Not even the biggest supporters of telehealth could have seen this coming. For years, stakeholders have been touting the promise of telehealth, as a supplement to in-person physician visits, as a key component of transforming healthcare delivery. The option has been seen as even more appealing for patients living in rural areas and miles away from a primary care doctor or specialist.
But despite the persistent buzz around virtual care, on the ground, usage rates remained low going into 2020, demonstrating that potential wasn’t meeting reality. A 2019 survey from a telehealth provider, American Well, found that just 23 percent of physicians said last year they had used telehealth to see patients. While this was an increase from the 5 percent of physician telehealth users in the company’s previous survey from 2015, research has shown that core barriers were preventing greater adoption, such as uncertainty around reimbursement, questions about clinical appropriateness, lack of physician buy-in, and poor leadership support. Other data has shown that patient awareness of telehealth has been quite low; a 2019 survey from marketing services company J.D. Power revealed that nearly three-fourths of Americans said they either didn’t have access or were unaware of telehealth options.
And then just like that, in a blink of an eye, everything changed as the COVID-19 pandemic put the spotlight on virtual care in unprecedented ways. With patient care organizations being forced to shut down many in-person services, providers across the U.S. quickly turned to telehealth to fill that care delivery gap, when appropriate.
Over the past several weeks, Healthcare Innovation has heard from several healthcare organizations that have shifted their telehealth services into hyperdrive. Some of those recounted stories from health system leaders include:
- At MedStar Health, based in the Baltimore–Washington metropolitan area, in the month of February, the organization conducted just 240 telehealth visits, an average of eight visits per day. These virtual sessions were mostly for urgent care rather than scheduled visits, of which there were usually only two or three per week, recalls Ethan Booker, M.D., medical director of the MedStar Telehealth Innovation Center and MedStar eVisit. Then, from March 23 to April 22, MedStar performed 50,000 telehealth sessions. On average, weekday outpatient telehealth visits reached 3,626 visits during the week of April 12, signifying more than 500 percent growth when combined with MedStar eVisit urgent care telehealth volumes.
- For Lucile Packard Children’s Hospital Stanford, prior to the pandemic, the organization was conducting approximately 20 telehealth visits per day in the ambulatory setting. When the shelter-in-place orders came out, those numbers began to grow, and within a matter of weeks the health system was up to 700 to 800 telehealth visits per day, recounts Natalie Pageler, M.D., chief medical information officer (CMIO) at Stanford Children’s Health. Even more exciting, she says, as the organization was reopening for in-person visits in May, it still was doing the same number of telehealth visits—about 800 a day consistently, even as in-person visits continued to grow.
- Thomas Jefferson University in Philadelphia has had a robust telehealth program for the last five years, and in the summer of 2019, its leaders celebrated hitting the 100,000 virtual visit milestone. Now, says Judd Hollander, M.D., the organization’s senior vice president for healthcare delivery innovation, the health system is reaching that 100,000 visit number every five or six weeks.
- CareMount Medical, the largest independent multispecialty medical group in New York State, was only doing about 25 telehealth visits a day—out of some 6,000 total visits—leading up to the pandemic. But at the height of COVID-19, says Scott Hayworth, M.D., the organization’s president and CEO, providers were conducting 1,500 virtual visits each day.
Undoubtedly, as internal health system data continues to come out, it’s become evident that for many, the surge in telehealth visits has been beyond anyone’s expectations. In mid-June, the College of Healthcare Information Management Executives (CHIME), one of the industry’s leading associations, went as far as attesting that “Telehealth has been a resounding success…” The group pointed to data it recently gathered from a few hundred healthcare organizations, noting that prior to the pandemic, 73 percent had conducted less than 25 virtual visits per day. Once the epidemic began, 84 percent of organizations were conducting more than 50 visits per day and a full one-third of those were scheduling over 250 visits per day.
Those healthcare stakeholders who have been touting telehealth are not declaring victory just yet, however, and realize that these enormous surges are a direct result of the epidemic. Key questions do remain, such as if the massive usage increases have staying power, and if government-granted flexibilities that have expanded access to telehealth in the face of COVID-19 will be removed as in-person visits get back on track.
Core lessons learned
In the meantime, leaders interviewed for this piece point out a plethora of valuable lessons they have learned throughout this journey. For most health systems, these experiences will be seen as evidence that substantial IT infrastructure undertakings can be accelerated when needed, assuming that a collaborative culture is in place.
MedStar Health had been using telehealth services vendor Bluestream Health to perform its virtual visits, and began to pivot from a business-to-business deployment use-case to a direct-to-consumer strategy that was jumpstarted by the pandemic, Booker says. Previously, as he explains it, MedStar used the Bluestream platform that enabled attending physicians in a command center to provide remote triage to eligible patients in the emergency department via video.
As a health system, MedStar had done about 80,000 virtual visits using this B2B approach, so even though they were transitioning to a direct-to-consumer model to meet the demands created by COVID-19, Booker says having the infrastructure already in place from an onboarding, provisioning, and security standpoint was a big help. In late February, when conversations among MedStar leaders on how COVID-19 would impact care delivery began to ramp-up, Booker’s team was able to fall back on the several telehealth use cases already established via the Bluestream platform as opposed to needing to reinvent the wheel. “Rather than trying to rebuild infrastructure from the ground up to respond to the new digital reality, we used the infrastructure that existed already and pieced it together in ways that made a lot of sense,” he says.
Meanwhile, on one early March day in Georgia, clinical and IT leaders at Augusta University (AU) Health, an academic health center that manages the clinical operations associated with Augusta University, began to realize that things were about to change very quickly. The patient care organization, which includes a 478-bed adult care facility and a 154-bed children’s hospital, was set to roll out a direct-to-consumer telehealth platform in partnership with Amwell later that month. But then as the COVID-19 outbreak began hitting the region during the first week of March, the health system decided that it needed to pivot, turning the platform into a COVID-19 virtual screening tool.
In just a matter of days, that conversion was complete, and the process included a number of key details, such as changing marketing tactics, changing the tool’s intake questions that aligned with CDC and Georgia Department of Public Health (DPH) COVID-19 guidelines, as well as training ED faculty and residents over a course of just two days, explains Lauren Williams, the director of population health at AU Health. In just a week, AU Health conducted more than 1,500 virtual care screenings throughout the Augusta region. What’s more, Williams reports there are now more than 35 ambulatory clinics live on the Amwell telehealth platform, with over 400 providers using it. “We have done 8,000 telehealth visits for ambulatory care since March 23. That compares to less than 100 ambulatory telehealth visits a month before [COVID-19],” she attests.
Stanford Children’s Pageler emphasizes that there are many different aspects of supporting a digital health program and the technology is definitely one piece of it. However, the programmatic infrastructure is even more important than the technological element, she contends, adding that the health system had been evolving its digital health portfolio and had the right pieces in place when the pandemic hit, allowing for a quick ramp-up. Pageler notes that Stanford Children’s does have an EHR-integrated solution, though the video isn’t stored in the medical record, but all details about scheduling the visit, checking in, and the appointment itself are facilitating a more efficient experience for patients and providers, she says.
The organization also redeployed a large portion—more than 50 staff in its IS department—to supporting its digital health program. A patient support model was set up and those staff members called all patients before their telehealth visit to make sure they knew how to use the platform, and that they had the right app downloaded, Pageler recalls. “We also had a provider support model and an-in home technology check support model to check with those providers working from home. We had our training team take over all the development of training tools for both patients and families. That quick redeployment of human resources enabled us to provide the support necessary to ramp-up a program like this.”
According to Ann Mond Johnson, CEO of the Arlington, Va.-based American Telemedicine Association (ATA), one of the biggest infrastructure issues that the ATA is hearing from its members is ensuring that patient data goes in the right direction. Many organizations are working to make sure that it becomes easier to get telehealth visit data accurately and efficiently into the patient’s health record, notes Mond Johnson. Another challenge, from a workflow perspective, she says, is confusion around coding. “In one city you may have two or three different payers coding a well-child visit differently. Those sort of things can stymie [progress], making it less fluid than it [should be] from a workflow perspective,” she says.
Will the interest stick?
The leaders interviewed in this piece fully acknowledge that it would be next to impossible to keep up these levels of telehealth usage rates, since for many health issues, offering virtual care services was the only option during the height of the pandemic. Even at Stanford Children’s Health, where telehealth visit volume remained consistently high as in-person appointments ramped back up, Pageler admits that “Time will tell what the future holds, and I expect some drop in the telehealth numbers as we go forward, but clearly, we won’t return to the baseline we were at before the pandemic.”
But the plan was never to have telehealth visits outgrow in-person ones anyway, as there are clearly certain scenarios in which patients need to physically see their doctors, contends ATA’s Mond Johnson. “I don’t see the telehealth sector combatting people wanting to go back to the physician’s office. There are clearly situations where people to want to be seen in person, and we would be the first to support that. But we are saying there are lots of different ways to access services, and that telehealth is valuable for more than just [the common] cold and sniffles; it has much broader expansion,” Mond Johnson contends. She notes that before COVID-19, physician and consumer adoption rates were around 15 to 20 percent, with those numbers surging up to 80 to 90 percent at the height of the pandemic. “I think it’s safe to say the [percentage] going forward will be somewhere in between, as we learn how technology can be used to reimagine care,” she says.
Indeed, as organizations continue to reopen for previously withheld non-essential services, folks point out that the most likely near-term scenario will be hybrid-type ecosystem that integrates telehealth into physicians’ regular workflows where in-person care is also provided. The more critical question, experts ask, is if the telehealth restrictions that have been loosened by the federal government in response to COVID-19—mainly related to lifting payment restrictions on virtual care and easing licensing barriers—will fade away once the pandemic does the same.
Providers, as one might expect, are largely in favor of keeping many of these telehealth policies permanent, especially in the near-term when virtual visits will still be incredibly important as patient care facilities—even after reopening—will need to limit the number of people in their buildings as long as COVID-19 remains a threat.
For Stanford Children’s, the relaxation of interstate licensing was “huge”—it was previously difficult for providers to practice across state lines—”especially for a quaternary children’s hospital like ours where we do see patients from all over the country and the world for some of our sub-specialty care,” explains Pageler. She adds that “We are unfortunately already seeing some of those state licensing requirements tighten back up, and of course it’s very individual from state-to-state, which makes it more challenging to keep track of.”
During an early June virtual event, Seema Verma, Centers for Medicare & Medicaid Services (CMS) Administrator, remarked that expanded access to telemedicine should continue after the pandemic wanes, and that federal officials are examining ways to act without waiting for legislation from Congress. “I can’t imagine going back,” Verma told the news publication STAT, a statement that made headlines across the industry.
In a recent KPMG analysis of the situation, the firm’s analysts noted that CMS has authority to make incremental telehealth requirement changes through further regulatory action (e.g., permitting audio-only technology or certain “face-to-face” requirements to be fulfilled via telehealth) and is being encouraged to extend them; however, more significant, permanent changes to the conditions for telehealth reimbursement (geographic, originating site, eligible practitioner, and other requirements for providing certain services in-person) will require Congressional action to amend the Social Security Act.
The ATA is one group urging lawmakers to make sure these changes don’t revert back to their pre-pandemic days. Mond Johnson says the association is in the process of identifying which policies ought to remain permanent. “Our view on the waivers is quite frankly that regulation has finally caught up with what technology has been able to do for quite some time,” she says. One core area of focus for the ATA will be removing geographic restrictions on payment for virtual care services rendered. The geographic limitation imposed by Medicare’s originating site requirement—that the originating site be outside of a major metropolitan area—has been a major barrier, and Mond Johnson notes that her team will be working hard at keeping that restriction off the table.
During a recent webinar presentation, John League, a senior consultant at Advisory Board, had a less optimistic view, predicting that the only provision that he’s confident will remain after the emergency is over is patients accessing telehealth visits from home. “The extension of eligibility for telehealth visits being extended to providers in nursing homes, etc., should probably stay. But I think the other provisions will be rolled back,” he stated, noting that a key issue being the lack of security of the platforms, such as Skype.
Of course, keeping the polices intact will require regulatory change, so in the short-term, stakeholders would be well-advised to collect data emphasizing the value of telehealth visits. MedStar’s Booker says that providers and vendors ought to take this opportunity to collect “really good data about the quality, safety, cost and benefits” of telehealth, which would then bring solidified information to the table for when stakeholders meet with CMS, payers and regulators about what should happen after the crisis winds down.” He acknowledges there’s a real possibility that some guardrails will go back up, “and it’s incumbent on us who have been doing this work to collect the data and be thoughtful about which [elements] do go back in place.” To this point, in the Advisory Board webinar, League cited data that Blue Cross Blue Shield of Massachusetts saw a 3,500 percent increase in telehealth claims between February and March 2020.
In the context of proving that a good portion of healthcare delivery could be virtualized, a recent report from consulting firm McKinsey & Company predicts that the telehealth market could grow to $250 billion. Of the $250 billion—or 20 percent of all Medicare, Medicaid, and commercial outpatient, office and home health spend—that could potentially be virtualized, the analysts further broke it down by healthcare delivery segment. They believe that 35 percent of home health services could move to virtual, as could 24 percent of office visits/outpatient encounters, with another 9 percent moved to “near virtual,” as well as 20 percent of ED visits that can be diverted to virtual.
In the end, many of the leaders interviewed for this piece firmly believe that the proverbial “genie is out of the bottle,” in regard to telehealth, and it won’t be going back in anytime soon, as CMS Administrator Verma stated. As Peter Pronovost, M.D., chief clinical transformation officer at the Cleveland-based University Hospitals (UH), puts it, “We galvanized around a common purpose—in this case defeating a vicious virus—and the visibility of harm led to an urgency we have never seen before. In telemedicine, we matured more in a month than we did in 10 years.”
