Sun River Health, based in Peekskill, New York, is a not-for-profit system of federally qualified health centers. It provides culturally sensitive and linguistically appropriate primary, preventive, behavioral and oral healthcare, and a full range of enabling and support services. It serves predominately low-income and highly vulnerable patients living throughout a 16-county region of southeastern New York, encompassing the Hudson Valley, New York City and Long Island.

Sun River's 64 health center sites (including both directly operated FQHCs and sub-recipient sites) serve more than 245,000 patients annually in both urban and rural medically underserved communities. Sun River Health was among the first organizations to receive funding under the Federal Communications Commission COVID-19 Telehealth Program.

THE PROBLEM

Prior to implementing the telemedicine technology supported by the FCC program funds, Sun River Health had relatively limited and targeted capacity to support remote visits. Mostly, Sun River Health's telemedicine services met the needs of the HIV, Medically Assisted Treatment patients.

"The use of this modality given the clinical conditions of the patients was the most effective approach to clinician/patient co-management," said James Sinkoff, deputy executive officer and CFO at Sun River Health. "The health center predominantly used video-based telemedicine technology to support site-to-site visits within the Sun River network, or to provide access to contracted specialty services such as dermatology."

This type of programming was focused on overcoming barriers to care for Sun River patients, particularly for specialty services not typically available to patients in underserved communities where Sun River sites are located. In many instances, time-limited grant funding was the only financial support for this type of telemedicine programming.

"Quality assurance work was similarly focused on this relatively focused scope of service in order to ensure a level of patient satisfaction and HIPAA compliance comparable to that offered by face-to-face visits," Sinkoff said. "The site-to-site programing rode on Sun River's fiber network and used Cisco Telepresence SX10s and Cisco Jabber on Dell laptops with the provider controlling the camera on the patient side."

While this work allowed the health center flexibility on sourcing provider time between Sun River sites, and with contracted providers, it still required both patients to be physically housed in a clinical setting.

"Our legacy telemedicine program also was limited to a certain degree because of restrictions on reimbursement for services, particularly reduced rates for off-site telemedicine paid by New York State Medicaid funding," he explained. "As a result, Sun River's program did not typically utilize technologies that operated on non-health center network infrastructure and faced ongoing challenges in sustaining telemedicine programming."

"Coupled with seamless EHR integration and clarity on reimbursement methodology, our new telemedicine infrastructure will push Sun River to thoughtfully consider patient experience in the development of a resilient yet flexible model of care."

James Sinkoff, Sun River Health

The technology mirrored the reimbursement environment and the physical network of health center locations and was limited to specific provider types rather than providing capacity to accommodate a larger quantity of Sun River visits, he added.

The advent of COVID-19 radically disrupted the paradigm in which Sun River Health was operating. Situated in the epicenter of the worst initial outbreak in the United States, patients faced lockdowns, job loss and fear from a poorly understood viral threat.

"At one point in April, the 16 counties that make up Sun River's service area accounted for approximately 97% of all confirmed COVID-19 cases in all of New York," Sinkoff recalled. "Many patients, particularly those with chronic conditions, were at a loss to balance public health recommendations to isolate at home with routine medical appointments."

Sun River Health therefore needed to quickly scale telemedicine capacity to provide large numbers of patients with access to providers throughout its network as opposed to targeted access aimed at overcoming specific barriers to specialty services.

PROPOSAL

Sun River immediately recognized the limitation of the existing on-premise solution within the context of the COVID-19 pandemic because it clearly did not conform to public health strategies focused on reducing crowding and maximizing interpersonal space.

A relaxation in reimbursement criteria that included telemedicine visits originating from locations outside physical health center space incentivized the adoption of a new solution and promoted rapid adaptation to potential service delivery modification.

"However, building capacity to accommodate a substantial increase in telemedicine visits originating from non-clinical locations presented a significant challenge to Sun River's legacy operational model," Sinkoff explained.

"Additionally, the lack of readily available remote diagnostic devices limited the breadth of what Sun River providers could offer within the context of a telemedicine visit, particularly among a subset of patients with underlying conditions most at risk for complications arising from COVID-19 infection."

To address these concerns, Sun River's proposal sought to acquire new audio-visual capabilities that could be implemented outside of health center facilities. This required a shift from using technology dependent on internal networks to a telemedicine solution capable of operating from diverse remote locations.

"We also recognized that building remote monitoring technologies would be a critical next step in managing ongoing patient care remotely and sought out connectable diagnostics that would facilitate remote monitoring between Sun River sites and beyond," Sinkoff said.

"The integration of these technologies presents on ongoing challenge as our telemedicine program moves toward sustainability and has relied on ad hoc workarounds leveraging existing informatics capacity in order to deliver services in response to the immediate demands resulting from the COVID-19 pandemic."

A change in New York State and Medicare reimbursement, along with receipt of the $753,367 FCC grant, infused working capital on top of Sun River Health's investment in telemedicine.

"Within three weeks, the health center's telemedicine network covered our entire service area, was fully operational and was delivering patient care remotely," he said. "Notably, our persistently mentally ill and chronically ill patients were the first to benefit from this service expansion. Some operational kinks needed to be worked out, however, but our ability to connect patients to their primary care providers immediately reduced anxiety and fear associated with the pandemic."

MARKETPLACE

There are many vendors of telemedicine technology and services on the health IT market today. Healthcare IT News recently compiled a comprehensive list of these vendors with detailed descriptions. To read this special report, click here.

MEETING THE CHALLENGE

Once Sun River recognized the critical need for a more widely scalable telemedicine solution, an internal team quickly evaluated its eClinicalWorks EHR's capabilities, but eClinicalWorks faced limitations broadly implementing its internal solution.

"This prompted us to subsequently evaluate telemedicine vendor Doxy.me and quickly pilot it with a handful of providers," Sinkoff noted. "This relatively straightforward and simple solution offered Sun River a platform accessible from phones, tablets and laptops. As a standalone, HIPAA-compliant telemedicine platform, Doxy.me allowed two-way video visits to be scheduled quickly and without undue demands on patients."

A virtual waiting room simplified the wait times for patients were providers to run late. After it was vetted, Sun River quickly rolled out 245 Doxy.me licenses to medical and behavioral health providers. Within a few weeks, Sun River Health was able to make remote telemedicine visits accessible to almost all of its primary care and behavioral health patients.

"Sun River also sought to align the use of Doxy.me with its existing EHR capabilities," Sinkoff explained. "Doxy.me does include an application programming interface that allows Sun River to extract some utilization data. This capability allows us to align that information with provider visit volume, and patient scheduling. The ease of use and scheduling flexibility made provider and patient adoption straightforward and timely."

RESULTS

Two metrics demonstrate the efficacy of Sun River's FCC-supported telemedicine efforts, Sinkoff said.

"The first compares pre-COVID-19 and post-COVID-19 telemedicine utilization," he said. "For the week ending February 28, 2020, Sun River had conducted approximately 30 visits remotely using its existing telemedicine solution. For the week ending May 29, 2020, Sun River Health had conducted 2,792 visits utilizing telemedicine with video (9,815 using all telemedicine modalities)."

This measure reflects the raw numerical increase in the use of telemedicine within one month of implementing the expanded telemedicine program, he added.

"The second metric looks at Sun River's capacity to deliver services remotely," he said. "For the week ending May 29, 2020, the health center provided approximately 67% of its visits via telemedicine. This metric speaks to the scalability our telemedicine program achieved. This metric is particularly salient given the fact that certain service lines – COVID-19 testing, for example – simply were impossible to deliver virtually."

Sun River Health's percentage of visits provided via telemedicine compares to an average of 53% among other New York State FQHCs during the same time frame, as reported by survey data collected by the Health Resources and Services Administration. Sun River's transition to this level of capacity, for clinical and support staff, was accomplished in large part due to the FCC program, Sinkoff noted.

USING FCC AWARD FUNDS

"Apart from the implementation of Doxy.me, Sun River used FCC funding to ensure that providers and support staff had connectable devices capable of securely accessing the health center EHR from remote locations," Sinkoff said. "This accommodated telemedicine visits from patient homes to providers working in diverse settings."

This was particularly important given the health center's commitment to COVID-19 testing in community locations where WiFi connectivity was necessary to establish and record patient results.

"We have deployed telemedicine to promote a broadly scaled and readily accessible option for the majority of health center patients in the event of pandemic resurgence, natural disaster or other events that might disrupt physical access to Sun River Health's clinical locations," he explained.

"Additionally, we anticipate that this infrastructure will inform ongoing quality assurance and improvement activities in a way that meaningfully translates and aligns legacy clinical, administrative and financial benchmarks with the experience and outcomes associated with virtual visits."

Sun River's program also supported its efforts to enhance remote monitoring technologies.

"These technologies will allow objective diagnostic information to supplement video and telephonic consultations," Sinkoff said. "While the promise of these technologies is vast, they also hasten constructive disruptions to the operational models FHQCs have traditionally deployed to address social determinants of health and other barriers evidenced in our patient populations."

Moreover, Sun River's accountable care organization efforts and other value-based care models will benefit as the organization foresees significant reductions in emergency room utilization, increases in virtual in-home visits, and improved rates of engagement in transitions of care and care management programming.

"Coupled with seamless EHR integration and clarity on reimbursement methodology, our new telemedicine infrastructure will push Sun River to thoughtfully consider patient experience in the development of a resilient yet flexible model of care," he concluded.