Children’s Hospital Colorado in Aurora developed an active and growing telemedicine program over the past eight years. Telemedicine has been particularly important because of the large, multistate service region with many rural and frontier patients, mountain passes and snow that complicate travel, and limited numbers of pediatric subspecialists in the Rocky Mountain region outside of Denver.

THE PROBLEM

Before COVID-19, almost all specialties were using telemedicine in some aspect of their practice. However, use was sporadic, spanned a wide variety of use-cases, and there was not a great deal of depth in each specialty.

The limitations in use were primarily due to the same barriers stated by most entities – worries about reimbursement policy, multistate licensure and credentialing issues, and concerns about telemedicine’s relative value compared to traditional in-person models.

Children’s Hospital’s telemedicine platform vendor has been Vidyo, and the platform was integrated with the organization’s Epic electronic health record. The organization also uses a custom-developed, HIPAA-compliant photo-sharing platform.

PROPOSAL

“COVID-19 hit Colorado early with a substantial number of cases and an associated marked limitation of in-person care by mid-March, necessitating an exponential rapid expansion of telehealth and redesign of care delivery that impacted each and every aspect of our operations,” said Dr. Christina Olson, telehealth medical director at Children’s Hospital Colorado. “We set out to make this change in three phases with a range of services and creative solutions occurring in each.”

Phase One was mobilization, ramping up telehealth services quickly to meet patient and family needs.

"We overhauled our telehealth training and onboarding effort to ensure provider acceptance, knowledge and compliance with best practice standards for tele-enabled practice."

Dr. Christina Olson, Children’s Hospital Colorado

“We overhauled our telehealth training and onboarding effort to ensure provider acceptance, knowledge and compliance with best practice standards for tele-enabled practice, and made it fully online/on-demand to reach more than 1,000 clinicians over three weeks,” Olson explained.

“Given the necessity to immediately convert more than 90% of ambulatory care from in-person to virtual, leverage staff resources across several campuses and add video capability to our ED and inpatient rooms, we significantly increased the number of licenses for our Vidyo telemedicine platform, and upgraded our server and hardware infrastructure capacity.”

Further, the healthcare organization adapted its hospital space and added the technology and processes to safely replace in-person care with home-based care, both for patients and by providers, she added. Staff collaborated with primary care partners to train as many as possible on the integration of telemedicine into their workplaces.

Phase Two was mitigation, stabilizing the delivery of care and mitigating the risks and effects of COVID-19 on team members, patients and families.

“We expanded the use of telemedicine in the emergency department and inpatient care spaces to limit the spread of infection, reduce use of PPE and promote safety of our workforce,” said John F. “Fred” Thomas, director of telehealth services at Children’s Hospital Colorado. “Process improvement, data analytics and project management resources were allocated to telehealth to facilitate efficient resource utilization and growth following the initial rapid expansion phase.”

Additionally, the organization is continuing to expand the home-based care model and is adding monitoring of chronic illnesses in vulnerable populations, Thomas said.

"In the first six business days of April 2020, Children’s Colorado providers completed more than 5,000 telehealth visits. That’s roughly equal to the number of telehealth visits that had been completed for all of 2019."

John F. “Fred” Thomas, Children’s Hospital Colorado

Phase Three was the optimization of telehealth as in-person visits return.

“We are providing ongoing support of telehealth to augment in-person ambulatory visits as we reestablish in-person care in a socially distanced manner, and as our operating rooms and procedure center increase operating hours to accept pent-up demand of elective visits and procedures delayed due to the pandemic,” Thomas explained.

“We are expanding our telemedicine platform capacities to our primary care network of providers and to regional care alliances across the rural states of Montana, Wyoming and New Mexico to streamline communication across partners, patients and specialists.”

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MEETING THE CHALLENGE

Early on, Children’s Hospital realized that how it dealt with this crisis would be critical from public health, organizational, team-member and community-provider perspectives. So, once the governor of Colorado issued a statewide stay-at-home order, staff members were initiating efforts to overhaul practice models to ensure safe provision of care for our vulnerable patients.

“Through a well-designed and coordinated effort of hundreds of people spanning the organization, multiple planning teams were organized to strategize and operationalize plans for near every operation in the hospital, including, but not limited to, clinical teams, IT, clinical informaticists and therapy services,” Olson noted. “Prior to COVID-19, thousands of clinicians and administrative staff had had no experience with telemedicine.”

The engagement of these teams supplanted and enhanced the efforts possible by the relatively small telemedicine team, she added. With many more fresh eyes, staff have been able to accomplish a great deal of growth and integration of operational improvements that would have taken much longer without the need to improvise quickly because of the pandemic, she said.

“In the first six business days of April 2020, Children’s Colorado providers completed more than 5,000 telehealth visits,” Thomas recalled. “That’s roughly equal to the number of telehealth visits that had been completed for all of 2019. We also accomplished in two months what had ultimately been most of our five-year plan for instituting practice change.”

This included:

• Telemedicine devices in all inpatient rooms and several EDs.
• Seamless integration of Epic MyChart telehealth-enabled visits for patients and their families.
• Effective work-from-home strategies to assure the safety and health of our workforce.
• Integration of an improved model for language interpretation services for our diverse patient population.
• An improved model for multidisciplinary care.
• The addition of patient satisfaction assessment specifically targeting telemedicine visits.
• An improved model of training for providers and their clinical teams.
• Research and quality improvement efforts regarding novel clinical efforts to demonstrate the clinical effectiveness of telemedicine.
• Exploration of integration of medical devices for home-based models.

RESULTS

Children’s Colorado is the only quaternary children’s hospital in the Rocky Mountain region, serving as a hospital for children with severe acute and chronic diseases from Montana, Wyoming, New Mexico, western Kansas, Nebraska and South Dakota, along with other states.

“Many rural areas have limited resources and access to care under normal circumstances,” Olson explained.

“With travel severely restricted, yet care needs for these medically fragile patients remaining, we were able to reduce travel and economic burden [and] potential stress on local intervening adult-focused health systems, and continue to serve children and families without skipping a beat. We were able to expand to meet the demand, supporting a 5,500% growth in telehealth visits in less than one month.”

The organization was able to incorporate telemedicine care models to maintain parallel ambulatory visits simultaneously with the reestablishment of in-person care once the stay-at-home orders were ended. These operational changes allowed for conservation of critical PPE and promotion of physical distancing in clinics and facilities, resulting in protecting patients, families, providers and staff from potential infection.

“As our hospital has returned to more normal operations, our system is much better prepared to address a potential reemergence of COVID-19, if it occurs as numerous models predict,” Thomas said. “Additionally, it has allowed us to evaluate a right-sizing of our telemedicine capacities and a thorough evaluation of right-fit for proportion of telemedicine and in-person visits.”

There are numerous metrics of success, Thomas noted; a few noteworthy highlights include:

• Number of telemedicine visits completed. March-June 2020, total visits, 60,444.
• Number of providers trained and completing telemedicine visits, 1,993.
• Patient satisfaction with care provided via telemedicine. Patient-family experience, overall, 86.3% positive (n=995), which is on par with the organization’s overall satisfaction for in-person ambulatory care.
• Innovative care models including fetal cardiology, seizure-rescue-medication teaching for school nurses, and virtual nurse visits to reduce post-discharge readmissions.
• And a great deal of reduced travel and economic burden for families who were able to complete their visits from home.

USING FCC AWARD FUNDS

Earlier this year, Children’s Hospital was awarded $807,090 by the FCC to implement telehealth services to provide continuity of medical care for children, adolescents and young adults with complex pediatric illnesses in the Rocky Mountain region.

“COVID-19 has become the catalyst that intensified the existing fragile relationship between the healthcare ecosystem and at-risk populations, like the vulnerable children, adolescents and young adults treated by Children’s Colorado,” Thomas said. “Previously, while aspects of their care might have incorporated some aspect of tele-enabled care, for the most part, these vulnerable patients had to travel to our main hospital location in Aurora, Colorado, to receive care.”

This need to travel was a potential gap for some of the most vulnerable, economically disadvantaged patients; however, this pandemic has escalated the need to assure our vulnerable populations experience continuity of their medical care and not be at risk of exposure to this potentially deadly virus, he added.

What’s more, the disruption also has presented an opportunity for a change in the model of care: The FCC grant allowed the organization to escalate its plans for an overall integration of telemedicine, said Thomas.

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