing 85-90% of their visits via telehealth both to protect staff and to prevent patients from coming to the facilities in person. This was followed shortly by specialists conducting follow-up appointments and reassuring patients whose surgeries had to be cancelled that suspending their procedures was the safest option available given the circumstances. Between mid-March and the beginning of April, the number of telehealth visits increased to approximately 300 video visits a day. By May, GBMC was conducting over 600 telehealth visits a day, including video visits, scheduled telephone calls, as well as telephone consults. Their biggest challenges have been ensuring that truly ill patients receive immediate attention, as well as ensuring there are options available to patients so that technical failures, such as limited internet access or a failure to connect to a video visit, do not create gaps in care.  GBMC has recently established a “Restart Task Force” focused on determining which visits and procedures in the backlog of those suspended due to COVID-19 can safely be implemented via in-person care and what can be transitioned to telehealth.

We spoke with Dr. Neri Cohen, a Cardiovascular and Thoracic Surgeon and informaticist. In this role, Dr. Cohen serves as the Lead Clinical Informatics Liaison between the clinical operations and the informatics teams at the health system.

Dr. Kendall Hall: We talk about the technology requirements for telehealth on the doctor’s side a lot. But how do you work with your patients to ensure that they are comfortable with doing a telehealth visit? What are the options available for patients?

Dr. Neri Cohen: Right now, we are hard at work getting as many of our patients as possible signed up on Epic MyChart as possible. It’s essentially a portal that is very easy for the patient to use once they have set it up. From MyChart, it is very easy for the patient to receive their healthcare by participating in telehealth. The first option that we try with all patients is conducting a true video visit through Epic using MyChart. That allows the clinician to actually speak to the patient, see the patient, and document and record the visit all at one time. That said, there are currently some limitations to the architecture of an Epic video visit, so if that does not work, or if there are technical issues, we will try a second approach. Actually, one of our biggest problems is that we still have a significant, not huge, but a significant slice of our patient population that is not on the internet or doesn’t have a smart phone, so they can’t be on MyChart. Our second option for patients is scheduling a telephone conversation in advance and then documenting the conversation in the electronic medical record after the encounter, explaining that it was a telehealth encounter. The third option is for when there are unique needs for the encounter, some of the commercial products available do integrate with Epic and better facilitate sharing some information with the patient in real time in a way that we can’t when just using Epic. For example, an educational video or interactive questionnaire that has to be done for some of our therapies, or the ability to record someone's gait for physical therapy. We allow the use of commercial products in these circumstances.

KH: I would like to shift a little bit and talk about remote patient monitoring. What kind of remote patient monitoring are you doing and how does that factor into how you’re using the telehealth during COVID-19, or even after?

NC: Right now, we're not doing any true remote patient monitoring because the patients don't have the necessary devices yet. There are still policies in place that require that clinicians obtain and record vital signs in the office in order to record them in the proper field. At the moment, you can’t have the patient purchase a pulse oximeter or a smart scale or a blood pressure machine that integrates with the electronic medical record and actually accept those metrics as a valid vital sign as a part of the physical exam. But it is clear that this is changing. As part of a demonstration project, CMS has approved two metrics – blood pressure and weight – as targets for remote patient monitoring, so we are setting up to monitor those metrics and more. There are now products out there that allow you to do auscultation of heart sounds and breath sounds using a digital stethoscope. There is an entire suite of products that allow ophthalmologists to do visual field, visual acuity, and even retinal examinations remotely. The continued surge of cardiovascular disease in America is going to create a big push for remote patient monitoring. There is currently the ability to do remote EKG rhythm and EKG monitoring from something as simple as a smart watch. Obviously, temperature is a big thing in the COVID-19 era, and you can get either a digital thermometer that literally goes under the tongue or a contactless digital thermometer that integrates with a smart device that then can be uploaded into the electronic record. It is coming, we’re just not there yet.

KH: So let’s talk about attitude and culture. What kind of culture do you need to have in place for telehealth to be successful? Is it just openness to new technologies?

NC: I think it's two things; I think you need a survivor culture that realizes that circumstances change, and you must be open to accepting that there are things outside of your control, and you have to do what needs to be done to live the change or manage the change. I think part of it is also a startup culture and looking for innovation to extract more value from the human interactions that we have. You also have to be willing to and actually have a desire to leverage the machines to let the machines do what machines do well, so you free up the people to do what the machines can't do. Machines can't do human touch and empathy, but they can do a whole lot of the other stuff. We've got clinicians whose attitude is “this should work and I'm going to keep at it until I get it to work.” A lot of our specialists are also embracing it because it's a way to make them more efficient. Then you've got other providers who have very mature practices with patients who are very resistant to change, and the clinician feeds into that resistance to change. They feel like they just can't wait until the stay-at-home orders are lifted because they want to come into the office and they want to look you in the eye and they want to ensure physical touch is part of the exam. I think there are certainly some things that have to have human touch and can’t be done by telemedicine, but we can make that interaction a lot shorter and a lot more efficient if you bundle some aspects of the visit into telehealth services.

We've got the individuals who are very successful clinicians, who are, I'm not going to say resistant, but they are reluctant. They have to embrace telehealth right now because they’ve got the survivor attitude and they're just waiting for all of this to go back to normal so that they can ignore everything we have done in the last three months. Then we've got clinicians that have discovered a brand new world in telehealth and that have figured out how to increase their volume, how to be more efficient, and how they can take better care of patients. 

KH:  So how do we turn around those that are more resistant?

NC: You can lead a horse to water but you can't make him drink. Sometimes it's just not worth what it's going to take to change those individuals’ frame of mind. What you do is you make it as easy as possible and you reduce the barriers as much as you can. We are also big believers in the idea that if something becomes part of the standard work flow, everyone has to stick to it. That is what we are hoping happens here.

KH: Do you think that the level of business being conducted via telehealth will continue, or are you hoping to get most people back into the office? I think patients are starting to realize that you don't always need to come to the office and that it's actually safer to stay at home.

NC: Right now, it’s easy for us to push forward because all the restrictions on telehealth have been suspended, but it's unclear what is going to happen when the crisis has passed. I will tell you that the patients are going to drive this. The patients have figured out that a fifteen-to-thirty minutes visit with their doctor is much more efficient than having to take a half a day off from work, drive to the office, find parking, figure out where the office is, wait for the doctor who may be late, get in and spend their fifteen minutes, then spend all the time that's involved in the egress from the office. That's even without any of risks associated with the exposure to coronavirus. I think that our primary care clinics have definitely figured out that there are absolutely specific diagnoses that they can follow from a distance (e.g. ADHD or chronic anxiety) and a concerted effort is being made to get those patients into telemedicine. The same is true for certain conditions that are being followed from either surgery or medical specialties. For example, say you are following a lung nodule, all you really need to do is look at the CT scan with the patient. They don’t have to step into the office for that, you could review that from a distance as long as the patient is comfortable with that approach.

There are of course other examples where the patient has to be seen in-person. An orthopedic surgeon has to be able to examine your knee to figure out your restriction to motion and mobility. A general surgeon has to be able to examine you to get a literal feel for your hernia. But once they fix your hernia, you can show them a picture of your incision and you don’t have to step into the office if the wound looks exactly the way it should. My guess is that it will be specialty-specific, but probably 30-50% of visits are going to stay in telehealth as long as the infrastructure for reimbursement remains intact.

University of Arkansas for Medical Sciences

Based in Little Rock, Arkansas, UAMS is a 535-bed academic medical center. Prior to COVID-19, the Institute for Digital Health & Innovation (IDHI) at UAMS boasted more than 30 digital health programs designed to improve access to specialty physicians for rural patients. The IDHI provides training and education opportunities to providers interested in implementing telehealth in their practices.

In response to the COVID-19 pandemic, UAMS has invested in services to address patients who suspect they may have or had the virus or who are recovering from the virus. These medical services include telehealth-enabled COVID-19 screening through an online-portal, medical advice delivered over live telemedicine to providers and nurses across the state, a computerized virtual agent to respond to COVID-19-related patient questions and screening questions, use of telemedical communication in the hospital between providers located outside of negative pressure rooms and the patients boarded inside them to reduce the use of personal protective equipment, a mobile triage unit to provide COVID-19 screenings, eICU software to manage the surge of COVID-19 patients, and a range of other telehealth applications that have extended pulmonology, infectious disease, and other medical services. 

UAMS has increased the use of technology and gives patients the option to see their providers over interactive video or the telephone to evaluate their medical needs. Primary technologies deployed are based on real-time HIPAA-compliant video, artificial intelligence, and digital solutions. Additionally, IDHI has seen a noted increase in requests for guidance from medical providers and nurses on how technology can be used to respond to the crisis. To meet the need, IDHI has created a new series of live educational support and online educational modules.

The use of this technology allows UAMS to limit staff exposure to potentially ill patients, conserve personal protective equipment, offer individualized support to rural providers on the care of COVID-19 patients, and reduce the risk associated with rural patients traveling into metropolitan centers. Moving forward, IDHI expects to increase their investment in remote patient monitoring and hopes to continue direct patient-to-provider communication.   

We spoke with the core IDHI team at UAMS. This team oversees all the telehealth services and educational opportunities offered by UAMS statewide, regionally, and nationally. This team is led by Dr. Curtis Lowery. 

Dr. Kendall Hall: It sounds like you had a robust telehealth infrastructure in place before COVID-19 and that you have been able to actually bolster those services. How do you interact with the rural providers in your state? How do you help them with equipment and other technologies to optimize their telehealth capabilities?

IDHI: Every hospital in the state has telemedicine equipment in their emergency department. That infrastructure has allowed us to do statewide education on the COVID-19 virus in the hospitals that are in the critical access area that do not have resources or education, clinical or otherwise. It has allowed us to provide that education across the network to anyone who wanted to participate, which has included all 80 hospitals across the state, as well as other providers who have connected to our educational services via the internet. We also have been able to expand its use internally within the critical areas - PACU, MICU, SICU, the ED – where the clinician presence in the room is now limited, so not everyone has to dress in the PPE. This enables us to conserve critical equipment needed to care for those patients. A nurse will be in the room with an iPad or some other kind of mobile device and the provider will be on the outside of the room to cut down on the risk of infection and the contamination of those critical pieces of equipment.

KH: Let’s talk about all of the resources you have around providing the telehealth experience. How do you train your providers to provide care in this manner?

IDHI: We've been doing this for a long time and it’s dependent on physicians/providers coming to us and saying that they want to do this. We have been capitalizing on the leaders in the field, the early adopters. With COVID-19, all payers in Arkansas are starting to reimburse for telehealth services, so it has been a whole different ball game. Our model before was to send in nurses and let them hold the hand of the providers and help them to adopt telehealth services in the clinic, but with COVID-19, telehealth got a jump start. People started using software and devices we had little experience with and for which we had not provided training. We had to learn about these programs very quickly so we could make similar videos to what we have for other resources and provide the type of support providers in Arkansas are used to receiving from us. We hope that after this is all over we're going to go back to something more structured. Ideally, the program should be HIPAA-compliant. We really think that providers should be using HIPAA-compliant software to do this and we think they will once this crisis subsides. Telehealth is also better if it works with the electronic medical record and enables you to conduct a video visit and access the electronic medical record at the same time.

KH: Let’s talk more about the technology side of it and the infrastructure. What are some of the lessons learned about providing care this way, particularly in a rural environment? It sounds like education is a significant piece and that you have to keep updating the education to match the technologies?

IDHI: Rural providers, and really doctors in general, tend to stick with one way of doing things. However, when there is a crisis of some sort, you don't have the luxury to only stick with one approach. Almost all healthcare providers started doing telehealth suddenly because they didn't have a choice in the matter, but they’ve struggled in the rural areas a lot more than urban areas because they have lower scale. A big system like ours struggles with these adaptations but we have a lot more resources, we have a lot more people that can help you. If you're an individual practitioner in the rural area, you have a lot less resources to be able to make the transition to this new model. The education piece is then critically important.

KH: What do you think your landscape will look like after COVID-19? Do you think this mode of care delivery can be sustained?

IDHI:  I think that in a traditional model, like in the University of Arkansas or other healthcare systems that we have around the state of Arkansas, they're going to begin to adapt some of their system towards doing digital health. It won't be all of care and it won't be to the level we're doing right now, but I think we will reach some kind of balance and understanding of what works and what doesn’t work for care and patient safety. For example, there's no reason why a lot of post-op visits can’t be conducted via video conferencing. Prenatal care can be done digitally, which is something we’ve done for many years with high-risk pregnancy patients through the ANGELS program. So there are a lot of things like that that you can do that will drive down costs, improve efficiency, and be more convenient for the patients themselves. Everything can't be done this way, maybe first visits and visits with particularly complicated patients need to be done live and then follow up can be done differently. One of the things that I don't really know the answer to is: If you start doing remote patient monitoring on individuals with chronic conditions, such as congestive heart failure and diabetes, how frequently will you need to see them given the remote monitoring but also wanting to ensure that their condition doesn’t worsen?

I don’t think we’re ever going to go back to the model of care we were in before, so we better be thinking of how we're going to produce a hybrid-like system, capable of managing a larger population of patients and moving the treatment of disease to more upstream, preventable care. That's the way we are going to have to think.

KH: Is there anything else that you think we should cover or things that you would like to highlight about your program?

IDHI: During this crisis, the ED’s around the state just wanted the answers. There are mountains of reports from institutions about what to do, about the management of PPE, and the management of intubation. But it is very difficult to filter all of that information. They want a reliable source to come in and say, okay this is the way we're doing it at UAMS. You guys can do it this way too if you like, and we will help you. The more we can engage different groups like that and support them, interact with them, and be good colleagues with them, I think that we can make huge in-roads in improving the quality and safety of healthcare for citizens of rural America, while simultaneously building a product that delivers value at a lower cost.

KH: What are some pointers that you can provide to facilities who are new to telehealth who may feel like they got thrown in the deep end?

IDHI: Find somebody that’s doing it and talk to them, that's the first thing. Additionally, there are Telehealth Resource Centers all around the nation operated by The Health Resources and Services Administration (HRSA) that have a lot of free educational resources that are readily available. These Resource Centers all work with one another. I would also talk to groups in your region. We have many people in Arkansas that have come in to see what we've done and learn about our program over the years, and that's the best way I think. I think it is very important to make sure that the resources you're getting are objective, like the materials coming out of the Telehealth Resource Centers, that are affiliated with teaching institutions and independent of the commercial telehealth industry.

Conclusion

All three case studies highlighted in this Perspective demonstrate innovative ways that health systems are using their telehealth capabilities to respond to the COVID-19 pandemic. The experiences of these systems highlight the varied approaches that can be taken to incorporate telehealth into day-to-day care that helps to ensure the medical needs of their patient communities are met, while maintaining the safety of patients and staff through limited physical interactions.

Authors

In addition to their positions listed below, Dr. Cohen serves as a paid faulty reviewer for Johnson & Johnson’s C-SATS program, as the Chief Medical Officer for Bearpac Medical, and as a Board member for the Ulman Foundation. Dr. Curtis Lowery serves on the Board of Directors for both Angel Eye and Air Toco.

James P Marcin, MD, MPH
Professor

Director, Center for Health and Technology

UC Davis Medical Center

Sacramento, CA

Neri M. Cohen, MD, PhD
Lead Clinical Informatics Liaison

Vice-Chair (Innovation, Information, & Technology)

Department of Surgery

GBMC Healthcare, Inc

Baltimore, MD

Curtis Lowery, MD
Director, Institute for Digital Health & Innovation

The University of Arkansas for Medical Sciences

Little Rock, AR

Eleanor Fitall, MPH
Research Associate, IMPAQ Health

IMPAQ International

Washington, DC

Kendall K. Hall, MD, MS
Managing Director, IMPAQ Health

IMPAQ International

Columbia, MD

Bryan Gale, MA
Senior Research Analyst, IMPAQ Health

IMPAQ International

Columbia, MD

References

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[6] Telehealth: A Path to Virtual Integrated Care. American Hospital Association. https://www.aha.org/system/files/media/file/2019/02/MarketInsights_TeleHealthReport.pdf. Accessed July 7, 2020. 

[7] Landi H. UnitedHealth execs: Patients are using telehealth for convenience, not as a necessity. Fierce Healthcare. https://www.fiercehealthcare.com/payer/unitedhealth-execs-patients-are-using-telehealth-for-convenience-not-as-a-necessity. Published June 10, 2020. Accessed July 7, 2020.

[8] Reynolds KA. Survey: Telehealth on the rise, popular with patients. Medical Economics. Published May 21, 2020. Accessed July 7, 2020.