“Telemedicine is a game changer—it’s going to change the way we practice medicine.
Truly ‘life changing medicine’ as UPMC says.” –Jaishree Hariharan, MD
Telemedicine in Outpatient Care
Though the way care is delivered has changed a lot in the past month, UPMC General Internal Medicine (GIM) has been paving the way for telemedicine since last fall. Prior to March, about 10% of outpatient care was completed via telemedicine. Uptake initially was slowed due to questions of insurance company reimbursements, but UPMC was on the forefront, covering telemedicine visits as of December.
Now, with telemedicine being more of a necessity than an option, COVID-19 has rapidly pushed telemedicine volume to 90% of outpatient clinical care as of mid-April.
A few changes needed to happen quickly to help limit the number of face-to-face outpatient clinic visits. First, webcams were installed in all physician offices and a few clinic rooms as well. Then, the front desk check-in team, truly instrumental in making the transition successful, began calling patients to see if upcoming appointments could be converted to telemedicine visits.
“The past few weeks have shown us that we have the ability to do telemedicine on a grand scale. This will change the way we deliver medicine in the future. I don’t think we’ll be going back to the way things were. There will be some significant component of telemedicine that will continue,” said Zach Lenhart, Senior Director of Clinical Operations for the Department of Medicine, who has been integral in rolling out telemedicine within the division as well as in the department of medicine broadly.
The telemedicine process was developed collaboratively amongst the clinic care team, with a routine that mimics in-person visits. Medical assistants do intake by video or phone: entering vitals, medication records, and chief complaint. Innovation driven by the medical assistants established a system for switching a color notification to virtually indicate that the initial intake history was completed, and the patient was ready for the physician visit.
“It’s amazing how the clinic team—schedulers, check-in, check-out, nurses, medical assistants—all came together,” said Dr. Jaishree Hariharan, Resident Clinic Director at GIM Montefiore clinic who worked closely with Dr. Gary Fischer, Medical Director of the GIM clinic, in getting telemedicine up and running. “Everybody did their part.”
The new residents who started in GIM during this transition were quickly initiated into the way health care is changing due to COVID-19. For their first week, they primarily did phone visits. A major focus was on establishing an efficient workflow and comfort with the new process for quickly gaining experience with telemedicine. Residents demonstrated adaptability to moving between in-person clinic visits and phone or video telemedicine as needed.
Outpatient telemedicine visits are popular among patients, saving time and money. Lenhart described that through informal surveys, they have found it is saving patients anywhere from 1 to 3 hours, as some patients come from the middle of Pennsylvania, or even out of state. Feedback revealed additional benefits, such as allowing a family member in the home to also attend the visit or taking pictures of a rash to send directly to dermatology and place in the medical record.
Of course, part of the advantage of telemedicine is that it works well for certain problems just like an in person visit. The provider has access to patient medical record and medications. Blood work can be sent directly to the lab and prescriptions directly to pharmacies.
However, GIM will never be 100% virtual. There are patients that will still require physical examination for listening to heart and lungs or evaluating joint pain and swelling. Annual physicals, urgent visits, and pre-operation appointments may need to remain face-to-face. Right now, those visits are carefully screened to determine which are necessary.
Telemedicine in Inpatient Care
Whereas outpatient medicine was actively pursuing telemedicine prior to COVID-19, telemedicine is brand new to inpatient GIM, piloted in the last few weeks.
Though the incorporation of telemedicine in inpatient care has been an on-going consideration, the current environment necessitated changes. Specifically, telemedicine can allow the workforce to expand beyond who is in the hospital. Attendings who were quarantined due to COVID-19 exposure but remained health worked from home during quarantine. Telemedicine also helps to conserve personal protective equipment, as many patients require droplet or contact precautions, even if they are not COVID-19 positive.
The process was initially piloted by residents and APPs who would bring a device—such as a workstation-on-wheels (WoWs) equipped with microphones, cameras, and Microsoft Teams—to a new patient admission so that the attending physician can participate remotely in the history and interview of the patient, as well as witness the physical exam.
Other technology, such as Bluetooth stethoscopes, ease the transition. Dr. Gena Walker, Medical Director of Hospital Medicine at UPMC Presbyterian, said GIM recently ordered Bluetooth stethoscopes that will allow a physician to perform a physical exam remotely with the assistance of a telepresenter to listen to heart, lungs, and abdominal sounds.
When introducing the new process, residents and APPs use a script that incorporates guidelines for obtaining consent for telemedicine. This script ensures that the patients know there are attending physicians available if there is an issue that requires an in-person visit. It also provides reassurance that the same level of care will be provided: “This is not a shortcut, but actually an enhancement to the care the patients are receiving now,” said Dr. Walker.
Overall, patient feedback has been positive and supportive of the situation. So far, the only negative feedback was from a patient who wished that the first encounter with the physician was in person, as that would have made subsequent telemedicine visits more comfortable. Among providers, technology issues are the biggest hurdle. Documentation and billing logistics have been confusing but continue to improve.
“Many of us are accepting of telemedicine as what we will be doing going forward. It behooves us to do it, and to do it well. We will figure out how to best deploy telemedicine, knowing that we’ll be leveraging it in the future,” said Dr. Walker.
The Future of Telemedicine in GIM
GIM has found that post-discharge follow-up visits are one of the best uses of telemedicine. Whereas the goal was previously to see the patient within 2 weeks—which could sometimes stretch into a month depending on scheduling, transportation, and health condition—telemedicine technology allows follow-ups to be scheduled 2 to 5 days after discharge. Lenhart mentioned the possibility of seeing positive downstream effects from seeing a primary care provider so quickly, such as fewer patients being readmitted. Post-discharge follow-up is an obvious place that telemedicine has the potential to improve care and will therefore likely continue in the future.
Other types of visits that make sense to stay in telemedicine include medication checks or anxiety or depression visits. Dr. Hariharan described a scenario in which telemedicine would work especially well in referring a patient to a diabetic educator or social worker. Most of the work is already done on the phone and it would save the patient a return visit. Plus, video visits can be used to ensure patients are using proper at-home blood pressure techniques.
Even if the load reduces to 50% telemedicine visits in the future, that will have far reaching implications, such as reducing GIM’s physical footprint, reducing costs and rent and utilities. It would free up clinical space so that more procedural visits could be accommodated, for example.
However, it is important to continue to evaluate the effect of telemedicine on patients and providers. For Dr. Hariharan, a primary focus is maintaining quality: how can we ensure that labs are followed through and that patients receive the proper instructions, especially if they do not have My UPMC accounts to receive the information online? Dr. Walker raised a concern that “in this era where there has been an emphasis on getting physicians back to bedside as a remedy to physician burnout, I don’t want telemedicine to be a step in the wrong direction.”
Looking beyond the COVID-19 situation, GIM sees many ways in which the telemedicine lessons learned now will continue to benefit patients. For example, Lenhart talked about building a clinical pathway, or algorithm, for different types of diseases that would help map out what care could be done virtually versus in person.
Another future possibility for telemedicine that Lenhart described is a vision of telemedicine as a triage mechanism. If instead of scheduling with a specialist directly through the UPMC call number, the patient were to do a short 10-minute video visit with a nurse practitioner or physician assistant, the provider could take care of any of the patient’s immediate concerns and ensure that they are routed to the right specialty. For a change like this to be possible, GIM will need to work with insurance companies to see if they would be willing to waive patient co-pays for these types of visits. The patient would get a higher level of service from someone who can more appropriately triage, and the insurance company would save money from patients not going to unnecessary specialty care or emergency departments—benefits all around.
Telemedicine also may be able to ease the burden of unpredictable surges in patient volume within hospital medicine. Having remote physicians available to help would expand the workforce and keep the workflow going smoothly. There are models where one attending might cover two campuses–typically smaller community hospitals by participating in scheduled rounds with an APP virtually. Given the telemedicine experience GIM inpatient medicine has gained, these models could be replicated remotely.
“We don’t want to lose quality of care or the human touch of care that we value so much in the work we do every day,” said Dr. Walker. “Ensuring that everyone feels that they’re having a real connection and healthcare experience is going to be our next big challenge going forward.”