At the onset of the COVID-19 pandemic, the immediate challenge for Baltimore-based Kennedy Krieger Institute was shifting an almost-100% on-site outpatient workforce to an almost entirely remote one. (Its hospital has remained open, serving inpatients throughout the pandemic.)
Kennedy Krieger has had a small behavioral-telehealth program for military families for four years. The Center for Autism and Related Disorders program has provided limited telehealth services. And the organization had been using a tele-education system to train providers in rural areas. So the foundation for telehealth was established, but the organization did not have a network that was built to support nearly the entire workforce being remote.
“Since Kennedy Krieger serves mostly children, our telehealth solution had to be something that would work for families and also allow our providers to engage both the child and the parent/guardian participant,” explained Jennifer L. Crockett, director of training, department of behavioral psychology, at Kennedy Krieger Institute.
"One of the most remarkable achievements we experienced was getting our outpatient visit volumes back to pre-COVID-19 levels by the third week of the pandemic."
Jennifer L. Crockett, Kennedy Krieger Institute
“We were able to be agile and flexible when the challenge arose and quickly pivoted our resources to accommodate the needs of the institute. We primarily use a HIPAA-compliant Zoom system along with our Epic EHR to conduct our telehealth operations,” she said.
When Kennedy Krieger looked at expanding its telehealth services, it did not seek any new vendor support. The institute already had an existing HIPAA-compliant Zoom account and it already was on the Epic EHR.
As such, it simply expanded its Zoom accounts and created a new workflow and training for providers to follow both within and outside of the Epic system. It also upgraded its external internet connection to accommodate higher volumes of traffic coming into the network from the outside.
MEETING THE CHALLENGE
There are existing functions within Epic to integrate with Zoom (or other video conferencing technologies) to conduct telehealth through the use of Epic’s MyChart patient portal. Epic is a newly implemented system at Kennedy Krieger; the first anniversary of go-live was July 1.
During the scoping of the project to implement the Epic system, the institute performed very little telehealth. It had not yet implemented the required build to use Zoom integrated within Epic. Therefore, it had to create an innovative workflow and develop a process that combined working in Epic with working outside of Epic.
“The initial phase of the workflow begins in Epic where patients are scheduled for upcoming telehealth visits,” Crockett said. “Initially, we modified the ‘arrival department’ in the system for tracking and identification of telehealth visits. Our Patient Access call center teams, along with providers, then worked together to ensure that a Zoom meeting instance was established for each visit, and that the appointment information is sent out to patients.”
Both providers and Patient Access center staff also worked directly with patients/families to ensure that they were set up with Zoom and have instructions for the telehealth visit. To add additional support for patients and families, staff established a hotline for Zoom technical support. At the time of the visit, providers initiate the Zoom session and send a link to the patient, typically via email, so that the patient/family can join.
“Patients with recurring visits or a series of visits often will have existing meeting instances to access,” Crockett said. “Our providers have been resourceful with existing equipment to perform telehealth visits, as the majority were performing services from home. They use the best equipment combination available for the visit.
“This may be one computer attached to multiple monitors with the Epic system on one and the Zoom system on the other, or they may use a smartphone or tablet for the Zoom session while using their computer for Epic,” she explained.
After the session, the clinic care center staff perform typical workflows to complete a visit from a scheduling standpoint and providers perform typical work to complete notes and close out encounters.
“One of the most remarkable achievements we experienced was getting our outpatient visit volumes back to pre-COVID-19 levels by the third week of the pandemic,” Crockett stated. “Some of our programs require on-site person-to-person interaction/assessment/treatment, so the transition to telehealth for those programs was more limited, and some are not expected to fully transition during the course of the pandemic.”
However, other programs have seen extraordinary success, both in clinical outcomes and productivity, with some clinics or programs operating at 120%-130% of their pre-COVID-19 appointment levels, she added.
“We have measured these achievements by tracking completed appointment volumes and telehealth billing using Tableau, where we consistently look at several metrics, such as year-over-year completed appointment volumes – both in numbers and as a percentage – cancellations, no-shows and cancellation reasons,” she said. “And we look at on-site versus telehealth-appointment-completion volumes, referral levels, and average charge per visit.”
All of these metrics were developed within Tableau using the rich data available within Epic, as well as from data structures in the healthcare organization’s data warehouse, which allow staff to combine legacy data with Epic data and then blend that data to visualize it in Tableau, Crockett explained.
USING FCC FUNDS
Kennedy Krieger Institute was awarded $994,950 by the FCC earlier this year to expand its video telehealth and remote patient-monitoring services to continue to provide care to vulnerable and high-risk children, adolescents and adults with disabilities.
“Upon receiving the FCC awards, we were able to purchase 100 laptops for distribution to staff to conduct telehealth sessions,” Crockett said. “And, of even greater significance, we were able to purchase 380 iPads and 265 internet hotspots for loan to families to increase and improve their access to care.”
Staff started by surveying providers on their families’ needs, including families who were unable to consistently access telehealth services. This informed the first group of family distribution. Staff then conducted an Epic data analysis of families who had participated using audio-only services. This provided the second group of families.
“We are also dedicating some tablets to our patients who receive multidisciplinary services, and to our patients admitted to our inpatient hospital to reduce the number of providers working bedside,” she added. “Additionally, we are using remotely administered assessments and testing that historically would have been in-person, paper/pencil-conducted assessments. This new process allows our important evaluation and data-collection work to continue, while continuing to track treatment progress.”
The staff hopes that lending equipment and connectivity technology allows more families to benefit from telehealth from the privacy and safety of their homes, regardless of their ability to purchase necessary equipment. Staff members are deploying the awarded FCC funds to augment the existing Kennedy Krieger initiatives to reduce health disparities and improve healthcare equity.