As patient care organizations of all types continue the process of reopening for in-person treatment that may have been postponed due to the public health emergency, health system leaders have a great challenge of preparing for this resurgence of patients who previously delayed care due to the pandemic, along with meeting the needs of COVID-19 patients.
There have been a variety of logistical and technological elements to consider for leaders at Lucile Packard Children’s Hospital Stanford, part of Stanford University Health system and the heart of Stanford Children’s Health, as they reopen for all children and their families. In a recent interview with Managing Editor Rajiv Leventhal, Natalie Pageler, M.D., chief medical information officer (CMIO) at Stanford Children’s Health, who also works in the pediatric intensive care unit, weighed in on these issues while discussing the organization’s digital health progress during the crisis. Below are excerpts of that discussion.
This virus hasn’t spared any age group, but the data shows that children are not as likely to contract it. What’s been Stanford Children’s Health’s experience in how COVID-19 has impacted pediatrics?
We have been relatively lucky in pediatrics that children have not been as affected, but of course, as part of our community, we have taken all the same precautions to ensure the safety of all our children, especially our high-risk children, and their families. So with the shelter-in-place guidance from our county and state, we followed all the appropriate procedures to protect our patients and families, [while] moving to digital health as much as possible. And we’ve seen a dramatic increase in telehealth utilization and the growth of our digital health program.
For children, there isn’t a whole lot that can be considered under the “elective” bucket, yet some procedures still were considered non-essential, per the state mandate. How did that play itself out at Stanford Children’s Health?
We were very thoughtful in the steps we took to protect our patients and families, both in enacting protocols to keep people safe, evaluating which procedures could be delayed safely, and recommending that those be delayed. But in pediatrics there aren’t a whole lot of procedures which are truly elective.
In the ambulatory setting, where there were more visits that could be delayed or converted to telehealth, we did see active conversions to telehealth that were appropriate. For some of our patients and families, there was concern about coming to the hospital, and sometimes inappropriate delays in seeking care, so we have really been trying to do a lot of education and communication about our protocols to keep everyone safe [as well as] keep up with necessary care as appropriate.
To your point on the virtual visit surge, tell me about your organization’s experience in pivoting to telehealth as a response to the pandemic?
We had done a lot of work in building out our telehealth platforms and in promoting our digital health programs prior to the pandemic, which served us well and let us ramp-up quickly. Prior to the pandemic, we were seeing approximately 20 telehealth visits per day in the ambulatory setting. When the shelter-in-place orders came out, we rapidly saw those numbers grow, and within a matter of weeks we were up to 700 to 800 telehealth visits per day.
What’s even more exciting now is that as we [have been] trying to reactivate and getting patients and families back in the clinics for in-person visits when appropriate, we’re still seeing the same number of telehealth visits—about 800 a day consistently, even as our in-person visits continue to grow. We are seeing [such an increase] in awareness of the capabilities of telehealth and digital health, and we’re seeing so many lessons learned from the provider perspective, as well as the patient/family perspective about the value of telehealth visits and the type of care that can be delivered via telehealth.
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. There are so many stories of both patients and providers who have discovered unknown value in telehealth, and in many cases telehealth may be the more optimal method of delivering care. We have had cases where our developmental and behavioral pediatricians are seeing children in their home environment and are getting much more information about their development in their natural environment compared with the clinic setting. It’s actually gotten to the point in which our division chief for developmental and behavioral pediatrics has said that going forward, [the at-home assessments] will be a standard part of these evaluations.
Additionally, we have had some of our sleep doctors do telehealth visits, watching the child asleep in his or her home and be able to do an evaluation of how that child sleeps, so they are then able to give a lot more information than just talking about it. We [are hearing] similar stories for occupational therapists who see children eating at home in their kitchen. There are just so many instances of discoveries showing telehealth can actually be a better way of delivering care.
What was required from an infrastructure perspective to make this telehealth shift successful?
There are different aspects of supporting a digital health program and the technology is definitely one piece of it. The programmatic infrastructure is probably even more important. We have developed our program, and had the right pieces in place when the pandemic hit, [allowing] us to ramp-up quickly. We do have an EHR-integrated solution [the video isn’t stored in the medical record, but all details about scheduling the visit, checking in, and the appointment itself are] which makes for a more efficient experience for patients and providers.
But we also learned a lot about our technology as we had to significantly ramp-up, and realized there is new functionality that we needed to deploy. One that came up very quickly was the need for multi-party telehealth. In an academic organization like ours, you may have an attending physician in one location, a trainee in another location, and the patient and family in a third location. You may need to bring an interpreter into the visit, or you may even have two parents in different locations and need to have multi-party [ability]. That’s functionality we have been developing very quickly. Additionally, things like being able to share screens or capture images of the visit, or share documents, are all things coming out as necessary technologies to really support the most effective telehealth.
As far as the programmatic aspects, we had the basic infrastructure for technology in place, but we also quickly realized that the nature of the pandemic [made us] refocus our energy. So for example, we redeployed a large portion—more than 50 staff in our IS department—to supporting our digital health program. They set up a patient support model and called all the patients before their telehealth visit to make sure they knew how to [use the platform], and that they had the right app downloaded. 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.
Over the past few months, the government has loosened several restrictions around telehealth licensing, while also increasing reimbursement for providers. What’s your view on how this will play out going forward?
There are many relaxations of regulations that have been incredibly helpful, and I think we need to continue our advocacy to keep those. For example, the relaxation of interstate licensing was huge, especially for a quaternary children’s hospital like ours where we do see patients from all over country and the world for some of our sub-specialty care. The ability to be able to meet those patients’ needs’ wherever they are, especially if they can’t travel to us in the pandemic, was incredibly important and will remain so for providing the optimal virtual care going forward. 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. We are advocating for those state licensing restrictions that have been loosened up to remain. For pediatric care especially, specialists could be few and far between.
In terms of reimbursement, on the pediatric side we have been fortunate, even before COVID, as we work more for Medicaid than Medicare, and we had been seeing fairly good reimbursement [dollars]. Reimbursement is critical; we have shown we can provide very good care, and in some cases, better care via telehealth than in-person, so we should continue to be reimbursed at full rate. I think it will be a mix; some pieces I definitely would encourage that these changes [remain intact], but it remains to be seen which will stick and which won’t.
