Expanding Telehealth During a Pandemic: How 4 Health Systems Did It

Intermountain is among scores of health systems that faced a surge in patients in intensive care units as COVID-19 spread. Clinicians everywhere were forced to cope with a shortage of personal protective equipment and to comply with stay-at-home orders that closed outpatient facilities and canceled elective procedures. 

They also had to address a long-standing image problem.

“The biggest obstacle for virtual care and telehealth has always been adoption,” says Alex Lennox-Miller, a senior analyst with Chilmark Research. “Patients always wanted it, but providers were concerned about the standard of care and the pressure it would put on them. COVID-19 is giving both sides a chance to test this.”

Handling the Skyrocketing Adoption of Telehealth

The telehealth response to COVID-19 took different forms at different health systems. Some simply expanded current programs or accelerated their timelines for previously scheduled implementations. Others started from scratch, standing up programs in a matter of days.

Whatever the strategy, adoption skyrocketed.

“It would have taken IT months — and, in some cases, years — to convince our end users to try telehealth,” says Novlet Mattis, CIO for Orlando Health, an eight-hospital system based in central Florida.

Orlando Health completed about 24,000 virtual visits between March 16 and May 22, with 56 percent over the phone and 44 percent via the Microsoft Teams collaboration platform. 

Inside the ICU, Orlando Health deployed robots running a telehealth platform to “see” inside rooms and check vital signs from monitors, lowering the risk of exposure for clinical staff. ICU rooms also were outfitted with iPad devices so patients could conduct video visits and connect with family members they hadn’t seen since being isolated. 

“We were proofing and piloting and deploying all at the same time,” says Mattis, whose team relied on iPad devices to conduct virtual rounding and the Microsoft Bookings scheduling tool to manage the deluge of appointments. “The way the end users quickly adopted and accepted a less-than-perfect solution was pretty amazing.” 

Intermountain, which in 2018 opened a “virtual hospital” to bring together 35 telehealth programs and more than 500 clinical staffers in a single department, was able to map out its strategy for a virtual command center in 12 hours, Palakanis says.

The health system located the command center within the virtual hospital and staffed it with physicians, administrators and more than 60 nurses per shift — with many redeployed from departments that had been shut down.

At the height of the COVID-19 response, the command center handled 4,000 calls per day. Intermountain also saw a surge in scheduled video visits — from 80 for all of February to 60,000 per week in April — and met the demand with laptops, tablets, smartphones, high-definition cameras and other tools.

The protective measure quickly became routine. “Now, everyone expects and wants to have video visits,” Palakanis says. “We’re not at a place where people are comfortable yet going back to the hospital with routine or emerging conditions.”

MORE FROM HEALTHTECH: Discover the four ways VDI is critical to scaling up telehealth.

Encouraging a Culture with an Openness to Change

The health systems that are best able to rapidly scale telehealth adoption aren’t necessarily the largest or most advanced, according to Lennox-Miller. 

“It’s a culture of flexibility and innovation, it’s a willingness to try new things, and it’s the ability to rapidly train providers and distribute information to patients,” he says.

Flexibility became top of mind on March 17 when federal officials temporarily waived potential HIPAA violations for “good faith use of telehealth” and also temporarily expanded Medicare coverage for telehealth visits. (Many private insurers followed suit.) This alleviated the pressure for health systems reluctant to invest in hardware or software for telehealth, Lennox-Miller says.

Boston Medical Center, the largest safety-net hospital and trauma center in New England, had little experience with telehealth prior to COVID-19. But when it became apparent that the hospital would need to close down its ambulatory services — which saw 21,000 patients each week — leadership moved quickly.

Within 48 hours, BMC stood up a telephone visit program that was soon handling 1,500 calls per day. The hospital released additional Cisco Systems VoIP software licenses and purchased several iPad devices for each clinic so staffers could handle the load. 

The process would have taken three months under normal circumstances, says Dr. Rebecca Mishuris, the organization’s associate chief medical information officer. Within another week, the hospital was piloting a video visit program using Zoom. 

Still, limitations of the hospital’s patient population led BMC clinicians to focus on telephone visits. “We know almost all of our patients have phones, but many don’t have a smartphone or a computer or internet connectivity,” Mishuris says.

Ramping Up a Training Program for Virtual Care

For Jefferson Health, the primary challenge for ramping up telehealth adoption wasn’t the equipment or infrastructure. 

The Philadelphia organization already had a robust on-demand platform, numerous inpatient telehealth programs and a “tele-triage” system in its emergency department, which uses videoconferencing as a first point of contact with some incoming patients. 

The system also had plenty of iPad devices earmarked for other projects that were instead configured for the COVID-19 response. In addition, the hospital worked to develop an online chatbot so patients could check their symptoms from home and rolled out a remote monitoring program for discharged COVID-19 patients. 

But many more providers, some of whom used smartphones to deliver care, needed to be educated — and fast.

“It’s never about the technology,” says Dr. Aditi Joshi, medical director for JeffConnect, Jefferson Health’s telehealth program. “You need the connection and you need to communicate. You need the staffing and the process. That’s a bit harder.”

That’s why Joshi and her colleagues pivoted in mid-March to shift telehealth training from a small-scale, in-person model to an online program with a Zoom webinar and a Microsoft SharePoint documentation portal. 

The online modules enabled Jefferson to train 700 providers in scheduled visits and 160 providers in on-demand visits in a three-day span, says Dr. Judd Hollander, senior vice president for healthcare delivery innovation at Jefferson. 

As a result, the system transitioned from 200 virtual visits per day to 3,000, with 90 percent of all visits completed via telehealth and 70 percent of patients with previously scheduled visits able to keep their appointments. 

“From day one, we said, ‘Let’s not ignore the non-COVID patients,’” Hollander says.

DISCOVER: Learn how organizations deliver telehealth to rural and high-risk patient populations.

Preparing for the Future of Telehealth

Despite the ongoing momentum, experts agree the current state of telehealth use will change post-COVID-19. The HIPAA waiver will expire, meaning that health systems won’t be able to use consumer products such as FaceTime and Skype for video visits. (Microsoft Teams and Zoom for Healthcare are HIPAA-compliant.)

Insurance coverage is another unknown. What had previously been an “ongoing and slow process” to changes in reimbursement will likely continue, Lennox-Miller says, especially now that Medicare is on board. 

Understanding that landscape is important for assessing future telehealth investments, Hollander says.

“A lack of guidance on what will live afterward makes it hard to do builds in the platform that are not related to patient care,” he says, citing the example of being able to determine in real time whether a patient’s insurance covers on-demand telehealth visits. 

Experts say the low-volume days for telehealth are over. Even if yearly volume drops by 70 percent from the height of the COVID-19 response, it’s still “millions more appointments,” Lennox-Miller says. 

Plus, telehealth is now a core part of what health systems do. “Even if the reimbursements weren’t there, we still would have done it,” says Mattis, of Orlando Health. “Our mission isn’t just the margin. It’s to take care of patients.”