Though questions remain around issues of interoperability, patient awareness, physician readiness, reimbursement and broadband availability, it’s hard to find anyone in healthcare who contests virtual medicine’s merit or potential. Whether it’s called virtual medicine, telemedicine, virtual visits, telehealth or connected care, the paradigm-shifting use of technology to deliver healthcare or health education from a distance is gaining traction on a grand scale.
A constellation of forces is fueling telemedicine’s growth, ranging from the rising prevalence of chronic diseases and the aging of the population, to the shortage of healthcare professionals and the need for more affordable options to contain costs. Add in the proliferation of mobile technology, the demands of highly connected consumers and improvements in the telecommunication infrastructure, and it’s easy to see why telemedicine has finally taken off.
For instance, more than 75 percent of hospitals have implemented some form of computerized telehealth system, according to the American Hospital Association.
Use of Telehealth in Hospitals Has Grown Rapidly
One of telehealth’s main promises is increased patient engagement. “Satisfaction rates are very high,” says Jennifer Bordenick, CEO of eHealth Initiative, Washington, D.C., a collaborative of stakeholders focused on digital technology in healthcare. “Patients who’ve used telehealth become repeat users—frequent fliers, if you will—once they recognize that they don’t have to take off work and can accomplish the same thing through their tablets or phones.”
The experiences of some organizations indicate telemedicine can be a tool that wins competitive advantage when they provide a valued service that others lack. For example, one institution gained market share by offering teleneurology for multiple sclerosis patients.
The technology also helps providers work toward their goals around population health management and reducing disparities by increasing access to care. “In many rural communities, there is no Uber. The closest doctor is three hours away, and it’s not necessarily the doctor the patient needs. Telehealth answers that call,” Bordenick says.
There will also be cost implications. In April 2019, the Centers for Medicare & Medicaid Services announced that beginning in 2020, it will allow Medicare Advantage to provide telehealth services as part of basic benefits—a policy change that will improve payments and expand options for beneficiaries.
The Federal Communications Commission, which recently announced $100 million in funding for a telemedicine pilot program for low-income Americans, estimates that remote patient monitoring and virtual visits could save healthcare $305 billion yearly.
Most organizations are at the early stages of implementing some aspect of virtual medicine or telehealth. The early adopters are largely academic medical centers. Following, we profile the journeys of three organizations that have committed to telemedicine on a variety of fronts. For those in the planning stages of their virtual health strategy, please visit the Web Extras section at HealthcareExecutive.org for advice from the experts.
Monitoring Total Knee Replacements Remotely
University of Utah Health, Salt Lake City, is testing a remote monitoring alternative to the standard of care for total knee replacement surgeries that will more directly engage patients in their recovery and improve outcomes.
The alternative revolves around an app that pairs the convenience and popularity of wearable devices and smartphones to track patient activity and heart rate, cues patients to check their smartphones for preplanned and timed patient education and reminds patients about tasks and assigned exercises. The care team logs onto a dashboard to monitor patients’ progress.
“If we see something of concern, we reach out to patients proactively,” explains Christopher Pelt, MD, associate professor of orthopaedic surgery, who is spearheading the study at University of Utah Health. (Disclosure: Pelt is a consultant for the app developer.) “The physical therapist can quickly tailor treatment to the patient’s needs.”
The clinical study’s current phase, which involves University of Utah Health and 16 other hospitals and surgery centers around the country, randomizes patients to the app or a control (standard care). The goal is to gather baseline data on 10,000 participants nationally to assess the technology’s feasibility for more widespread use.
“The current standard of care is intermittent, time-consuming and very expensive,” says Pelt. “You operate on somebody, you send them home, and you hope for the best, but you don’t really know unless they call and tell you they’re having a problem.”
Pelt says those phone calls often produce anxiety for the patient and the care team because they’re usually unexpected and are not an ideal way of communicating. “Virtual health offers a better, less expensive way to interact, educate and engage with patients,” he says. “By being more present in the patient’s day-to-day life, we can intervene sooner and, potentially, produce a better outcome. It makes sense in 2019 that technology would have some role in that.”
It makes sense, but whether the technology confers measurable value remains unknown. “We can say how exciting it is, but we really haven’t proven that it’s better or less expensive than the standard of care,” Pelt says. “We need enough data to tell us whether the app helps identify patients who are at risk for complications and enables the care team to optimize them or personalize their care pathway based on their activity, strength or heart rate.”
Connected Perioperative Care
Ronald Reagan UCLA Medical Center launched its foray into telemedicine in the perioperative space. The medical center’s anesthesiologists and surgeons triage patients to a virtual preoperative visit; an in-person visit at the clinic; or, for the healthiest patients, a bypass of a preoperative visit directly to the OR based on history and an informatics-driven screening tool.
Patients triaged to a virtual preoperative assessment log in from a personal device that connects to the EHR. They undergo a comprehensive 30-minute history and evaluation, including an examination of neck mobility and the airway. The anesthesiologist takes photos of the airway remotely and embeds them in the EHR.
The virtual visits have received superior satisfaction ratings and saved patients thousands of driving miles in one of the most traffic-congested areas of the United States, reports Nirav V. Kamdar, MD, director of quality in the department of anesthesiology and pain management.
Case cancellations are slightly lower among patients seen virtually before surgery than among those seen on-site. “We tend to triage a slightly healthier population toward telemedicine, but I think the data reflects that in the perioperative space, we can make the most of our clinical decisions based largely on history alone,” he says. He adds that telemedicine’s strong convenience factor has yielded a much lower no-show rate than in-person appointments across specialties systemwide.
The perioperativists have begun using remote monitoring to optimize patients before surgery. For example, after being set up with a nutrition and weight loss program, total knee and hip replacement surgery patients with a body mass index over 40 have their weights followed remotely via a Bluetooth-enabled scale that automatically ports to their mobile phone, which pushes the data to the EHR. Patients are then scheduled for surgery when they reach their target weight.
“We’re beginning to use remote patient monitoring to stepstone in many other directions,” says Kamdar. “The hardware is only going to get better.
Anne Lin, MD, medical director of the telehealth programs, adds that the organization’s goal is for providers in most clinical service lines to offer video visit appointments by the end of 2020.
Virtual Services On Demand
NewYork-Presbyterian introduced a suite of telehealth services called NYP OnDemand in 2016 in collaboration with ColumbiaDoctors and Weill Cornell Medicine. The 11-hospital health system’s accomplishments garnered Most Wired recognition from the College of Healthcare Information Management Executives in 2018.
The system’s expanding teleportfolio offers consultations in psychiatry, pediatrics and stroke services between the health system’s physicians and the hospital’s leading specialists via high-definition video cameras at patients’ bedsides. Specifics include:
- The time-saving option of a remote video visit with a specialist in a private room for ED patients
- A digital second opinion from the hospital’s specialists for patients anywhere in the country, with opinions delivered in days
- Self-service kiosks in selected pharmacies and convenience stores in New York City that connect individuals with physicians
- Virtual visits for pre- and post- follow-up appointments
- Peer-to-peer consults across specialties and campus locations
- A remote monitoring system that tracks physiologic data on ED patients in real time and allows clinicians to communicate as needed with ER nurses
Daniel Barchi, CIO, cites three factors driving the system’s far-reaching commitment, which has major support through a philanthropic partnership. “It allows us to deliver the right care at the right time in a way that’s convenient for patients and physicians. It lets physicians work at the top of their license, focused only on the care and not on anything extraneous. And it offers a way to level disparities and remove barriers of transportation, cost, language and education for the third largest population of underserved Medicare and Medicaid patients in New York state.”
Virtual visits—currently offered in dermatology, psychiatry, pediatrics, transplant services, ophthalmology, orthopedics and sports medicine, but slated for other specialties as well—are helpful for physicians and respectful of patients, Barchi says. “It makes no sense for a patient who comes to us from Michigan for their liver transplant to have to come back again for a follow-up visit eight days after they’ve gone home,” he says.
The system has found that the technology works best when physicians incorporate virtual visits into their practices as a scheduled part of their day—from 8 a.m. to noon and 1–5 p.m. on Thursday, for example—rather than moving back and forth repeatedly each day between modalities.
It’s a learned skill—referred to among staff as “website manner”—to work with patients via video without the ability to touch them and ask the right questions to get the needed answers, Barchi says. But some of the ED physicians report that video visits enable them to interact with patients in a more thoughtful, engaging and focused manner because there are fewer distractions.
The hospital embarked on telemedicine using many different systems, but knowing the importance of interoperability, especially in the current regulatory environment, “we’re driving more and more of these tools into our core EHR,” Barchi says.
The health system performed 100,000 virtual visits last year and expects to conduct more than half a million this year.
“Our telemedicine team is developing the tools that not only work well for the doctors and patients but that are integrated with the EHR. We’ve had to create more interfaces to achieve that, but it’s been worth it.”
Susan Birk is a freelance healthcare writer based in Chicago.