When demand for telemedicine skyrocketed during the first few months of the COVID-19 pandemic, healthcare leaders scrambled for solutions. Organizations that hadn’t seriously considered telemedicine before were suddenly making it a priority; they jumped in with teleconferencing platforms, promoted their services to the public, and urged physicians to get on board. State legislatures passed payment-parity laws to
ensure greater access and reimbursement.
Stuck at home but still needing medical care, patients responded enthusiastically to telemedicine. In February 2020, telemedicine usage for primary-care visits in the United States accounted for a sleepy 1 percent of all visits. By April 2020, it had ballooned to 43.5 percent. When outpatient clinics reopened in May and June, patients returned to their doctors' offices for check-ups and episodic care—but telemedicine
remains an attractive option for many. According to a recent McKinsey report, utilization has stabilized at a level 38 times higher than before the pandemic.
New COVID-19 variants and vaccine hesitancy have since created new uncertainty within the healthcare ecosystem. But it doesn’t take a crystal ball to see that telemedicine—with its convenience, widespread acceptance, and potential for continued reimbursement—is here to stay.
What does your organization need to do to survive and thrive as you weather the challenges ahead? In this article, we’ll take a look at seven key strategies that will help you create a sustainable telemedicine program that benefits patients, providers, and your organization as a whole.
ASSESS YOUR INFRASTRUCTURE
In the pandemic’s early days, the spike in telemedicine was a stress test for many health systems’ information-technology infrastructure. It also tested the digital capabilities of telemedicine vendors, and not all of them passed with flying colors. Inadequate data storage, slow servers, unreliable broadband connections, and weak security can sink a telemedicine program in a hurry; so can a telemedicine vendor whose software won’t integrate with your current information technology landscape. In its “Telehealth Implementation Playbook,” published in 2020, the American Medical Association recommends that organizations work with their IT department and a telemedicine vendor to:
- Ensure that the telemedicine platform seamlessly integrates with your organization’s electronic medical record
- Assess the platform’s impact on your internet and local network usage
- Capture data important to patients and providers and make it available to patients as appropriate
- Allow customization based on patient and provider preferences
- Ensure the ability to maintain patient identity across platforms, if applicable
- Establish patient geolocation for licensure purposes
- Connect remote patient-monitoring and biometric devices to the platform
- Offer a dedicated help desk for providers and patients facing technical challenges
EXPAND INTO SPECIALTY CARE—WHEN APPROPRIATE
Primary-care visits were the main attraction for telemedicine users during the height of the pandemic. Now, health systems are
expanding video visits to include multiple specialties. Real-world experience is helping leaders identify which specialties are appropriate
for telemedicine and which ones make more sense for in-person appointments. (See “Liability Implications and Recommendations for Telemedicine,” pg. 28.)
UW Medicine in Seattle has been grappling with this question and developing best practices for its clinics, says Dr. John Scott, medical director
of digital health at the University of Washington. “We are finding that in person visits are most appropriate for
patients with eye complaints, since ophthalmologists use specialized equipment to view the retina,” he explains. “The other two in the ‘inperson’
category include patients with abdominal pain and medically complex patients who tend to be brittle and need routine blood tests.” He adds that telemedicine can work well for patients with chronic diseases such as hypertension and diabetes—as long as they use at-home medical devices to monitor and report biometric information such as blood sugar and blood pressure.
Mental-health services can be effective in the virtual and in-person setting; Dr. Scott says UW Medicine leaves it up to providers to decide which they employ. “Only half of the counties in the state of Washington have a psychiatrist—some patients would have to drive two
hours to see one,” he says. “We need to be flexible in those situations because, for these patients, the choice may be telemedicine care or no care.”
Dr. Scott, an infectious-disease specialist, has long been a proponent of telemedicine. In 2008, he launched Project ECHO at UW Medicine. This
innovative telehealth platform helps clinicians in rural and underserved areas treat chronic diseases. Dr. Scott began using Project ECHO to treat
patients with Hepatitis C, and the program has since expanded at UW Medicine to include other conditions.
As telehealth gains wider acceptance among patients and providers, investors are taking notice. According to Rock Health, total venture-capital investment in the digital space in the first half of 2021 totaled $14.7 billion, more than twice the investment in 2019. That puts pressure on virtual health companies to innovate—which is good news for health systems that want to provide cutting-edge technology for their patients.
Some health systems, such as UC San Diego Health, have launched centers for innovation to develop telehealth devices
and platforms. “Doctors, nurses, and medical teams know best where there are existing technology gaps in patient care,” Dr. Christopher Longhurst, the health system’s chief information officer, said in a press release. “Our in-house teams of clinicians and scientists will
innovate solutions that lead to things like lower blood pressure with longer term goals, like reduced number of hospitalizations and a longer life. With our proximity to the health and biotech sector as well as to the cross-border region, the number of collaborative opportunities is immense.”
Your organization may not have the resources to develop the next big thing in telemedicine—but you can partner with vendors who do. Take it from Deb Muro, chief information officer at El Camino Health in northern California. Her team works with a telemedicine vendor that is launching closed captioning and translation services for patients. (See "Lessons Learned by an Early Telehealth Adopter," page 12.)
If your organization cobbled together a telemedicine solution during the pandemic, you likely used multiple platforms that didn’t necessarily play well with others. That may have worked temporarily, but long-term sustainability requires a more streamlined approach.
The key is to fully integrate your telemedicine platform with your organization’s EHR. It should be noted that some hospitals may have limited
ability to achieve this, as they often use a host site, and thus their ability to customize is limited. Nonetheless, doing so will mean that:
- Providers can easily document visits and refer to the patient’s medical record
- Patients can self-schedule visits and pre-register online
- Visits can happen within the EHR (e.g., on MyChart)
- The system can capture insurance information and process payment
- Providers won’t have to use multiple screens (e.g., Epic and Zoom) while interacting with patients
If your telemedicine platform is difficult to use or inconvenient, patients won’t use it and providers won’t encourage it. A streamlined offering can make a difference.
LOOK TO STATE MEDICAL BOARDS FOR LICENSING GUIDANCE
Second to reimbursement, licensure portability has been the most significant hurdle facing telemedicine. The default presumption under state law (which controls physician licensing) is that a physician needs to be licensed in the state where the patient lives. But the particulars for out-of-state telemedicine providers vary state by state. “Most states require a full license to care for one of their citizens, but some allow telemedicine practice with a limited license,” says University of Washington School of Law Affiliate Instructor Cindy Jacobs, an expert in telemedicine legislation.
Jacobs adds that there are other state regulations governing out-of-state practice, and these also vary from state to state. Some states may require
providers to see a patient in person before offering a telemedicine visit, for example. A very small group of adjoining states (such as Maryland and
Virginia, plus the District of Columbia) have reciprocal arrangements in place. Jacobs recommends that healthcare leaders keep tabs on applicable
legislation by relying on their state medical board or policy organizations such as the Center for Connected Health Policy.
TAKE ADVANTAGE OF PROXY CREDENTIALING
Credentialing is time-consuming for any organization, but proxy guidelines can simplify the task when it comes to telemedicine. Proxy credentialing
means that a hospital that uses telemedicine providers who work for a hospital outside their system (a "distant site") can rely on the other hospital's
credentialing process as a proxy for full-blown credentialing. The Centers for Medicare and Medicaid (CMS) began allowing proxy credentialing in 2011.
“Proxy credentialing streamlines the work a hospital must do to bring telemedicine in from another hospital or other entity,” Jacobs says. “Not very
many hospitals take advantage of it, either because they aren’t familiar or because they don’t trust it. But it is legitimate and worthwhile.”
Jacobs adds that when using providers from a “distant site,” it’s important to ensure that they have received appropriate training on the telemedicine platform being used. Training can be offered either by your system or by the distant-site system in order to ensure a
compliant experience for patients and providers. A written agreement meeting CMS criteria must also be in place.
INVEST IN CONTINUOUS QUALITY IMPROVEMENT
As your telemedicine platform continues to mature, a continuous quality-improvement strategy will ensure its long-term viability and value,says Dr. Scott of UW Medicine. “UW is very fortunate to have a full-time physician and staff member dedicated to telemedicine CQI,” he says. “But every organization should incorporate telemedicine operations into its CQI efforts, even if they have to start on a small scale.”
UW Medicine’s telemedicine CQI strategy has four pillars:
- Surveys that collect patient feedback. Telemedicine teams use this feedback to identify issues (doctor running late, poor “web-side manner,” etc.) and provide coaching to the clinical team as needed.
- Anonymous reporting tools.These allow providers and clinic staff to report information about patient-safety issues, enabling the telemedicine team to review incidents, conduct critical analyses, and make changes as needed.
- Random chart reviews. Dr. Scott and a colleague complete about 30 chart reviews every month to ensure providers are documenting each visit correctly.
- Special projects help the team address safety concerns, technical issues, and other problems.
“Patients are already choosing providers, health systems, and hospitals based on telemedicine access,” Dr. Scott says. “CQI programs help ensure
that you are offering a consistent, secure, easy-to-use platform that patients will keep coming back for.”