Roswell Park Comprehensive Cancer Center in Buffalo, New York, faced several challenges in rolling out an effective telemedicine strategy, many of which were unrelated to COVID-19. If anything, COVID-19 served as an accelerant to solving many of the challenges, since the organization had no alternative but to move forward.

THE PROBLEM

"First, while we had in place technology to enable telemedicine – in particular virtual visits – it had not been optimized for use nor integrated within our clinical workflows or our EHR," said CIO Thomas Furlani. "Integrating virtual visits with a typical in-person clinic operation is far from trivial and even today we have challenges effectively implementing it within all clinics since the workflows from one clinic to another can be very different.

"There also is a challenge at the patient side, since not all patients have the same technical skills or have access to devices to facilitate virtual visits from home," he continued. "What we refer to here as a great digital divide that is common across healthcare."

Fortunately for Roswell Park, prior to the onset of COVID-19, the information technology team already had an ongoing project to develop and deploy virtual visit technology. So the organization had a solid foundation on which to build and improve its telehealth solution.

"The main problems we wanted to address with our telehealth platform prior to COVID-19 surrounded our goals of expanding the reach of our clinical care services and allowing our clinicians to meet our patients at their convenience to avoid unnecessary long commutes to our city campus," he said. "In 2016, we began exploring various telehealth workflows to meet those needs but hit many billing-related roadblocks due to the restrictive New York State and federal regulations.

"The largest barriers involved provider licensure requirements for the treatment of out-of-state patients and geographic restrictions on billing patients for telehealth within our own state," he added. "For that reason, we settled on piloting a self-pay, international second opinion program. The platform launched using WebEx Meetings and later migrated to Microsoft Teams."

In the year before the COVID-19 pandemic, Roswell Park Comprehensive Cancer Center expanded its platform and developed an integrated nurse triage telehealth solution pilot to prevent critical care patients from ending up in the ER.

In this use-case, a patient would call the Nurse Triage/Assessment and Treatment Center, where with the click of a button, a staff member could escalate to a video conference with a medical staff member in order to help determine next steps. The platform was developed in-house using Cisco WebEx APIs for WebRTC. From the patient's perspective, they received an email to start the visit from their browser with the click of a button.

"When the pandemic hit, this work on the platform development for triage gave us a major head start to replace some in-person visits with virtual visits in order to reduce the COVID-19 transmission risk to our patients and clinicians," Furlani explained. "However, since the previous visits were designed for more on-the-fly visit workflows, they were not tied to billing and the workflows had not been optimized for use nor integrated within our regularly scheduled visits or billing to payers."

PROPOSAL

As a next step, the organization proposed expanding the platform to integrate with its enterprise scheduling system, allowing the clinical center associates to schedule telemedicine visits that automatically appear as links on the patient schedule on their MyRoswell patient portal.

"They could use this type of scheduled visit for any visit that did not require in-person labs or hands-on care," said CTO Paul Visco. "Example visit types include results review, surgical follow-up visits and pre-surgical consults."

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MEETING THE CHALLENGE

The virtual visit technology was made available to everyone at the organization at the peak of the early pandemic. The technology makes it simple for a provider to not only speak with and assess the patient but to include any friends and family they wish, third-party providers or other staff. Having a telehealth platform also makes it a lot simpler for patients who live far away to complete follow-up visits.

"The registration staff got a bit over-zealous with ease of scheduling and began to schedule virtual visits to patients without first checking they had the patient's capability or interest in using the web or a mobile phone for a virtual visit," Visco said. "While this issue resolved itself rather quickly, it created a sense of irritation for some clinicians who went into virtual visits and not only had to handle the clinical care but tech support, which often ended in the patient who should have never been scheduled for a virtual visit in the first place, transitioning to a telephone visit."

As a response, staff started to customize the workflows of several clinical centers to standardize and build their in-person workflows into the platform. This included features that allowed for the passing of the visit between clinical care providers, allowing a nurse to complete the visit questionnaire with the patient and then pass the visit off to a physician as they would in an in-person visit.

"We built in the ability for patients to self-check-in their virtual appointments via a text message," Visco noted. "This placed them on our Allscripts Sunrise EHR tracking boards within the clinic, alerting the staff a virtual patient was ready. This integration let virtual visit workflows blend seamlessly with an in-person clinic day."

RESULTS

Metrics were critical to measure the program's success. Virtual visits information was tracked by a structured documentation section in the provider's EHR documentation.

Data collected included whether a visit was conducted via video or telephone, the platform used, the length of the visit, and the option to select the most common technical issues if unsuccessful. These data points were queried and reported on dashboards within Microsoft PowerBI.

"During the height of the pandemic, we conducted around 150 billable virtual visits a day," Visco reported. "That number has since dropped to 30 a day, mostly due to preference by patients and providers for in-person visits.

"However, for many patients who live outside our area, this technology is critical as it allows them to schedule their follow-up visits without a long drive to the hospital. It has also proved useful during the cold winter months when many local patients would prefer that a checkup visit be virtual to avoid dealing with possible bad weather."

USING FCC AWARD FUNDS

Roswell Park Comprehensive Cancer Center was awarded $600,456 by the FCC telehealth fund for network upgrades and security equipment, as well as teleconferencing software licenses, to provide virtual patient visits to continue comprehensive cancer care, including surgery, chemotherapy, immunotherapy, radiation therapy, imaging diagnostics and regular checkups, while reducing the exposure of an at-risk patient population and clinical staff.

"As our virtual visit platform rolled out and rapidly expanded we hit some infrastructure roadblocks," Furlani said. "These issues centered on our internal firewall and network hardware, degrading the performance WebRTC video. WebRTC is the technology backbone that powers most of the modern telemedicine and collaboration platforms including WebEx, Doxy.me, Doximity, Teledoc, Zoom and MS Team.

"Luckily, with the help of the FCC grant, we were able to upgrade our network hardware to accommodate the remote workers/patients increased bandwidth, as well as to provide better experience with WebRTC by reducing packets lost."

The organization also moved from requiring an app to a telehealth experience that revolved around simply getting a text message with a link and clicking on that link, all still through the portal and based on WebEx APIs.

"We also used FCC money to provide iPads and better cameras and microphones so clinicians could appear in higher quality to the patients," he concluded.

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