Oftentimes when people think about telemedicine, they envision a patient in a clinic with a technological setup they address, with physicians on the other end at another clinic far away doing the same.

"But that model does not work in 2020, because where would staff set it up?" remarked Dr. Jignesh Y. Sheth, chief medical officer at the Wright Center for Community Health in Scranton, Pennsylvania. "A community space, like a bank or a parking lot? So that model does not work, because that is really just remote patient care. It's not true telemedicine."

For example, in rural or less populated regions, too often there is a scarcity of specialists and subspecialists available to patients. So a patient will have to travel to a primary care or clinic setting and the on-site providers will set up a telemedicine cart within their room. Two hundred miles away, a specialist will consult with them via video, but only because none such specialists were available to them in their area.

Care in the home

"If a patient is still required to go to a local facility, I feel that is remote patient care, not telemedicine," Sheth opined. "The intent of telemedicine is for patients to remain in their homes and still have the ability to receive care from their provider."

To jump into Sheth's "true" telemedicine, the first thing the Wright Center needed to do was define it, he said. Traditionally, the organization had been using the remote model versus what Sheth says is a true telemedicine model that would allow patients the flexibility to not only use their own device, but also connect with their providers from their preferred location.

So why wasn't the healthcare organization doing this in the past? It all comes down to barriers, Sheth said.

"In the past, insurance companies would only reimburse for telemedicine services if the patient was physically present at a medical facility – also known as an "originating site" – and the physician was remote," he said. "Payers would not consider the option of allowing patients to remain in their homes to receive care."

How the pandemic changed things

COVID-19 changed everything. The government temporarily allowed originating sites to be moved out of clinical settings and mandated insurance companies pay for these visits. This was a first for the country. Previously, Sheth's "true telemedicine" was only available to patients who were part of a closed system, like an HMO plan, where physicians are reimbursed for taking care of a population versus the traditional per-patient, per-service model. After all, it was convenient and cost-effective for these physicians to perform video visits with at-home patients.

"So now COVID-19 has removed the payment barrier for all," Sheth said. "So although COVID-19 truly helped us, it also brought into play that we now had to provide services we were not prepared for. Practically overnight, we had all these patients connecting with providers using their personal devices and from home."

Staff had to figure out, fast, how to integrate this new model of care in a HIPAA-compliant model. The organization was awarded $630,000 in funds from the FCC, and used the funds to develop an infrastructure that was never present before COVID-19. No one was going to invest in a technology that was not reimbursable. So at the onset, the infrastructure was missing.

"That's why grants like this FCC one became so important," he said. "It equipped us to become the destination site. COVID-19 forced us to implement new technologies and the FCC committed assistance to help us see it through."

Integrating telehealth into the EHR

First up with the funding, in order to support the high volume of telemedicine requests, the organization needed a system that integrated directly into the EHR, Sheth said. There are numerous practices across the country providing telemedicine services. But physicians are required to use two separate systems: one to see and talk to patients, and one to log onto in order to document the visit. If this setup wasn't complicated enough, the two separate systems couldn't talk to each other, he added.

"As a result, it was often up to the front desk staff to make sure, for example, that this calendar matched this calendar," he noted. "They ended up manually inputting all this information every single day. At the Wright Center for Community Health and Graduate Medical Education, Medent is both our EHR [and] telemedicine service provider."

"I can have a patient's blood pressure and heart rate for a whole month delivered to me, and I can know those vital signs next time I have a telemedicine visit."

Dr. Jignesh Y. Sheth, the Wright Center for Community Health

Wright worked with Medent to develop a tool that bakes right into the EHR, which automatically combines on a single calendar the appointments of patients being seen via telemedicine with physicians' usual patients coming into the office. That means physicians are allowed to see one, comprehensive schedule of patients that is a mix of both telemedicine and traditional appointments. And the process of seeing patients is also the same workflow physicians have been using for years. They open a chart, click the video icon, and they're in.

"We developed a protocol working with Medent that has no extra steps. They were very responsive," Sheth said. "We used part of the FCC funding to pay for the development and licenses for providers of this product. Developing this fully integrated telemedicine solution within our EHR into one unified calendar with ease-of-use that works with the scheduling software already in place. This saved us from having to retrain staff, making it a seamless process. They click a button to create a virtual visit and it sends the patient, via both a text message [and] an email, a link and instructions for the appointment. It required very minor tweaks to existing protocols. This system will be helpful and sustainable in the long run, too."

Telemedicine on any device

Second, the product developed is a web-RTC protocol, which is operating system agnostic. So patients can use Windows, Android, iOS or any other operating system. As long as patients have internet availability and a web browser, the system works. This also did not require its own app, which can create issues with updates on user devices while also limiting innovation, since updates can take up to 30 days for review by individual app store owners, Sheth noted.

"This means patients don't require any special instructions, and the security of communication is not dependent on an app," he added. "Patients are only dependent on a browser and stable connection, WiFi or Cellular. We developed a process that is seamless for providers, schedulers, and office staff, and a protocol that is extremely simple for our patients."

As a result, Wright was able to extend its reach, largely due to the simplicity of the system. The adoption of telemedicine at the employee level and patient level at the Wright Center has been "phenomenal," Sheth said.

"We adopted full telemedicine services within three days of Medicare's billing approval," he said. "In the month of April, our patient visits were 20% telehealth, 80% in-person. In May, it was 50-50. On the behavioral health side, however, our telemedicine appointments for May were 90% telehealth and 10% in-person."

Blunting the loss in revenue

While many healthcare providers across the country faced reductions in revenue because of a drastic drop in patient office visits, telemedicine helped blunt that effect for Wright by at least 30%. Without it, Wright would not have survived, Sheth revealed.

"What we found especially reassuring is that we saw the highest number of behavioral health patients ever treated at the Wright Center in our entire history," he said. "Obviously, the community was under stress from COVID-19. But I think the real reason is that no-show rates were under 10%, when they traditionally hover around 30%. And this was because patients were afforded the convenience of talking to their counselor or behavioral health provider from the comfort of their home."

This service is something patients really needed, and Wright must do whatever it takes to continue offering moving forward, he added.

"The increased use of telemedicine did put a strain on the existing system," Sheth said. "As a result, we had to upgrade our equipment to make sure every physician had a device to support telemedicine – camera, microphone, speaker, etc. Desktops don't work. All counselors without laptops had to get one, so FCC funding was used to buy the hardware required. Still, that cost was significantly lower than in the past, when we were buying fancy, inefficient carts. Now we were buying laptops with good cameras and microphones with solid noise-cancelling features."

A doctor visit while hiking

With this new technology installed and ready to go, Sheth was able to see patients logging in from home, the park, hiking trips and wherever they were. Many Americans were trying to stay healthy, so he had patients who were literally hiking in the forest while still keeping their visits with him. He feels he is connecting with his patients at a deeper level, because they're more relaxed when they're in the comfort of their home.

"My no-show rates have gone down," he said. "The patients are feeling more comfortable if they don't have to travel and then sit in a waiting room. Offering a choice to come into the office or see their provider from home delivered the message that we care and truly want to support all patients. We never gave them the feeling that we were only offering telemedicine, even though we had the capability. Again, I wanted to make sure we offered patients a choice. We were and are still available to patients on-site, if they really feel they need to come into our offices."

And by reducing the number of patients who have to come through the building, Wright was able to offer a safer environment for those who absolutely needed to be seen in-person. Telemedicine actually helped Wright reduce the volume of patients coming through the building, which allowed staff to better implement protocols like social distancing. It afforded additional levels of safety. It has also allowed Wright to quickly evaluate patients in the midst of a pandemic, when everyone's attention is on COVID-19, but regular life is still happening.

"While telemedicine has been amazing for us, it also delivered a major caveat: While providing telemedicine services, I really missed seeing my patients in person," Sheth said. "I needed their vital signs and wanted to listen to their heart and lungs. Another part of the funding went to remote patient monitors. I want to do well visits. I was sending prescriptions straight to the pharmacies. I was sending lab slips straight to the lab, so everything was taken care of except that small, interactive exam piece."

Remote patient-monitoring technology

How did he get around that? Nearly a third of the FCC funding is being invested in 100 patient-monitoring kits that include a blood pressure monitor, a heart rate monitors, a pulse-ox monitor, a weighing scale, and a thermometer. They will eventually include a smart stethoscope, which will be delivered for in-home patient monitoring. Wright also invested in a cloud-based system where all these devices in the patient's house will connect to a gateway via 4G that reaches the cloud and connects to a system that will eventually interface with the patient's chart.

"So I can have a patient's blood pressure and heart rate for a whole month delivered to me, and I can know those vital signs next time I have a telemedicine visit," Sheth said. "It makes my job so much more effective and efficient. I feel like I am making more educated decisions, and patients feel that the doctors really care. We have chosen to utilize a single gateway solution versus individual gadgets with their own 4G connection, so we are not paying for five different devices to connect, which is unsustainable, and ensures these fancy gadgets don't become paperweights in a few months due to financial constraints."

Sheth is working with entrepreneurs like Hum World that are developing these tools for Wright. He also has a dashboard the devices will talk to. It will work not just now, but into the future, thus giving doctors historical data that makes for more effective data, he said. Wright will deploy these efforts to more high-risk patients.

"Even though in-person volumes may be down, call volume has been more than double, due to patients seeking care over the phone," he said. "Most of these calls were merely questions or worries about what's going on in the world. Patients needed – and still need – a lot of reassurance from their healthcare providers."

Nursing and ancillary staff

FCC funding also was used for enhancing care-management services offered by nursing and ancillary staff. They are now remotely taking care of their caseloads, which is especially helpful with chronic care management. The process tracks everything from how patients prefer to be contacted, to a list of their chronic conditions, their mutual care plan, and their preferred frequency of calls.

"CCM helps us to offer self-quarantine protocols to patients who are either under investigation, waiting for their test results, or are truly COVID-19 positive but asymptomatic, with daily check-up calls to monitor," Sheth explained. "This reduces the number of patients seeking care at hospitals, easing the burden on emergency departments and ICUs, and allowing these critical care services to remain available for those patients who truly need them. Again, I don't want hospitals flooded. Our enhanced CCM solution reduces unnecessary visits to the ER."

When all is said and done, Sheth admits he still finds it "kind of crazy" that it's taken a global pandemic for patients, providers and legislators to finally accept and embrace telemedicine. With telehealth regulations and reimbursement models less burdensome, healthcare now is recognizing the convenience and effectiveness that this technology offers.

"I'm hopeful we can expand these services permanently, long after the pandemic subsides," he said. "I'm thinking of those patients who live in rural, remote areas who often drive more than 50 miles for a doctor's visit. Telemedicine can save them time and money, so funding broadband internet access will also be important, because telehealth requires a strong connection for audio and video."

Telemedicine is about much more than flattening the curve. The pandemic has catapulted healthcare technology into the future, and Americans have benefited significantly from the expansion of telemedicine and have come to rely on its availability, Sheth concluded.

"Our country needs to recognize telemedicine as a sound, long-term investment," he said. "We can't stop what we started."

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himss.org
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