How do you go from conducting 70,000 telehealth visits per year to 70,000 per week? Even health systems that had already created robust telehealth programs have had to scramble to meet demand to deal with the pandemic. On May 5, two leaders of such efforts, Todd Czartoski, M.D., of Providence St. Joseph Health and Judd Hollander, M.D., of Jefferson Health, shed light on how their organizations made the transition.
The two physician leaders spoke during a webinar sponsored by the Patient Centered Outcomes Research Institute (PCORI). Czartoski, chief medical technology officer and chief executive of telehealth at 51-hospital Providence St. Joseph Health headquartered in Renton, Wash., noted that telehealth volumes have grown year over year, doubling or tripling. “We were impressed with ourselves. At the end of 2019, we had done 70,000 visits for the year,” he said.
But all of a sudden, with the COVID-19 spike, Providence St. Joseph had to ramp up to handle 70,000 telehealth visits per week. Most of the demand has come from clinics, which was one area where they had done the least telehealth, due to the lack of alignment and incentives around reimbursement. That changed when CMS lifted certain restrictions. “One March 24, we turned on over 7,000 providers at once,” Czartoski recalled. It was the only way they could reach the patient panels they care for. Making that happen involved taking three to five years of work and condensing it into two weeks.”
“I have been in the telehealth space for 12 years and devoted time to convince doctors this is the right thing to do,” Czartoski said. It has been a tough sell with the clinicians historically, he noted, but when the clinics shut down due to the pandemic, it has been a powerful force to convert people. “It has been like pushing this large boulder up a steep hill. All of a sudden it turned into a snowball coming down the hill, taking me and my team with it.”
One key to success, he said, was building a chatbot in partnership with Microsoft to educate and triage the population to screen the worried well from those who needed to go to the emergency room or see a provider via a virtual platform or be referred to drive-through testing clinics.
They set up a “train the trainer” model to get 800 clinics up and running in one week. They developed a playbook and distributed it at the clinic level to help providers with a central team of experts to guide them. Because they are an Epic shop, they tried to do everything through the EHR and the patient accesses it through the MyChart portal.
Providence St. Joseph also ramped up tele-triage for walk-in clinics and EDs to use less PPE, because they were experiencing shortages. They also increased their home monitoring program for COVID-positive patients, giving them a pulse oximeter and thermometer and having nurses and ICU physicians monitor symptoms, oxygen saturation and heart rate.
Looking ahead, Czartoski said there should be research done on the health outcome impact of the ramp-up in virtual visits, noting that telehealth as a field has not done a great job of being rigorous around documenting its efficacy and safety. “That is the opportunity in front of us now,” he said. “As we are transitioning to a mode where we are doing 10,000 visits per day, we need to measure patient-reported outcomes, physical outcomes and financial outcomes or else it will increase the chances that healthcare will roll back to the way it was. There is an opportunity to disrupt how care is delivered and have this become the norm. Telehealth will not replace in person visits, but we have moved the needle so far, we should keep it that way as much as possible.”
Sudden Expansion at Jefferson
Hollander, senior vice president for healthcare delivery innovation, at Thomas Jefferson University, and associate dean for strategic health initiatives at the Sidney Kimmel Medical College in Philadelphia, said the experience at 14-hospital Jefferson Health has been very similar to that of Providence St. Joseph. It also had a robust telehealth program called JeffConnect that it had to prepare for a 20-fold increase in volume in one 24-hour period.
“We have built telehealth programs across the care continuum, but we had to take our three-year plan and in 48 hours morph it for the COVID response,” Hollander said. To meet the increased demand, they brought in providers from other parts of the health system and trained several hundred people using web-based training modules. They added 160 new people handling their on-demand platform.
“We geared up to make use of quarantined physicians,” Hollander added. Jefferosn decided when people were under investigation or COVID-positive but still feeling OK, they could work from home in the on-demand platform. “It keeps them engaged and they can still take care of patients,” he said.
Jefferson integrated the on-demand platform with COVID test ordering and coordinated with testing sites near the patient’s home to make sure the results were shared in a closed-loop fashion.
Like Providence St. Joseph, Hollander said it wasn’t always easy to get ambulatory providers interested in telehealth before the pandemic. “We held 200 training classes in February and very few wanted to be trained,” he said, but in March hundreds wanted to be trained overnight. “We got them all up and running in three days,” he added.
Also like Providence St. Joseph, Jefferson created a chatbot to keep low-risk people off the JeffConnect platform. They also set up “tele-intake” across emergency departments so that people coming to the ED are seen by remote provider within nine minutes of arrival on average.
Jefferson had used a small cadre of five telehealth coordinators to do pre-visit check-ins with patients to make sure the patients were comfortable using the technology and to help increase the number who actually show up for telehealth appointments.
“It is pathetic that we need to do that,” Hollander said. The telehealth platforms should be intuitive enough to use that it shouldn’t be necessary, he believes.
As the telehealth volume skyrocketed, the five coordinators could no longer handle all that work, so they converted those five to a knowledge center for the hundreds of practices across the enterprise to help the office staff and nurse practitioners do those pre-visit reach-outs.
“We worked with our vendor to reconstruct the product to simplify for this volume of patients since we didn’t have support to take providers through the whole process. So it was really a massive rapid revamping of the way we provided support,” Hollander explained. “We revamped our internal structures, which is an iterative process over and over for improvements into two daily meetings to figure out what are the biggest issues and work with the technology in our own IT department and our partners that make the products externally to relieve the pressure points for patients and providers. It has dramatically improved the experience over time in a manner that is much faster than we would have gotten to otherwise.”
Asked whether the relaxation of certain rules by CMS has helped, Hollander said “the rules served to provide job security for people who need to try to figure them out. These were well-intentioned but created so much confusion it is unbelievable.”
The federal relaxation of guidelines effectively says the OIG won’t prosecute you if you violate these things, but they also relaxed federal guidelines that the feds don’t have any control over, Hollander said. Medical practices are regulated at the level of the states. Most states have telemedicine regulations about what you need to do. It might include items such as security issues and making sure the provider is licensed in the state where the patient is, and it might also include informed consent you obtain telling the patient this is a video visit, and it is not the same as an in-person visit, he added. It might even require things that are platform-specific such as an audit trail to know that if you are going to bill the state Medicaid payer, that it was telemedicine rather than telephone. “So the feds could say they are relaxing these things, but it doesn’t mean the state is. There are a lot of really easy-to-use platforms out there that don’t meet state regulations in most, if not all, states. But they are so easy to use that all the providers want to use them. It has been really difficult to make sure we are able to focus the providers who are new to telemedicine on using the platforms that met criteria to be a real telemedicine platform before COIVD, meet it during COVID, and will meet it after COVID, because the worst-case scenario is having a patient use platform A to see their neurologist, platform B to see their primary care doctor, and and platform C to do their on-demand care. Keeping the approach standardized and consistent with state and federal policy during normal times has been really challenging, and the confusing way the federal guidance has come out has made that torture, to be honest.”
