Telehealth, COVID-19, and a Suddenly Rearranged Future

May 20, 2020
No area of U.S. healthcare delivery and payment has been revolutionized more rapidly because of the COVID-19 pandemic than telehealth—with major implications for the future of care delivery nationwide

If there’s a single marker that speaks to what a shattering development the COVID-19 pandemic has been in the first half of 2020, it’s what’s happened in the area of telehealth in the U.S. healthcare system, transforming the landscape of care delivery within weeks.

In February, the Chicago-based American Medical Association (AMA) published the results of a comprehensive study of the area of digital health, including of the development of telehealth in U.S. patient care. That study, entitled “AMA Digital Health Research,” found that the adoption by physicians in practice of televisits and virtual visits doubled between 2016 and 2019, while the use of remote monitoring and management for improved care increased from 13 to 22 percent. Given how limited the actual adoption, healthcare system-wide, of telehealth was before February 2020, those numbers seemed noteworthy.

But then, the COVID-19 pandemic hit the United States, as well as the vast majority of countries around the world, and 22 percent was simply no longer going to cut it any longer. And as hospitals, medical groups, and health systems began shifting as much patient care to remotely based as possible, to protect everyone’s health and safety, and to minimize the use of personal protective equipment (PPE) in hospitals and medical clinics, the federal Centers for Medicare & Medicaid Services (CMS) on March 17, announced a temporary but sweeping change around the approval of and reimbursement for telehealth services for Medicare beneficiaries. Following up that policy change, which temporarily abolished most of the interstate physician and nurse licensing restrictions previously inhibiting telehealth-based care delivery, within a few weeks, huge numbers of hospitals, medical groups, and health systems had shifted vast portions of care delivery, including both routine primary care and specialist physician-patient visits, and initial triaging of patients prior to hospitalization, to tele-based formats. What’s more, CMS on that date not only opened the floodgates to telehealth-based care delivery for primary care and for triaging purposes, but also to preventive health screenings and to mental health counseling, nationwide.

Most industry observers believe now that the lifting of most licensing restrictions will inevitably be maintained, meaning that all those bureaucratic obstacles to telehealth’s expansion will finally be eliminated, hopefully for good.

Among those industry experts is Jay Backstrom, vice president and telehealth practice leader at the Naperville, Ill.-based Impact Advisors consulting firm. Backstrom says, “More has happened in the past few weeks with telehealth than in the past 20 years. And that includes the policy and reimbursement side. It’s been a real stimulation for telehealth, in an unfortunate crisis—the greatest thing to happen to telehealth, for the worst reason,” he says. “But COVID-19 will create a new normal, and telehealth will be a big part of that, going forward.”

Backstrom not only confirms the scale of the sudden transformation; he also notes its breadth. “Usually, when I talk about telehealth, most people focus on the ambulatory/outpatient side, with video visits for physician offices, clinics, and urgent care centers,” he says. “Each client was in a little bit different situation; some had already established a telehealth solution that had been adopted at a certain level, and then exponentially went up to 90 percent or more of their visits. But, he notes, much needs to be put in place, around training, support, and clinical protocols. In other words, he says, “There’s a whole lot of operationalizing that has to occur.”

Indeed, the COVID-19 pandemic has forced innovation along a number of dimensions, including on the inpatient side of care delivery, where the need to do everything possible to minimize infection, as well as to minimize the overuse of PPE, has led to pioneering work in hospitals worldwide. For example, leaders at the 1,700-bed Sheba Medical Center in Tel Aviv, Israel, have been making major advances in treating patients with COVID-19 or who might have COVID-19, leveraging a range of telehealth-capable and telehealth-related technologies to keep clinicians and hospital staff members safer, while also enhancing the patient experience.”

As Eyal Zimlichman, M.D., a practicing internal medicine specialist and the chief medical officer and chief innovation officer of the hospital, and who has helped lead the telehealth initiative, told Healthcare Innovation in late March, Sheba Medical Center clinicians and administrators have been working hard and fast to set up telehealth as a fundamental strategy for safely delivering care to patients suspected of having COVID-19 and those who have been diagnosed. They have been partnering with three Israeli vendors to develop an integrated technology platform to help launch a full telehealth-facilitated care delivery process. Among other advances at Sheba, clinician leaders have extended their innovation into the inpatient sphere and home-based care delivery and management, protecting clinicians and other patients in caring for COVID-19-positive patients who are in isolation units in the hospital, while also caring for patients with milder symptoms in their homes, messengering them packages that contain Bluetooth-enabled thermometers, pulse oximeters, and stethoscopes, and having patients share their vitals with their physicians under telecommunicated directions.

Real innovations are taking place here in the U.S., too, of course. For example, On March 24, a team of clinicians and clinician informaticists at UCSD Health in San Diego published online in the Journal of the American Medical Informatics Association (JAMIA) an important paper on their organization’s response to the COVID-19 crisis, entitled “Rapid Response to COVID-19: Health Informatics Support for Outbreak Management in an Academic Health System.” As the article’s nine authors, all of them practicing physicians associated with the UCSD Health system noted, a key element in their innovation has been this one: “An Incident Command Center was established at UCSDH on Feb. 5, 2020 for 24-hour monitoring and adaptation to rapidly evolving conditions and recommendations on a local, state, federal, and global scale. An assessment of the institutional current state revealed the need to develop a rapid screening process, hospital-based and ambulatory testing, new orders with clinical decision support, reporting/analytics tools, and the enhancement/expansion of current patient-facing technology.” The result? “With the guidance of the Incident Command Center, our clinical informatics team prioritized projects related to COVID-19 to enable expedited build and implementation. In response to the pandemic, we configured our EHR” with a variety of technology-based tools, providing practicing physicians with EHR-embedded clinical decision support, as well as EHR-embedded information on resource use (including beds occupied in the system, ICU beds occupied, etc.).

Once the COVID-19 crisis has passed, the leaders of hospitals and health systems will need to quickly put in place greater security for all these systems, particularly for remote-based clinicians and other health system staffers, notes David Finn, executive vice president of strategic innovation at the Austin, Texas-based CynergisTek consulting firm. “There are some really huge privacy and security concerns right now. We know there will be HIPAA waivers for certain requirements around the hospital response; and we have to do that. Care will always trump privacy and security, and that’s appropriate. But as we make that shift and realize that telehealth can be effective, we have to figure out how to do this right.”

Moving forward into the near future, Impact Advisors’ Backstrom says, “I see three stages here. Stage one is crisis management. Stage two is recovery and resilience; once we’re out of the crisis, there will be six to nine months in which an organization can take a breath, and assess its overall situation—not just telehealth, but business issues around having had to postpone elective surgeries, for example. And that will be a time when you’ll be standardizing telehealth platforms, and enhancing them for the future. And in that stage, because you’ve rolled out so many solutions, maybe even remote monitoring, you’ll need a platform that tracks usage, performance, even clinical quality and operational metrics, and patient wait times, and you won’t want to have to go to the five or ten vendors you’ve been using; you’ll need a central analytics tool. And the last stage will be the new normal after you’ve recovered and hardened your platforms. And that will require an integrated delivery platform. Maybe telehealth won’t even exist any longer as a concept,” he says; “it will just be absorbed into overall healthcare delivery.” 

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