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Making Choices With Telemedicine: Stanford’s Approach

By Deborah Borfitz

May 26, 2020 | Healthcare providers across the country have unexpectedly become part of a forced natural experiment in rapid telemedicine deployment that will be providing answers about the technology’s potential, limitations and unintended consequences, says Christopher Sharp, M.D., clinical professor of medicine, primary care and population health at Stanford Medicine and chief medical information officer at Stanford Health Care.

While providers all feel a “tremendous sense of urgency to do the right thing,” says Sharp, there are many unresolved issues surrounding digital healthcare. For example: In which scenarios is it good for patients? When does it increase and decrease costs? Where does it open up access to care or, conversely, enlarge the digital divide?

Then there are all the nagging liability and reimbursement questions behind the historically low penetrance of telemedicine that await long-term answers, he adds. As a practical matter, digital technologies also have to integrate with existing workflows because clinicians already have a lot on their plate.

Stanford has a decided advantage in this arena because it operates in California, one of the more “visionary” states where some payers were paying equally for video and in-person visits prior to the pandemic, he says. It also opted to do the hard work necessary to find the right model for patients and the delivery of complex and advanced academic care.

An early foray in 2018 was a telemedicine clinic, coined CardioClick, a program for patients at risk for cardiometabolic disease where two out of three physician visits are conducted virtually via the Stanford MyHealth app, says Sharp. Patients have virtual visits with members of the care team to check progress on lifestyle behaviors that affect cardiometabolic health.

In this scenario, flexibly meeting patients “where they’re at” helps them receive care in the comfort of their home, Sharp says. The proof is in outcomes: whereas previously only 55%-60% of patients had reclassified their cardiac risk levels, with CardioClick that number has risen to nearly 90%.

Telemedicine has also been working remarkably well for Stanford’s preanesthesia clinic, where patients have traditionally presented in person for evaluation by an anesthesiologist prior to surgery. The primary purpose of the visit is to examine their readiness for anesthesia and potential for complications as determined by pre-existing conditions like high blood pressure and diabetes as well as the size of their mouth opening, says Sharp.

Such exams can easily be done via a video visit. After answering a few questions, patients open their mouth wide while looking at the camera and the doctor can take a picture that goes into their health record so every other physician who interacts with them knows what to expect in the operating room. About a year ago, anesthesiologists moved about 90% of their low-acuity patients from in-person to video visits, he says.

‘Overnight’ Conversion

When the COVID-19 pandemic hit, physicians across Stanford who had been shrugging off telemedicine for years were suddenly clamoring for it all at once, says Sharp. Growing numbers of their patients were quarantining at home either because they fell in a high-risk category, they were exhibiting symptoms of the virus and possibly infected, or they were simply scared to move about.

Stanford’s first move was to convert an express care clinic "pretty much overnight” into a triage center for patients with COVID-19 symptoms, he continues. More than 90% of all visits were virtual, and as appropriate patients were directed to a drive-through testing center and sent back home to shelter in place and limit their exposure to other people.

The second wave of traffic to the clinic included “everyone else,” notably immunocompromised cancer patients needing continuity of care from home, Sharp says. “We went from less than 2% of all ambulatory visits being virtual to more than 70% in about two weeks.”

To meet the need, Stanford had to make some quick choices and scale its technology at lightning speed. Fortunately, says Sharp, it didn’t have to take advantage of newly relaxed patient privacy provisions of the Health Insurance Portability and Accountability Act (e.g., do FaceTime visits with patients absent a business agreement with Apple) because it had already developed a fully compliant, secure, and integrated telehealth solution.

The core technology is the Epic electronic health record, which allows for video exchange with patients in the same place clinicians already go to document care and order medications, notes Sharp. Patients can also connect to their doctor from the Stanford MyHealth portal that is linked to Epic versus searching for (and perhaps never finding) an unfamiliar URL buried in their email inbox.

MyHealth is the primary way Stanford interacts with patients digitally. For example, the portal offers navigational support for getting to the right parking lot on campus and the right elevator and floor for in-person visits, Sharp says. It’s also where patients are alerted of upcoming virtual appointments and can find the one-click button to show up for them.

Based on its key reliability and integration requirements, Stanford opted for the video connecting technology of Vidyo, he says. In this “crowded space,” Vidyo was on the shorter list of vendors able to embed a Zoom-like product into the existing clinical workflow.

Moving forward, Stanford plans to send patients tips on how to prepare for virtual visits, including how to ensure their computer and video are ready for the interaction, says Sharp. They will also be asked to answer a few check-in types of questions in advance of appointments.

The prework with CardioClick and the preanesthesia clinic helped Stanford ramp up its telemedicine capabilities faster than many other provider organizations. It acted quickly to get 3,000 clinicians trained in a matter of days to ensure everyone had the same fundamental knowledge of how to engage patients via video, he says. Online learning was also extended to schedulers, so they’d know how to set up virtual visits and support staff, so they’d know what to tell patients when they called.

In the first month of the pandemic, 1,400 physicians had their first-ever video visit with about 50,000 patients for whom the telehealth experience was also new. Virtual visits now account for more than 70% of all physician-patient interactions at Stanford and aren’t expected to drop off, says Sharp.

Moving Forward

One worrisome development is that the emergency department is less busy, Sharp adds, and not just because California hasn’t had a surge in COVID-19 cases like New York City. Confoundedly, the number of patients coming in with chest pain, heart attacks or strokes is below normal levels—and it’s unlikely because people are no longer beset by such conditions.

“It’s a total head scratcher; we didn’t see this coming,” says Sharp. “At the same time, it really begs the question: How do we reopen safe portals of care for patients to get the care that they need?”

Anecdotal reports indicate some patients are opting for video visits who ought to be in a higher level of care, he says. One doctor was recently evaluating a patient via telemedicine and quickly realized that what was being described were not signs of indigestion but symptoms consistent with a heart attack. While the patient stayed on the line, the doctor called 911 and an ambulance brought the individual to the hospital for cardiac catheterization.

“We have no interest in diagnosing heart attacks by video,” he says. “That’s not the best practice.” Digital health has a role to play here, he adds, but in this case to make patients feel more comfortable getting in-person care safely when a digital visit is not a good alternative.

In the “new normal” in the near future, “digital will be an important component of safety, of continuity and of connection,” Sharp says. “Our lesson learned is… that we need to really hardwire this into the way we practice.”

For Stanford, one of the key difficulties on the horizon is related to liability and reimbursement. Right now, Medicare will pay for telemedicine visits across state lines—for example, if an existing patient traveling to (or quarantined in) Florida reaches out with a concern or a specialty physician in Hawaii wants a potential organ transplant patient to be evaluated for the procedure, says Sharp. But in the absence of cross-state licensure, it can be legally dicey for a physician to make a virtual visit outside of California.

Two patient populations who might be more immediately addressed via remote monitoring are people with COVID-19 who came to the hospital but are ready to go back home and patients with other conditions, including cancer, who are also better off not leaving home for needed care. The ability to measure vital signs and move the information through a connected device to the healthcare team can be a critical part of the care mix, says Sharp. “But the healthcare dollar is not infinite, so we need to find the places where is makes the very most sense first.”

Widespread COVID-19 monitoring is already underway, thanks to the National Daily Health Survey launched in April by innovative faculty in response to the dearth of test kits for the virus, he notes. The interactive platform, which invites people to regularly report in on any COVID-19-like symptoms they’ve experienced or contact with people who have the disease,  serves as an “early warning system” to predict surges so public health officials can take action to mitigate the impact.

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