Like many physician groups before the COVID-19 pandemic, Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center only used telehealth in a limited way. It had some tools to work with, but they were not optimized for enterprise use.

THE PROBLEM

As the pandemic hit, and the group's physicians needed to leverage existing telehealth tools, staff identified significant room for improvement.

"When providers did engage with the available platforms, they ended up spending a considerable amount of time technical troubleshooting with patients to help install the apps, create accounts and make sure their sound and cameras were working during the appointment," said Dr. Oren Mechanic, medical director and director of telehealth at HMFP at BIDMC.

"It was frustrating for patients and wasn't a good use of clinical time," he continued. "And we didn't want to create a divide between tech-savvy patients who could easily engage in telehealth and those who needed more assistance than we could consistently provide."

The clinical workflows were equally problematic.

"There was a complete lack of integration with existing clinical workflows and the EHR, which meant that these visits were disconnected from the established health IT environment," he said. "Because we traditionally used telehealth so rarely, there was no standard way to conduct and document the visits. Obviously, that's a problem for the coordination and continuity of care."

PROPOSAL

The goal became to develop an enterprise-wide telehealth platform robust enough to stand up to the dramatic increase in use during the height of the COVID-19 pandemic – and beyond. Staff knew it had to happen very quickly, because the practices had basically shut down to all non-emergent care in a matter of days. But they also knew they could not replace one inadequate system with another.

"Even though the need was urgent, we had to take the time to analyze our needs and design tools that clinicians and patients wanted to use," said Dr. Lawrence Markson, chief medical information officer and vice president, clinical information systems, at BIDMC. "We completed a needs assessment and thorough analysis that included provider feedback.

"Through that process, we came up with a set of guiding principles," he continued. \

"First, there should be no downloads necessary and no complicated log-ins. The tool had to work in a web browser on a desktop, tablet or smartphone to maximize access."

Second, the organization needed to provide multiple channels (text, email and chat) to easily communicate with patients, he added. Third, it needed deep and tight integration with the EHR to ensure providers could easily schedule and launch visits right from their existing workflow, he said. Fourth, staff wanted to improve language support for non-English-speaking populations through live interpreters.

"Privacy and security were also overarching concerns, naturally," he noted. "Our new platform had to be HIPAA secure in a technical sense, but we also had to think about the unique challenges of ensuring privacy on the patient's end when family members or other people could be nearby."

Last but not least, he added, staff had to build a supportive organizational culture around telehealth with frequent reminders, tips to physicians, guidance and leadership support.

"Telehealth can give the perception that providers are – or should be – on call 24/7," Markson said. "That can quickly lead to burnout. We didn't want to create an 'always on' expectation among our patients or our providers.

"We also wanted to avoid some of the other negative effects of telehealth, from the physical fatigue of staring at a computer screen all day to the cognitive strain of trying to build relationships with patients without being in the same physical space," he added.

MEETING THE CHALLENGE

At the onset of the pandemic, and seemingly overnight, the healthcare organization launched telehealth to the entire 1,400 BIDMC-based physician workforce, juggling three existing video conferencing tools. In parallel, the technology team led the development and deployment of the organization's new enterprise-wide program, which integrated video conferencing tools with the new, customized telehealth offering.

"We were using various tools: SnapMD, Google Meet and Zoom, among other platforms," said Venkat Jegadeesan, chief technology officer at BIDMC. "Physicians self-leveraged Doximity, Doxy.Me and many other organic efforts. For an integrated solution, we were looking for a browser-based solution with APIs to integrate with our EHR system.

"We reviewed leading video conferencing and telehealth products available in the market and Amazon Chime was the one that met all of our criteria," he explained. "Our platform is hosted on BIDMC's AWS cloud, and we used some of their services to build the platform. We are still iterating to make it even better for our patients and providers."

Jegadeesan said the team is proud of its EHR integration.

"If you are a provider in the EHR, you can see the status of your telehealth visits," he explained. "You can click to initiate a new visit, which will send a personalized link to the patient. When the patient joins the waiting room, you let them into the video visit and begin the consultation. You can also communicate with patients via chat.

"As a clinician, you can also take a look at someone else's schedule and click on the visit to join," he continued. "That's a really valuable feature for specialist consultations. It also allows medical trainees to observe patient care, since we are part of a teaching hospital."

This flexibility also is important on the patient side. Up to four people can take part in the visit from different devices, so the patient can include a family member, caregiver, social worker or other care team member to support their care.

"The other major innovation is our integration of language support," Jegadeesan noted. "When using the chat function, Google Translate automatically translates the message into the patient's language of choice. We also have a service that is something like an Uber for live translators: When a patient needs translation services, the request goes to a pool of translators, and the next available person can grab that visit, click the link to the video visit and work with the patient.

"All the patient-facing screens that support the video appointment are translated into the patient's native language, from invitation to consent form, so patients can have full access to critical information in the language that's most comfortable for them," he continued.

Outside the technical development of the platform, staff also created a new telehealth patient navigator position. This staff member does outreach to patients with upcoming video visit appointments to ensure they know how to connect to the visit and answer any questions ahead of time.

"We have found that this intervention results in more successful video visits and patients are appreciative of the outreach," Jegadeesan observed. "This also helps take the burden off of our providers' shoulders and makes everyone more comfortable about using the telehealth system."

RESULTS

At the height of the pandemic in March and April of 2020, the healthcare organization expeditiously onboarded physicians onto telehealth, and 66% of ambulatory visits were being done virtually.

"Despite this incredible success, during those early months 73% of visits were being done by telephone, and only 27% were being done by video," recalled Leanne Harvey, CIO at HMFP at BIDMC. "There were several reasons that phones were prevalent. For one, we had been using various platforms, all of which were not connected to our EHR, making it more difficult to do video.

"Secondly, the platforms were cumbersome to use, and we found that patients were using different platforms with each department," she continued. "Most of all, we feared that we were not reaching certain patient populations, thereby widening health disparities during the pandemic. As we prospectively studied patient data, interviewed clinicians and called patients following telehealth calls, we learned how to best design a telehealth experience that would be successful."

Over the next year, as staff developed the seamless integration of the telehealth platform into the clinician workflow, they were pleased to identify two success metrics.

"The percentage of telehealth visits done by video increased from 30% in January to nearly 50% in June, and 65% of the video visits are being done through the integrated telehealth platform," she reported. "This increase in the number of video visits is attributed to the implementation of the integrated video platform.

"We expect telehealth to continue at the current volume of 20% of all ambulatory care visits," she continued. "More than 1,400 BIDMC staff and HMFP physicians use the platform, and we conduct approximately 4,200 patient visits each weekday, totaling more than 300,000 telehealth visits since the onset of COVID-19."

The rich experience of video visits for patients and clinicians has led to a low same-day cancellation rate, she added. Feedback has been positive, and staff are excited for its continued success.

ADVICE FOR OTHERS

For BIDMC and HMFP, it was only possible to create a highly integrated homegrown telehealth platform because the organizations also have a homegrown EHR infrastructure, said CMIO Markson. Most physician groups don't have their own highly skilled technical development shop, but BIDMC and HMFP are fortunate to have a technical team to support innovation and growth across the IT enterprise, he added.

"We found that creating our own platform gave us the flexibility and customization to control and optimize the patient experience," he advised. "Not every out-of-the-box telehealth tool is going to give you that same level of flexibility, even if they have an API. So consider your needs, expectations and resources very carefully before committing to a mainstream product.

"And don't forget about the provider experience, which is just as important as the patient experience," he added. "Ideally, you want the telehealth environment to mirror the in-person experience as closely as possible so your providers can focus on patient care. The technology should serve to enable that, not to become the focus of the relationship."

Think about efficiency, ease-of-use and functionality from the provider's perspective, as well as from the patient's perspective, he suggested. There are ways to serve all those needs at the same time if one goes deeper than what's available off the shelf, he said.

"Lastly, even though we're past the chaotic beginning of the pandemic, you still need to make sure you think before you act," he advised. "It's never a waste of time to conduct assessments and collect feedback from stakeholders. This will prepare you to make smarter decisions that serve the goal of creating simple, intuitive, high-quality experiences."

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