Experiences of Informatics Health Care Workers Redeployed to Provide Telehealth in a Coronavirus Disease-Screening Hub
Background
In March 2020, our health system responded in several ways to the coronavirus disease 2019 (COVID-19) pandemic in the United States. In addition to many operational changes necessary to ensure patient and team member safety, our health system established a virtual care COVID-19 screening hub within 24 h of Indiana’s first case of COVID-19 to provide free screenings to the public using telehealth platforms and provide connections when needed to access appropriate in person care.
To meet the clinical needs of this service, the virtual health team recruited team members with nursing clinical backgrounds and licenses, which included team members from the clinical informatics department. Clinical informatics is a specialty that requires additional training and experience beyond the primary clinical licensure of health care workers.1,2 Gardner et al.1 describe the physician specialty as the intersection of the health system, clinical care, and information technology and communication systems. Owing to the operational pressure needed to respond to the pandemic, our clinical informatics teams were recruited to practice as nurses in the COVID-19 screening hub.
With the need to adjust quickly to changing clinical guidelines from the local, state, and national level, as well as the need to learn a new system for providing virtual visits, clinical informatics team members provide a unique perspective on the skills required to rapidly adapt to telehealth. Given their background and additional skills in informatics and technology, they also provided valuable insights that informed process and technology during the study dates.
The primary objective of this study was to delineate areas for improvement for sustaining existing operations in the virtual care COVID-19 screening hub, as well as to inform future expansion for clinical team members looking to develop skills in providing virtual care.
Methods
Operational Logistics
Initially, telehealth services were provided based at a physical location in Indianapolis. As the volume of screening visits grew and the necessary workforce expanded, the health system provided clinical team members with equipment to do the virtual care screening remotely from their homes to allow for social distancing. The virtual care COVID-19 screening was provided free of charge to the patient and was conducted on the system virtual care platform and electronic medical record (EMR). Patients were able to access free COVID-19 screening through the health system app on a smart phone or desktop, and then connected for a video telehealth visit.
Clinical Operations
Team members providing telehealth in the COVID-19 screening hub assessed the patient using a series of protocols and accompanying scripts devised from state and federal sources such as the Centers for Disease Control and the Indiana State Department of Health and approved by clinical leaders for the health system. Based on the protocols, their risk, and symptoms, patients were advised to quarantine, offered anticipatory guidance, referred for further evaluation (either with a virtual provider visit or in person), or referred for emergency care depending on their level of symptoms identified in the screening.
Team members were oriented by other team members trained in telehealth. Daily huddles and weekly team meetings were held during the initial phases of support, and updates to protocols and scripts were managed on a secure system tool (Microsoft Teams®). The other primary systems utilized were the system EMR and virtual care platform (for video connection to the patient).
Survey Evaluation
The survey for clinical informatics team members was developed based on identifying roles and stressors, overall satisfaction with training and support, and gathering free text responses from team members. Institutional Review Board was reviewed and deemed nonhuman subjects research. The survey was administered to eligible clinical informatics and clinical information services (IS) team members using an e-mail link and was open for 3 weeks.
Results
Over the course of 90 days (March 1, 2020 to May 23, 2020), 76 clinical informatics team members served 12,407 h of clinical service in the virtual care COVID-19 screening hub. Sixty-four out of 76 (85.3%) of eligible team members responded to an eight-question survey, which included a free response on their favorite and least favorite aspect of providing virtual care.
The majority (82%) of the participants were nurses with a range of clinical backgrounds as well as a range of current clinical informatics responsibilities ranging from educator, to analyst, to project manager. The majority were also primarily based in Indianapolis (60.9%) or within a 1-h drive (15.6%); however, 23.3% lived >1 h away from Indianapolis.
In general, team members felt prepared, with 57% (n = 44) strongly agreeing or agreeing that they had adequate technical training. The majority also felt confident providing advice to patients, with 13.3% (n = 8) strongly agreeing, and 55% (n = 33) agreeing. The distribution of feeling prepared with the adequate clinical protocols was more evenly split (Fig. 1).
Fig. 1. Respondents commenting on participant feelings of readiness.
Respondents consistently endorsed feeling supported by their primary team, their direct leader (i.e., their manager), and the virtual care team (Table 1).
| QUESTION | STRONGLY AGREE, % (N) | AGREE, % (N) | NEUTRAL, % (N) | DISAGREE, % (N) | STRONGLY DISAGREE, % (N) |
|---|---|---|---|---|---|
| I felt supported in providing virtual care by my primary team | 41.67 (25) | 41.67 (25) | 10 (6) | 6.67 (4) | 0 (0) |
| I felt supported in providing virtual care by my manager | 51.67 (31) | 31.67 (19) | 11.67 (7) | 3.33 (2) | 1.67 (1) |
| I felt supported in providing virtual care by others in the virtual care hub | 38.3 (23) | 53.33 (32) | 6.67 (4) | 1.67 (1) | 0 (0) |
Regarding questions on whether the respondents would want to have more training, the responses were evenly split between yes (32.76%), no (36.21%), and neutral (31.03%), and respondents were generally positive for providing future virtual care (Fig. 2).
Fig. 2. Respondents commenting on likelihood of providing virtual care in the future.
More than 85% of respondents (n = 50) responded that the work in the virtual care COVID-19 screening hub made them feel connected to the mission and values of the health system.
Respondents were also provided free text fields regarding their personal comments of providing telehealth in the COVID-19 screening hub. The comments were reviewed for specific keywords and themes, as seen in Figure 3a for the challenges, and Figure 3b for the “favorite things about the virtual care work.” The most common stressors were the rapidly changing COVID-19 protocols and gaps in communication. The favorite parts of the effort were alignment with the system values of teamwork and purpose, the chance to work with patients and reassure them, and also helping during a crisis.
Fig. 3. Shows respondents’ comments on the challenges (a) and the most rewarding or favorite part of the experience (b).
Discussion
Telehealth During COVID-19: Rapid Adoption Provides an Opportunity to Learn and Experiment
Despite evidence that proceeded COVID-19, integration of telehealth into clinical practice was limited before 2020 in the United States.3 A systematic literature review in 20164 revealed that clinician behaviors have been studied across many settings and revealed common themes for success that have only been enhanced since the widespread adoption driven by the COVID-19 pandemic: perception of the utility of telehealth, differences in communication (compared with in person visits), reliance on visual cues by provider to build rapport and confidentiality and privacy.
In this study, we had the opportunity to gain valuable input from team members with two unique characteristics: additional training and skills in health technology and the immersion of a novel virtual screening hub to serve a statewide population provided at no cost to the patient. The necessity of establishing this virtual screening hub required unprecedented speed for establishing protocols, training on both equipment and clinical protocols, and the need to rapidly iterate and improve the support for the clinical team members providing virtual care. Clinical informatics team members responded that the rapid changes in workflow in the screening hub was a major stressor. Some comments also provided insight that the rapid expansion from the central location into remote workspaces made it difficult to use the “traditional” workflow support for technology implementations.
Virtual Care Skills: Best Practices “Web-Side” Manner
One challenge was the lack of an established infrastructure or training that could be leveraged quickly for large groups of nurses. This was highlighted as one of the most common challenges identified by team members on our survey. The associated skills and training for clinical workers providing telehealth has not been well defined, based on Edirippulige and Armfield review of the literature in 2016 found only nine articles with limited scope to establish guiding principles for this skill set.5 Chike-Harris et al. in 2020 fared similarly, identifying eight articles regarding the integration of telehealth education into the health care provider curriculum.6 Some studies have demonstrated that application of quality improvement cycles of plan-do-study-act coupled with didactics have been effective.7
As of yet, the literature does not reflect widely the “skills” of establishing rapport and trust while providing virtual care. In fact, one study showed that patient trust in telemedicine depended on the technology itself—even more than the trust in the provider, the treatment, or the organization.8 Other studies have shown that it may be the specialty or service that correlates to efficacy—for example, O’Reilly et al. studied efficacy of face-to-face and telepsychiatry services in a randomized control trial and both groups showed high patient satisfaction.9 However, at this point, in a meta-analysis of telemedicine in doctor–patient communication, Miller stated that “there is, in fact, little agreement beyond the assertion that doctor-patient communication using telemedicine is different.”10
Although not formally studied, some basic tips on staying patient centered while using technology are standard provisions for many virtual care software groups, in the medical literature9 as well as in the lay media citing the new “web-side” manner as an extension of the “bedside” manner.11–13
In this COVID-19 screening hub, training for team members included the protocols and scripts, as well as job aids and observation of the technology setup, and basic advice on team member standards and appearance when providing telehealth. These resources can extrapolate from known recommendations from the literature. For example, eye contact has been described as a critical part of nonverbal engagement in a clinical encounter.14,15
In our survey, we specifically surveyed redeployed clinical team members with additional information technology training. These health care workers specifically working in clinical informatics analyze workflows, implement health technology, and also train others health care workers on new technologies. As “technology challenged” staff have been identified as barriers to adoption in other studies,3 strengthening our original plan of integrating clinical informaticians into the support for this new workflow in virtual care. Of interest, the screening hub has continued for an additional several months with support from clinical informatics, including an optimization effort to apply what has been learned and improve efficiency.
Conclusion
Team members with clinical informatics training who were rapidly deployed to support a telehealth hub to help screen for COVID-19 symptoms provided unique insights to the training and support for clinical operations. They reported mainly positive experiences and remarked on the sense of purpose and connection. Generally, those who participated said that they would serve again in the virtual care role. Operationally it was extremely challenging for the group to sustain and support both the clinical need of the virtual care hub and their informatics and IS roles. This experience gave important insight on the most effective ways to mobilize an emergency virtual care workforce, the effective use of clinical informatics expertise for continuous improvement and helped establish priorities during the process of establishing a decentralized telehealth response.
Our health system, similar to many, is establishing telehealth for as an ongoing part of operations post-COVID-19. Direct outcomes of the success of the screening clinic are additional new clinical positions for expanded programs of remote home monitoring as well as ongoing on-demand telehealth visits. COVID-19-specific support also continues. The findings of this survey help inform and advise both the recruiting and training of these new roles, with the goal of providing ongoing engagement and satisfaction with the work, as well as continue to establish and improve the role of a virtual care provider in the future.
Authors’ Contributions
E.C.W. conceived the research idea. E.C.W., K.W., H.L., and M.S. contributed to the design and implementation of the research, to the analysis of the results, and to the writing of the article.
Acknowledgments
The authors thank the Indiana University Health virtual care team and clinical informatics and clinical information services teams for their participation. The authors would like to thank Ian McDaniel, Lori Stark, and David Kogan for their collaboration.
Disclosure Statement
None of the authors have any disclosures.
Funding Information
This study was not funded.
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