Before COVID-19, telemedicine was practiced by many health systems, but seeing patients in person was still the norm.
Within a few short weeks in March 2020, health systems and practices were forced to adopt new ways of seeing patients and delivering care.
Although face-to-face visits will always be a part of health care, there’s no going back, providers say.
There are still obstacles that need to be overcome — especially when it comes to insurance coverage and access.
Nevertheless, the pandemic is spurring advances in delivery of patient care that might otherwise have taken years to develop.
VIDEO AND MONITORING
“Pre-COVID, we were interested in making telehealth part of our five-year plan,” said Dr. Christopher Davis, UCHealth emergency medicine physician and medical director of virtual health. “That was critical when COVID hit in March, because we had infrastructure in place that we could rapidly scale rather than building from scratch.”
At that point, “we made three years of progress in three weeks,” he said.
The innovations that have become routine because of COVID-19 fall into four categories: live, interactive video; remote patient monitoring; app-based mobile health; and secure messaging or “store-and-forward” telemedicine.
Live video has become commonplace in health care just as it has in most other industries. “Live, interactive video might be the only way that you could get health care in an outpatient setting” when the pandemic first struck, Davis said.
“The growth that we saw in that period [March-April] was just shockingly dramatic — like 2,000-3,000 percent growth in the number of video visits that we were using across the health system, and especially in the primary care space,” Davis said.
Virtual urgent care grew dramatically as well — about 1,000 percent in March-April compared with the previous months.
Remote patient monitoring of chronic conditions such as high blood pressure, diabetes and congestive heart failure had been on UCHealth’s strategic roadmap for a couple of years pre-COVID.
“The system had some infrastructure in place, and we pretty rapidly experimented with a couple of models where we could use a remote monitoring device,” Davis said.
UCHealth chose a device manufactured by Masimo that continuously monitors patients’ pulse oximetry — their blood oxygen level.
Patients wear the device, which resembles a disposable Apple watch, at all times except when bathing. Patients can view their vital signs through an app on their phones. At the same time, data is transmitted 24 hours a day, seven days a week, to UCHealth’s virtual health center, where clinicians review the data and watch for signs of deterioration.
These devices have been particularly valuable when hospitals were crowded, Davis said.
“They allowed us to discharge patients faster and more safely, especially high-risk patients, because we were basically watching vital signs in the patients’ homes,” he said. “We ran that in the spring and learned an awful lot.”
Use of the remote monitoring devices tapered off in the summer but began to be used again in the fall when the second COVID surge struck. To boost monitoring resources, UCHealth added staff at the virtual health center as well as shifting people from other departments.
UCHealth has experimented with other types of remote monitoring devices, including small patches and buttons that are worn over the heart.
“They’re less noticeable to the patient — they don’t get in the way of typing, and they’re more waterproof,” Davis said. “The downside is that they typically do not measure pulse oximetry, and we felt like that was the most critical thing needed for COVID-19 monitoring.”
But he foresees a big future for these bio patches and buttons, as well as a ring device made by Oura that monitors temperature, heart rate and other health information.
“We’re not deploying that actively,” Davis said, “but I’ve experimented with them, and it’s pretty impressive what they can do.”
While devices like Apple watches and Fitbits aren’t a good fit for COVID use, “they definitely have value in chronic disease management,” he said. These devices can deliver data to a patient’s cardiologist, or the patient can track data and send it to the provider.
“I’ve heard about patients diagnosing atrial fibrillation through their Apple Watch,” he said.
APPS AND MESSAGING
Smartphone apps can perform thousands of health-related functions, and UCHealth decided to develop its own mobile app to avoid reliance on a third-party provider.
The app is a gateway to UCHealth’s My Health Connection, an online portal where patients can access services from refilling a prescription to communicating with a doctor.
“It has been vital to how we’re addressing COVID, through testing and now through vaccine appointments,” Davis said.
The mobile app existed before the pandemic, but its users increased 160 percent from the start of the pandemic to the end of 2020, said Paula Freund, UCHealth public relations manager. The system saw an overall 57 percent increase in My Health Connection users during the same period.
Store-and-forward technology, also called asynchronous telemedicine, is based on a secure messaging system that allows for HIPAA-compliant communications with patients and with other providers.
“The number of secure messages that have been sent through our data portal has been in the hundreds of thousands over the COVID pandemic,” Davis said. “It really is efficient and has changed how we communicate dramatically.”
A primary care provider can send a clinical question to a specialist through this store-and-forward modality, along with the patient’s clinical background. In many cases, the specialist can answer the question without having to see the patient.
“So it’s sort of an amplifier for patient access, which, especially in COVID, is a big deal,” Davis said.
These four forms of telemedicine overlap and interact and are replacing older forms of communication such as paging and faxing. They’re also facilitating the collection of data that could transform health care.
“Health care is one of those industries that hasn’t truly crossed into places like finance and transportation, using data for predictive analytics,” Davis said. “Where health care systems are going is, how do we partner with big tech, and who are the specialists in machine learning and AI, and how do we bring those tools to bear into health care? We’re still on the cusp of that.”
Smaller systems such as Peak Vista Community Health Centers and Matthews-Vu Medical Group also have deployed new ways to communicate with patients.
At Matthews-Vu, about 60 percent of patient interactions were conducted virtually during the height of the COVID stay-at-home orders, said Debbie Trittschuh, head of the clinical IT department. Virtual consultations currently are about 10 percent of patient visits.
“We do a lot of car visits … to accommodate patients who aren’t willing to walk into the office or shouldn’t be walking into the office,” Trittschuh said.
The practice has designated parking spots for patients, who alert staff by phone that they’ve arrived, she said. Then a medical assistant, fully gowned and protected, conducts intake procedures and takes vital signs. The patient’s provider will either visit outside at the vehicle or complete the visit via telephone.
Matthews-Vu uses a platform called Ero Health that allows providers to see a patient on-screen, document the visit and access lab results and other clinical information, and also utilizes remote monitoring for some chronic care and high-risk patients.
“When COVID appeared in Colorado in March, Peak Vista Community Health Centers right away realized the urgency that we would need to bring to the forefront, to continue to allow our patients to have access,” said Dr. Lisa Ramey, chief medical and dental officer.
Within the first two or three weeks, Peak Vista’s IT and business intelligence teams accomplished what normally would have taken four to six months and ramped up telehealth care via phone calls and video.
“We were fortunate to receive some funding from the Colorado Health Foundation, which allowed us to obtain some more IT infrastructure and equipment to help support our providers in getting telehealth access to our patients,” Ramey said.
One of the benefits of telemedicine is improved compliance, especially with behavioral health and pain management patients, Matthews-Vu CEO Debbie Chandler said.
“Our pain management providers have definitely had less no-shows with telehealth,” Chandler said, because of issues these patients may have with transportation and limited mobility.
Telemedicine also is more efficient and helps reduce inpatient readmission rates and emergency room visits.
But Chandler and other health care executives are concerned about barriers to telemedicine, including insurance coverage and access to care.
Colorado is one of more than 30 states with a telemedicine parity law on the books, Davis said.
“If you are delivering care remotely and it’s covered as in-person service, then you get covered equally — that’s the idea,” he said. “But it’s not foolproof. E-consults really are reimbursed at a quite low level.”
While there are new insurance codes for remote patient monitoring, “The red tape to actually bill for those services is considerable.”
As long as medical care continues to be billed primarily on a fee-for-service basis, “ it still pays you better to see patients in person,” Chandler said. “As we move more into value-based [reimbursement],which can be capitated, where providers get paid a certain amount per month per patient, that’s where you don’t have a disincentive to do telehealth, and you can do more of it.”
For Peak Vista patients, the majority of whom are on Medicaid or Medicare, access can be an issue, Ramey said. That’s because some patients lack internet access, especially in rural areas, or smartphones, or the means to afford telemedicine.
“I have concerns that it will be somewhat unattainable for a certain subsector of our patient population,” she said.
Nevertheless, telehealth resources are coming online every day.
“You can do an eye exam now … on an iPhone,” Chandler said. “I think it’s just going to expand more and more.”