By Deborah Borfitz
May 5, 2020 | Before COVID-19, Washington was already one of the nation’s most progressive states when it came to reimbursement policies around telemedicine. That made it financially feasible for healthcare organizations to build programs connecting doctors and patients digitally—and this often did not require a video component or even to be in real time.
But a lot can change in a month, even for a digitally-savvy health system like the University of Washington (UW) Medicine in Seattle. Just ask John Scott, M.D., its medical director for digital health, who only weeks ago watched telemedicine usage swell 70-fold from a couple hundred visits monthly to around 14,000.
Until then, telemedicine at UW Medicine was limited to people with lower-acuity conditions and non-urgent issues served by a virtual clinic and e-consult service. The sudden upsurge required compressing two years’ worth of work into a 30-day timeframe, but “all things considered,” the transition has gone remarkably well, Scott says.
Training clinicians in all 45 specialties to provide telemedicine visits was a key enabler, as was the lifting of many restrictions on telehealth paid for through Medicare. And it has been a “valuable way to triage patients who may not have COVID-19 but still need to be seen,” Scott says.
A primary strategy from the get-go was to leverage existing processes, technology, and relationships, since “a crisis is not a great time to change things,” he notes. Another was prioritizing the training of primary care physicians, the ones on the front lines of triage, on week one. In the second wave of training were practitioners in clinics taking care of the most vulnerable patients, including transplant recipients and people with cancer, neuromuscular disorders, and chronic lung conditions.
Since early February, the number of providers trained in telemedicine skyrocketed from 230 to about 2,500, says Scott. The final 1,000 or so providers don’t do much outpatient care and will likely opt out of the training. “We’re moving to more of an opt-in system, making telemedicine part of core privileges for everyone, he adds.
Three-Pronged Response
“In terms of the number of clinics, we previously had 40 with telemedicine capabilities and that is now up to 180, so it has been a logarithmic increase,” Scott says.
UW Medicine’s initial response to the COVID-19 outbreak included installing technology of InTouch Health (interactive videoconferencing technologies originally designed for stroke care) in the intensive care unit (ICU) of one hospital that got hit by about half of all COVID-19 cases within the health system but had not yet staffed up to provide 24/7 coverage by intensivists, Scott continues. The equipment includes a 12-inch monitor and pair of cameras whose zoom and sweep functions can be remotely controlled by an intensivist at one of the system’s other three hospitals when a consult is needed.
The technology was quickly deployed to all ICUs where COVID-19 cases subsequently escalated, says Scott. “It has been really great for us to be able to check on patients, especially post-intubation when a lot of ventilator settings have to be adjusted and we want to keep a close eye on them but without nurses and doctors having to gown up.”
The role of the four-year-old virtual clinic UW Medicine had been running through American Well Corporation (Amwell) also expanded to serve not just “lower acuity” urgent problems such as urinary tract infections and rashes, but also to triage potential COVID-19 patients, says Scott. That service was provided free of charge to any patient 24/7 during the height of the pandemic and, unsurprisingly, resulted in a more than tenfold increase in calls. The standard $35 fee has since been reinstated.
American Well could meet the demand for about one week before the usual 10-minute wait time for a virtual visit grew lengthy, Scott says. UW Medicine filled the void with some of its own doctors who, for health reasons, couldn’t see patients in person. It also created a chat bot to serve the vast majority of people who either had a mild case of COVID-19 or wanted to be seen for an unrelated health issue. “We really wanted to make sure those people stayed out of the emergency room and urgent care, and the bot helped to answers some of those questions… and bring the wait time [for virtual visits] back down.”
Remote patient monitoring is additionally rolling out this week via a collaboration with Amazon. This SMS (text)-based intervention will ask recently discharged patients with COVID-19 questions about their health status, says Scott. “Patients have the option to add physiologic measurements like blood pressure, temperature and pulse. UW Medicine clinicians will review this information regularly and reach out to any patients with concerning symptoms or measurements.”
UW Medicine anticipates about 200 patients per month will be monitored from home, and this is part of its long-term response to COVID-19, Scott says. Although cases have been leveling off in recent weeks, “it’s inevitable we’ll see another wave [of patients] once some of these social distancing policies have been lifted. We just don’t know how big it’s going to be.”
Home monitoring of COVID-19 patients is part of the discharge planning process, and reimbursable by Medicare, he says. “We’re just as concerned about the patients who don’t have COVID-19 but might have pretty bad heart failure or emphysema. We don’t necessarily want them to come into the hospital, but we want to know what’s going on.”
This is the “future of medicine” for patients with chronic diseases, Scott adds, and “an example of how COVID-19 has spurred us to think beyond the crisis about a more general population that is frail and brittle.”
Smooth Transition
With few exceptions, patients have been highly adaptable to the various telemedicine modalities, says Scott. Forced to work from home, many people are now quite familiar with communication technologies such as Zoom and Microsoft Teams.
Recently, a provider accommodated an older patient who only knew how to use FaceTime on his smartphone. While not compliant with the Health Insurance Portability and Accountability Act, FaceTime is allowed for short-term use by the Centers for Medicare & Medicaid Services (CMS), Scott says.
Providers at UW Medicine have a high comfort level with video teleconferencing technology because that’s how meetings have customarily been conducted, Scott says. But outside of hospital walls, there have been a few bandwidth issues.
One doctor tried to conduct a virtual visit from his home and the video was jumpy, so he called Comcast only to learn that his neighbor had 75 devices connected to the internet. “We’re in Microsoft and Amazon land, so everyone is working from home, doing Zoom meetings and… watching Netflix.”
Webcams have also been in short supply—a phenomenon Scott terms the “toilet paper of medicine.” UW Medicine is fortunate to be ahead of the game, having ordered 400 webcams early on and locating another 1,000 through its connections at Microsoft when the first surge of COVID-19 cases hit.
During the wait time for the next wave of patients, UW Medicine is circling back with doctors to ensure they’re comfortable with the technologies and workflow. It also just integrated its telemedicine platform (Zoom) directly into Epic, its electronic health record (EHR) system, so patients can effortlessly start a virtual visit with their doctor by logging into Epic’s MyChart web portal. Providers can likewise start a patient visit with the push of a button.
Planned Ramp-Up
The big unknown is whether CMS will make its temporary payment policies for telehealth visits a permanent feature of the Medicare program, Scott says. For patients covered by Medicaid and commercial plans, reimbursement for telemedicine visits was mandated in the State of Washington four years ago. This past February, the state legislature also gave telemedicine visits payment parity with in-person visits.
Additionally, Scott chairs the Washington State Telehealth Collaborative that last year developed a training program for providers that includes the “etiquette” of virtual patient visits. “We’re in a pretty good place in Washington to ramp up telemedicine.”
Asynchronous telemedicine—referring to the “store-and-forward” technique where patient images and reports get sent to specialist physicians for diagnostic and treatment expertise—will be the major mode of expansion, says Scott. It’s an efficient way to take care of non-urgent issues, “much cheaper than in in-person visit” and a Medicare-reimbursable service as of 2019.
UW Medicine’s e-consult program has logged about 15,000 such visits since its launch three years ago, he says. When patients say yes to an e-consult, their primary care doctor sends their records to a specialist who picks up the request via the EHR and typically responds within a day. It has been especially valuable in dermatology where the wait time to see a specialist is about six months.
When the pandemic ends, Scott envisions a “new normal” for primary care physicians who’ll be spreading their time between in-person appointments, e-consults and telemedicine visits one-on-one with patients or in a three-way conversation with a specialist. He also expects to see many more modalities of care, including greater adoption of the hospital-at-home model of telemedicine for people with chronic diseases.
Telemedicine lends itself particularly well to any kind of mental health diagnosis, notably depression, especially in states like Washington where half of all counties lack a psychiatrist, Scott says. It is also well suited to high-prevalence conditions such as diabetes and hypertension that are treated with medicines and monitored by simple laboratory tests and physiologic measurements.
It’s a future where healthcare is more convenient for patients to access, as well as “more proactive than reactive,” he adds. “I really hope that in the long run this leads to healthier lives and lower costs.”