Prior to the pandemic, Rush University Medical Center in Chicago, Illinois, had been using Adobe Media Server integrated with its Epic electronic health record for telehealth video visits. The technology was thoroughly tested both onsite and offsite, with employees working from home, and had a high connection-failure rate of about 30%.
Rush was relying on the patient’s home Internet connection to be good enough to connect, and five to six years ago it was common that home Internet was not good enough to stream content, even in the big city environs of Chicago. Unfortunately, there was very little troubleshooting staff could do once they realized that a patient’s Internet was not high-speed, and that led to many awkward calls between the IT helpdesk and patients.
Another barrier: Adobe Media Server relied on Flash player to be installed on a patient’s web browser, which was a fairly common plug-in for older PCs using standard browsers. But the world was moving to new browsers like Chrome and mobile applications and tablets, and Flash was no longer a standard.
“Not only did the patient need it installed, it also needed to be the right version, and Flash was so finicky that it would not auto-update; sometimes it needed to be uninstalled and reinstalled to take,” explained Marisa Truesdell, information systems manager at Rush University Medical Center. “Moving to telehealth technology from Vidyo was like night and day compared to the amount of patient technical issues and calls we received with Adobe Media Server.”
"Assemble a tenacious cross-functional team and get moving or you will be left behind. They should consist of the Ninja-Warrior-Salesperson-Writer-Conciliator-Researcher-Tech Geek variety."
Marisa Truesdell, Rush University Medical Center
Rush’s current connection failure rate is below 10% and Rush, like many other healthcare organizations, has defaulted to mobile-first workflows, which ensure a certain technology spec is met on the patient’s side, making the workflow much simpler for IT to support and the patient to connect, she added.
The Vidyo Connect workflow resolved the problems. The new platform allows for Rush’s bandwidth to provide extra buffering if the patient’s Internet speed is not quite up to snuff. It also does not require the patient to download anything extra, and they can be on any mobile device and most browsers to connect to telemedicine visits.
“Troubleshooting the workflow for visits using Vidyo Connect now can be done by a layperson – typically a medical assistant virtually rooming the patient for their video visit – instead of an IT telemedicine expert,” Truesdell said. “This was essential for the ability to scale our telemedicine platform.”
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MEETING THE CHALLENGE
About the fifth week of the pandemic in the United States, the state of Illinois shut down except for essential services. What did this mean to a large, academic healthcare institution? All non-emergent surgeries and all nonurgent appointments were cancelled. Rush had a staff typically used to seeing approximately 50,000 patients per month that was now asking to be redeployed to do other work so its members wouldn't be furloughed.
“There was only one practical option: Rapid implementation of HIPAA-compliant telemedicine workflows,” Truesdell said. “The workflows we implemented at first were four standard flows that we made available immediately and trained physicians on over the course of a few weeks: New Patient Scheduled Telephone, Return Patient Scheduled Telephone, New Patient Video and Return Patient Video.”
On the patient’s end, they would receive custom appointment reminder texts via Rush’s texting vendor, Mutare, at seven days, three days and one day prior to their scheduled virtual visit, reminding them to electronically check in and log in to join the video visit 10 minutes prior to its start.
Every day, medical assistants monitor the schedule for upcoming telemedicine visits. If there is a video visit coming up and the patient has joined, a medical assistant jumps on to gather normal rooming documentation and greet the patient.
If the patient has not joined, Truesdell’s team developed custom ad hoc text message buttons that medical assistants can press in specific situations to remind the patient what to do next in order to connect to their visit and to provide troubleshooting documentation.
“For physicians, medical assistants and other supportive providers like interpreters, they can see if the patient is connected right from their Epic EHR schedule via a grey camera icon that turns green when the patient is connected,” Truesdell explained.
“Medical assistants set a dot on the schedule as well letting the physician know the patient is ready. All providers can join the visit the same way. We require two devices in order to perform telemedicine: 1) They should be at a workstation that has Epic hyperspace on it, so they can document during their visit like they would for an in-person visit, and 2) They need an iPad with Epic’s mobile physician application Canto.”
The physician can launch the video visit directly from their navigator in Epic and have the screen thrown to their iPad, which acts as their video camera as well. Generally, the call moves forward like any other video call, with the important exception that it is being launched from HIPAA-compliant platforms that are protected by encryption and the appropriate legal agreements with Rush’s vendors.
“Rush was able to leverage the energy generated from the crisis to completely roll out a HIPAA-compliant video platform, which was the right solution, instead of something that was potentially more convenient but not HIPAA-compliant that ultimately would need to be ripped and replaced,” Truesdell said.
Rush’s KPIs for telehealth are “beyond our wildest dreams,” Truesdell said, especially given Rush serves a state lacking payer parity. She points to two work streams. First, forward COVID-19 triage.
“When COVID-19 first hit, and Rush was working on setting up a command center and ED triage tent, our CMO Paul Casey had the brilliant idea to repurpose our on-demand video platform for forward COVID-19 triage,” Truesdell explained.
“Redeploying 183 outpatient physicians to cover the video lines, we set up our platform in a matter of days to be able to triage patients with COVID-19 symptoms, exposure and anxiety to the right level of care – be that the ED, a drive-through testing location, or just isolating at home at the guidance of a compassionate physician, directly from our My Rush app.”
At the end of the video visit, the patient automatically is sent a detailed clinical recommendation via the My Rush app and assigned appropriate educational videos to watch about their condition, in addition to any referrals or prescriptions being sent to their preferred pharmacy.
Thus far this year, Rush has completed 8,718 on demand video visits, which have approximately a 23-minute wait on average, 22% new-to-system patients, and a Net Promoter score on average of 89. Some 52% of these visits were for concern for coronavirus.
The second work stream Truesdell points to is scheduled video visits. Rush was able to greatly improve KPIs here.
“When outpatient clinics closed due to the pandemic, most staff were redeployed to deliver services via telemedicine,” she said. “Having staff that are immediately ready to engage with technology in this way was unprecedented. Our providers immediately took to the process and engaged with us to provide quick solutions and optimizations. This operational/IT collaboration resulted in patient care – virtually, where there would otherwise have been none.”
So far this year, Rush has performed 90,533 scheduled video visits with an average Net Promoter score of 80. Some 25% of these have been scheduled into same-day or next-day availability; 2% of these patients have been new to the system; and10% of them have been new to practice.
ADVICE FOR OTHERS
“First I would say that this is the future: Assemble a tenacious cross-functional team and get moving, or you will be left behind,” Truesdell advised. “They should consist of the Ninja-Warrior-Salesperson-Writer-Conciliator-Researcher-Tech Geek variety. Virtual care is not for the faint of heart, so you want to find a team that is resilient, creative and never takes ‘No’ for a final answer.”
Second, shop around, she cautioned. Telehealth is even more of a hot topic in the COVID-19 world, and video technology is now ubiquitous and getting cheaper by the day.
“Most vendors are not going to be able to offer much to distinguish themselves in today’s cutthroat market, except price,” she concluded. “All vendors are working on usability, so soon there will be no way to distinguish between them in that space either. The real missing link in virtual care is an all-in-one vendor that does it all and integrates it all seamlessly – e-visit to scheduling, to video visit, to remote monitoring, etc. This is where your ninja team comes in, and why we IT folk have job security … for now!”