There is no doubt the COVID-19 pandemic resulted in the modernization of the “house call.” In a matter of weeks, healthcare providers around the world found creative ways to provide quality care to patients in a safe, completely distanced way. Yet, delivering telehealth services isn’t as simple as signing into a smartphone or tablet for a virtual visit.
That was made clear in late 2020 when Zebra’s Chief Nursing Informatics Officer (CNIO), Rikki Jennings, and Zebra’s global healthcare practice lead, Chris Sullivan, hosted a customer advisory board (CAB) discussion to share best practices around pressing issues in the healthcare community. With the pandemic reaching new peak levels in many regions of the world, doctors, nurses, IT leaders and hospital administrators were most focused on how they could adapt their practices to address both acute and non-acute issues without compromising patient or provider safety.
Below is a summary of the stories and insights they shared, as conveyed by Chris and Rikki to our team:
Your Edge Blog Team: Though telehealth isn’t a new concept, it wasn’t widely utilized prior to the pandemic was it?
Chris: Not really. Even though some providers may have offered telehealth consults via Nurse Advice Lines or for appointment follow ups, 2020 was really the year that virtual health took off. In fact, one of the physicians on our CAB told us that when her division’s Chief Information Officer (CIO) was brought on in late 2019, the plan was to wait about two years before proposing a widespread telehealth program. She thought it would be too much to bring on all at once. Then COVID-19 hit a couple months later and she said “we’ll put this in place in two weeks.”
Your Edge Blog Team: Was there a certain subset of the healthcare community that adopted telehealth faster than others?
Rikki: We saw both clinics and hospitals move pretty quickly toward telehealth as nearly everyone had to reduce capacity per local regulations or experienced an increased number of patients cancelling appointments for fear of exposure to the virus. Even specialty providers and surgeons sought new ways to “see” patients without requiring in-person visits.
Continuity of care is so critical to those suffering from chronic conditions and imperative to the prevention of missed diagnoses for diseases that could be controlled or cured if caught early. Yet, nearly a third of Americans delayed healthcare in 2020, especially in the first few months of the pandemic, and that number grew to 50% among seniors. Even emergency departments saw their patient volumes sharply decline, upwards of 60% in some areas. This was a strong call to action to acute and non-acute providers alike to introduce – or expand – remote care capabilities, even for emergency situations. At a minimum, telehealth could be used by a nurse to triage a patient to determine whether or not he or she absolutely has to come in for diagnostics and confirm if further intervention is needed by a physician. It really became a case prioritization tool in addition to an infection control mechanism.
Your Edge Blog Team: Was it fairly easy for the healthcare community to scale telehealth services when demand started to grow?
Chris: Not necessarily. Even within clinics and hospitals that had some telehealth infrastructure available, it became apparent that gaps existed once appointment volumes increased. For example, a CNIO for one of the largest healthcare systems in the U.S. said that, prior to COVID-19, they offered some telehealth services but didn’t see much uptake. Once the pandemic started restricting in-person appointments, they saw close to a 3000% increase in this care delivery format, with the “visits” increasingly being conducted via video. Other CAB members reported telehealth visits up 10,000% from their baselines at one point. But that type of rapid onboarding brings new challenges from a technology and staffing perspective.
Rikki: Many of our CAB members agreed that it has been a learning process, and it was interesting to hear just how much of a leadership role that informatics professionals took in this effort. Many telehealth projects had been planned or in-flight already, so not everyone was starting from scratch. But you have to understand that these types of implementations normally take months. Everything had to happen in a matter of days or weeks. In addition to getting the technology infrastructure in place, which was a challenge in and of itself, they had to open and staff new call centers just to manage the volume of patients. And those who had to set up and support a “hospital in the home” model faced even more obstacles. They had to discharge patients early to create extra capacity for COVID-19 patients and then get physicians in a position where they could conduct virtual rounds.
On top of that, they were trying to implement telehealth within the four walls of the hospital to reduce the number of people who were going in and out of COVID-19 patient rooms. In some cases, nurses were actually managing the inpatient critical care units while the intensivists stayed in virtual command centers.
Your Edge Blog Team: Patient “screening” really took on a whole new meaning, didn’t it?
Rikki: Absolutely. It’s remarkable what’s possible with technology these days.
Your Edge Blog Team: Speaking of technology, there's a perception that as long as you have some sort of voice and/or video-enabled device available to both parties, you can provide telehealth services. Is that true?
Chris: Everyone wishes it were that simple. The reality is that not all communications technologies are conducive to telehealth. Plus, there is much more to virtual care than just the technology component.
First off, it’s not easy to diagnose certain conditions by a visual assessment of a patient – and that’s assuming you’re conducting appointments via video and not just the telephone. Though we’re seeing progress being made in remote diagnostic capabilities with tools like echo stethoscopes and vital monitors that can be sent to patients’ homes, those are more for chronic condition monitoring and won’t necessarily help with diagnosing acute issues for other patients or even addressing new symptom onset for non-acute patients.
Secondly, you really have to have the right demeanor to connect with patients in this manner. You have to ensure the patient feels the same level of engagement on the screen or over the phone as they would receive if they were in the clinic or hospital. It’s the typical customer service consideration. If someone tries telehealth and they weren’t satisfied with the experience or outcome, they may not try it again – and that can contribute to the continued drop off in patient visits, which is a problem.
Of course, none of these things matter if the quality of the technological connection is poor or people don’t have access to the right devices to begin with. Although telehealth is becoming the norm for many people, some are still struggling to be seen by their healthcare providers. There are quite a number of factors that can decrease one’s accessibility to telehealth services even in our digital era.
Rikki: Exactly. It’s hard to believe in this day in age, but not everyone has a smartphone – or a cell phone, for that matter. Even fewer have tablets, laptops, or other video-enabled devices. Surprisingly, one of our CAB members was telling us that it was difficult for her hospitals, especially the ambulatory divisions, to find webcams and other hardware needed to set up virtual care consults when COVID-19 first hit. They didn’t need cameras for this type of scenario before, so they were trying to stock up just like everyone else. Online e-commerce sites were out of stock and brick-and-mortar retail stores were closed. So, they were restricted to phone conversations only for a bit. This goes to show that the definition of “telehealth” is widely varied depending on one’s circumstances and resources.
Even if you have the right devices on hand, you have to worry about the reliability of the wireless connection. This can be a problem on both the provider and patient sides. Many people don’t have Wi-Fi or even internet access, and not all clinics have the bandwidth to support frequent or simultaneous video chats. Hospitals are also notorious for their dead zones due to the density of the walls and the mechanisms used to protect some of the equipment in those facilities. Of course, a weak wireless signal can disrupt phone conversations as well, making for a frustrating experience for both parties. The last thing anyone needs is for critical information to be lost in translation – or lost completely.
Chris: Plus, as one of our CAB members pointed out, you can’t just send a patient a link and assume they’ll know what to do. This applies to clinicians too. You have to completely re-engineer your workflows and your communications strategy to ensure everyone was educated on the process and supported throughout.
Your Edge Blog Team: Does telehealth pose any data security or patient privacy risks?
Chris: Let me address security first. Some of our CAB members reported that private practices were using FaceTime and other more consumer-type apps to communicate with patients early on. But they required patient waivers because of the risks of using such an open platform. Others opted to go through Doxy.me, which is HIPAA-compliant telemedicine software, or something similar. Of course, we always remind our customers – even in situations like this – how critical it is to prioritize security and safety. Even if you’re using clinical smartphones or tablets like the ones Zebra offers, which all have enterprise-grade security tools built in, you just don’t know how secure the patient’s device or network may be. That’s why your software or app selection is just as important. Telehealth demands a multi-layer approach to security and privacy.
From a privacy perspective, many healthcare systems are trying to figure out how to get into a patient's home without becoming intrusive. They’re looking at how they can effectively monitor a patient’s vitals, trigger an alert when one’s blood pressure is too high or a medication is no longer controlling the patient’s cholesterol, and then automatically prompt a video visit with a provider to address that issue. The technologists are working collaboratively with clinicians and even patients to work through the system design, rules of engagement and more.
Your Edge Blog Team: Are there any cost hinderances to either delivering or accessing telehealth?
Chris: There could be, and the issue is really two-fold. The cost of the infrastructure and resources needed to set up and maintain telehealth services may exceed the budget of both private practices and public health clinics. Then there’s the cost of the visit. Not all insurance companies cover telehealth visits as a “standard” visit, so patients may incur high co-pays or be denied insurance reimbursement completely.
Your Edge Blog Team: Are healthcare leaders reporting progress in resolving these issues?
Chris: Well, from a technological perspective, companies like Zebra are working with healthcare providers to scale and strengthen their systems. We’re making sure they’re buying the right mobile devices, making the right integrations with healthcare information systems, strengthening their wireless network architectures, implementing stronger security, and more. We’re also helping them implement software solutions that can improve workforce planning so that staff doesn’t get burned out pulling double duty with in-person and telehealth services. But what we can’t control is patient access to technology, unless the healthcare system decides to provide the devices to consumers – in which case we are essentially working with them to extend their solution to the field, into people’s homes.
Rikki: I know there’s a lot of effort being made from a policy perspective as well to better fund telehealth services and ensure that patient privacy is protected.
In time, we should start to see some of these issues be resolved as it becomes clear that telehealth isn’t just a “temporary fix” for the challenges posed by the pandemic. With an increasing number of patients and practitioners successfully engaging from a distance, some expect to see telehealth become a more standard form of care for many.
Your Edge Blog Team: Are there also some mental health benefits to video-based visits?
Rikki: For sure. The “face-to-face” component is so important right now for everyone. Plus, it’s amazing what providers can deduce about a patient’s current physical, emotional and mental state when they can see them. They can pick up on subtleties that may help improve the quality of care, which also impacts one’s mental health.
Chris: Something else to remember is that, even though most people think of telehealth as an interaction between providers and patients, many healthcare systems are utilizing mobile technology to connect admitted patients with their loved ones. For example, hospitals that aren’t allowing visitors due to COVID-19 restrictions are giving patients tablets for two-way video calling. This can lift everyone’s spirits and also coordination of care, which benefits everyone involved.
Your Edge Blog Team: Are you hearing about any patient, or even provider, resistance to telehealth?
Chris: According to our CAB, it isn’t unusual for patients to reject the telehealth appointments offered to them. Despite the risks, one physician said some people simply insist on “coming in.” In fact, her husband is an orthopedic surgeon and said patients won’t even consider a telehealth consult. It’s an office visit or nothing.
Rikki: Even now, despite a significant increase in telemedicine visits, a recent American Medical Association poll found that 70% of physicians are conducting fewer total patient visits than before the pandemic. So, everyone is doing their best to provide multiple options to patients, including phone and video appointments. It’s definitely a balancing act, as you have to accommodate so many different preferences in a very fluid situation. But we’ve seen some healthcare systems implement some pretty incredible programs to ensure continuity of care for everyone.
A practicing physician from the largest nonprofit health system in the U.S. explained how it onboarded nearly 3000 care providers within two weeks to get its around-the-clock telehealth services up and running at the capacity needed to meet demand. Its facilities were already offering telepsych and telestroke consults prior to COVID-19 as needed, especially at night, but recognized the need to expand virtual care to all departments. At one point, her division was conducting between 20-40% of its ambulatory visits virtually.
And a care innovation principal for an integrated care management consortium reported that his hospitals – and many others – actually created centers of excellence or care expert groups to give people remote access to specialists for things such as stroke care, perinatal cardiology and more. In fact, nearly 52% of all doctor “visits” across the nationwide care system in the last year were completed via telehealth, and that number continues to grow, especially in situations where multi-practice care coordination is important. Families and patients no longer have to go into the facility and risk exposures for every conversation with a specialty care team member. Much of that can occur via phone or video.
Chris: By reducing the number of unnecessary in-person visits, you also reduce the risk of exposures overall, which may help patients feel more comfortable coming in when deemed necessary. So, there are benefits to all parties, even those patients who may not directly engage via telehealth platforms.
Your Edge Blog Team: Do you anticipate that demand for telehealth services will decline to pre-pandemic levels at any point? Or is it here to stay?
Chris: The CAB anticipates that there will be a need for widespread telehealth services for the foreseeable future. The pandemic isn’t over, and there are still many people who prefer virtual appointments for routine care. In fact, people who live in rural or remote areas will likely appreciate having greater access to telehealth services, as they won’t have to drive into a larger town or city to get care for every little ailment. Plus, telehealth is much more than just an alternative care delivery method.
Rikki: Chris is right. Many of our CAB members are starting to pilot things such as remote patient monitoring. This is really exciting because, even in ambulatory environments, providers will be able to track things such as blood pressure, weight and glucose and conduct some diagnostics using either a clinician or consumer-grade mobile device. This could be really game-changing long term.
Healthcare systems are also using telehealth mechanisms for clinician training and workforce management. As one clinical executive noted during our discussion, virtual nursing programs or mentorship programs could present a tremendous opportunity to offset the widespread staffing shortages and improve skillsets. He also suggested that telehealth could serve as a respite for staff that has been completely burned out over the last several months. They could be assigned to the remote monitoring of acute care patients or serve as a virtual preceptor, for example. This still helps hospitals maximize resources but gives people a chance to recover a bit. It could benefit both patient care delivery and the clinician experience.
Of course, telehealth won’t solve all problems for all people. Many patients will still need or want to be seen in person when possible. But experts agree that it can certainly ease the burden caused by COVID-19 and help close the gaps in care that existed before the pandemic. We believe – and our CAB agrees – that the investments being made now to introduce and expand telehealth are going to have a long-term return.
If you’re contemplating the benefits and feasibility of telehealth for your practice and patients, the Zebra healthcare team would be happy to set up a virtual meeting to discuss the challenges you’ll need to overcome and the solutions available for each. You can contact them here.
And, in case you missed it…
Watch Dr. Gordon of Alfred Health in Australia talk about how the decentralization of care from hospital settings and uptick in telehealth is impacting patients and providers in his region in this three-minute interview.