Yale New Haven Health in Connecticut is a five-hospital, seven-campus health system that includes a large physician practice, numerous ambulatory centers and a home care agency. It is affiliated with the Yale School of Medicine and its clinical faculty practice, Yale Medicine, which provides a depth and breadth of clinical expertise to support much of the health system's telemedicine programs and provides existing infrastructure that supports joint development of telehealth programs.

All Yale New Haven Health entities are on a single instance of the Epic EHR that spans Connecticut into western Rhode Island and Westchester County, New York. The health system has developed tele-stroke, tele-ICU and on-demand video visit programs.

The crisis sets in

The COVID-19 crisis presented several challenges to the health system that amplified the need and impact of telehealth services.

To safely care for patients and provide additional safeguards for clinical staff, Yale New Haven Health had three clear needs to address:

1. Rapidly expand the tele-ICU services to support a ballooning ICU census.
2. Provide supportive services in med/surg units to allow nursing staff to cluster care activities to reduce utilization of PPE and potential staff exposure.
3. Rapidly scale ambulatory telehealth to provide ongoing access to medical care for patients.

"The northeast U.S. was among the regions of the country affected early in the pandemic when little was known about transmission and when treatment was largely supportive care," said Dr. L. Scott Sussman, physician executive director telehealth at Yale New Haven Health. "Additionally, since the availability of COVID testing was limited, patients who were suspected of having COVID needed the same isolation precautions and PPE as those patients who had already been diagnosed while we were awaiting test results."

Early in the pandemic, Yale New Haven Health, like the rest of the nation, faced significant shortages of essentials including PPE, negative pressure rooms and testing supplies. These limitations had a direct impact on patient care and posed several problems:

• Patients were cared for behind closed doors and with no visitors allowed, adding to their feeling of isolation.
• Clinicians were anxious for the safety of the patient, themselves and their families.
• PPE was in short supply.
• Yale New Haven Health needed to maximize the safety and efficiency of care teams.

"To address these issues, we turned to telehealth to increase connections between patients and the families, to enable the care team to provide care while minimizing exposure risk," Sussman explained. "We were fortunate to have enough PPE to see our patients, and innovative stewardship efforts and our telehealth equipment helped ensure our supply lasted, though we did not have excess."

Challenges for physicians and nurses

These obstacles created a challenging environment for nursing and physician staff.

"The impact of our telehealth intervention is demonstrated by just one example: One of our ICU nurses was caring for a COVID-positive patient in March 2020," Sussman recalled. "She heard the ventilator start to alarm because the tube became disconnected and ran into the room to care for the patient, without concern for her own risk of exposure."

This level of commitment is not unique among frontline caregivers, and it was exactly the reason Yale New Haven Health put telehealth in place to monitor and intervene with patients remotely, he added.

"Not surprisingly, between lockdowns, limited PPE, visitor restrictions and concern about virus transmission, in-person outpatient care was not an option for most patients," he noted. "We recognized that delaying important ambulatory care would be detrimental to health and could result in emergency department visits, which would put additional strain on those resources."

Ambulatory video visits

Yale New Haven Health needed a solution that would connect clinicians with patients to provide care for both acute and chronic diseases. It leveraged and rapidly scaled its ambulatory video visit platform to meet the need for ambulatory care.

"In the past, we would have relied heavily on our vendor partners to provide these technical solutions," Sussman observed. "Given the need to work quickly and at scale, the team looked to internalize these solutions, leveraging commercial computer and AV equipment along with software provided by our telehealth partner, InTouch, now part of Teladoc."

"We see telehealth as a great opportunity to provide increased access to care, enhanced convenience, and to enrich the relationship between patients and their care teams. With that opportunity, though, are other challenges, including ensuring patient access to technology, broadband and digital literacy."

Dr. L. Scott Sussman, Yale New Haven Health

Over the course of around a month, the team was able to support an expansion of tele-ICU services from 94 monitored rooms across three hospital locations to more than 200 rooms across the health system.

"This was done in conjunction with the expansion of clinical services from a 7 p.m. to 7 a.m. model to full 24/7 remote monitoring through the tele-ICU," Sussman explained. "From a med/surg perspective, more than 1,000 telehealth carts were delivered to inpatient units throughout Connecticut and Rhode Island to ensure that nurses had the capability to interact with COVID-positive patients through real-time audio-visual solutions.

"The size of this effort and the time in which it was completed was nothing short of amazing," he continued. "While Yale New Haven Health recognizes and appreciates the assistance offered by the FCC through its multimillion-dollar telehealth grant, we are equally as appreciative for the outpouring of support that allowed this to happen."

Everyone pitched in

For several weeks, Yale New Haven Health had staff from across all aspects of the organization participating in this process – through the construction of equipment, testing and validation, and coordination of deliveries to inpatient units. This collaboration not only rapidly allowed the health system to meet patient care needs, it also resulted in more than $3 million in savings.

In-hospital telehealth, a combination of hardwired rooms in select ICUs and mobile carts in other units, facilitated care for admitted patients at each of Yale New Haven Health's delivery networks and promoted PPE preservation. 

This would allow two-way audio and video communication for patients who were admitted to the hospital. The InTouch platform allowed the care team to access patients who were admitted using audio and video technology, while decreasing the amount of PPE needed and minimizing exposure to COVID-19.

"For the tele-ICU, the telemedicine technology was expanded in conjunction with efforts from our clinical engineering team to integrate physiological monitoring into the proposed solution," Sussman said. "In conjunction with the rapid construction of a new tele-ICU bunker to accommodate additional clinical support staff, the integrated team designed and built the capacity to monitor more than 200 simultaneous locations directly through our EHR."

As a result of this work, Yale New Haven Health was able to:

• Reduce the burden on intensivists to cover extended shifts.
• Allow patients to remain at the local hospital location and receive medical care from a tertiary care hospital, which was especially important since many of the ICUs were full.
• Reduce the need for direct patient/provider contact for COVID-positive patients.
• Improve the overall safety and efficiency of services provided by allowing for an additional set of eyes and ears to support these critically ill patients.

"From the med/surg perspective, the primary focus was to address nursing needs around the preservation of PPE and the reduction of direct patient contact," Sussman said. "Our implementation plan included rapid deployment of telehealth carts, as well as communication and education of nursing staff on the appropriate utilization of the new technology."

Bi-directional communication with patients

All clinical staff were granted access to the telehealth platform through both mobile devices and desktop workstations in the units. The bi-directional communication with patients allowed the caregivers to remotely visit with the patients to assess care and answer any questions.

As an added benefit, the team was also able to develop a support model for virtual consults. This enabled specialty providers to meet with patients virtually when not available on site and is a care pathway that the health system intends to develop well past COVID-19 to improve both the efficiency and timeliness of care.

"In the ambulatory space, we set up telehealth visits for every department and section, which involved tremendous work by the Epic team," Sussman noted. "They designed new workflows, created training for patients and clinicians, and provided support for patients who were new to telehealth, and set up a team of volunteers to convert patient visits to video and support patients on the download of necessary applications."

The Vidyo platform was integrated into Epic and the MyChart patient portal, which facilitated patient video visits. This infrastructure allowed visits to occur virtually, since large numbers of face-to-face visits were not feasible.

"Telehealth technology allowed us to care for patients who were admitted to the hospital in a new and meaningful way," Sussman observed. 

"By facilitating connections between patients and the care team – nurses, trainees, nurse practitioners, physician assistants, therapists, physicians, etc. – we were able to provide care in ways that simply were not feasible without video technology. For example, our workforce, which at times was limited in seeing patients in person due to health restrictions, could care for patients remotely."

New models of providing care

This also allowed the team to use new models of providing care – including assigning virtual advanced practice providers to provide care for groups of patients overseen by multiple attendings, who would use PPE and see the patient in person, and perhaps follow up in the afternoon via telehealth.

"Rounding on patients across multiple units became more straightforward, and taking the shuttle between campuses became optional, as we could see patients via telehealth as a supplement to in-person visits," Sussman said. 

"PPE preservation was another key factor, especially early in the pandemic. It is largely because we were able to use video technology to care for patients that we were able to maintain adequate supplies of PPE that our supply chain team worked hard to secure."

In the ambulatory setting, telehealth facilitated care that otherwise would not have been possible.

"Initially, we used Vidyo and ultimately transitioned to Zoom," Sussman recalled. "We provided individualized patient support for video visits – assistance with downloading software, logging in to the patient portal – and provided extensive training for clinicians on how to use the software effectively in order to connect with patients in meaningful ways."

Zoom is integrated directly into Epic and allows links to be texted and emailed to patients and their family members so they can easily join visits. In addition, it incorporates interpreter services directly into the video visit to help ensure access to patients who might speak languages other than English.

The results

Since expansion of tele-ICU services, Yale New Haven Health has had more than 3,500 distinct video assessments performed by tele-ICU staff and more than 14,000 interventions ranging from ventilator management to restraint order compliance.

In addition, the tele-ICU staff are responsible for best practice rounding to ensure that patients have appropriate orders in place based on systemwide ICU patient management policies. While overall compliance goals are still being developed, the tele-ICU team has established greater than 90% compliance in management of CVAD, Foley Catheter and DVT prophylaxis order management.

"Overall, there have been thousands of inpatient consults completed using telehealth, which otherwise might not have been able to occur since some specialists were not able to see patients in the hospital due to their own health restrictions," said Sussman.

"The technology helped mitigate burnout, since clinicians were able to care for patients across greater geographies without needing to travel, and allowed more clinicians to participate in care than would have otherwise been able to."

Since March 2020, clinicians, nurses, therapists, chaplains and many other members of the team connected with patients and have spent more than 9,500 hours with admitted patients using telehealth.

"In 2019, we performed 316 ambulatory video visits across our health system, and in 2020 we completed more than 516,000, which is growth of more than 100,000%," Sussman said. "Put another way, the number of patients we used to see per month now happens in 10 minutes. This unprecedented growth in video visits allowed patients to access care in ways that were meaningful to them, while keeping patients and clinicians safe."

Taking care of patients at home

There was hesitancy to seek medical care in-person early in the pandemic, and telehealth provided a way for patients to receive medical care without leaving their homes.

"In two surveys of our patients and the public, we measured the adoption of and satisfaction with video visits," Sussman said. "From greater than 3,000 responses, 72% of patients indicated they had participated in a video visit, 75% reported the quality was excellent or good, and 74% said they might or would do it again. Sixty-four percent of people responded that the ability to do video visits is a primary consideration in their selection of a provider or hospital.

"These are important indicators for us," Sussman continued, "that telehealth is a durable and important mode of care."

The FCC bequeaths $2.9 million

In May 2020, the FCC's telehealth funding program awarded Yale New Haven Health a $2,875,781 grant to expand telemedicine during the COVID-19 crisis.

"These funds allowed us to understand how to effectively use telehealth technologies to support our clinical operations," Sussman said. "Based on our experience through COVID, we are now redesigning our approach to telehealth services including significant investment in both technology solutions as well as staff to ensure that the program continues to grow to support the needs of our patients and caregivers."

In addition to supporting the hardware acquisition to perform video visits, the FCC funds also covered the costs of software licensing with vendors. The combination of these created the infrastructure to complete more than 500,000 patient visits during COVID-19 and sets Yale New Haven Health up to meet the growing consumer demand for high-quality and accessible telehealth far beyond the pandemic and public health emergency, Sussman said.

"It is a silver lining of COVID, since it quickly accelerated our program to provide a service that our patients have clearly indicated they want," he said. "We now offer telehealth visits in all specialties and are expanding our offerings outside of traditional hours to include evening and weekend appointments."

Answering patient questions virtually

In addition, the telemedicine team has partnered with the patient access center to connect patients with medical questions, initially related to COVID-19, though now any topic, to facilitate telehealth visits on-demand.

"We see telehealth as a great opportunity to provide increased access to care, enhanced convenience, and to enrich the relationship between patients and their care teams," Sussman said. "With that opportunity, though, are other challenges, including ensuring patient access to technology, broadband and digital literacy."

Future federal funding may help address some of these issues, he added.

"Regardless, our system will continue to promote and deliver equitable access to healthcare through telehealth technology," he concluded. "The infrastructure that now exists, due in part to the FCC funds, provides the foundation upon which our telehealth program can grow to extend health into our local communities and beyond by facilitating connections and making it easier to do the right thing."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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