Two years ago, I started seeing patients virtually in their homes for medical psychotherapy visits using the Ontario Telemedicine Network (OTN). I was recruited as part of a pilot study with a limited number of provider participants and was given an incentive payment for each billed encounter in order to encourage adoption. It took me a month to get myself set up, and a few sessions with the OTN help desk to remember how to use the tool. I learned a few lessons as both my patients and I tried to work around the wired connection suggestion. Last month about 20% of my visits were done virtually.
This week, 100% of my clinic is virtual. Additionally, my colleagues throughout Canada and the U.S. have pivoted to virtual care on a dime. Providers who had never done a virtual visit before miraculously launched into a full virtual practice without months of lessons. Patients have jumped onboard and have outright demanded these services be available. A transformation that had been moseying along exploded with an infectiousness even greater than the pandemic that prompted it.
What were the barriers to this kind of adoption in the past? Was it a burning platform that was missing or are there still some barriers that will rear their heads as the current urgency settles? Will we go back to our old ways or continue at the new pace? What will our world look like when the ashes settle?
In order to answer some of these questions, let’s go into details about some challenges in our virtual visit environment and discuss what can be done to address those that remain.
Patients need support in learning how to use virtual systems or putting in place adequate technology and environments to do a visit. In the urgency of our pandemic adoption, clerks, administrative assistants, IT help desks and patient family members have stepped up to the plate to make this a success. In the process, these people have had to learn how to use the systems themselves. Formalizing the informal processes that have developed will be essential to maintaining the patient support needed going forward. Additionally, these patient-facing support personnel are ideal candidates to gather feedback for system improvement. We need to make sure they have a clear process for sharing suggestions for optimization. Administration should establish new job descriptions and perpetual education requirements for these roles.
Not all patients can manage to assemble or use the technology required to support virtual video visits despite extra support services. Unfortunately, these are the patients that tend to be most vulnerable in these turbulent times. Some of these people can gain access using basic telephone technology. Although this can be tremendously beneficial with lack of an alternative, there is still likely to be a need for visualization. During our crisis, we will need to find new ways of bringing together a workforce to support these people. Although many patients in this category may return to in-person visits once they become available, there is value in increasing access to vulnerable patients more permanently. Telephone visits will continue to be a valuable mode of access. Perhaps some additional lessons learned during our enforced virtual care time will add new value to this population going forward.
Providers need support as well, and in some organizations where provider processes are still predominantly paper, the support personnel do not currently exist. IT help desks alone are not enough to manage the clinical adoption and leverage these systems as a clinical tool. Technology in healthcare should be led and supported by clinicians. If your organization does not have a clinical informatics team at present, consider the Epic Honor Roll best practice benchmark presented by UCLA of one physician informaticist per one hundred physicians and imagine that need will only increase as technology plays a more predominant role in healthcare.
One of the biggest challenges in clinician workflow is the lack of connectivity between virtual care systems and electronic medical records.
To give you an example, in order to ensure that I am aware of and present for a virtual patient visit, the following needs to occur:
- Appointment needs to be blocked in my personal calendar, so I know I’m working;
- Appointment needs to be entered into my electronic medical record (EMR) so I have a patient encounter to document against and the visit coordinates with my in-office patients;
- Appointment needs to be entered in the virtual platform so my patient and I can connect.
If all entries are not identical, the meeting might not happen. Until the virtual platform can schedule out of my EMR, and my EMR can communicate with my personal calendar, I am at the mercy of the successful juggling of three calendars.
Workflow is not just about scheduling; it is about having the information you need when you need it. Prescribing medication during video visits in Canada can be a challenge. Most EMRs do not have electronic prescribing and we still depend on handing the patient a paper prescription or having a healthcare worker fax or call in prescriptions to pharmacies. If rapid deployment of integrated electronic prescribing does not occur, both patients and providers are likely to abandon the frequent use of virtual care platforms.
Vendors/organizations will need to build virtual platforms into office EMRs and hospital electronic health records (EHRs) for seamless integration in order to support continued adoption.
There is little more disruptive to clinical workflow than glitchy systems. If a video visit freezes, hiccoughs, or completely drops in the middle of an encounter, there needs to be a quick rescue. Rapid deployment of video technology has overrun the technical capacity of many virtual platforms. As an example, OTN increased their daily visits 10-fold in two weeks. It is challenging to scale up a system in that short order. I have heard of a variety of workarounds developed to deal with unreliable systems. A common solution has been to use phone lines to communicate with the patient while simultaneously running a virtual platform. If the video freezes, the audio continues, and less disruption occurs. Though patients and clinicians are willing to cope with these less-than-ideal solutions during a crisis, their patience will wear thin when more options become available.
In addition to technical challenges there are functional requirement challenges. The traditional one-on-one between a doctor and patient at a scheduled time works in some instances, but there are other, more expeditious ways of providing certain types of care. Virtual platforms built into EMRs need to be able to accommodate multiple workflows including:
- asynchronous communication
- virtual waiting rooms for walk-in services
- group sessions for education
- group sessions for therapy, which may require individual breakout sessions
- group session for care teams and family members
The workflow, scheduling, and documentation of these types of sessions will challenge many EMRs to expand upon their functionalities. EMRs will need to build new workflow, scheduling, and documentation functionality to facilitate a variety of virtual workflows.
Policy and Procedure
In the U.S. and Canada, medical licenses are issued and managed by provinces or states. Early adopters of virtual care have puzzled over how licensing applies to virtual care. Does the license apply to the location of the provider, the patient, or both? Is the location determination based on the participants’ permanent address, or temporary location? Does it make sense to require patients to go to walk-in clinics to access care when they are traveling, even though they could have consistent care from their own provider who already knows their history? Does it make sense to limit virtual specialty services to provinces or states when we could reach beyond borders and improve the quality and accessibility of care? There are many questions with few reasonable answers from current policy and procedures. In order to truly leverage the benefits of virtual care, Public Health Acts will need to be modified to broaden the jurisdiction of medical licensing to coincide with the reality of virtual care or provide guidelines that allow for patients to fully benefit from the technology.
Reimbursement of patient care is currently managed by provinces/insurance carriers. How does the blurring of provincial/state borders by virtual care relate to billing and reimbursement? Public Health Acts and payer policies will need to be modified to adapt to cross state/province services.
Though, perhaps more importantly, reimbursement for virtual care has been limited in general. Many payers historically did not pay providers for telephone encounters or virtual visits that occurred in patient homes. The current large-scale test of virtual care may help ease the fears that limited this opportunity in the past and allow for payor comfort with reimbursing virtual visits. The continued use of virtual care will be dependent upon adequate reimbursement for the services. Payers will need to change temporary reimbursement codes to permanent ones that reasonably cover the expense of providing the service.
One of the challenges with care in virtual environments is the fluidity of the experience. A patient may begin with a virtual screening tool or telephone discussion with a non-physician, flow to a physician over the telephone, then be switched to video for further investigation and finally be sent into an office. How do you express that type of a fluid environment in discrete billing codes? Perhaps the complexity of the situation explains why many documents are being produced to explain our “temporary” billing procedures during this crisis. The more sensible ones are two-three pages, the more typical extend to 20-50 pages. Hopefully the reimbursement for these codes takes into consideration the salary of the coders that will be necessary to interpret them while the providers are busy caring for patients. In Canada’s administration light ambulatory system, that could mean a significant new expense. A more appetizing alternative would be to simplify the billing process in the first place. Perhaps it is time to reconsider salaried providers, bundled payments, or new methods of workload measurement.
Changes to Care
Level of Care
As new ways of accessing care evolve, our determination of appropriate level of care must evolve as well. Is a patient appropriate for chatbot medicine or do they require a telephone visit? Do they need to be seen in a virtual visit or an in-office appointment? We have struggled with ensuring appropriate level of care with outpatient, inpatient, intensive care, and long-term care. Now we face even greater complexity. Telephone visits may be easy, but they are not always the right thing to do. Seeing our patients provides a tremendous amount of information that can change a diagnosis or treatment plan. We will need ways to monitor appropriateness of level of care to maintain quality care.
A global move to virtual medicine will likely have many other impacts. On the positive side, there will be less time lost from work, less pollution as people no longer need to commute to appointments, and reduced overhead for physicians who may need less office space. Challenges remain as providers need to re-evaluate the space they do have. If much of the work will be done from physician’s own homes, they will need adequate networking, appropriately soundproof rooms, and thoughtful camera set ups. If virtual care will be integrated with office work, the physician office will require fewer exam rooms and more private office space. Just as clinicians benefited from instruction on how to incorporate the computer into a pleasant patient visit, so too will they need guidance on how to craft a comforting virtual environment. My recent discussions with colleagues are trending to the tune of; “How do I frame myself on the camera?” and “Being mindful of the disturbing effect of art growing out of your head.” If virtual care is here for good, we are going to need to do some office space redesigning and etiquette training in virtual visits.
If we expect to see virtual care continue beyond pandemic planning. Here is a summary to do list to make it happen.
- Establish new job descriptions and perpetual education requirements for patient and provider support roles.
- Assess your current clinical informatics support team and right size it for technology heavy care.
- Build virtual platforms into EMRs for seamless integration.
- Expand EMR/EHRs function to facilitate a variety of virtual workflows.
- Modify Public Health Acts to broaden the jurisdiction of medical licensing to coincide with the reality of virtual care or provide guidelines that allow for patients to fully benefit from the technology.
- Modify Public Health Acts and payer policies to adapt to cross state/province services.
- Payers will need to change temporary reimbursement codes to permanent ones that reasonably cover the expense of providing the service and are simple to use.
- Establish metrics and standards to ensure the level of care supports quality care.
- Office spaces will need to be redesigned and virtual etiquette refined.
Predicting the Future
In discussions with my own patients, I am anticipating that 20% will return to exclusively in-person visits, 60% will find their own mix of convenience and person-to-person contact and 20% will remain my predominantly virtual patients. Whatever evolves, I suspect it will not be back to business as usual and we will have some work to do to clean up our workflows from the grab-off-the-shelf stand-alone emergency virtual service to an integrated, well architected and appropriately utilized virtual care option.