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The Long Game On Telehealth

By Deborah Borfitz

August 11, 2020 | Five months into the sharp pivot to telehealth and some clinicians are still struggling to get through basic encounters, says Jeanette Ball, R.N., a client solutions executive with health IT consultancy CTG who works primarily with ambulatory care providers. As the pandemic has dragged on, medical practices everywhere have also started thinking seriously about how to better fit telehealth into their patient care workflow over the long term.

Healthcare professionals saw telehealth skyrocket from roughly 2% of patient visits to over 60% back in March and are “not willing to go back” to pre-coronavirus norms because patients value the convenience, she says. There’s also clearly a niche for it among certain populations—most notably, patients with behavioral health and substance abuse disorders, women at risk for post-partum depression, people with chronic diseases, and the throngs of the formerly-well suddenly taken down by COVID-19, adds Ball, a recent survivor of the virus. “It’s an extremely isolating, scary thing to go through when you have nowhere to turn.”

Telehealth is a useful way of helping patients feel more connected to the healthcare system, and during large-scale public health emergencies it may be the only option for creating that bond, she continues. But unlike the way telehealth might have previously happened, with patients making virtual visits with university-based specialists from a satellite clinic, the environment for these encounters is no longer under the direct control of providers.

If patient visits will be via a screen in someone’s home office or living room—or the parking lot at Starbucks—it’s no longer business as usual for the care team, says Ball. Will visits start and stop on time? Will patients have a reliable internet connection? Would anyone even know what address to give a 911 dispatcher in the event of an emergency?

CTG has a growing list of happy clients for whom it provides 24/7 helpdesk support for telehealth visits, says Ball. The helpdesk focuses on ensuring a good audio-video connection on both the patient and provider side so visits can stay on schedule. It started as a managed service for a large university system whose IT issues were creating bottlenecks.

Heightened attention to technology and bandwidth are among a long list of changes afoot in both inpatient and outpatient settings to enable telehealth to live up to its potential as a driver rather than a detractor of efficiency. That involves, most immediately, identifying appropriate populations for telehealth and conducting a rigorous vendor selection process to find the best possible platform for the long haul.

While in panic mode at the start of the pandemic, many providers “jumped into whatever technology they could get their hands on quick,” Ball says. While many university centers either already had an established telehealth program or the resources to make a new capital investment, many Federally Qualified Health Centers were limited to lower-cost alternatives ranging from FaceTime visits by cell phone to videoconferencing via Zoom.

What will happen on the reimbursement front is anyone’s guess, says Ball. The U.S. Department of Health and Human Services recently decided to extend the federal public health emergency that leaves numerous flexibilities and waivers in effect through Oct. 23, 2020, including coverage of telehealth visits to the Medicare population. Physicians are watchfully waiting to see if the lobbying efforts of organizations such as the Medical Group Management Association and National Committee for Quality Assurance are successful in advancing permanent telehealth reform.

Targeted Populations

The geographic location of a medical practice and the social determinants of health (SDOH) issues faced by its patient population will help determine the types of cases that get targeted for telehealth services, says Ball. But good choices tend to be patients struggling with depression or substance abuse issues, since ongoing audio outreach is a central component of the treatment plan.

New moms, particularly if they are isolated, are vulnerable to depression and shouldn’t be unnecessarily moving around with a newborn whether or not a pandemic is underway. Providers can visually see what’s going on in the home, and what the mother’s and newborn’s needs are, ensure understanding of post-discharge instructions, and help connect them to practical support services. “I think this is an important area that needs to be expanded,” Ball says.

She routinely recommends the telehealth option for patients who tend to be medically unstable, such as those with chronic obstructive pulmonary disease and stroke, who benefit clinically from more frequent eyes-on monitoring but may be burdened by the travel and coordination required for on-site visits.  “Maybe you could have some nice touchpoints once a month and… elongate the patient’s [in-person follow-up] intervals.”

Having experienced COVID-19 firsthand, Ball also encourages providers to think about doing virtual check-ins with those affected by the virus and quarantining at home. Even as a nurse, she had trouble assessing whether she was experiencing shortness of breath and should head to the emergency room, per her doctor’s instructions. “I would have loved to have heard from my doctor, even every couple of days, to ask, ‘How are you doing? Are you eating? Having any pain? Describe it to me.’

“It would have gone a long, long way to help that horrible feeling of isolation and disconnect from any healthcare environment,” Ball continues, recounting how she had to drag herself to a testing site 30 miles away, alone, with a screaming fever only to wait four weeks for the results. “We have done too good a job of isolating COVID patients, and I am sure there are people at home in emotional trauma who could use the contact.”

Create a registry of all patients who call in with COVID symptoms, even if they test negative, advises Ball, noting the high false-negative rate. “Check in and see how they’re doing just to stay connected. It will endear patients to you.”

Finding Efficiencies

Telehealth suppliers abound and “more and more are cropping up every day,” says Ball, who recommends a disciplined approach to technology selection. Whatever the choice, she adds, the platform should be compliant with the Health Insurance Portability and Accountability Act, as well as interoperable with whatever electronic health record (EHR) system the organization is using for provider convenience and ease of scheduling. Now telehealth visits have become a reimbursable service, “EHR vendors are scrambling to get better at this.”

While televisits with patients represent a new book of work for medical practices, certain tasks—e.g., medication reconciliation and assessing SDOH—can still be handled by in-office staff since they’re less busy with in-person visits, Ball says. But medical assistants can’t be expected to deal with disruptive IT issues, where it’s useful to call in third-party help.

With the proper support, and one-click launch of a telehealth session from an existing EHR system, physicians should have no trouble balancing a workload that has partially, if not largely, shifted online, she says. Once the “electronic front door” opens and everyone is familiar with patients portals and automated check-ins, the administrative burdens of running a practice should also lessen.

Keeping virtual visits to the 15 minutes standard for in-office visits is simply a matter of setting the expectation with patients, aided by the visible reminder of a clock right behind the physician’s head, Ball continues. Someone on the care team needs to document patients’ location in case there’s an emergency and, if visits are going to happen where other people are present, ask that patients get to a room where they can quietly talk about private matters.

Ball says CTG is in discussions with providers about potentially setting up an asynchronous tool that can be loaded into a patient portal that asks questions prior to virtual visits to help steer the direction of physician-patient dialogue. On the physician side, templates can be developed with all the key talking points. “Obviously, we have to build our knowledge around remote visits because we’re still too new to it, but that’s kind of the fun part moving forward—how to make telehealth visits uncover things just by the way we ask questions.”

If a patient just doesn’t like the telehealth experience, give them the option of an on-site visit, says Ball. Healthcare is, after all, a “customer service” industry. A telehealth visit will never be as good as an in-patient visit, particularly for conditions that require more hands-on care, but the only other alternative is to not be seen at all if patients are afraid to come in. “Telehealth does create a bridge.”

It’s still too early to comprehensively gauge the cost-effectiveness of telehealth, Ball adds. But she expects it will become a key component of value-based care arrangements in the near future. Growing numbers of health systems are looking to get more of their ambulatory practices involved in risk-based contracting with payers and the technology has to be a part of the conversation around patient access, chronic disease management, and improving both clinical outcomes and the satisfaction of providers and patients.

To make it easier for patients to interact with the healthcare system—whether or not a pandemic is the major hurdle—will likely require the development of apps people can use to ask and answer questions and access the information they need for improved care outcomes, says Ball. The app could be configured to make routine, condition-specific inquiries, spot concerning trends, offer education and route messages to a nurse whenever an answer is different than expected thresholds.

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