Morgan L. Waller, RN, says she and her team were well invested in telemedicine way before COVID-19 – and have not yet paused their journey to improve access to highly sought-after medical professionals via virtual care technology.

Waller is director of telemedicine and regional multispecialty clinics at Children's Mercy Kansas City, where the telehealth program is mature and advanced, staffed with clinicians who have deep and hard-won expertise. 

We spoke with her to learn more about what the program, which is based around Teladoc technology, looks like, what it has accomplished – and even what the program still might be missing. We also discussed why healthcare still talks about telemedicine as though it were special, rather than a standard of care.

Q. You describe your telemedicine program as mature if not advanced. What does a mature or advanced telemedicine program look like?

A. A mature or advanced telemedicine program is characterized by a pervasive network of modern, audio-visual technology, which delivers healthcare remotely. It ensures the standard of care is maintained and improves efficiency.

An advanced telemedicine program offers an alternative to in-person communication and assessment for nearly all traditional patient-provider encounters, including specialized care, chronic disease management, pre- and post-operative assessments, inpatient and ambulatory nursing, and allied health services, as well as primary, urgent and mental healthcare.

The essential features of a mature telemedicine program include:

• High-quality AV systems and networks

• Consistency in user experience (for example, similar graphic user interfaces across services)

• Integration or compatibility with existing electronic health records

• Multiple access points, including websites, apps, kiosks, clinics, inpatient rooms, rehabilitation facilities, skilled nursing facilities, home, schools, college campuses

• Compatibility with specialized, high-definition, digital examination devices (for example, stethoscopes, dermatoscopes, ophthalmoscopes)

A telemedicine program like this should also have a resolute, centralized team of forward-thinking professionals with a mix of clinical, technical and creative talents. This team is responsible for regulatory compliance, submitting and advising on telemedicine initiatives, education and training, selection of telemedicine technology, quality control, oversight, and user support.

While there are privacy, security and regulatory expectations (for example, the Joint Commission, Centers for Medicare and Medicaid Services, private insurance) for telemedicine programs, there is not yet an official group evaluating or designating maturity levels for these programs.

Telemedicine is seen as an alternative method of delivering healthcare, not as a distinct area of medicine or surgery. Some argue designating levels for telemedicine programs is not necessary, while others suggest failing to do so could slow the development of new care delivery models to the detriment of patients and providers.

Q. What have you accomplished to date with your telemedicine program?

A. In fiscal year 2024, we've had 4,689 RN-facilitated, digital device-enabled, level 2-5 encounters hosted at five regional outreach multi-specialty telemedicine clinics; 49,992 direct-to-patient home appointments; and 54,681 total telemedicine visits accounting for approximately 16% of total outpatient visits.

These visits were completed from among the 36 pediatric specialty services, including adolescent medicine, cardiology, cognitive behavioral therapy, ears-nose-and-throat, epilepsy, general surgery, infectious disease, orthopedic surgery, radiology, rehabilitative medicine, social work, urology, urgent care, and weight management.

There are more than 775 specialty healthcare physicians and advanced practice providers and 2,800 registered nurses employed by Children's Mercy Kansas City. Hundreds of additional professionals support pharmacy, nutrition, social work, respiratory, occupational and physical therapies. 2,704 of these pediatric healthcare experts are active users of telemedicine.

In 2021, a new direct-to-patient home technology was implemented in a phasic approach for all users. Within the following 12 months, the patient and provider satisfaction rates were 80% or higher and before the two-year anniversary, they were consistently 90% or better.

The telemedicine program partners with business development to establish asynchronous telemedicine services for regional and access healthcare facilities throughout Kansas and Missouri. This allows the local facility to provide interpretation of radiology and cardiology diagnostic studies by some of the best pediatric radiologists and cardiologists in the nation. In fiscal year 2024, 2,791 radiology and 4,025 cardiology studies were read by pediatric radiologists and reported to the patients' local facilities.

The regional multi-specialty telemedicine clinics are equipped for laboratory specimen collection. A courier service delivers the specimens to the main laboratory in Kansas City for processing. This gives patients and families the option of having an experienced pediatric lab technician that uses comfort protocols for their child's specimen collection.

The results of the laboratory tests are entered directly into the patients' chart, which is faster and reduces the possibility of transcription error when compared to using an outside service.

This fiscal year, the telemedicine team partnered with inpatient nursing leaders and health informatics to add telemedicine technology to all medical-surgical inpatient rooms at both the Missouri and Kansas hospitals. We are one of the first pediatric health systems to go live with what the telemedicine industry has chosen to call virtual nursing.

Nursing and care assistant shortages impede the care of inpatient populations and cost organizations millions of dollars in incentive and overtime pay. Data collection agencies are forecasting dire nursing shortages when looking at the increases in the populations over age 65 and nursing enrollment. Too many nurses want to leave the bedside and/or are unhappy in their current positions.

Although healthcare has undergone tremendous change in the last few decades with the implementation of electronic health records and constantly evolving patient care devices, the responsibility of the bedside nurse to do everything the patient needs has changed little. We have continued to add regulatory, safety, monitoring, education, documentation and other requirements to the patient's needs without evaluating or implementing changes to the nursing model.

The virtual nursing care delivery model impacts care and staffing – virtual nursing does not replace nursing jobs – by:

• Providing options for the aging nursing workforce

• Following recommendations for improved efficiency through reallocation of responsibilities by type

• Improving nursing experience by decreasing interruptions

• Improving patient and family experience with faster response times

• Improving patient safety by supporting caregiver focus and retaining experienced nurses

These accomplishments are amazing and impactful. What has made all this work more meaningful is that every real-time telemedicine appointment is available with a video translator in more than 65 languages. Our telemedicine program offers on-demand interpreters, decreasing wait times and improving communication beyond measure.

Q. What are you yet missing in your telemedicine program?

A. Our telemedicine program does not yet offer an audio-visual telemedicine presence in the emergency rooms, in our ambulatory clinic exam rooms, nor our critical care units. Although we do asynchronous retinopathy of prematurity interpretations, I would like to see us do more.

We do not yet have asynchronous telepathology, nor asynchronous dermatology. We have had in the past real-time tele-surgical collaboration; we do not currently.

Q. Why do you need these?

A. We need these things to improve healthcare, not just for patients and families but for our providers. Telemedicine technology can reduce the stress of travel and interruptions in workflow. Our physicians need options. This country loses a doctor a day to suicide. The rate of suicide for physicians is double that of the general population.

Q. Why do you think healthcare still is talking about telemedicine as though it were special rather than a standard of care?

A. Personally, I underestimated the investments health systems made in telemedicine the decade prior to 2020 and I repeated that mistake in 2022. These "curses of knowledge" distorted my expectations, leading to a sense of esoteric disappointment.

A collection of issues that have hindered our national healthcare for decades are getting worse, not better. What makes it difficult for health systems to implement and maintain telemedicine is:

• The struggle between fee-for-service and managed care    

• The healthcare delivery to reimbursement labyrinth grows daily

• Insufficient numbers of providers

• CMS and private insurance dictating who provides care, what kind of care, when it can be delivered, why it is being delivered and how it gets to the patient to be worthy of reimbursement – and frequent changes to all of those

• Consumer understanding of telemedicine and empowerment to ask/demand for the services is in the toddler phase

Q. What would be the most important piece of advice you would offer your peers at other hospitals and health systems looking to grow a mature or advanced telemedicine program?

A. I recently came across a quote by our 44th president, "A budget is more than just a series of numbers on a page; it is an embodiment of our values." The intended message aligns with what is required to create a mature telemedicine program. You cannot improve access to and the quality of healthcare through alternative delivery methods without financial investment.

Additionally, hire a natural leader – someone with experience, not so much to have become cynical, but someone with energy who believes anything is possible. Give them access to the resources they need, time, people, a well-funded budget. Remove barriers and tell them they "won't be the first, but they will be the best" (borrowing a quote from Steve Jobs), and then let them build the telemedicine program.

On a side note, the world has entered the era of artificial intelligence, yet health systems still function like it is the 1990s, bogged down by complex computer systems rather than paper. Telemedicine needs to become ubiquitous quickly, as the newest innovations for healthcare will make even early adopters pause.

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