By Mandy Roth
With the arrival of the COVID-19 pandemic, telehealth has finally come of age. Like a lonely teenager who once struggled to make connections with a broader network of friends and was bound by strict parental controls, suddenly, telehealth has blossomed into the most popular kid in school by becoming an essential tool in the healthcare armament against this pandemic.
Almost overnight, telehealth providers reported an upswing in demand (see item #4 in this story) as key barriers to widespread telehealth usage vanished, including consumer awareness and physician and consumer acceptance. In an effort to quell the spread of disease and direct patients to the most appropriate setting, the Centers for Medicare & Medicaid Services changed access requirements and reimbursement restrictions, and many other payers have followed suit.
While the primary focus of telehealth during these early days of the coronavirus public health crisis has been on screening COVID-19 patients and treating those who can manage their symptoms at home, there are four ways this form of care can help hospitals and healthcare systems address the issues that the pandemic has created.
1. Increase Physician Supply Through Geographic “Load Balancing”
There is no question that responding to COVID-19 will create an overwhelming burden on providers. “We are going to get to the point where the supply does not meet the demand,” says Roy Schoenberg, MD, MPH, president and CEO of Boston-based telehealth company Amwell (formerly known as American Well). He points out, however, that not all areas of the country will be impacted equally at the same time.
“One of the beauties of telehealth is that we can use it to do load balancing,” says Schoenberg. “We can take a supply of [clinicians] from one side of the country, and almost like Star Trek, beam them through this technology to patients in a place that is overwhelmed.” Patients could be at home, or virtual visits could be conducted through telehealth carts and devices inside emergency rooms, he says.
Many healthcare systems contract with national telehealth companies, such as Amwell; MDLIVE, which is headquartered in Miramar, Florida; or Purchase, New York–based Teladoc Health. While some hospitals may use these resources for all telehealth services, others rely on these thousands of online doctors as an adjunct to their virtual care team. Because these clinicians are geographically dispersed, this approach could be helpful to facilities struggling to serve patient’s needs during peak periods of an outbreak, says Schoenberg.
In addition, the current crisis may inspire some organizations to try creative solutions. While it may be possible for a healthcare system to recruit its own physicians based in other states into telehealth service—or contract with a system that offers multistate telehealth services— there could be licensing, credentialing, and liability issues, cautions Ann Mond Johnson, MBA, MHA, president of ATA, the industry telemedicine association based in Washington, D.C.
“Things are unfolding very quickly,” says Mond Johnson. As a result, there are misperceptions and confusion about numerous issues. For example, Vice President Mike Pence said in a White House press conference last week that President Donald Trump has directed the U.S. Department of Health & Human Services to change regulations, allowing clinicians to practice across state lines. HHS has not yet issued such a directive and the news has perplexed some industry experts.
“That’s not the purview of the federal government. ” Mond Johnson explains. “That’s still a state domain. You’re seeing real movement in many states—[such as] Massachusetts, Mississippi, Tennessee, and North Carolina—to allow clinicians to practice across state lines.” Because all these barriers have not been eliminated, healthcare systems should ensure any professionals they draft into telehealth services are appropriately licensed to work in the state where they will be delivering service or that the state allows it.
2. Maximize Workforce Potential by Using Quarantined Physicians for Telehealth
On March 9, The New England Journal of Medicine published a Perspective piece, Virtually Perfect? Telemedicine for COVID-19 postulating that coronavirus has created the ideal circumstances for this approach to healthcare. The article was written by Judd E. Hollander, MD, associate dean for strategic health initiatives at Sidney Kimmel Medical College at Philadelphia’s Thomas Jefferson University and professor and vice chair of finance and healthcare enterprises in the department of emergency medicine at Thomas Jefferson University Hospitals and Brendan G. Carr, MD, MA, MS, associate dean of healthcare delivery innovation at Thomas Jefferson University.
In addition to many other ideas, the authors suggest that health systems can maximize their workforce by using quarantined physicians to provide telehealth services.
“Reports that as many as 100 health care workers at a single institution have to be quarantined at home because of exposure to COVID-19 have raised concern about workforce capacity,” the article says. “At institutions with [emergency department] tele-intake or direct-to-consumer care, quarantined physicians can cover those services, freeing up other physicians to perform in-person care,” they write. The authors also suggest that office-based practices can employ quarantined physicians to care for patients remotely.
Like many of the nation’s healthcare systems, Jefferson Health, the 14-hospital, Philadelphia-based healthcare system affiliated with the medical school, is deploying telehealth so that clinicians can continue to care for established (nonexposed) patients by converting scheduled office visits to telemedicine visits. “These visits can be conducted with both patient and clinician at home, greatly limiting travel and exposure and permitting uninterrupted care of established patients,” the article says. One key element of successful deployment is that online training modules and remote training sessions are available for clinicians or patients who require just-in-time training or assistance during their first call.
3. Use Telehealth to Treat High-Risk Non-COVID-19 Patients
Beyond treating and screening potential COVID-19 patients, telehealth provides an option for providing routine care to the elderly and other high-risk patients.
“We tend to forget that’s the virus actually does discriminate,” says Schoenberg. The effect of this virus on the elder population is much worse than it is on everybody else. We tend to think of telehealth to treat patients that have the virus or who may have the virus.” It also should be a strategy to protect at- risk patients from exposure and provide routine care, he says.
During the pandemic, he suggests that healthcare systems could use telehealth to deliver care to patients with chronic conditions, such as diabetes, asthma, and heart disease. “If we can lower their exposure to the waiting room, or the physician office, or the waiting area of an emergency room so that they can take care of those conditions in the home, we are allowing them to lower the risk of contracting that virus,” says Schoenberg.
4. Create System Efficiencies Through Chatbots and AI Tools to Streamline Intake
As patients flock to telehealth, demand has increased. For example, last week Charlotte, North Carolina–based Atrium Health, which operates 40 hospitals and 900 care locations in the Carolinas and Georgia—not currently COVID-19 hot spots—reported a 500% increase in telehealth usage. Companies that cover a national base also report an uptick in services.
- Last week, Teladoc Health reported call volume was up by 50%.
- Doctor on Demand, which provides services to tens of millions of Americans through their health plans and employers, reported a couple of weeks ago that visit volume was about 15%–20% above projected forecast and continues to trend upward since the Centers for Disease Control and Prevention began recommending that Americans use telemedicine as a frontline source of care.
- Last week, Amwell’s weekly activity was up about 158% overall nationally compared to projected traffic volume. In Washington, where the COVID-19 outbreak originated in the U.S., usage is up 600%.
As demand for telehealth services rises, the online waiting queue for patients is becoming longer, and physicians providing these services are becoming overburdened. Help exists in the form of up-front screening questionnaires, chatbots, and AI tools to streamline intake processes and make encounters more efficient for providers.
“A lot of the telemedicine companies are having a struggle with the onslaught of inbound [calls] for telemedicine,” says Alan Pitt, MD, professor of neuroradiology, Barrow Neurological Institute, and chief medical officer, CloudMedx. Pitts formerly served as chief medical officer for Avizia, a telemedicine company purchased by Amwell in 2018, and is a participant of the HealthLeaders Innovation Exchange.
“The next phase of telemedicine is having an AI bot in front of that encounter where basically the patient can enter information while they’re waiting,” says Pitt. By the time the practitioner encounters the patient, Pitt explains that the history, symptoms, and other information have been aggregated for the physician. Some approaches to this could perhaps even present a suggested diagnosis and treatment plan.
Some companies already have innovations to address this need, that may or may not incorporate AI into their offerings. Zipnosis offers a tool that SSM Health has been using for a while to create such efficiencies. Patients complete an online questionnaire that guides them through their history and symptoms before a nurse practitioner initiates the virtual visit.
The “chat-first” approach “offloads the huge influx at the front end or allows a delivery system or physician group to scale in a way that they haven’t been able to before,” says Mond Johnson. She mentions other companies doing interesting work in this realm include Conversa and Ro.
Johnson says it is inspiring to see her industry come together to deliver an essential approach to care at a time when the country needs it most. Now that more consumers have experienced the benefits of telehealth, she says the landscape will permanently change after the pandemic abates.
“I think consumer expectations and consumers’ perceptions of what can happen are going to change and, therefore, it’s going to be hard to go back.” she says. “Once you give people something, it’s really difficult to take it away.”
Mandy Roth is the innovations editor at HealthLeaders.