Raleigh Medical Group is a multispecialty group that serves the Research Triangle area of North Carolina with 115,000 patient visits a year in its internal medicine, gastroenterology, dermatology and rheumatology divisions. Cary Medical Group is one of its three internal medicine practices.

THE PROBLEM

The COVID-19 virus interrupted Raleigh Medical Group's daily schedules and challenged patient care. Focused on safety for patients and staff, the group wanted to find a solution to ensure patients received care when and where they needed it.

"We had to adapt quickly to the ever-changing science and CDC guidelines, and continue to be accessible," said Dr. Sujatha Raman, an internal medicine physician at Cary Medical Group.

 "For several years, we have maintained contact with our patients through the FollowMyHealth patient portal. During the past year with the portal, we continued to reach out to patients when we needed to, and the portal gave them an avenue to reach out to us."

Raleigh Medical Group has more than 55,000 patients on the portal.

PROPOSAL

Cary Medical Group uses the Allscripts Professional EHR and the FollowMyHealth patient portal. Once the coronavirus surfaced, it had to implement new approaches to patient care to enhance remote patient care.

"Many of our patients already interacted with the patient portal to message their physician or view test results," Raman said. "For us, that familiarity helped when the public health emergency hit because many of our patients understood not only how to use it, but why it worked for connecting with their doctor."

In March 2020, Cary Medical Group started a drive-through clinic to see acutely ill patients – to obtain vitals, conduct examinations and run diagnostic tests on those who needed that level of care. Not only did staff manage acute visits, but at times they were able to do point-of-care testing for A1Cs, blood clotting or protime tests, and vaccinations for those who were not comfortable with going to the lab or coming into the office.

"I believe telemedicine is here to stay, because I have proof that it works, and remote patient encounters are a viable option for physicians."

Dr. Sujatha Raman, Cary Medical Group

"During these visits, we pulled the Allscripts ProMobile application to see the records of those patients and document a quick assessment and plan," Raman explained. "This approach now continues, and we continue to see some chronic patients – in their cars – with high-risk conditions or mobility issues."

MARKETPLACE

There are many vendors with electronic health records systems on the health IT market, including Allscripts, athenahealth, Cerner, DrChrono, eClinicalWorks, Epic, Greenway Health, HCS, Meditech and NextGen Healthcare.

MEETING THE CHALLENGE

The physicians in Cary Medical Group's practice have been using Allscripts Professional EHR since 2003. This platform includes Allscripts Practice Management and Allscripts Payerpath, plus the FollowMyHealth patient portal.

"Within a week of the pandemic hitting the United States, we also rolled out Zoom Business and Doximity to our patients as a telehealth option," Raman recalled. "Both modalities allowed us to not only remotely monitor patients on their chronic conditions, but also continue to see those who had COVID-19-like symptoms."

Staff used the ProMobile and FollowMyHealth applications in the drive-through clinic. The tools also integrated with Raleigh Medical Group's telehealth solutions and Phreesia check-in platform.

Patients digitally shared their information through the telehealth, patient portal and check-in apps, and then came to the garage clinic based on the assessment by the provider. For example, Raman used her mobile phone to view a previous telehealth encounter for one of her patients with abdominal pain. She relied on that additional data to determine the need for blood tests and medication in the drive-through clinic.

"We have had several patients think they had one illness and, after assessment, it was completely different," Raman said. 

"For example, a patient complained of coronavirus-like symptoms on the telehealth encounter, but on assessment in the drive-through clinic, the clinician referred the patient to the emergency department, where he was diagnosed with a blood clot. This type of situation arose at least 3-4 times a week during the peak of the pandemic, and even now."

Eventually, the staff set up a hot spot in the drive-through clinic to manage the many patients coming to see their providers. While this garage clinic became the staff's primary setting to treat sick patients as the coronavirus unfolded, the staff also used the patient portal app for emergency calls to patients in the evening and, in general, to access patient data.

"We followed up with patients diagnosed with the coronavirus using telehealth appointments for us to check in, continue to monitor them, and provide education and support," Raman said.

RESULTS

Cary Medical Group's three main success metrics focus on continuity of care – that is, the practice's ability to provide quality patient care through telehealth services.

First is the management of chronic conditions, March 2020 through March 2021: The practice continued care over the past year for patients with diabetes, hypertension and other chronic conditions. Using the Allscripts Reporting module, staff maintained lists of patients with chronic health conditions.

"In my practice of 4,000 patients, I was able to monitor and manage through telehealth 40 of my most high-risk patients with diabetes," Raman reported. "Among those patients, 28 out of 40 maintained their glycemic control, and eight improved. Management strategies included monthly, and sometimes weekly, check-ins via the portal, frequent telehealth visits and drive-through A1C checks."

Second is continued care for sick patients with the drive-through clinic, March through December 2020: During these nine months, the practice managed 11,500 telehealth appointments, with 3,500 of those visits conducted in Raman's office in Cary. The drive-through appointments totaled 1,221 in the Cary office and 2,889 throughout the practice.

"I believe these numbers tell a story of patient care we were able to deliver because we had telehealth and mobile applications in place," Raman stated. "Without them, these patients would not have received the care they needed."

The third metric is improved or reduced clinician stress or burden using mobile access to patient data. Here are four examples Raman points to of the ways telehealth and the mobile app made his job easier:

• Flexibility: Primary care doctors tend to worry about their patients, she said, so seeing them via telehealth and maintaining connections gave the doctors peace of mind. Telehealth, the patient portal and mobile check-in allowed them flexibility in caring for their patients.
• Safety: Remote care meant doctors could continue to see patients without exposure at high levels to the coronavirus – and with less concern about transmission to family members.
• Convenience: Doctors worked from home, if needed, and in a situation where staff could not go into the office.
• Easily accessible data: The Allscripts ProMobile app made it easy to quickly answer on-call patient requests and with a few clicks access data, send medication and document visits, she said.

ADVICE FOR OTHERS

"All of us in the practice understand the challenges patients faced during this last year of the pandemic," Raman said. "My colleagues and I also dealt with the hurried transition from in-person care at our offices to complete remote care. My advice to others focuses on ensuring that my patients not only received the care they needed but knew that I, as their physician, was available to them."

For example, the practice pulled a report to identify patients over 65 years of age, the high-risk population first eligible to receive the vaccines. (There are now shots available to everyone 16 years of age and older in North Carolina.) With a small allotment of vaccine, staff wanted to ensure the elder patients who wanted the vaccine received it.

The portal facilitated the process because Raman could confirm they had scheduled their vaccine appointments. She also answered any questions they had about the vaccine. If a patient still needed an appointment, she sent them the link to the page for scheduling that time.

"The coronavirus vaccine represents only one component of care for my patients managing chronic disease or other high-risk conditions," she said. "All patients need easy access to me, as their physician, to ensure they receive care. The drive-through clinic offered sick patients a convenient and an efficient approach to care."

IT integration matters as well in providing that care, she said. One of Raman's patients came to the garage clinic after her telehealth visit. She had chest tightness and a cough. Raman evaluated her oxygen levels and conducted a lung exam when she saw her. The data led Raman to prescribe additional tests to rule out a pulmonary embolism. Raman also prescribed steroids to treat her wheezing.

"With remote technology, I could access her patient data and view previous telehealth visits using my smartphone," Raman explained. "The information indicated past history of potential blood clots and simplified the exam and diagnosis process, a benefit for both the patient and me, as her doctor."

As a clinician, Raman knows which patients can contact her using digital resources and those that prefer a phone call. She recognizes that limitation in her own daily practice of medicine, because not all her patients have an Internet connection. It's her responsibility to meet their health needs as it works for them, she said.

"Like so many medical practices across the country, we transitioned to telehealth quickly a year ago to ensure patients received care and clinicians could deliver that care," she said. "I believe telemedicine is here to stay, because I have proof that it works, and remote patient encounters are a viable option for physicians.

"That meant my patients sent photos of a rash or their logs of blood glucose or pressure," she continued. "In several situations, I was the only person they would see for months at a time. I was able to provide emotional support as well. Anxiety and depression were dominant during the pandemic."

Raman connected through technology in these situations for these patients who did not need an in-person appointment. She reviewed information and treated each patient, again with the advantage of remote care convenience.

"I consider telehealth integral to quality, safe and continuous care delivery so crucial to my patients and me," she concluded.

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