Medical Undistancing Through Telemedicine: A Model Enabling Rapid Telemedicine Deployment in an Academic Health Center During the COVID-19 Pandemic

Introduction

Academic health centers (AHCs) offer highly specialized clinical care and technologically advanced diagnostic/treatment modalities for their communities while serving a key function as regional health care partners.¹ The community looks to AHCs as leaders with the expectation that they can offer innovative ways to provide health care.

Telehealth is defined as technology-enabled health and care management and delivery systems that extend capacity and access.² Currently, this is generally represented by the use of Health Insurance Portability and Accountability Act (HIPAA)-compliant, secure, two-way audio and video technology (and/or imaging access) for patient care. In many areas, telemedicine is used to bridge the gap between care needs and provider availability where physical travel is restricted by time constraints or risk to participants. For example, in emergency stroke management, time is critical and treatment is contingent on rapid specialist evaluations.^3,4

The use of telemedicine in times of emergency is well documented.^3–5 At present, the world’s population is being threatened by the COVID-19 pandemic. What started as a few cases in Wuhan, China, has grown exponentially and spread to the rest of the world.^6,7 Initial containment strategies have been replaced by requirements for social distancing to flatten the curve.^8–10 AHCs have rushed to adapt to the unintended patient care consequences that were a result of social distancing. These consequences include restrictions to health care provider access to patients and ability to provide care with the same models available before the pandemic. Postponement of procedures also created challenges to health care systems and imposed burdens on patients whose health depends upon treatment that is delayed.¹¹

The implications of safety in patient contact have resulted in reduced medical student participation in care, reduced resident and fellow staffing of clinical rotations, and increased use of personal protective equipment, causing critical shortages. Telemedicine can help restore important patient care experiences and mitigate shortages of essential supplies. Clinical specialties that have had a historically strong foothold in telemedicine have now transitioned to telemedicine-only platform solutions.¹² In addition to video, the use of wearables (devices that can collect medical information when worn by patients) has potential to improve care.¹³ Despite the current crisis, the pieces are in place to counteract social distancing with medical undistancing through telemedicine, using technology to put providers back into contact with their patients while ensuring the safety of all involved.

Materials and Methods

University of California San Diego Health Enterprise Telemedicine: Prepandemic

University of California San Diego Health (UCSDH) has a long history of performing telemedicine, but our deployments were largely focused on the AHC as the core resource in a hub-and-spoke model of delivery. Essential telemedicine elements (Tele-Ments) for setting up the telemedicine infrastructure were in place before this pandemic.¹⁴ Our telemedicine infrastructure included providing large-scale care to spoke centers through services such as telestroke and telepsychiatry to remote centers in need of hyperacute, acute, or routine consultations. Up to 15 service lines had been deployed in the past 10 years.

Before the pandemic, our health system had been working through small-scale pilot deployments for home telemedicine needs where providers desired to use telemedicine to care for patients in the home setting. Twelve service lines had some experience with home telemedicine before the COVID-19 outbreak. Experience was limited, amounting to only 870, ambulatory, home telemedicine video visits in the prior 3 years. With this pilot foundation in place, we were positioned to leverage that experience to rapidly build out required elements necessary for implementing enterprise-wide telemedicine in the pandemic.

Electronic Health Record and Telemedicine Systems

UCSDH implemented an electronic health record (EHR), integrated, video visit solution several years ago, but had not scaled the deployment. We chose a mobile-to-mobile “bring your own device” solution for our providers to access and use the EHR and other video visit solutions, which allowed providers to start conducting video visits as soon as they were trained. Most providers use iPhone operating system-based mobile devices, and some clinics elected to purchase iPads for provider use. The Information Services (IS) team partnered closely with these areas and deployed devices within days. Using a quick response code posted at a standard, internal, URL internet address, devices could be quickly configured to UCSDH standards.

UCSDH also worked with our software vendors to increase concurrent license capability and enable multiparty video visit capabilities, both of which were important to support trainee participation. We found that the vast majority of our patients were aware of using video for two-way communication and possessed the appropriate devices to do so.

Telemedicine Governance, Operations, and Leadership Infrastructure

The telemedicine governance model consists of a Telemedicine Executive Board, a Telemedicine Steering Committee, an Operations and Strategy Committee, and a set of organizational telemedicine policies and procedures. We recommend creating focused work groups and regular report-outs to leadership to ensure that a telemedicine program operates smoothly and remains focused on its goals. This governance structure proved to be essential to the success of our rapid telemedicine expansion. Our success goal, in response to this pandemic, was set to convert 50% of our ambulatory visits to virtual care. Expectations were made realistic by leadership as many patients require in-person care.

Operational Pandemic Teams

The complete list of essential operational elements and pandemic team roles is detailed in Table 1. Having representation from each process area allowed effective cascading of information and direction from organizational leadership. These included the legal, risk, compliance, IS, physician group, human resources, Telehealth Program Director, Medical Director for Enterprise Telemedicine, School of Medicine Department leadership, learning center, provider and patient educators, and revenue cycle team members, as well as medical staff office (MSO) and graduate medical education (GME) office leads. Members in each area focused their efforts on overcoming challenges to the rapid deployment of broad telemedicine capability.

Recently, numerous federal regulatory restrictions on telemedicine care have been suspended, and state-specific laws have been put into effect. These changes removed limitations regarding reimbursement for telemedicine, allowed expansion to patients who are new to the organization, and lifted restrictions that had limited telemedicine use only in rural areas. Our legal, risk, and compliance and privacy departments efficiently reviewed these changes and provided appropriate guidance to the telemedicine deployment team. Front-line personnel could find the latest guidance on these topics at a newly created, online, telemedicine resources website.

To quickly train users on telemedicine workflows, training modules for providers and schedulers were created and posted on our internal-facing, online, learning management system. We deployed ambulatory trainers to clinics with highest virtual appointment volumes for onsite rollout support. Our provider educator team was leveraged to educate providers on appropriate billing processes for telemedicine encounters. Nurses, clinic staff, and volunteer medical students educated patients on how to access and participate in video visits. An all hands on deck approach by the organization was vital to the success of our telemedicine rollout.

Tele-Sprint Command Center

UCSDH already had in place an ambulatory optimization team (Sprint) to improve workflow and technology issues in the clinic setting. As part of the plan for broad deployment of telemedicine capability, a Tele-Sprint team was created, and a Tele-Sprint Command Center for post go-live was established. The command center included administrative and physician operational leadership, an IS director of web services, operational and IS experts in telemedicine (with knowledge of EHR and video application setup), a scheduling trainer, help desk representatives, and various administrative leaders within the AHC.

The command center operated on weekdays from 7:30 AM to 5:30 PM and provided a videoconferencing virtual room to allow remote communication with the command center. Daily debriefings allowed prompt updating of websites, tip sheets, educational plans, and organizational communications related to telemedicine efforts. Help desk support remains available 24/7/365 through the help desk, and the command center hours are modified upward or downward depending on enterprise needs.

Provider Tools and Training

Specific tip sheets and checklists were developed for providers wishing to use telemedicine (Fig. 1 shows a sample provider checklist). We created and disseminated training documents for schedulers and educated schedulers on how to create the appropriate telemedicine visit types in the EHR. Education for helping patients navigate video visits was also provided, and patient-oriented tip sheets and videos were created. Within the first 7 days of our telemedicine rollout, all providers and staff, enterprise-wide, were offered live video training sessions with physician telemedicine champions through group videoconference. Specific departments requested and received training as well. Finally, group training was offered for department trainees when requested, allowing their participation in patient care. Over 1,000 users were educated in the first week of deployment.

Although waivers have been put in place regarding the need for obtaining consent for telemedicine evaluations, and HIPAA-compliant telemedicine systems are utilized to protect patient privacy, our enterprise’s best practice is still to obtain verbal consent (and/or through the conditions for treatment documentation method for inpatient care) from the patient regarding the risks, benefits, and alternatives to telemedicine evaluations and the inherent risk of potential loss of confidentiality as sensitive patient information may be transmitted over the internet. Providers document a verification of consent in their clinical notes. Training sessions on privacy, consent, and charting best practices are all included in the enterprise training rolled out to our hub-side providers.

Patient Education and Support

In our rapid expansion to virtual care, the care team was encouraged to call the patient and inquire whether they had a patient portal account and smartphone capability. If so, patients were given verbal and written information on how to download the application as well as access to support if they were encountering challenges. For patients needing additional support, a volunteer medical student pool was trained on patient processes to aid clinic staff in outreach efforts.

We assessed the highest risk patients from our Accountable Care Organization, defined by the chief medical officer for population health, to ensure these patients were properly set up for any video visit needs. This allowed us to proactively set up patients before appointments and offset the overwhelming influx of calls to our support line. Instructions were given to patients to verify they had internet access (wired or wireless, as per patient preference) and on how to test the system. Internet was not provided to the patients by our institution. Fifteen minutes before the appointment, clinic staff were encouraged to call and confirm the appointment and ensure the patient was using the correct application.

Billing and Credentialing

One of the most important aspects of provider education is guidance regarding optimal billing practices. As changes in legal and regulatory requirements related to telemedicine continue to be issued, our revenue cycle and provider educator teams have assisted with developing standardized language for providers to include in the telemedicine visit documentation.¹⁵ This standardized guidance has been added to tip sheets for providers and posted to our online telemedicine resources page. At the time of this writing, both video visit codes (new visit 99201–99205, consult 99241–99245, and return visit 99211–99215, but with the additional applied GT modifier, signifying synchronous audio/video technology) and telephone visit codes (99441–99443) are being used.

Although new privileging and credentialing processes are not strictly required to start performing telemedicine, some credentialing bodies and good clinical practices encourage a standard organizational approach to ensure that providers are properly trained in telemedicine workflows. We require our providers to review the online learning, management telemedicine modules before conducting video visits and attest to having reviewed our organizational telemedicine policies and procedures. Adherence to these requirements is tracked by our MSO and GME offices for staff and trainees.

Organizational Telemedicine Deployment

UCSDH’s initial plan was to limit telemedicine deployment to patients infected with or being tested for the novel coronavirus, and the rollout was to be completed one provider or clinic at a time based on prioritization. As the extent of the COVID-19 pandemic became apparent, we reassessed this initial strategy and moved to rapid enterprise-wide deployment. In addition to the logistical efforts described above, the organization decided to make available a set of standardized telemedicine tools that any provider or clinical area could use. While this approach required a short-term increase in need for IS resources, once standard tools were in place, a rapid deployment throughout UCSDH was possible. Initial deployment was to early adopters and department leaders, with quick expansion to all faculty members, and then other practitioners and trainees after attending the training described above.

More recently, the need for inpatient telemedicine capability has also been identified. UCSDH had previously deployed iPads to inpatient rooms, meaning that a telemedicine-capable device was already available to all hospitalized patients. Within a week of the identified need, a standard approach to inpatient telemedicine visits was also implemented. Other recent enhancements include multiprovider access to outpatient video visits (allowing faculty, trainees, and multidisciplinary teams to participate in the remote care) and video interpretation services. At all times, it is left to the discretion of the care practitioner and the patient to determine whether a clinical encounter could be conducted using telemedicine or whether in-person care is required.

Communications Strategy

UCSDH prioritizes transparency and communicates frequently with frontline providers and staff. At times of national disasters or pandemics, clinical situations are dynamic and new information is available multiple times per day. Organizational leadership and our enterprise command center conducted huddles several times each day. Information was distributed to providers and staff by e-mail multiple times a day, during daily afternoon debriefings, and through the UCSDH intranet site in real time. This communications infrastructure has allowed our rapid telemedicine deployment to be well communicated, quickly adopted by end users, and sustained with regular use.

Results

Our organizational goal was to convert 50% of our ambulatory care visits to virtual care (preferring video visits over telephone visits). Early on, we engaged our enterprise operations and reporting teams to develop the appropriate metrics and reports that could be used to track the extent of telemedicine use and the types of telemedicine visits conducted. Results within the first week of our enterprise rollout are noted in Figure 2a and b. Within 4 days of forming the Tele-Sprint Operations Teams, 698 providers were trained and >1,000 clinic appointments were scheduled (Fig. 2a). Within the first 4 days, 1,961 video visits were completed (compared with our total enterprise video visit experience of 870 ambulatory visits in the prior 3 years) (Fig. 2b). In the first week, 1,111 providers completed their online training modules. On day 6, our daily telemedicine visits (997 video visits +289 telephone consults = 1,286) surpassed our in-person visit totals (1,178) with preservation of total visit numbers overall (total visits = 2,464). On day 7, we totaled 1,071 video visits +297 telephone consults = 1,368.

Our providers are adopting this technique based on provider-determined need. The most active providers are completing >20 video visits per day, while many departments perform >50 cases per day. At the end of this first week’s rollout, 45.8% of our ambulatory care visits were being conducted through video visit (58.6% if telephone is included). Over a 5-month period, the enterprise has since conducted over 119,500 ambulatory telemedicine evaluations (a 1,000-fold rate increase from the pre-COVID-19 time period).

Discussion

Our historical experience with telemedicine positioned us to rapidly deploy an enterprise telemedicine solution in both the ambulatory and inpatient care environments during the COVID-19 pandemic. We successfully converted over 50% of ambulatory care visits to telemedicine to help medically undistance health care providers and patients while maintaining the core necessity for social distancing during this pandemic. In addition to providing important clinical care and training, telemedicine improves clinical providers’ ability to triage in-person care and maintain access. This has relevance to patient care, training, and education, contributing to the financial stability of the organization.

As this is a real-world rapid implementation, limitations and challenges were significant. Our enterprise was only somewhat prepared for the scale and scope of transitioning decades of practice from bedside to virtual visits. Educating hundreds of providers of different types and practice scope was difficult. Attempting group training was successful, but having tips and tricks documents ready and updated regularly proved to be critical. We required providers to complete training and have this documented by our MSO and GME teams to ensure that best practices are followed. This was critical as delivery of care through telemedicine was new to most of our providers.

The changing landscape of billing and removal of numerous legal restrictions took multiple resources to continually digest and create dynamic policy. Procedures for developing workflows for when telemedicine systems should be used and when in-person assessments would be necessary continue to be modified as new data and use cases develop. In the inpatient arena, workflows related to converting bedside care for COVID-19 or at-risk patients require dedicated clinical and IS teams to develop robust practices.

Recent focus has been placed on incorporating telemedicine as part of a global, COVID-19 outbreak response system.¹⁶ Our aim is to strive to this end by offering potential best practices of defining success, setting goals, providing provider support and guidance, and ensuring safety while preserving security and confidentiality. The importance of a clear organizational goal for telemedicine cannot be overstated. Ensuring technical security while enabling patient access to care through telemedicine is vital. Setting realistic expectations and maintaining a proper balance between telemedicine and in-person care, based truly on patient needs, must occur.

Over the long term, we intend to measure patient satisfaction, assess specialty-specific clinical outcomes, and assess how this substantial telemedicine deployment has affected provider practice patterns in terms of persistent use of telemedicine after the current crisis. We will want to assess whether telemedicine reduces the need for physical supplies (e.g., masks and gowns) that would normally be needed in face-to-face clinical encounters and whether telemedicine can improve the system’s capacity to serve patients by reducing the need for mild cases to be seen in EDs with limited resources. Future pandemic directions are difficult to predict. We hope that the UCSDH strategy for rapid telemedicine deployment can serve as a model for other AHCs during this COVID-19 pandemic or in other similar situations in the future.

Acknowledgments

The authors wish to thank the UCSDH System leadership for their support in this enterprise-wide telemedicine initiative and would particularly like to acknowledge Patty Maysent, Parag Agnihotri, MD, Dennis Price, Laura Handy-Dineen, Susan Guidi, Connie Eckenrodt, Kendra Ramada, Tyler Cowart, Lydia Ikeda, Will Sutherland, Jeffrey Schlosser, Venktesh Ramnath, Jessica Thackaberry, Sarah Suskauer, Gabrielle Wilson, Steve Koh, Belinda Hein, Cheryl Wagonhurst, James Killeen, Thomas Savides, Precious Presto, Christine Thorne, Stephanie Brooks, Emily Perrinez, and Leticia Aguilar.

Disclosure Statement

No competing financial interests exist for any of the authors. C.J.K., MD, has no conflicts related to this article. His only health care conflict is stock ownership in Stratify Genomics. A.M.S., MD, has received a contribution from EPIC for a Population Health Boot Camp in 2019. She has no direct financial disclosures related to this work.

Funding Information

No funding was received for this article.

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