The Evolving Role of Telehealth

Episode Overview

• COVID forced health care organizations to adopt telehealth, and adopt it quickly. In the post-lockdown world, organizations are now looking at how they can continue to evolve telehealth. It is expected that the various telehealth platforms and EMR (electronic medical records) will continue to integrate the technology.  In the next five years, we will see the marketplace evolve to greatly improve operational efficiency.
• The shift to telehealth has provided primary care providers the ability to identify care gaps that they can close during the telehealth visit; alerts pop up on the screen to help providers in real-time, which leads to better outcomes for the patient.
• Large IT initiatives are expensive, complicated, and require buy-in. Adopters must be methodical, diligent, and patient with the approach. Converting to new telehealth models will take time and effort.

Transcript:

Daniel Marino: Welcome to another episode of Value-Based Care Insights. I'm your host Daniel Marino. In today's episode, we're gonna spend a little time talking about telehealth and the impact on telehealth in the provider community and in particular with physicians, and also with patients. Before COVID, telehealth was almost nonexistent, many health systems, as we all know, probably had an adoption rate of maybe 5%, if we were lucky. Then as COVID hit and we saw that we were really locked down, physicians had trouble connecting with patients, patients had trouble getting medical services from both hospitals and physicians, telehealth explodied. We went from probably a 3- 5% adoption rate to probably a 70-80% adoption rate, really over a couple of weeks. I know even within Lumina, we spent a lot of time talking with providers, helping providers with telehealth, we created a telehealth playbook to really help fuel that adoption. Frankly, it's been a really good thing for our healthcare industry on a number of fronts. Since then, we've seen telehealth slow a little bit, backtrack if you will, but many people and many providers, many physicians still believe that telehealth has a very strong place in our healthcare delivery model. I am very pleased today to have a wonderful guest Dr. Alan Kumar. Dr. Kumar is the chief medical officer of Community Healthcare System in Munster, Indiana. He participated in a wonderful article that was sponsored by HFMA, Healthcare Financial Management Association that was published in HFM magazine last month, May, 2022, as a matter of fact, and the title of that article is “Telehealth is Primed for Growth Despite Post-Lockdown Fade”. And Dr. Kumar was great in providing a lot of good context and, and just putting a lot of the key topics of telehealth in perspective. Dr. Kumar, welcome to the program.

Dr. Alan Kumar: Good afternoon, Dan. Thank you for having me.

Daniel Marino: Dr. Kumar, when you look at telehealth and maybe specifically telehealth within your organization, what have you seen as the biggest impact of telehealth for your patients or how your physicians have delivered care?

Dr. Alan Kumar: I think the most important thing that we've enjoyed with telehealth and its growth has been access for our patients across the community. Our health care system serves an urban and suburban community, not rural, but as we've expanded into more telehealth options for our patients, both for primary care and for specialty care, our reach has been extended. The access and the convenience has been extended, and that access is really what we're trying to expand upon for our patients across the entire region that we service. There is always difficulty because there's only so much brick and mortar you can have, and this explosion of telehealth, availability and options through the area has allowed us to really expand our footprint and extend our reach out further, to get more access to patients that struggle either from a transportation point of view, a distance point of view, or for specialists, really just more access. So it's been a wonderful thing to see grow over time

Daniel Marino: Interesting that you bring that up as the major points related to the impact of telehealth. I agree with you. I think it has really revolutionized how we think about patient access, and when you focus on access, you can't help but think that it's really expanded primary care services. So it's allowed not only primary care physicians, but really the whole primary care delivery model to expand, to change, to provide additional services. Have you focused a lot on that within your organization?

Dr. Alan Kumar: We've used a combination for primary care. While the physician now is not working on looking at the patient and focusing on the patient, which we've taught them to do. Some of this now has flipped to having data sets in front of them, looking at care gaps that they can close while they're on the phone or on the video screen, they have other alerts that can pop up on the screen to help them with the patient visit real time, because of the interactive aids that you can have built into the conversation with patients. So on the primary care side, you've seen improvements both in access for the patient convenience for the physician in terms of being able to get more patients in because you don't have that same issues with room turnover to the same degree, as long as you can solve the technological difficulties of connection, and then being able to put technological overlays into the visit so that you can have more care gap closure, quality items, and better outcomes for the patient real time.

Daniel Marino: That's interesting. So you've really focused on telehealth and the processes of telehealth. Not only in terms of how you're supporting the direct interaction with patients, but really incorporating care management. And it sounds like you've tied a lot of that to some of your outcomes of your value based care contracts, if you will, managing the populations around care gaps, and ensuring that some of the physicians are interacting with the patients with the goal of achieving some of those quality outcomes, if you will.

Dr. Alan Kumar: So cycle back to before COVID, our use of telehealth was done much more so on a pilot model on a test model because payer strategies weren't in place to make this ready for prime time across the board, many payers weren't using it, weren't allowing the use very easily. Even Medicare and Medicaid were very on board as much as we would have wanted. And so it was more of a test model because we knew a day would come where it would be needed more aggressively and we wanted to have the infrastructure in place. So we were testing different versions of it prior to COVID in March of 2020. When COVID came in March of 2020, and the country literally shuts down, we had to stand up a product within 14 days. That was the test I put to our technological team to say  this needs to be stood up immediately systemwide, because we cannot lose our patient access. Otherwise, health care will suffer in the region. They did an absolutely wonderful job, and for the first three to six months, the entire focus was getting the technology out, getting it easy for our providers and the office staff and making it easy for patients to get the access, to link in through whatever modality, whether it's mobile, whether it's desktop, to be able to get the access that they need, whether it's tablet based to get the access and have the conversations and to get in front of the provider so they can have the conversations needed to continue their healthcare. Once that was stable, then you start becoming more sophisticated. Then you start evolving into further things. How can we now take this to the next level? How can we now use this and leverage the skill sets that we have that we've always focused on, which are key quality care outcomes, quality, outcomes, care gap closure, ACO metrics, all the other care management metrics that we wanted to do all along. And how can we bring that to bear here? And we use our EMR (electronic medical record) appropriately to do that. We use our analytics teams and all the reports and dashboards that we have, and we link it to the patient record and have it available for the provider at the time of the visit. So they can use that to get more done in the same amount of time to improve the efficiency. So we've had great response from our providers and a great response from our patients.

Daniel Marino: Well, it sounds like as you're describing that, it sounds to me that it was almost a natural progression of your care model. So you're focused on what the physicians were truly doing and doing well in the traditional model, incorporating data, incorporating direct processes with the patient, even incorporating some of the care gap activities. And sounds to me you sort of expanded that as you overlaid telehealth and expanded your access with the patients.

Dr. Alan Kumar: Correct. Now we have varying levels of penetration. We have some providers that have taken the technology like fish and water, and we have some that have struggled a bit more to incorporate it as well as we would like. Some of that is something that we can assist with along the way, but it definitely has to come from the provider. It has to be something internal to them and they all want to do the right thing by their patients, but there's different levels of sophistication with technology. So the evolution continues along those lines for those that can flip back and forth as quickly, because all of these platforms aren't yet integrated, because it's still relatively new. There's no one platform that does everything at the same time. So you're bringing things together and they're not fully integrated. They don't always talk to each other. So some people are very good at flipping between platforms for what they need to be able to do. And others struggle a bit more and we can assist with that. But I think this will be an ongoing evolution in the marketplace and where the market will be five years from now will be much more advanced than where it currently stands today.

Daniel Marino: I agree with you. I think it's an ongoing evolution, and I've heard from many providers and many health system leaders as well that the integration is a challenge. You have to create some innovative processes to take the telehealth technology, if you will, to focus on the interacting with the EMR, updating the notes. Even a lot of the virtual activities for one of our providers actually were able to record some of the video content and incorporate it into the EMR as a pilot project so that there's a lot of opportunities there. But I agree with you, I think that integration with the platforms is something that is gonna be really important, that this is gonna continue to take hold and really become a key part of our care delivery model. Let me ask you one question that came to mind as you were talking now, you said you were very focused on the data and I know you share a lot of information with your physicians. Have you been able to track the impact of telehealth on either physician productivity or cost of care or the key indicators that you look at RVUs (relative value units) or anything like that? Anything that you can speak of, both good and bad, in terms of how telehealth has impacted some of your outcomes?

Dr. Alan Kumar: So I can speak on a few different models that we've used. So the simplest and easiest to track is obviously RVU productivity and seeing what is the impact on RVU productivity. We initially saw a decrease in RVU productivity when we first stood up the platform. The problem is how much of that was less patients signing for appointments and schedules not being as full as everyone hibernated for a little while and how much of that was technology based limitations. I'm sure it was a little bit of both. As time has gone on and providers and patients have become more familiar and facile with the technology. I do believe that technology is no longer the main issue of limitation. And from an RVU standpoint, our productivity literally runs almost one to one. Some providers are actually more productive. Some providers are less productive, but all-in, people tend to find that they can still see the number of patients in an hour that they saw before telehealth, as they're seeing during telehealth. Incorporated with, in some practices, they might be fully telehealth on certain days. Other practices are hybrid. That has not created a huge issue. What did create the issue was time of appointment basically. How much time are they spending in a visit with a patient virtually versus live? And what does that actually mean? And how much time is spent? One of the areas we saw a significant increase was in new visits, new visits took longer to complete than established patients. I think the providers are more comfortable with their established patients. They already had a relationship with this patient so that we're doing a follow up appointment for our primary care providers. It was a much easier visit and the time difference between an in-person visit and an online visit wasn't that much different. For new visits, however, I think there was a relative discomfort as they're trying to develop a relationship. And those visits tended to be longer, which kind of makes sense.

Daniel Marino: I've heard the same thing. It's just for a physician seeing a new patient in the office, you're able to make that connection. There's more of a personal connection that you have. You're actually hands-on in terms of being able to evaluate the patient. In a virtual situation, I could see where that could be a little bit more difficult and probably, I would think some physicians were certainly challenged with it.

Dr. Alan Kumar: Yes. We had some that gravitated more towards phone call visits, and that's not ideal. I think there's definitely something lost when you're not physically looking at the patient and doing part of the exam that you can do in that setting. So we really had to push certain providers that were more hesitant, let's say, to go towards the video visits, which is what I consider telehealth. A phone call to me is not the same thing. So that did take some conversations and education back at the beginning of the pandemic.

Daniel Marino: I could see that as well. I think there's a positive impact for primary care and I think for certain specialty care. For some organizations who are continuing this evolution into what I would call virtual health of which telehealth certainly is a piece of that. We're starting to see some telehealth activity occurring for say pre-surgery surgical evaluations and even the post-surgical evaluations. Are you trying any of that within your organization? Do you see that as a progression of telehealth or is that still a little far out or a little bit of a challenge?

Dr. Alan Kumar: We have not put it into practice yet extensively. I'll give you a couple examples of what we're currently doing and what we're in the process of planning right now. One thing we're currently doing is we do pre-surgical clearance evaluations by anesthesia. So we have a presurgical clinic that after the surgeon meets with the patient and sets them up when they need to get cleared from anesthesia, before they go into the OR, that visit we've switched many of those to telehealth so that they meet with an anesthesia NP and they go over their preoperative risks. And if something needs to be done, certain tests need to be ordered. We've found that our preoperative NP clinic is much more efficient than the surgeons, which take generally a more shotgun type approach basically. And that has been very valuable from a utilization and efficiency point of view. Moving that to telehealth was actually very easy to do that interview. One of the things that we're currently working on is creating a specialty clinic to do outreach into rural areas. So our catchment area is the four hospitals across two counties, but we have four to six counties east and south of us that are very rural, that have very limited access to specialty care. So we're in the process of setting up a virtual clinic where there's a physical location that patients can drive to and come in and see a specialist that they can be referred to in their local marketplace. We could set it up completely virtually, but patients almost want to feel that there's someone that they're going to go see in a local area and they can connect with. Doing some research I found that there is some value to this type of a setup. So we're in the process of setting up a virtual clinic in a central area in some of these regions so that patients can go in, see multiple specialists for issues. And then if we need to arrange a visit up to our primary medical campuses for multiple diagnostics or therapeutics to be done, we have a concierge model set up where they can get everything done in one day. They drive up, all the diagnostics that need to be done, any therapeutics that need to be done, can all be arranged and scheduled and coordinated. So it's all done at one time, as opposed to them having to piecemeal it together.

Daniel Marino: Wow. What a great model. I like that whole virtual clinic thought process. As you mentioned, it expands your region into the rural community. I think it just provides for such a great need where you're providing patients the best of both worlds, if you will. They're able to come in and see a specialist in-person if they have to, but yet still be able to connect with a specialist through telehealth or through virtual health for their follow up appointment. I don't know if you've launched it yet, but I would think your patient satisfaction outcomes would be quite high from putting that type of a model in place as well from your physicians.

Dr. Alan Kumar: The physicians are on board that has not been the hard part. The hardest part is how do you from an HR point of view manage staff in a remote location. Yeah. That's not something that we have as much experience with having a satellite clinic two hours from your closest primary place. It's something we have to work through

Daniel Marino: The administrative burdens come into play when you're thinking through how to deliver a model like that. I think that that's a great idea. I do think that as we become more proficient with telehealth and we're starting to truly see the benefits relating to cost of care. We've done a lot of research within Lumina, as well as other organizations have done research as well, that has shown that a telehealth visit is about 20 to 30%, um, less than what it would cost if for an in-person visit. And it doesn't totally take the place of an in-person visit, but if it's used correctly, it can really support that and support being able to really manage the patient as well as driving down the cost of care. I think we're only starting to see this within the specialty community. I think some specialists still and some of it is I think just the sheer economics of specialty reimbursement. Some physicians are still very much focused on the fee for service structure, the RVUs, seeing patients in the office, for them to incorporate telehealth into their practice. They're really not sure how to do it. I don't know if you've come across this and it sounds like you probably just provide continuing training for all your physicians, not just the specialists, but I would think for the specialist, this has gotta be really important.

Dr. Alan Kumar: Yes. I completely agree. We have the benefit of some early adopters that we then touted or had partners or other colleagues reach out to them to discuss it. Because hearing it from administration is one thing, hearing from colleagues that are living it, is much more valuable to them. So if you can get out to the early adopters and then the mainstream folks, it helps pull in those that are late to the party and getting the buy-in that you need. A lot of it is about setting the vision, getting the buy-in to what the vision is, and then getting those that jump at the chance to try something new. Those that'll come along mainstream and then using them to convince those that are much more hesitant in the process. You're not gonna win over everybody. But that process, if done methodically, if done with persistence and precision has almost always worked out well, slow and methodically, you can't do it quickly. You can’t make it a revolution. It has to be an evolution.

Daniel Marino: I agree with you, slow but impactful. Is what I say. I absolutely agree. To a certain extent, it is a culture evolution that you have to incorporate. And as you had mentioned, some physicians are quicker to make that change. Others, it's just gonna take a little bit of time to sort of get them there. Telehealth is not going away. I think it's only gonna continue to expand and be more impactful in our care delivery models. In the article, my colleague, Lucy Zielinsky contributed  a couple of key points to outlining a virtual health strategy. In that article, she mentioned a couple of things. One is to think about how it supports your value-based care contracts. Beginning to think about the impact on primary care technology advances. And then the last one is the benefits of virtual health, both providers and to patients. When you launched primary telehealth it sounds like you did it very quick, right? You had to respond to some of the COVID changes. As you said, you went up in 14 days, which is incredible. Thinking back, would you have done anything different as you rolled out telehealth? Thinking about how maybe you would incorporate it into more of a virtual health strategy?

Dr. Alan Kumar: That's a hard question to answer. Interesting. I think we, as an organization were very happy with the outcome that we had given the limitations that we were under during the start of COVID. Now if I had to go back and think that if this wasn't COVID, I honestly think that we had a better result because of COVID than if we had tried to launch this as aggressively as we did, were it not during COVID, because patients were hesitant to come in. So because of that, physicians had to move to a telehealth strategy to basically see the patients they wanted to see. If we did this in a normal timeframe. Patients wouldn't have been as hesitant to come in, and those physicians that didn't want to partake in this could have just told their patients well, come in. And then that would've continued and converting to a telehealth point of view wouldn't have occurred in those practices that didn't want to change. And because they were forced to change, they saw the benefits while it was happening, because they were forced into this scenario and the uptake and the buy-in system-wide was significantly higher because of COVID. So we all think of the negatives that happened because of COVID, there's some positives that have happened. And I would say, this is one of them. Access is now almost commonplace. And we have benefited from that. And I do believe that our system would be much less far along as we are were it done during a normal rollout strategy, as opposed to, during a pandemic and the crisis and the opportunity that it created from the crisis.

Daniel Marino: That's an interesting reflection. I agree with you. A lot of times in the case of telehealth, you're right. It was a slow adoption process, but sometimes disruption provides the greatest opportunity for change. And I think if there is a positive coming out of COVID, that disruption to the care delivery model forced us to think about delivering care differently and incorporating a lot of those aspects of telehealth. I agree with you. I think it's going to continue to have a major impact in healthcare. We've done a lot of research with patients and with different provider organizations around the country and patients want convenience in their healthcare delivery model. They want the option of being able to provide lower cost in their care delivery model. They would like quicker access to physicians in their delivery model. And I think telehealth and really the whole virtual health model provides some of that, which again, probably wouldn't have happened at this pace if it had not been for COVID.

Dr. Alan Kumar: Completely agree. I do think you have to look at the flip-side of that, and this is one part where we're struggling. I would consider myself a little old school in that patient-physician relationship and that hands-on nature of the exam and that time together is valuable. I'm seeing more and more, as you've mentioned, the increase in access, increase in availability, and the ease of the appointment, and this faster time. That's leaning more towards almost an immediate care, urgent care design where that relationship is being fragmented for those that are going for routine things into whoever's available to see me type of approach. And that can work, but there are consequences.

Daniel Marino: It has to be a balancing approach here. You can't rely too much on telehealth because you lose the personal interaction. And yet we can't go all the way back to the traditional model, because I think patients are excited about the technology. As you mentioned, it does provide different access models or opportunities rather. So I agree. I think it's a balancing act that we have to really look at. Well, Dr. Kumar, this has been fantastic. I really appreciate the discussion and I commend you and the organization on what you've done with telehealth. You clearly have used it as a way of interacting with your patients at a different level, but I love how you're using this as a strategic growth mechanism to continue to provide greater access and a greater reach to your patient community. Before we wrap up any pieces of advice or recommendations you might give to any of our audience members who are thinking about expanding, or focusing a little bit more on their telehealth initiatives?

Dr. Alan Kumar: I would say that IT initiatives are always sexy in appearance when you're looking to get into it, but they are expensive, they are complicated, and they require a significant amount of education and buy-in. Things that we've touched on primarily throughout the time we've had together today. Be methodical, be diligent, and be patient in the approach that people take because doing it too quickly or not putting enough thought into the approach, any one piece of the process can ruin the entire rollout, whether it's the technology, whether it's the education, whether it's the process building and the operations. All of it needs to work simultaneously. Routine old school patient interactions on an office basis was built over years and it’s tried and true. You can't just convert that electronic expecting it to work the same way. So you have to think through it well and be methodical and make sure you use people that have done this when you're working through this process to make sure you do it correctly.

Daniel Marino: That's great advice and learning from others mistakes as you're starting to think about rolling that out and that methodical approach I think is key. That's great advice. Well, Dr. Kumar again, thank you for coming on the program. Very impressed with what you've done. For our listeners, again, if you're interested in reading the article that highlighted Dr. Kumar and the organization, it is in the May 2022 HFM, which is a periodical by HFMA, and again my thanks to Dr. Kumar. As we wrap up just a few parting words, I would certainly highlight for our audience members that as you're thinking about expanding your virtual health capabilities, as Dr. Kumar said, you really want to think about how you can integrate your platforms. Think about the impact of the physicians. Think about starting small, starting slow, but making sure that it's impactful and do it in a methodical way. What we found, and I think Dr. Kumar highlighted this, if you think about that approach around the strategy and the impact to the physicians, impact to the patients, how it even impacts some of your contracting, those are the ingredients for success. So thanks again. I want to thank everybody again for listening to another edition of Value-Based Care Insights. Until next time, I'm Daniel Marino. Have a great day.

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners.