COVID-19 transformed the delivery of care, making the use of telehealth tools highly beneficial – and a priority area for research.

To further understand telehealth's impact in recent years and looking ahead, MedStar Health experts in connected care transformation and research are serving as co-principal investigators of two related Agency for Healthcare Research and Quality (AHRQ) grant awards:

• Dr. Ethan Booker, chief medical officer of telehealth for MedStar Health and a leader within the MedStar Institute for Innovation.
• Raj Ratwani, vice president of scientific affairs for the MedStar Health Research Institute and director of the MedStar Health National Center for Human Factors in Healthcare.

Healthcare IT News interviewed Booker and Ratwani to learn more about their work and how it can inform leaders following and advancing the future of telehealth.

Q. MedStar Health recently received a nearly $2 million grant from the Agency for Healthcare Research and Quality to study telehealth as a proactive tool to advance patient safety while also enhancing its safe use. The grant expands your research with two health systems focused on telehealth access, safety and equity. Please talk about the work you're doing.

Ratwani. We're collaborating with Stanford Medicine, Intermountain Healthcare and other experts in studying what the exponential increase in telehealth use has meant for patient access, safety and health equity, especially for those with chronic conditions and other vulnerable populations.

This latest award is a $2 million grant that will allow our applied researchers to establish a patient safety learning laboratory over a four-year funding period, applying a cross-disciplinary human factors and systems engineering approach to connected care enhancements.

This grant comes as we near the conclusion this month of our first two-year $1 million award studying how telehealth transformation impacted primary care access. Since health systems across the U.S. were experiencing these historic shifts, we asked Stanford Medicine and Intermountain Healthcare to collaborate in these grant research efforts to establish one of the largest patient-level data sharing and analysis alliances of its type to date, ultimately striving to enhance both clinical practices and policy.

Together, we have examined more than five million care encounters with 1.2 million patients to date. We are beginning to add to the national published data showing that telehealth is delivering unique value across the care continuum – and deserves ongoing policy and operational support.

Thanks to the continued support of AHRQ, now we will advance patient safety nationally by studying and scaling telehealth as a proactive safety tool while also enhancing its safe use within the diverse communities served by connected care.

Our team will continue work under the name Connected CARE – Care Access, Research, Equity & Safety Consortium and expand beyond the initial focus on primary care. We will study the care continuum tied to outpatient settings more holistically, with special attention to chronic care and health equity.

We'll also collaborate with experts at Microsoft Research and Bluestream Health to consider safety solution design, development and implementation, in addition to work with patient and family advisors.

Q. What exactly will you be doing with that big grant?

Booker. We have established an initial framework to shape our latest telehealth safety research, informed by both our first grant and our own telehealth innovation and human factors research expertise.

The major shifts in communication between patients and providers, and between providers, create a potential for transformation in the way we deliver care. We are thinking of not just how to effectively substitute telehealth for an in-person visit when possible, but how to redesign an entire system of care that accelerates a team approach, opens multiple channels of communication and data exchange, and creates better continuity while preserving a relational context between patients and their providers that is critical to successful care.

We've identified "4 Ps" of possible impact for a patient safety learning lab: proactive opportunities, process optimizations, personalization options and provider wellbeing.

First, we see enormous potential in proactive opportunities to advance safety and health through telehealth. Our research will start with reinforcing and expanding the safe use of telehealth, which is likely more reactive to our existing realities.

An example is the chance to enhance existing information transfer between stand-alone telehealth organizations and emergency departments. We are also especially excited by the potential to leverage telehealth technology to proactively increase safety, whether that's reviewing a patient's medicine cabinet or spotting a fall risk during a video visit.

Second, our experience indicates that process optimizations can be as important to safety progress as technology enhancements. An example is the ability to support care referrals surrounding visits, which is critical to the continuum of care. We will bring a blend of clinical, technical, human factors, systems engineering and other knowledge to this work.

Third, we know that the personalization of telehealth technology use is essential to both safety and health equity. Past research shows the ability to safely deliver care via phone, video and other unique telehealth technologies like chatbots is vital to serving vulnerable patients, people with disabilities, patients with diverse language needs, people with chronic conditions and those who may need to use telehealth to evaluate if symptoms require care now or can wait.

Fourth, prioritizing provider wellbeing is an urgent priority for patient safety as care becomes more connected. One new reality that illustrates this point is the enormous increase in patients' use of portal messages for clinical questions.

It is important to identify staffing and technology solutions to reduce any related after-hours provider workload for safety and wellbeing. We are uniquely positioned to consider advancements in this space because the MedStar Institute for Innovation is home to both our MedStar Telehealth Innovation Center and MedStar Health Center for Wellbeing and works regularly with our MedStar Health National Center for Human Factors in Healthcare team within our MedStar Health Research Institute.

Q. Also, recently you published a study that found the unprecedented availability of telehealth during the COVID-19 pandemic did not lead to an increase in unnecessary primary care sessions. Please explain your findings in this area and what they mean for telehealth.

Ratwani. This new grant activity will build on findings from research conducted under our initial grant award. This includes a study that was recently published by npj Digital Medicine titled "The impact of expanded telehealth availability on primary care utilization." It demonstrated telehealth is delivering on its promise to provide accessible and effective care.

Our grant research team analyzed more than 4.1 million completed in-person and telehealth (video or phone) adult primary care encounters for nearly 940,000 unique patients at MedStar Health, Stanford Health Care and Intermountain Healthcare from January 1, 2019 to December 31, 2021.

We also looked at each patient's payer type, including commercial, Medicaid, Medicare and other. We determined the mean number of encounters for these patients, as well as the subset who had at least one encounter every year.

Our study found that for both groups, the mean number of encounters showed little change from year to year, and those patients who had more than one encounter per year tended to use telehealth more than those with only one encounter per year.

The study reinforces that the unprecedented availability of telehealth during the pandemic did not lead to an increase in unnecessary primary care sessions, which is essential information for policymakers.

Q. The study findings also show that telehealth helps providers increase access and care continuity for patients who need it most. What does this mean for healthcare and patient outcomes?

Booker. While we expected to see variability in telehealth use in primary care, we were interested to learn that those patients with chronic illness and frequent primary care needs consistently replaced one to two visits per year with a telehealth visit. This finding underscores our entry into a new era of chronic care, as telehealth helps providers increase access and care continuity for patients who need it most.

Given the evidence that telehealth has expanded our care capabilities, we believe federal and state legislation and regulations should continue to protect telehealth access.

The case for improving chronic care speaks for itself. Research has shown that more than half of adults in the United States have a chronic condition. In addition, people with chronic conditions account for the majority of hospital admissions and physician visits, and chronic conditions are the leading cause of death and disability in the U.S.

While our research has found that those with chronic conditions are using telehealth, we have more work to do nationally to understand how to reach such a large group safely and more comprehensively.

Q. What is your advice to healthcare CIOs, directors of telemedicine and other health IT leaders who have embraced virtual care during the pandemic and are now looking to the future?

Booker. MedStar Health has also embraced this opportunity to scale connected care. In our own telehealth transformation during the initial peak of COVID-19 outpatient telehealth visits increased from around seven to 4,500 per day, with around 30% of primary care visits shifting to video. By the end of our fiscal year 2022 on June 30, we had delivered more than 1.7 million telehealth encounters.

As leaders stabilize and evolve similar work, my advice is to very intentionally transition ownership of ongoing operational work to the right teams so you can also continue to advance research and innovation within your organization.

I'll share one example of this innovation within our team. MedStar Health has established a connected primary care model that creates and deploys a central connected care team of virtual practitioners and virtual staff members who currently serve four key functions: prescription refills; same day/next day video appointments; remote patient monitoring for chronic disease management; and urgent lab/diagnostic result follow-up.

In its first year, we have delivered more than 7,000 visits within this program, driving results in both patient satisfaction and provider wellbeing. For example, with prescription refills, providers have reported they used to spend two hours a day on related tasks and still worry they missed something.

Following prescription refill automation under the connected care model, this now takes closer to 10 minutes of their time – and they don't have to worry about safety.

Looking ahead, by exploring, building and researching innovative connected care models like these and their safety benefits, we can better understand how to hopefully scale and continuously enhance them nationally.

For more information about these efforts and the consortium funded by the AHRQ, visit www.ConnectedCAREandSafety.org.