Presbyterian Healthcare Services serves one third of New Mexico's residents with nine hospitals, a medical group and a health plan.

THE PROBLEM

More than five years ago, the health system was facing a shortage of providers in New Mexico, widening gaps in access for primary care for patients – many of whom live in rural areas and have limited financial resources.

The health system was looking for new ways to improve access to quality care while sustaining operations and planning for the future, so it launched a Presbyterian delivery system redesign committee.

"The committee identified our acute care system as a major challenge ripe for redesign," said Dr. Denise Gonzales, medical director at Presbyterian Healthcare Services. "Our hospital-based EDs were seeing a large number of low-acuity patients [who] could easily be treated in an urgent care setting, while our urgent care system was seeing a large number of extremely low-acuity patients who ultimately didn't require an in-person visit with a clinician to be diagnosed and get effective treatment."

So the question became: How does the health system adjust its digital strategy and care offerings to address these issues and navigate patients to the right venue of care for their conditions while maintaining high quality, improving efficiency and decreasing cost of care for patients?

PROPOSAL

Presbyterian Healthcare Services decided on Bright.md, a vendor of a virtual care solution that automates clinical workflows, as a company that could help answer this question.

"We explored many different solutions to try to solve this problem of improving access to quality care for low-acuity conditions while driving operational efficiencies and lowering costs," Gonzales said. "We looked at partnering with local Walgreens or CVS to open clinic locations. But we saw no need to compete with the existing walk-in clinic options, plus those clinics had several logistic issues that would pose a large challenge for our system.

"Even the best providers or assistants may vary in how they ask questions or forget to include certain details, but the technology never does."

Dr. Denise Gonzales, Presbyterian Healthcare Services

"We also knew that large national vendors were providing synchronous telemedicine like video visits direct-to-consumer, and competing with them did not seem like the best solution for our population," she added.

When the health system started looking into other options, asynchronous technology was new to the team and a relatively new concept in healthcare at the time. When the team began evaluating the options asynchronous care presented and exploring the Bright.md solution, it saw that the technology could fill a void in the community and set the health system up for long-term growth, she said.

"We evaluated several vendors and found Bright.md to be the best-in-class solution," she said. "We were drawn to the company's clinical content and modules that could cover hundreds of the low-acuity conditions that we most wanted a solution to help address.

"We also were drawn to the fact that it could really meet any of our patient populations where they are: With just a 3G connection required and full translation into Spanish, how seamlessly it integrated into our EHR to automate chart-ready SOAP notes and billing to reduce paperwork for our providers, and its innovative technology that we felt would really set us apart and offer possibilities to expand in the future," she added.

MARKETPLACE

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MEETING THE CHALLENGE

Presbyterian Healthcare Services launched its Online Visits program, powered by Bright.md's solution, at no cost for its health plan members.

"We chose our urgent care provider group to staff the Online Visits due to their knowledge and expertise in treating this acuity of patients and these types of conditions," Gonzales explained. "We piloted our solution by treating Presbyterian employees only with Online Visits to ensure a tight feedback loop with any problems."

After finding very few issues with implementation, the health system quickly opened up to all Presbyterian Health Plan patients, and then to the general population.

"In an online visit, patients fill out an extensive, dynamically changing clinical interview about their symptoms," she said. "During this process, the system works to identify patient complaints that fall outside of the ability of an asynchronous visit to safely treat, and escalates those patients immediately to an in-person visit with our urgent care clinics.

"For patients with complaints consistent with a cold or flu, a UTI or a rash, as only a few examples, they complete the interview and the answers are then sent to an urgent care provider dedicated to Online Visits, who reviews the interview," she continued. "If the diagnosis and treatment are clear, they approve it, sign off on or add to the patient's After-Visit Summary, and care is delivered."

If the provider reviews the Bright.md diagnosis and treatment and determines the patient requires synchronous time with a provider, the patient is referred either to a video visit, if a few more questions are needed for clarity, or an in-person visit, for those who need an exam or test.

RESULTS

Since Presbyterian Healthcare Services implemented Online Visits more than five years ago, it has grown from a new program to at least 20,000 visits per year. In 2020 alone, patients completed more than 35,000 online visits through Bright.md.

These visits replace what typically required 20 minutes of provider time with a visit that takes a provider two to five minutes, on average, to evaluate and treat.

"Presbyterian providers who use Bright.md enjoy it and say they trust it because of how thorough and consistent the clinical interview is," Gonzales noted. "Even the best providers or assistants may vary in how they ask questions or forget to include certain details, but the technology never does.

"For patients, standard visits take about one to two hours out of their day, between travel, waiting rooms, intake and the provider visit," she added. "But the average patient wait time to get care with an online visit is less than four minutes for Presbyterian patients. We also hear from patients that they love using Bright.md and we have the data to back that up."

Almost half of patients who completed an online visit last year have used the technology before, and 96% of patients report they like their experience using the system, she said.

"The impact of the technology on our acute care system in New Mexico was significant as the ED and urgent care clinics both continue to see an increasing number of patients," she said. "The addition of another 20,000 patients who use Bright.md would have created delays in care, increased stress on providers and staff, and increased costs of care."

The technology is helping to triage low-acuity conditions with the right, low-cost level of care while saving time and resources in call centers, primary care, urgent care, ER and video visits, she added. In fact, 4% of Presbyterian patients who completed an online visit last year reported they would have gone to the ED had they not had access to the technology, resulting in significant cost savings, she said.

"An additional 11% of Presbyterian patients who used Bright.md would have 'done nothing,' so this is also easing patients to get care and treatment, rather than put off necessary care leading to more serious and chronic conditions," she said.

ADVICE FOR OTHERS

"We have a few key learnings on asynchronous telehealth that other health systems can use when considering this technology," Gonzales offered. "First, pick the appropriate provider group to use and deliver care using the solution. We've learned that ED providers tend to have a low comfort with uncertainty, and this format is difficult with that mindset.

"We use a dedicated set of providers, and other organizations have tried providers covering both clinic and asynchronous visits," she continued. "While both can work, we achieve amazing response time compared to national averages using a dedicated set of providers who are responsible for treating patients using asynchronous tools."

With the growth of telemedicine options, planning for integration is important in whatever system is present locally, she further advised.

"We anticipate the market will rapidly grow with freestanding, direct-to-consumer services as they can be delivered at relatively low cost and fulfill the expectations of patients for convenient, on-demand care," she said.

"From the provider's perspective, however, these services can pose great challenges as the patient's full record is rarely used for medical decision making and the actions taken don't make it back into the medical record for the PCP to review in an efficient way," she concluded. "Striking that balance is key for an organization like Presbyterian that is fully integrated and cares for a large population of capitated patients."

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