ROBIN ROENKER
Contributor to Health Progress
Illustration by Nicole Xu
Health care systems across the country have transformed the delivery of patient care, with telehealth programs in particular expanding during the coronavirus pandemic. The field of telehealth has seen dramatic shifts — mainly out of necessity — as patients experienced limited access to in-person health care services during COVID lockdowns. For many health systems, embracing virtual care services for patients prior to the pandemic's start proved to be a key factor in their systems' quick adaptation to the changing health care environment.
The exponential growth of telehealth since the onset of the pandemic has been driven, to a large degree, by new guidelines issued under the COVID public health emergency declaration of March 2020. These new guidelines, which have been extended through at least April 2022, have made both Centers for Medicare & Medicaid Services and private insurance coverage for telehealth visits possible, further boosting many patients' access to remote health services for the first time.1
COVID caused telehealth implementation to "jump ahead 10 years in the course of about a month," says Eric Pollard, virtual health system director for SCL Health, which serves patients primarily in Colorado and Montana. "Pre-pandemic, we spent a lot of time trying to convince providers to try telemedicine. Post-pandemic, that's not our conversation anymore," Pollard says. "Now, they're no longer questioning the value. Now, it's about logistics: How do we integrate this type of service into their workflow? There's been a real shift in the culture surrounding telemedicine."
CommonSpirit Health, which logged less than 5,000 telehealth visits monthly before COVID across its more than 1,000 sites around the country, has completed 2.14 million ambulatory virtual visits since the onset of the pandemic, says Dr. Marijka Grey, CommonSpirit's system vice president for Ambulatory Transformation and Innovation. The system now conducts roughly 8-11% of its visits virtually.
Similarly, while Providence health care system was already experiencing growth in its telehealth service prior to the pandemic, that increase surged following COVID. Between 2012 and 2019, Providence saw its telehealth services grow from 700 to 70,000 visits a year. But when COVID hit in 2020, their providers oversaw 70,000 video visits each week by April that year. Altogether, in 2020, Providence logged 1.7 million telehealth appointments. By the end of 2021, its providers had conducted more than 3 million visits since the beginning of the pandemic.
"Now, 1 in 5 visits at our clinics is telehealth," says Dr. Todd Czartoski, Providence's chief medical technology officer and chief executive for telehealth.
BENEFITS TO PATIENTS AND PROVIDERS
When Christine Storm first caught COVID at the end of 2020, her symptoms were relatively mild. But within a few days, her case worsened. "I got really sick, really fast," says Storm, 54, who lives in Ballwin, Missouri. "I couldn't walk up the steps. I crawled to the bathroom."
In the midst of her worsening symptoms, Storm remained in steady contact with nurses and physicians at Mercy, thanks to their COVID Care @ Home program, a telemedicine system that engages COVID-positive patients with 24/7 access to board-certified emergency physicians for two weeks via daily texts and, if needed, phone calls or video consults.
"Mercy Virtual gave me a great amount of comfort in knowing someone was checking on me, and I could reach out at any point of the day or night," Storm says.
From a provider's perspective, the initiative has been a resounding success as well: as of early this year, 81,379 patients deemed high-risk for COVID complications and facility-based care have been enrolled to Mercy's COVID Care @ Home program, with 18,404 clinical escalations to the virtual team. Of these referrals to the virtual team, the overwhelming majority were able to be cared for at home with only 929 patients requiring a visit to the emergency department. The remainder of patients were managed either at home or at one of several outpatient settings. In this way, virtual care services have allowed Mercy caregivers to recommend the most appropriate level of care for clinically triaged patients.
"One of our huge concerns was that the ERs were going to be overwhelmed," says Dr. Carter Fenton, an emergency medicine physician and medical director of Mercy's vAcute program. "We wanted to be able to have our ER team step in and help triage patients virtually. We were able to really guide patients and say, 'We think it's fine for you to stay home right now, given your symptoms — knowing that we'd be checking in on them daily — or, 'We think you should go to the ER.'"
Of course, the immediacy of telehealth also provides unmatched convenience — for both physicians and patients — particularly for routine follow-up visits, which don't always require an in-person examination. With telehealth, patients don't have to take off work or arrange daycare in order to drive the sometimes long distances to a major hospital hub. An appointment that might have once taken half a day or more can be checked off in a matter of minutes, even during a lunch break at work via cell phone.
Providers, too, can easily slot in patients via telehealth almost immediately if they experience a no-show. The easy transferability of telehealth appointments has allowed substance abuse recovery providers with Assisted Recovery Centers of America (ARCA) to expedite seeing a high volume of patients very quickly, says Dr. Fred Rottnek, ARCA's medical director who also serves as a professor and director of community medicine at Saint Louis University School of Medicine. He also serves on Health Progress' editorial advisory council.
"If somebody doesn't show up [for a telehealth visit], our providers can call another client and say, 'Hey, can you do an appointment right now?'" says Rottnek, whose team has found success using telehealth for both peer-to-peer counseling as well as prescription medication monitoring, among other services. "Time is of the essence in this work — you don't want to wait two weeks to get people into addiction treatment. We want to try to get people in that day or the next day. And telehealth has especially helped us with getting people into care quickly."
ADDRESSING PROVIDER SHORTAGES
Having a centralized virtual health team in place can also help health care systems address provider shortages — particularly in areas and communities where specialists and specialized care services are in short supply or nonexistent.
Rottnek says telehealth has allowed ARCA to reach a new population of patients in what he terms "treatment deserts," including rural settings where addiction recovery services are rare. "We have been able to provide treatment to folks that had never had access before," he says.
To help extend the scope of already limited specialists, Mercy's telemedicine system — which supports 43 hospitals across five states — includes a centralized virtual hospitalist team, as well as a virtual stroke team, virtual ICU team and virtual sepsis team, for example.
These virtual care systems have "allowed us to establish a standard of care that otherwise is not possible, because of lack of resources in some of the smaller communities that we serve," explains Dr. J. Gavin Helton, Mercy Virtual's president of clinical integration. Telehealth allows Mercy to "leverage our most rare resource, which is really our clinical expertise — our subspecialty care — in order to meet the needs of our patients, no matter what community they're in," Helton adds.
Moreover, adopting a virtual specialist model allows Mercy to ensure that the quality of care patients receive does not diminish, even if they're admitted on a weekend or during the middle of the night. "Traditionally, staffing looks much different in small to medium hospitals when you compare eight [a.m.] to four [p.m.], Monday through Friday, to anything outside of those hours," says Dr. Ashok Palagiri, vice president of Mercy Virtual Inpatient Services. "I want our patients to know their care will be the same whether you come in at 7 a.m. or 2 a.m. Our nurses are always able to reach out to any physician [working with Mercy Virtual] they need help from, at any time. The virtual intensivist or virtual hospitalist is able to manage these patients the same as they would at the bedside."
SCL Health has also leveraged telehealth to help provide specialist care in areas where few subspecialty providers are physically present. "Patients can arrive at a critical access hospital or clinic in a very remote location and, through video, connect with a specialist who might — in our case — often be in Billings, Montana, thereby saving the patient many hours of travel," says Pollard. "Sometimes the best thing we can do for patients is to make sure they receive care as close to home as possible."
PIVOTING SUCCESSFULLY
While many health care systems have successfully broadened their telehealth services during the pandemic, most say this transition was possible only because of frameworks that had been put in place before COVID began.
Mercy, for example, had fortuitously launched a new 24/7 virtual care service to expand its Mercy Care Connect virtual offerings — which provides at-home telecare for patients suffering from chronic obstructive pulmonary disease, congestive heart failure, asthma or other chronic conditions — in February 2020, just weeks before the pandemic hit fully.
Similarly, SCL Health had invested time in 2019 building capacity into its electronic medical record system to enable the scheduling of video visits, even before such visits were covered by Centers for Medicare & Medicaid Services. "We had no idea COVID was coming. We developed a six-wave plan to slowly introduce this service," says Pollard. "But then February [2020] came and we thought, 'We're going to abandon our plan and just turn this on for everyone and see what happens.' And we went from around 500 telemedicine visits each month prior to the pandemic to a spike in April 2020 of about 20,000."
At CommonSpirit Health, the pivot to virtual offerings was fast-paced in the wake of COVID. "We rapidly brought up a virtual visits system across our entire ambulatory footprint over the course of three weeks," explains Grey. This breakneck unveiling was only possible thanks to the expertise of the company's IT, digital and operational teams — who "looked for a solution that could rapidly scale" — and the clinical expertise of CommonSpirit physicians already working in telehealth, who "created really good teaching modules for our staff, so they could get up to speed quickly," she says.
Specifically, CommonSpirit physician training modules dove down into specifics, showing providers how to optimize the virtual visit for varying electronic health records platforms, how to share their screen with patients if they wanted to discuss results or data, and even how best to angle their camera to maintain proper eye contact with patients.
Systems like CommonSpirit and Providence — whose percentage of telehealth implementation remains above the industry average — say their success stems from a patient-centered approach and a commitment to keep fine-tuning their services.
"Our sustainability, I think, is a testament to our team's work to continuously improve the experience for both the patient and the provider," says Czartoski. "Telehealth is not one of those things that you can't just turn on and say, 'OK, we checked that box. We got that figured out.' We continue to improve our services — adding things like interpreter services, adding multiple participants, so you can add family members to the call as well — that we didn't have on day one, and that illustrates a commitment to continue to push for better and better patient experiences with this technology."
When he advises other systems about how best to implement virtual health platforms, Pollard encourages them to establish "a dedicated team for virtual health," he says. "But that does not mean a [solely] IT team necessarily. While we depend on technology, this work is clinical in nature. We always say we're providing a clinical service using technology. That helps to keep the focus on the patients' and providers' perspective."
CONTINUING QUALITY CARE THROUGH MEANINGFUL CONNECTION
When systems keep quality of care as their focus, telemedicine becomes a powerful tool — breaking down barriers to access and, at times, even deepening the provider-patient relationship.
"I practiced general internal medicine for 20 years before joining Mercy Virtual, and one of my concerns before taking this position was that I would lose those really valuable relationships with patients — that it would be too technology-driven or cold," says Helton. "But what I've found is the exact opposite: when a patient is enrolled in our vEngagement program, they have an assigned team, and we build relationships," Helton says. "And because you're caring for the patient in their home, where they are most comfortable, you really get to know them and their family members. It provides for a much more holistic approach to patient care."
ROBIN ROENKER is a freelance writer based in Lexington, Kentucky. She has more than 15 years of experience reporting on health and wellness, higher education and business trends.
NOTE
- "Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak," Federal Register, March 18, 2020, https://www.federalregister.gov/documents/2020/03/18/2020-05794/declaring-a-national-emergency-concerning-the-novel-coronavirus-disease-covid-19-outbreak; "US Extends 'Public Health Emergency' Due to the COVID-19 Pandemic," California Medical Association, January 14, 2022, https://www.cmadocs.org/newsroom/news/view/ArticleId/49631/US-extends-quot-public-health-emergency-quot-due-to-the-COVID-19-pandemic-1.