Prior to the COVID-19 pandemic, very few clinical areas at Upstate Medical University in Syracuse, New York, had established telemedicine programs, and there was little synergy among them and the organization’s Epic enterprise EHR.
Upstate’s telemedicine committee was in the process of defining needs for an institution-wide solution that integrated with the Epic EHR. Collaboration was underway with clinicians, and vendors were being evaluated.
At that time, some of the challenges included the lack of buy-in from caregivers in all of the clinical areas, who believed most patients would not want to engage in virtual care. There also was much uncertainty around reimbursement and regulations regarding telemedicine.
“In order to protect patients and staff from COVID-19 exposure, within a matter of days, Upstate created a telemedicine program for the entire institution, consisting of more than 200 sites,” said Mary Ann Gross, assistant director for healthcare information systems at Upstate Medical University.
“This entailed making a video visit solution available, creating workflows, and establishing billing and compliant documentation, as well as delivering all-encompassing education.”
Most clinical locations were not equipped to conduct private, effective video visits. Areas were outfitted with thin clients, which were not compatible with most video technology solutions.
“We needed to provide access to these virtual solutions to all staff within the clinic so that they could facilitate communication and virtual connections with patients,” Gross explained.
"These investments will allow Upstate to build on our telemedicine program to allow for community providers, caregivers and support services to connect with our institution to improve the continuity of care for our patients."
Mary Ann Gross, Upstate Medical University
“In addition, clinicians and staff who began working from home needed secure, remote access to all systems. Operational areas did not have an established process, and many were unfamiliar with how to transition their current patient flow process to virtual.”
The acute setting faced many of the same technical and operational challenges. Not only was a solution urgently needed to ensure the safety of staff and patients, but also to preserve PPE and provide a method for patients, family and friends to stay connected, rather than feel isolated.
“We did not have time, given the state of the environment, to propose the ideal solution, which would have been to complete a vendor selection and integrate the telemedicine solution with our EHR,” Gross said.
“Our immediate solution was to make available an audio/video communication to all outpatient areas first and ensure all patients for whom face-to-face visits were not critical could connect with their providers. This allowed patients and staff to reduce contact by connecting virtually, rather than physically, while ensuring continuity of care.”
The only HIPAA-compliant vendor Upstate had immediate access to and currently was using was WebEx. As an academic institution, its educational communications team already was facilitating remote learning via WebEx. Upstate broadened its license and provisioned all clinical areas with access, starting with clinicians.
“Establishing a process by which clinics could transition from physical to virtual patient flow also was a requirement,” Gross noted. “We proposed multiple options, from sending meeting links to making open meeting rooms available for patients for check-in and checkout. Documentation and billing still were to be completed within the EHR.”
In the acute areas, mounted Apple iPads were used to create a virtual connection between clinicians and patients (and patients and loved ones), which also would reduce the use of PPE.
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MEETING THE CHALLENGE
As an immediate virtual communication solution, Upstate provisioned more than 12,000 employees with WebEx accounts in a matter of days. IT, clinical and operational leadership collaborated to create workflows to facilitate the transition to telemedicine and establish virtual connections.
“In order to operationalize the telecommunication solution, strong collaboration was established among IT, compliance, finance and clinical areas, among others,” Gross explained.
“Education for these patient flows, compliant documentation, billing and video visits was critical to the plan’s success. Our training team pushed static and on-demand communication and information to all areas and clinical leadership and met daily with information management technology to share process improvements and efficiencies.”
Hardware assessments quickly were made in clinical areas to enable private and effective video visits from within the clinic. iPads and/or dual monitors compatible with video-visit solutions were utilized in many situations.
As HIPAA requirements were modified and updated, specific areas and providers adjusted their video solution by visit type and population, but the workflows and compliant EHR documentation remained fairly consistent throughout the institution. Other solutions used to a lesser degree included Zoom and FaceTime; Doxy.me also was used for some simple, one-to-one visits, since it offered a free trial to providers and did not require the patient to download an app.
“As the pandemic evolved and healthcare providers and facilities were faced with higher risks, employees were sent home to complete their tasks remotely,” Gross recalled. “This caused a surge in the demand for secure connections to the EHR and telemedicine-vendor software. The IT department provided both Cisco AnyConnect and Citrix RDP to meet this urgent need.”
One of the big goals of telehealth was to preserve PPE, which was successful with the use of an auto-answer feature using FaceTime on iPads. This allowed providers and staff to call into COVID-19 rooms from the nursing station. Also, WebEx facilitated HIPAA-compliant video chats with more than two attendees.
“Using 105 Apple iPads, FaceTime and Cisco WebEx, video connections were established within the nursing units,” Gross said. “These devices also had Zoom, Safari, Pluto TV and YouTube preinstalled, and they were stored in the unit Pyxis stations for safekeeping and tracking.”
Within two weeks of beginning an emergent telemedicine program, 68% of Upstate’s clinics had implemented telemedicine workflows. Provider engagement was growing exponentially, with 50% of outpatient visits conducted virtually. Within a two-week period, the number of telemedicine visits grew from 10 to more than 6,000, a gigantic increase of 59,900%.
Similar to most healthcare organizations, managing the number of no-shows in the outpatient areas is challenging. Comparing May 2019, when almost all visits were completed in the clinic, to May 2020, when the majority of visits were conducted via telemedicine, the no-show percentage went from 7.57% to 3.09%, representing a 59% decrease.
On another front, outpatient patient satisfaction was excellent. Upstate’s Press Ganey results and patient comments demonstrate that patients are engaged and appreciate the telemedicine option for its convenience and ease. Some patient remarks:
- “This was my first telemedicine experience. My scheduled appointment date and time for a regular office visit was changed due to circumstances dictated by the coronavirus pandemic. I appreciate and compliment the manner in which the appointment was handed, and the visit conducted.”
- “The appointment was a virtual one over WebEx, but the instructions were clear on how to download the app and click through the email link, so it was easy to connect.”
- “We had a videoconference telemedicine appointment. It went as smooth as silk.”
And regarding acute patient satisfaction, patients and families lauded Upstate’s efforts to provide for patient-family communication, as well as end-of-life visits for patients and their families in an unprecedented environment where loved ones could not be together physically, Gross added.
USING FCC AWARD FUNDS
Upstate Medical University earlier this year was awarded $373,731 for a telehealth platform subscription and tablets to deploy for COVID-19 patients and suspected COVID-19 patients to allow for virtual visits by nurses and physicians and to perform group consultations with specialists and family members. (Visitors are not allowed in the hospital.)
“Our goal is to use the FCC award funds to establish a strong, longstanding enterprise foundation for telemedicine,” Gross stated. “We will expand our current foundation by integrating video functionality within Epic and providing clinics with the necessary telemedicine equipment.”
Further, there have been several areas where implementation of patient-monitoring devices has been successful, and Upstate plans to incorporate this technology into its telemedicine suite of services.
“These investments will allow Upstate to build on our telemedicine program to allow for community providers, caregivers and support services to connect with our institution to improve the continuity of care for our patients,” Gross concluded.