While use of telemedicine technologies has been soaring throughout the COVID-19 pandemic, and success stories abound, not every healthcare provider organization has been satisfied with virtual care.

One example of just such a provider is Windrose Health Network, a federally qualified health center based in Greenwood, Indiana, near Indianapolis. Here's an easy way to explain the telehealth situation there: Physicians were volunteering to take eight-to-ten-hour shifts in full PPE in their open health centers, rather than do a shift of telehealth visits from the comfort of their own homes.

And there were challenges with patients, too, who prefer the hands-on treatment of an in-person visit, or who need an interpreter whose services simply work better in a three-way discussion at the same table.

Scott Rollett, CEO of Windrose Health Network, sat down for an interview with Healthcare IT News to discuss his organization's experience with telehealth since March 2020 and explain why telemedicine can be a heavy lift for some healthcare providers.

Q: You said that your patients have not really embraced telehealth, which surprised you. Why did they not embrace the technology?

A: I believe it's a combination of things. To begin with, we have a very diverse patient base – from the young and tech-savvy to the elderly who have no ability to connect via video. We have well-educated patients, and patients who did not complete high school, and some who are developmentally disabled.

A majority (60%) of our patients speak English, yet the other 40% do not, and require an interpreter. We have some patients with easy access to smartphones, iPads and laptops, but we also have patients who only have a smartphone with limited minutes available. So we serve a very broad range of patients with very different needs and abilities.

Second, like many Americans, I think some of our patients thought the pandemic would pass relatively quickly. So while us Hoosiers were being safe and hunkered down for roughly two and a half months from mid-March to May 31, people didn't think it was a big deal to not see their doctor for 90 days.

"Did our clinicians like it? A few did. Most did not. In fact, in the beginning, for a variety of reasons we were rotating shifts in our three live clinics, versus our four telehealth clinics, and some providers offered to pick up more live shifts if they didn't have to do telehealth shifts."

Scott Rollett, Windrose Health Network

As a matter of convenience, our staff and our medical providers were triaging patients and refilling any maintenance prescriptions they were on. Since the average patient only sees their medical provider about two to three times a year anyway, I think it was an acceptable gap of time for most of our patients.

Finally, for a portion of our patients, their relationship with their medical provider is a very close and personal one. They like that social interaction and enjoy seeing and interacting with our staff and our medical providers. This, of course, isn't true for every patient, but it is certainly true for our longtime patients and their families who have been seen in our health centers for the past 15 to 20 years. For them, unless it was an emergency, it was worth the wait.

Q: You hit a high of about 30-35% of total visits via telehealth back in April and May 2020, when four of your seven facilities were closed to in-person visits. Was telehealth operating successfully? Did clinicians like it? Did the patients who chose virtual care like it?

A: Like almost all healthcare organizations in America, we pivoted to telehealth very quickly. Prior to COVID-19, Windrose Health Network had really only been using telehealth very modestly for tele-psychiatry and other behavioral health services. In fact, I believe that if you asked a majority of our medical providers 15 months ago, they would have told you that providing primary care services via telehealth was simply not possible.

But when forced to improvise, we adapted very quickly, we got creative, and we learned that it was possible to treat patients for many things. Not everything, of course, but for many things we found a way.

I am not sure I would say our telehealth program ever went "smoothly." Yes, things got better over time, and we learned from our experiences and adapted on the fly. But even today, one year later, there are still many glitches, complications and frustrations that make a telehealth visit less desirable than an in-person visit.

Did our clinicians like it? A few did. Most did not. In fact, in the beginning, for a variety of reasons, we were rotating shifts in our three live clinics versus our four telehealth clinics, and some providers offered to pick up more live shifts if they didn't have to do telehealth shifts.

They disliked telehealth that much. Now this was in the early days of the pandemic, when we still didn't know a lot about COVID-19, so that's a pretty powerful aversion to telehealth – when a medical provider would rather put their own health at risk and suffer through eight-to-ten-hour shifts in full PPE in a live clinic than do telehealth from the relative safety and comfort of their home or another office.

Did our patients like it? Sure, some did. I'm a patient of Windrose myself, and I loved it, because it was very convenient for me, and I was pretty busy during the early days of the pandemic. So it fit my lifestyle very well.

I also think many of our younger patients and the parents of our pediatric patients liked it as well. But not everyone likes it, and if you look at our patient satisfaction scores and patient comments from 2020, you can clearly see that, while some patients understood why we were doing telehealth visits, they didn't prefer it and they let us know that.

Q: Your percentage of telehealth visits has fallen to about 15% in recent months, despite having one full day per week at each of your now six clinics solely dedicated to telemedicine. Why do you think the percentage fell off so much? And how does your 40% non-English-speaking patient population affect this?

A: I think it goes back to some of the points I discussed, which ultimately suggests that a majority of our patients prefer to be seen in person. Even though we were still offering one telehealth day per week (which was a strategy we employed to help manage the high numbers of staff who were out sick or on quarantine in late November, December and early January) patients were willing to wait an extra day or so to be seen in person.

For the non-English-speaking patients, this was doubly true. For the most part, we hire multilingual staff and try to provide live interpretation whenever possible. Our patients and our staff prefer that model. So while we still had the ability to provide an interpreter on a telehealth visit, it's simply not the same as having a personal, three-way conversation in an exam room.

Even when you don't speak another person's language, you can still convey empathy, compassion and caring through touch, facial expressions and visual cues. As a result, many of our non-English-speaking patients feel well cared for by our clinicians, and that experience sometimes doesn't come across in a telehealth visit.

Q: What are the challenges you, as a federally qualified health center in a half-urban/half-rural setting, face with telehealth adoption?

A: From a technological perspective, our rural health centers are as capable of providing high-quality telehealth care as our urban health centers. For about a decade now, all of our health centers are connected back to a data center via high-speed fiber. We have a single EHR. We have uniform equipment, and our staff can just as easily work in one health center as another.

The challenges, I think, have more to do with our patient populations, which are very different. Our largest health center is on the south side of Indianapolis and has a relatively young, middle-class, immigrant population base, of which nearly 70% do not speak English. Compare and contrast that with our health center in the rural town of Hope, Indiana, which is 42 miles away and tends to serve a very rural, poor, white patient base with ancestry from Appalachia.

Those two patient populations are very different, and have very different medical and behavioral health needs, and also require different types of enabling support. Despite those significant differences, outside of the language barriers our challenges for delivering telehealth services to both patient populations can be very similar – poor WiFi connections, no minutes on their smartphones, no privacy for the visits, etc.

Q: You've said you think that, regardless of your experiences, telemedicine will play a big role in the future of medicine. What will it take for your patient population to hop onboard that future?

A: I do think that telehealth and remote patient monitoring will play a big part in the future of medicine. As technology progresses, becomes more seamless, and gets easier to use for both patients and healthcare workers, we'll see that continue to grow both in popularity and scope of use.

But FQHCs have to also be realistic about the patients we serve. No matter how far technology advances, there will always be vulnerable and underserved populations that will be better served in person. When they come to our health centers, these patients often interact with an integrated treatment team that provides holistic care, as opposed to a more transactional, two-dimensional video interaction between a patient and a single medical provider.

Sometimes during telehealth visits some very subtle things – and some not-so-subtle things – can be missed. As a general rule, patients who come to FQHCs are sicker and more medically complex than the average American, so when those things are missed, they can lead to some very poor health outcomes.

Finally, FQHCs typically have well-established enabling services that they provide to patients outside of just medical care. For example, each of our health centers has a small supply of nonperishable food on hand. If a patient comes in hungry, you can be sure they will leave with enough food to eat for a few days and a referral to a local food bank. So our clinicians at least know that their patient is not going hungry that night. They wouldn't necessarily have that assurance with a telehealth visit. 

So yes, telehealth will play an important part in our future, but it will never completely replace in-person care.

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