Digital

AMA COVID-19 daily video update: Experts discuss obstacles, opportunities with telemedicine

Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.


Featured topic and speakers

AMA Chief Experience Officer Todd Unger speaks with AMA President-elect Susan R. Bailey, MD, Medical Director of CareConnect 360, Ochsner Health David J. Houghton, MD, MPH, and Assistant Vice President of CareConnect 360, Ochsner Health Jennifer Humbert on updates regarding COVID-19 including the expanded use of telemedicine during the COVID-19 pandemic.

Learn more at the AMA COVID-19 resource center.

Transcript

Unger: Hello. This is the American Medical Association's COVID-19 update. Today we're discussing the expanded use of telemedicine. I'm joined today by Dr. Susan Bailey, AMA's president-elect and an allergist and immunologist in Fort Worth, Texas, Dr. David J. Houghton, Medical Director of Care Connect 360, Ochsner Health system's telehealth program and chief of the Division of Movement Disorders at Ochsner Health in New Orleans, Jennifer Humbert, assistant vice president telemedicine at Ochsner Health in New Orleans. I'm Todd Unger, AMA's Chief Experience Officer in Chicago.

Dr. Bailey, can you talk a little bit about why telemedicine is so crucial right now and into the future?

Dr. Bailey: Telemedicine has proven to be a great tool to help us continue to deliver care and limit exposure of patients and of health care personnel to COVID-19 at the same time. Physical distancing is going to, I think, remain a very significant part of our lives for the foreseeable future. Telemedicine, I think, is going to be very important going forward.

Unger: You've ramped up telemedicine in your own practice over the last two months. We talked about it kind of early in this process. You know, what's changed since you started? What have you learned?

Dr. Bailey: Well, we have gone completely virtual in our office. I am seeing all of my patients online. Since our electronic health record is cloud-based, it really hasn't changed anything in the way that we document our visits or the way we do billing or anything like that. That has really been pretty seamless. There are some folks, however, that just don't get it. Every once in a while, you'll be all set up for a virtual visit, and all of a sudden, the patient on the other end can't figure out how to do it. That's been a little bit frustrating, but we're trying to predict those situations in advance. One thing that I've done is develop my own virtual private network here at work. I work off my own laptop through our small practice's wifi network, so I have my own VPN. That makes me feel better about my level of cybersecurity.

Unger: Dr. Houghton, Miss Humbert, Ochsner was a leader in telehealth years before the pandemic hit. How did that prepare you for the last few months?

Dr. Houghton:  Well thanks, Todd, and thanks so much for having Jen and me here to be able to speak to you down from New Orleans. As you mentioned, we had had a robust system that took care of patients both in the hospital and the clinics, as well as at home as part of our telehealth network, Ochsner Care Connect 360. As we were preparing for the pandemic, we knew there were really three avenues that we needed to take.

One, we needed to redeploy quickly in our hospitals to be able to take care of the sick of the sick with the models that we had already built with tele-ICU and our hospital medicine folks. This helped keep the patients seen as they needed to be and also kept the providers safer and was able to use the PPE necessary.

The second thing we knew was that the community had tons of questions. We really needed to triage them to be able to get testing when appropriate. We leveraged our Ochsner Anywhere Care Urgent Care app-based offering for that. We also were able to utilize our title care connections in the urgent care setting to be able to help leverage the testing.

Then finally, we knew that the most chronic patients may be our patients that were at the greatest risk. As Dr. Bailey had mentioned, we knew that they still needed to be seen. We were able to ramp up our Epic Virtual Visit program very quickly to the tune now that we're seeing between 3,500 and 4,000 visits per day within our system with patients staying at home, not coming into the clinics.

Humbert: Another one of the biggest response factors to COVID-19 for us was we did have that foundational infrastructure in place. Typically when we implemented a telehealth program, there was a lot of change management and a controlled pace of deployment. What we knew that we had to do very quickly was pivot to mass education and mass appointment with standardized workflows across the board that could meet the need of all level of health care providers and patients and their families. Implementing some standard workflows and processes that allowed nurses, respiratory therapists, pharmacy, social workers, the whole gamut of anybody and anyone that came in contact into a room to be able to mass employ some workflows to be able to meet the needs.

We had extremes from one end to the other. We had service lines that were in shortage of physicians, while we had service lines that needed to create, that had an overabundance of staffing. We had to be able to support both of those needs at the same time.

Unger: With the foundational elements in place, what has been the biggest surprise or challenge as you scale much more dramatically in a pandemic environment?

Dr. Houghton: Well, I'll take that question. Before the pandemic, the things that we worried about the most was with payer solutions, to make sure that reimbursement was in line, as well as some of the traditional mechanisms by which our boards of medical examiners treated telemedicine, as well as some of the other regulatory hurdles that everyone in telemedicine had dealt with. Now it seems like, most importantly, to be able to make that connection between the patients and the providers and recognizing that there will still be some gaps in the level of comfort with being able to meet exactly what needs to be done at that time.

What I encourage our providers is a virtual visit is really no different than what they're able to do in the office, when in fact you can't always meet all of the needs at that moment. Sometimes it's simply a triage tool to be able to recognize what will we do next? Will that require something in person? Will that require more testing? Will that be able to be remedied right here, right now, done a hundred percent virtually?

Unger: Dr. Bailey, you mentioned upfront two of the pitfalls that you've experienced, whether they're the patient's preparedness for this kind of interaction and cybersecurity. My question to the three of you, what are the other kind of pitfalls that you've encountered in getting that human contact in your patient care?

Dr. Bailey: I have found that some of the things that we do for our face-to-face visit in our office that prepare the patient to know what questions they want to ask, know what things tend need to get accomplished, that in a virtual visit that doesn't necessarily get done. We have to focus harder sometimes even with a call beforehand from my medical assistant to them say, "Okay, well do you need refills? What are your concerns today? What are your questions?"

A lot of patients just have basic COVID-19 questions that may not have anything to do with their needs. It's been a little bit more challenging getting the visit organized.

 Humbert: Yeah. We've experienced some of the same. I was actually just on a conversation this morning with some of our primary care leaders. Now we're really starting to think, okay, we've mass deployed. We're doing about 4,000 visits a day in the home, but how do we now refine and replicate that in-person experience? Everything that your MA does, all of those pre-questionnaires, how do we start incorporating that? This will be like round 2.0 of a mass deployment of a direct to consumer visits in the home and how we're refining that process.

Unger: Dr. Houghton, any thoughts there?

Dr. Houghton: Yeah, I think that's exactly my experience as a clinician taking care of some of my chronic neurological patients, particularly those with Parkinson's disease and Alzheimer's disease. I think what's interesting is the old saying necessity is the mother of invention. We've been able to even broaden, in short order, our utilization of our virtual visits with our resident clinic. Our neurology residents are able to see the patient first and then the attending physician comes in. We set this up as a three-way opportunity to be able to both teach the residents and take care of the patients at that highest level of care that you anticipate in an academic institution. We're building similar things for research modules.

The reality is we think that with telemedicine is the tool, really the sky's the limit so long as we think this well out on the front end. We create those workflows in place that's going to ensure its success, and we get creative. We solve for things that haven't historically been solved for.

Unger: Dr. Bailey, obviously there's a spectrum of preparedness for telehealth. Can you talk about what the AMA has been doing to help physicians navigate these challenges?

Dr. Bailey: The AMA has a wealth of resources on the website ama-assn.org. The COVID-19 Resource Center has pages and pages and pages of help for physicians. Most recently, the AMA and the American Hospital Association have co-published a four-page document, Working From Home During a Pandemic, which goes into a lot of the cyber security issues that I briefly touched on before. The AMA website has also got payment information and it's got coding information. There's a digital implementation playbook for telemedicine that's over a hundred pages long that provides an incredible amount of information for practices of every type. If a physician is looking for help about some aspect of COVID-19, it's probably in the AMA's COVID-19 resource page.

Unger: Thank you. Dr. Houghton, Miss Humbert, Ochsner just got a million-dollar funding grant from the FCC to expand telehealth. What are your plans for the future with that kind of investment?

Dr. Houghton:  Jen, you want to talk about the first part of that?

 Humbert: Sure. We'll really be focused on providing that care in the home. We have three tiers to that grant. One is the use of our Tyto devices which expand the peripheral device use for examination in the home to enhance that patient-provider experience. The second arm to that is in our digital med program to expand to our hypertension programs. Then we also have a Connected Mom program, as well. It's all about keeping patients as consumers healthy in the home and continuing those social distancing practices and extending our reach to them in the home.

Dr. Houghton: I think the most exciting part about that is really the way that this transforms the expectations for someone to not focus so much on their episodic illness, but rather on trying to maintain wellness. You can see next to Jen one of those Tyto devices, which is sitting to her left, is an opportunity to be able to bring more diagnostic tools to the home front. Similar to that is the way to be able to use connected blood pressure cuffs, glucometers. She'd mentioned our Connected Mom program, which is a way to monitor the expectant mother through her nine months of pregnancy, and be able to ensure that that mother and baby progressing normally, and even cut down on some of those visits to the doctor's office, which aren't the easiest things to do in the second and third trimester. We really are excited about the way that this is allowing us to reinvent health care into wellness and take advantage of these digital opportunities.

Unger: Dr. Bailey, I'm curious. You've gone from, I don't want to say zero, but a smaller amount of telemedicine in your practice to now you're at a hundred percent in this time period. When we progress to a place where the country has safely reopened, what portion do you think you'll be in telehealth?

Dr. Bailey: You know, that's a good question. I was thinking about that earlier today. It'll probably be more than 50% in-person visits, but it may be pretty close to 50/50. I've discovered that a lot of just the routine visits that I do for, say patients that are on allergy shots or whatever, the physical exam is really not that important a part of the evaluation. We might be able to do more of those virtually. However, for things like allergy testing, pulmonary function testing that we do for our patients with asthma, that's got to be done in person. Hopefully we'll be able to start doing that very soon.

Unger: Dr. Houghton, Miss Humbert, what do you see in the future regarding telemedicine?

Dr. Houghton: Yeah, I think it's a great question and like Dr. Bailey, we're already imagining how this sort of clinical reboot looks for our health system. I think our numbers may be quite similar, maybe a 50/50 cut, but it won't be broadly that. There'll be some that, as she implied, always need to come into the doctor's office and some that almost never need to come into the doctor's office.

I think what's unique is what we're already learning with a lot of our surveys and quality improvement projects that have come off the ground in dealing with the patients themselves. In fact, if you ask them right now, I think that number would be a lot more than 50%. They are truly realizing the advantages that we're seeing with the accessibility, the convenience, lower cost for them, ultimately, because they're not having to take away time from their jobs or from their families. Really more than anything else, they are enjoying the same level of reliability with the providers that they've come to know and trust. If the patients have their way, I think it will be even higher.

Unger: Well, we're certainly going to see a very different future, I think, in the post-acute phase of COVID. It's exciting to see how we've ramped up. That's it for today's COVID-19 update. Thank you very much, Dr. Bailey, Dr. Houghton and Miss Humbert for being here today.

If you'd like to find more resources on COVID-19, including the AMA's Guide to Telemedicine, go to the AMA COVID-19 Resource Center at ama-assn.org/COVID-19.

Thanks for being with us today.