COVID-19 as a Catalyst for Virtual Care: A Thought Leadership Roundtable

Introduction

COVID-19 rocketed telehealth in the U.S. from a sparingly used platform for delivering patient care into an abrupt necessity, with healthcare organizations having to swiftly ramp up services to meet the sudden need. Although the ballooning number of telehealth visits demanded in the early days of the pandemic may have declined, the experience has paved the way for the adoption of other virtual care solutions such as hospital-at-home services. The industry consensus is that telehealth and virtual care are here to stay, but to what degree? Can telehealth be expanded to enable a virtual care experience for patients and caregivers throughout the care continuum? The decisions made today likely will determine if and how virtual care evolves and thrives in the future.

Google Cloud Healthcare & Life Sciences invited six digital healthcare leaders from the College of Healthcare Information Management Executives (CHIME) to explore the future of virtual care in a thought leadership roundtable. Joining them were healthcare executives from Google and Amwell, a Google partner. CHIME President and CEO Russell Branzell moderated the discussion.

Participants included:

• Cara Babachicos, Senior Vice President and CIO, South Shore Health System
• Jennifer Greenman, CIO, Cancer Treatment Centers of America
• Aashima Gupta, Director, Global Healthcare Solutions, Google Cloud
• Adnan Hamid, former CIO, Good Samaritan Hospital
• Serkan Kutan, CTO, Amwell
• Tabitha Lieberman, Senior Vice President, Clinical and Revenue Cycle Applications, Providence Health and Services
• Scott MacLean, Senior Vice President and CIO, MedStar Health
• Sheree McFarland, Division CIO, West Florida Division, HCA Healthcare
• Shafiq Rab, MD, Chief Digital Officer and CIO, Wellforce Health System

Telehealth’s Rapid Rise

The COVID-19 pandemic accelerated both the provision and the adoption of telehealth in 2020, with huge upticks in the virtual services being offered across healthcare organizations. Almost all – 98% – of respondents to CHIME’s Digital Health Most Wired 2020 survey reported having patients who utilized telehealth services in the past year. Broken down by location, telehealth adoption in hospitals, patients’ homes and physicians’ offices increased about 40 percentage points while post-acute care settings recorded a more modest 13 percentage point increase. Patients and physicians alike lauded telehealth as a safe and effective alternative to in-person visits during the crisis. The rapid ramp-ups – some accomplished in mere days – were feats of ingenuity and perseverance. But they were not without problems, some correctable and some persistent. The roundtable participants represented a variety of healthcare systems: large, small, for-profit, private/nonprofit, academic/teaching/research, and specialty care. Despite their different types of organization, they encountered many of the same barriers, which fell into four general buckets. The list, while not exhaustive, touches on the primary challenges they experienced in the early phase:

• Technology
• Bandwidth issues
• Internet connectivity
• Delays to build out technology
• Inadequate technology on the patient side

• Physicians and clinicians
• Resistance among some users
• Unfamiliarity with the technology
• Difficulty establishing rapport with patients remotely
• Data entry errors
• Dissatisfaction with the experience
• Patients
• No or insufficient technology at home
• Digital literacy issues
• Accessibility, lack of broadband
• Reluctance to use the technology, especially among elderly patients
• Dissatisfaction with the experience
• Policies
  • Reimbursement
  • Infrastructure

The digital executives and their teams devised several near-term solutions that may serve as creative and effective models for the industry. As an example, MedStar Health tackled connectivity issues by developing a multiplatform app that was sent to patients in advance of visits. The technology allowed a MedStar team to test the camera and microphone on a patient’s device before a virtual visit. When bandwidth was problematic, the team instructed clinicians to downgrade to no video, audio-only service, or to phone. In another case, Cancer Treatment Centers of America quickly realized they needed to assist patients who were not technically adept and required guidance with computer-related tasks. “We decided very early on in the pandemic to stand up a telehealth concierge team that was exclusively dedicated to doing technical prechecks with the patient,” Greenman said. The precheck spared physicians from having to invest valuable time into technical troubleshooting and instead concentrate on the patient. “Interestingly, we saw as much as 45 minutes to an hour of prep time with some of our patients to get them ready to be comfortable interacting with the video conferencing platform.”

Training physicians and clinicians on how to use telehealth technology efficiently, how to submit order entries and billing correctly, and coaching them on effective strategies to interact through technology with patients has helped to reduce friction points and increase adoption rates. Adding digital use education into the patient education process is helping to address digital literacy issues. Using terminology like “standard care using technology” or simply “care” instead of “virtual care” signals that the services delivered satisfy both the physicians’ standards and patients’ expectations.

Historically, limited reimbursement in the U.S. constrained the adoption of telehealth. In a 2017 survey by CHIME and KLAS of healthcare IT executives, 69% cited reimbursement as the biggest drag on telehealth’s expansion, with payers slow to reimburse for services, reimbursing at rates that didn’t cover costs, and disincentivizing physicians by paying them less for a telehealth visit than an in-person visit. Telehealth received a boost in the spring of 2020 when the U.S. Department of Health and Human Services (HHS) enacted flexibilities under the COVID-19 Public Health Emergency to expand access to telehealth services for Medicare and Medicaid beneficiaries, equalize reimbursement for in-person and remote visits, allow physicians to provide Medicare telehealth services across state lines through cross-state Medicare licensure waivers, and made several other flexibilities. While not permanent, the flexibilities were extended into January 2021 under the HHS secretary’s extension of the public health emergency.

From Band-aid to a Strategic Virtual Care Platform

Virtual care is at a tipping point, poised to either become a sustainable mainstay in healthcare or teeter back to its pre-pandemic status. “The learning is we need to build it right for the next decade, having a platform-thinking approach that what we build now is not just a Band-aid,” Gupta said. “How do you make it as a strategic platform moving forward?”

At the peak of the crisis, healthcare organizations had to concentrate on an all-out effort to get their telehealth systems up and running. Once the urgency subsided in some regions, healthcare IT departments were in the position to reflect and assess what worked, what didn’t and how to overcome remaining barriers. Babachicos said South Shore is now in a “reconnaissance phase where we are developing strategies to standardize care across telehealth providers. We are trying to do a lot of playbook and best practice recommendations. We’ve moved from ‘just do it to now’ to ‘let’s make it better,’ and ‘let’s make it stick.’” Lieberman added that she and her team at Providence Health are reviewing processes to weed out inefficiencies, add value and create a seamless experience.

Consistent clinician and patient satisfaction will be key. “They now expect that great, smooth consumer user experience from telehealth,” Kutan noted. “That is a great place to be, but we have to get there. Currently, telehealth is not that easy to use.”

Public policy is also a lever that can greatly enhance the current and future adoption of telehealth and virtual care, Rab noted. Existing programs like the Federal Communications Commission’s Rural Health Care Program are designed to increase providers’ access to broadband; the FCC raised the program’s funding cap in 2018 and carried forward unused funds in 2020 in an effort to meet providers’ growing demand for broadband. The commission also is exploring how to accelerate the deployment of 5G, the fifth generation of wireless networks. If available, 5G could greatly improve the speed and reliability of telehealth services and facilitate the use of advanced care such as virtual surgery. Nearer term, the Centers for Medicare and Medicaid Services (CMS), which falls under HHS, in August called to expand the list of covered Medicare telehealth services to include a select set of services on a permanent basis.

“I always say first, follow the money,” Rab said. “Second, follow the technology. The third thing is the evolution. I call it follow the use case. In my mind, once the money part is settled, then the use case also improves.”

Transformational Change Through Virtual Care

Without proper financial incentives, small- and medium-size community-based hospitals that already face thin margins are unlikely to continue along a telehealth pathway, Hamid offered. The sheer day-to-day challenges of staying afloat preoccupy leadership, giving them little time to recalibrate to a model using telehealth, even if that model offers a potential route to sustainability. On the other hand, Providence Health helped some of their critical access and small community hospitals make the leap into telehealth solutions by leveraging the health system’s resources. “Sometimes just being in those rural areas has really forced them to be creative,” Lieberman said. Facilities in Alaska, for example, showed “a lot of willingness to adopt and push those technologies because they don’t have other financially viable solutions.”

Overall, reimbursement incentives – or disincentives – will favor a shift to at-home services. “We’re going to seeing a lot of services that used to be offered in the bricks-and-mortar settings like the hospital move to the home,” Babachicos said. Skilled nursing care facility-at-home and hospital-at-home approaches using remote monitoring, mobile integrated health and telehealth tools now seem more feasible. “If we can put sensors and one-button push technology for patients or caregivers to reach out to a PCP (primary care physician) or a specialist if they get nervous, that can make a big difference in the life of a patient and their experience,” she said. The strategy is a win-win; it lets patients recover in the comfort of their home with loved ones, which in turn frees up hospital beds for other patients. The hospital-at-home model may gain momentum in cancer care, too. “We’re going to see increased pressure from our payers, our large commercial payers, and eventually Medicare to shift more care out of the hospital setting and into the home or lower acuity areas,” Greenman observed, for instance, with infusions done at home with the proper remote patient monitoring support.

With technical and financial barriers removed, telehealth could expand beyond critical care to reach a much wider variety of patients. “I think this is going to open up a whole new area of different service lines for telehealth other than these traditional ones that we think about,” McFarland said, citing bariatrics as an example. Babachicos proposed behavioral health, noting that some patients prefer the telehealth platform over a face-to-face visit, in part due to the convenience and privacy, and noted the increase in need, given the elevated stress and anxiety that many people are experiencing under the pandemic. Innovation with artificial intelligence, sensors and advanced technologies could expand telehealth’s reach further. Gupta outlined a trajectory from primary care to disease-specific care pathways to services like teleradiology and telestroke to provider-to-provider consultations, “moving from episodic to continuum.” 

Virtual care could inspire new partnerships, like a collaboration that sprung up between HCA’s for-profit hospitals and the UK’s National Health Service during the pandemic. Telecommunications carriers could become part of the healthcare ecosystem, as could drug stores, libraries and any place where people congregate. Development of the platform to create an excellent user experience could transform healthcare, delivering what Gupta summarized as “the right care at the right setting at the right time for the right patient … It’s up to us how we write those rules and pave the path for that future.”

Conclusion

The COVID-19 pandemic accelerated the provision and utilization of telehealth and more broadly, virtual care, in the U.S., but whether telehealth is a short-term solution or part of a bigger sustainable virtual care platform for delivering healthcare is unclear. Healthcare organizations that quickly stood up telehealth programs showed the technology could be used to safely and effectively monitor and treat patients, but the platform also had shortcomings and challenges. By identifying and addressing barriers to adoption, stakeholders can position virtual care to become a permanent and potentially transformative way to serve patients across the continuum of care.