Case Study

How a Physician Group Rapidly Deployed a Successful Telehealth Program in Response to the COVID-19 Pandemic

AMGA COVID-19 Resources
 

May 12, 2020

This case study was prepared by Scott Hines, M.D., Chief Quality Officer at Crystal Run Healthcare, an independent multispecialty physician group in the lower Hudson Valley of New York State.

There has been much speculation on what would be the next disruptor in health care. Wearable devices? Minute clinics? Nontraditional participants such as Amazon and Google? It turns out that the greatest disruptor came from something no one saw coming: COVID-19. Unprecedented calls for social distancing and cancellations of elective procedures have left medical practices with fewer patients and reduced revenue. However, patients still need routine and urgent care despite being told to stay at home. After years of slow adoption by providers and patients, telehealth’s moment has arrived.

Crystal Run Healthcare, an independent multispecialty group consisting of 450 providers across the lower Hudson Valley of New York State, successfully launched a telehealth program in seven days and is now averaging 1,800 visits/day after just four weeks. Here’s how we did it.

A Burning Problem
Early communication with providers regarding the potential impact of COVID-19 on daily operations revealed the need for alternative methods to provide care. Despite a 50% reduction in office visits, the 75,000 patients that see us each month still have routine and urgent needs that must be met. Telehealth was promoted as the best mechanism to do so. Providers could either choose to adopt this new technology quickly or their patients’ needs would be met by someone else.

Choose a Platform
We decided to invest in a platform that is HIPAA-compliant (Zoom) despite the Department of Health and Human Services (HHS) waiving this requirement. We did so because it would allow us to continue providing telehealth services after this waiver expired. We also required all of our providers to use the same platform so that standard workflows could be developed. An additional feature important to us was a “virtual waiting room” that allows queueing of patients. This has been essential to our scalability and allowed some providers to maintain their pre-COVID productivity.

Choose a Team
Essential members of our team included IT, nurse educators, and coding/billing specialists. IT issued and activated licenses and made necessary EMR template changes. Nurse educators assisted in developing and disseminating standardized workflows to the clinical teams. Coding and billing specialists created easy-to-follow coding and documentation instructions for both audio-visual (AV) telehealth visits and telephone check-in visits.

Short-Term Pilot
Part of the challenge in launching a successful program was adapting the usual in-office workflows to telehealth over the course of just a few days. For this to happen, we launched a pilot with a handful of providers from primary care, medical specialties, and surgery who were tolerant of change. The weeklong pilot identified challenges that needed to be addressed prior to spread across the organization. Examples included the creation of a virtual check-in and rooming process, scheduling follow-up appointments, and dealing with technical glitches such as audio and video connections.

Rapid Spread Requires Standard Work and Assistance in Real Time
At the conclusion of the week long pilot, a final workflow was developed and shared with providers through webinars and email communication (Figure 1). Asking providers to adapt to telehealth while continuing to see some patients in the office is challenging both technically and operationally. To assist with the technical challenges, an IT Command Center was established for synchronous assistance and a “Telehealth Help” email group consisting of IT, educators, and billing/coding specialists was established for asynchronous assistance. To address the operational challenges, a Telehealth Super User Team, consisting of nurses and medical assistants, was established in each of our buildings. This team, which was previously leveraged for EMR upgrades, became expert in our telehealth workflows and circulated throughout the day to support struggling clinical teams.

Figure 1: Crystal Run Healthcare Telehealth Workflow

Crystal Run Healthcare Telehealth Workflow

Communicate, Communicate, Communicate
The need for frequent communication with providers, staff, and patients cannot be overstated. We have been hosting twice-weekly webinars where IT, educators, and coders review technical efficiencies, clinical workflows, and documentation requirements. Half of the meeting is dedicated to question and answer; a rolling FAQ was created and posted on the intranet.

Just as important as internal communication is external communication with our patients. A month ago, telehealth did not have a presence in our region, so patients were unfamiliar with the concept. An outreach team was deployed to contact patients with appointment cancellations. The benefits of telehealth were emphasized, such as the ability to connect patients and providers in the comfort and safety of home, that most health issues were amenable to telehealth, and that most insurers were waiving telehealth copays. On the technical side, instructional pamphlets and videos walking patients through downloading the app and joining a meeting were posted on our website and social media sites.

Setting Goals and Transparent Data Sharing
We are aiming to reach 2,200 telehealth visits each day in order to meet our initial goal of replacing 50% of lost office visits with telehealth visits during the pandemic; to date we are at 30%. We track our progress at the practice, specialty, and provider level and share this data daily (Figure 2). Transparent data sharing creates a competitive spirit between and among specialties and allows clinical leaders to focus on areas where adoption is lagging.

Figure 2: Telehealth Visits by Practice and Specialty

Practice Level

Telehealth Total by Day

Top 15 Specialties Based on Number of Telehealth Visits*

Specialty

Avg. Telehealth Visits/Day

Avg. Total Visits/Day (Office + Telehealth)

Percentage of All Visits Due To Telehealth

Family Practice

299

691

43%

Internal Medicine

270

610

44%

Cardiology

89

244

37%

Endocrinology

85

186

45%

Pediatrics

81

278

29%

Gastroenterology

75

148

51%

Neurology

66

151

44%

Psychiatry

54

124

43%

Pulmonology

54

78

69%

Hematology/Oncology

40

153

26%

Pain Management

35

90

39%

OBGYN

32

184

18%

Rheumatology

32

74

43%

Urology

29

83

35%

Dermatology

19

67

28%

*Measurement Period 3/23/2020 through 4/17/2020

Telehealth Provider Champions
Each specialty identified a Telehealth Provider Champion, who briefly huddles with their colleagues twice a week to promote utilization, identify new efficiencies, and create specialty specific use case scenarios. Examples of specialty specific telehealth opportunities are listed in Figure 3.

Figure 3: Specialty Specific Use Case Scenarios for Telehealth

Specialty

Use Case Scenario

Allergy

Asthma evaluation and reassurance during COVID

Bariatric Surgery

Weight loss counseling/adherence to diet

Cardiology

Congestive heart failure follow-up

Dermatology

Rashes, post-procedure follow-up

Endocrinology

Poorly controlled diabetes

ENT

Laryngopharangeal Reflux (LPR)

Gastroenterology

Colon cancer screening pre-procedure consult

General surgery

Post-operative check

Neurology

Migraine management, seizure management

OBGYN

Family planning, frequent UTI, vaginitis

Oncology

Survivorship visits

Orthopedics

Osteoarthritis

Pain management

Efficacy, safety, and refill of pain medications

Pediatrics

Seasonal allergies

Primary Care

Efficacy & safety of newly prescribed medication

Psychiatry

Anxiety and depression

Pulmonology

Asthma evaluation and reassurance during COVID

Rheumatology

Arthritis follow up

Urgent Care

COVID testing results and counseling

Urology

Erectile dysfunction

What Will the Future Hold?
The rapid growth in telehealth at Crystal Run and elsewhere would not have been possible without waivers allowing telehealth to be provided in non-rural settings and from patients’ homes. The past month has shown us that this technology can provide revenue, increase access, and improve health by making care more convenient. We hope that regulators and payers will continue these waivers after the pandemic ends. If so, next steps would include measuring clinical outcomes and patient satisfaction to compare telehealth with traditional in-office care. Such studies should be what determines the future of telehealth in our healthcare system.

Advertisement