Navigating Telemedicine In A - Phyins

6“Telemedicine can work well forpatients with chronic diseases suchas hypertension and diabetes—aslong as they use at-home medicaldevices to monitor and reportbiometric information such asblood sugar and blood pressure. ”DR. JOHN SCOTT, MEDICAL DIRECTOROF DIGITAL HEALTH, UW, SEATTLE, WA(Telemedicine Is Here to Stay, continued from page 5)users during the height of thepandemic. Now, health systems areexpanding video visits to includemultiple specialties. Real-worldexperience is helping leaders identifywhich specialties are appropriatefor telemedicine and which onesmake more sense for in-personappointments. (See “LiabilityImplications and Recommendationsfor Telemedicine,” pg. 28.)UW Medicine in Seattle has beengrappling with this question anddeveloping best practices for its clinics,says Dr. John Scott, medical directorof digital health at the University ofWashington. “We are finding that inperson visits are most appropriate forpatients with eye complaints, sinceophthalmologists use specializedequipment to view the retina,” heexplains. “The other two in the ‘inperson’ category include patients withabdominal pain and medically complexpatients who tend to be brittle andneed routine blood tests.”He adds that telemedicine can workwell for patients with chronic diseasessuch as hypertension and diabetes—as long as they use at-home medicaldevices to monitor and report biometricinformation such as blood sugar andblood pressure.Mental-health services can be effectivein the virtual and in-person setting; Dr.Scott says UW Medicine leaves it up toproviders to decide which they employ.“Only half of the counties in the stateof Washington have a psychiatrist—some patients would have to drive twohours to see one,” he says. “We need tobe flexible in those situations because,for these patients, the choice may betelemedicine care or no care.”Dr. Scott, an infectious-diseasespecialist, has long been a proponentof telemedicine. In 2008, he launchedProject ECHO at UW Medicine. Thisinnovative telehealth platform helpsclinicians in rural and underservedareas treat chronic diseases. Dr. Scottbegan using Project ECHO to treatpatients with Hepatitis C, and theprogram has since expanded at UWMedicine to include other conditions.SEEK INNOVATIONAs telehealth gains wider acceptanceamong patients and providers, investorsare taking notice. According to RockHealth, total venture-capital investmentin the digital space in the first half

7on Best Practices andTelemedicine Legislation withThese Helpful Resources American Telemedicine Association(AmericanTelemed.com)—Resourcesand information to help providersensure access to safe,appropriate care. Center for Connected Health Policy(CCHPCA.com)—The CCHPCA isthe federally designated NationalTelehealth Policy Resource Center.It works to maximize telehealth’sability to improve health outcomes,care delivery, and cost-effectiveness.of 2021 totaled 14.7 billion, morethan twice the investment in 2019.That puts pressure on virtual healthcompanies to innovate—which is goodnews for health systems that want toprovide cutting-edge technology fortheir patients.Some health systems, such as UC SanDiego Health, have launched centers forinnovation to develop telehealth devicesand platforms. “Doctors, nurses, andmedical teams know best where thereare existing technology gaps in patientcare,” Dr. Christopher Longhurst, thehealth system’s chief information officer,said in a press release. “Our in-houseteams of clinicians and scientists willinnovate solutions that lead to thingslike lower blood pressure with longerterm goals, like reduced number ofhospitalizations and a longer life. Withour proximity to the health and biotechsector as well as to the cross-borderregion, the number of collaborativeopportunities is immense.”Your organization may not have theresources to develop the next big thingin telemedicine—but you can partnerwith vendors who do. Take it from DebMuro, chief information officer at ElCamino Health in northern California.Her team works with a telemedicinevendor that is launching closedcaptioning and translation services forpatients. (See "Lessons Learned by anEarly Telehealth Adopter," page 12.)STREAMLINE OPERATIONSIf your organization cobbled togethera telemedicine solution during thepandemic, you likely used multipleplatforms that didn’t necessarily play(Continued on page 32) smedia website connects withleading subject-matter experts toprovide news, featured stories, andemerging trends in mobile health,telemedicine, remote patientmonitoring, and connected healthfor providers. Northwest Regional TelehealthResource Center (NRTRC.com)—Assists healthcare providers,organizations, and networks in sevenNorthwest states in implementingcost-effective telehealth programsto serve rural and medicallyunderserved areas and populations.Depending on your state, state medicalboards can be a valuable resource.The UW's Cindy Jacobs encouragesproviders to reach out to medicalboard staff about issues affectingtelemedicine, attend public boardmeetings (particularly when the boardis proposing telemedicine-relatedregulations), and sign up for theorganization’s newsletter, if available.THE PHYSICIANS REPORT FALL 2021Stay Upto Date

8RemotePatientMonitoringHow to MakeIt Work forProvidersand Patients

9No matter how much providers and staff work to make ahospital stay or office visit pleasant for patients, there’snothing like being in your own surroundings, with your owncreature comforts.Healthcare providers are increasingly finding ways to keeppatients at home when they might otherwise have needed tobe at the doctor’s office or in the hospital—particularly thosepatients who have chronic conditions that require frequentchecking, or even those with acute conditions who are ableto be discharged. Providers are accomplishing this withemerging remote patient monitoring programs that improvepatient outcomes and overall quality of life, as well as reducecosts to providers.Like much in the telehealth and telemedicine arenas, thedevelopment of remote patient monitoring (RPM)—even to theextent of “hospitals at home”—has accelerated dramaticallybecause of the pandemic and the need to keep patients—especially vulnerable ones—safe from exposure to COVID,reduce exposure for healthcare professionals, and free uphospital beds. Also, prior to the pandemic, reimbursementof RPM was limited—but since COVID, Medicare coverage ofRPM services has expanded, furthering its growth.“Hospital at home” care is next-level RPM for patients withacute conditions such as pneumonia, congestive heart failure,or even moderate COVID, managed via devices such asspirometers and ECG machines. These patients require morefrequent remote monitoring and perhaps also regular homevisits by medical providers.How Did It Start?Mark VanderWerf, a telehealth and telemedicine advisorand consultant in Worcester, Massachusetts, has seen theevolution of remote patient monitoring over the last threedecades. A recognized leader in telemedicine and relatedtechnologies from the points of view of technology providers,service providers, and healthcare provider executives,VanderWerf has built successful telehealth programs andfounded telemedicine companies. RPM began with clinicianto-clinician applications, he says—for example, a patient in arural area would be connected remotely, through the primarycare physician they saw in person, to a specialist elsewherefor treatment.This type of application has developed in many specialtyareas; one where dramatic success has been seen is stroke(Continued on page 36)RPM DefinedRemote patient monitoring, sometimes called remote patientmanagement or abbreviated as RPM, is a means of deliveringhealthcare using technology—usually through wireless mobiledevices—to capture and transmit patient data, either from aremote healthcare location or outside of traditional healthcaresettings altogether—that is, in the patient’s home. Providersremotely monitor and assess the gathered data and giverecommendations and directions. Usually RPM is managedby nurses or physicians’ assistants—or contracted third-partyRPM administrators—and escalated to a doctor when that’swarranted by a change in the data.RPM is most commonly used to check on patients withconditions like high blood pressure, diabetes, and obesity.Providers can use RPM to collect a range of health data,including blood pressure, heart rate, weight, and blood sugarlevels, via devices like blood-pressure monitors, weight scales,and blood-glucose meters. Medication compliance can evenbe monitored when patients wear a patch that detects whenthey take their medications and relays that information toproviders. Patients may also be given tablets for video callswith providers, or in order to fill out answers to questionsabout their symptoms.“You can create anICU anywhere.”MARK VANDERWERF, FATA,TELEHEALTH AND TELEMEDICINEADVISOR/CONSULTANT,WORCESTER, MASSACHUSETTS, MATHE PHYSICIANS REPORT FALL 2021There’s no place like home.

10Addressing theDigital DivideOvercomingTelehealth InequitiesThe explosion of telehealth catalyzed by the pandemicis changing healthcare forever.A hybrid model of care that includes both in-person andtelehealth visits has emerged, and it’s here to stay. But a veryreal digital divide is threatening to exacerbate health equity gaps,and it’s up to healthcare providers to understand and addressthose disparities now, during telemedicine’s nascent stage.Here are some startling facts about Internet access. Accordingto Pew Research, 26 percent of Americans earning less than 30,000 rely exclusively on smartphone Internet access,and although most without Internet access live in rural areas,digital barriers also affect urban dwellers. For example,in New York City, almost 50% of low-income householdslack internet access, according to the mayor’s office. Alltold, anywhere between 21 and 42 million Americanslack high-speed Internet access, according to the FederalCommunications Commission. Nearly half of Americanswithout at-home Internet were in Black and Hispanichouseholds, according to the Harvard Business Review. TheAmerican Medical Informatics Association (AMIA) has urgedthe federal government to recognize broadband access as asocial determinant of health.

11are encountering,and will continue toencounter, obstacles intelehealth. But we arelearning a lot, fast, andfinding solutions.”DR. JOHN SCOTT, MEDICAL DIRECTOROF DIGITAL HEALTH, UW, SEATTLE, WAIn addition, even among those who are using telehealth,The Los Angeles Times recently reported that many who arenot fluent in English do not get telehealth in their preferredlanguage—especially those who do not speak Spanish,according to research by the California Pan-Ethnic HealthNetwork. Its surveys also found that Asian respondentswere less likely to have a private place for a telehealthappointment, and that Latinx respondents were most likelyto report technological barriers such as an unreliable Internetconnection.As daunting as these challenges sound, John Scott, MD,Medical Director of Digital Health for UW Medicine, urgeshealthcare providers not to become overwhelmed by thedigital divide.Dr. Scott is an early telehealth pioneer and currently overseesthe development of new telehealth applications throughoutthe Pacific Northwest. He’s seen the gradual developmentof telehealth as technology became more affordable, cloudbased videoconferencing took hold, and people began usingthese technologies in their personal lives. He’s seen what onceseemed impossible become everyday practice. As healthcaremoves into the brave new world of telehealth possibilities andchallenges, he’s already seeing providers find solutions tobarriers—at warp speed, no less—and knows it’s a harbingerof more to come.“Healthcare providers are encountering, and will continueto encounter, obstacles in telehealth,” he says. “But we arelearning a lot, fast, and finding solutions.”(Continued on page 13)THE PHYSICIANS REPORT FALL 2021“Healthcare providers

12LessonsLearnedby an EarlyTelehealthAdopterBy Deb Muro, Chief Information Officer at El Camino HealthWhen the need fortelemedicine surgedduring the pandemic, many healthcareleaders probably thought the samething: Oh no! But for people like mewho have been promoting telemedicinefor years, it was more like: Finally!My interest in telemedicine goes backto my days as a nurse, when I wasasked to lead the implementationof a new bedside computer systemto help care for inpatients. I wascaptivated by technology’s potentialto assist clinicians in their daily work.I eventually left nursing and becamea healthcare tech professional, andin 2014 joined El Camino Health, asystem that includes two not-for-profitacute-care hospitals in Los Gatos andMountain View, California.For the next five years, my teamsworked with various departments tointroduce telehealth initiatives, suchas remote monitoring and psychiatryconsults. We launched video visits,too—but up until early 2019, thoseonly represented 1 percent of all clinicvisits in the industry.I was eager to do more with telemedicineand started digging into what it wouldtake to expand our video-visit platform.I saw video visits as a way for physiciansto ensure that patients were doing wellbetween episodes of care. It took timeto convince our organization of this newtool's capability, and progress was slow.In late 2019, we selected a vendor whocould staff and provide on-demand videovisits 24/7 and help us deliver videovisits with physicians in our clinics. Thathybrid approach was important to us. Wewant to be available for patients 24/7,but we cannot staff a service like thatfrom within.The pandemic hit just as we wereplanning our launch. One day earlyin the crisis, my team was asked toramp up a telemedicine offering toassess patients exhibiting symptoms ofCOVID-19. Thankfully, our vendor wasable to do it in a matter of days.The service met a vital need for peoplein our community who needed careduring a stressful time. Soon we addedprimary-care and even specialty-carevideo visits. Now patients can use theircomputer, smartphone, or tablet toschedule a virtual appointment withone of our providers, or see a provideron demand.At El Camino Health, in Los Gatos andMountain View, CA, we were fortunate tohave a telemedicine partner in place justbefore the pandemic began. But we wereeven more fortunate to have selecteda vendor who could help us ensure theplatform’s long-term growth and stability.If you are choosing from the hundredsof telehealth vendors out there today, Irecommend looking for one who:1.Is fully dedicated to healthcare, andnot serving multiple industries. Asingle focus on healthcare meansmore knowledge, expertise, andspecialization.2.Offers a product that will fullyintegrate with your health system’selectronic medical record system.This will allow doctors to conductthe visit, enter notes, viewdocumentation, and see other datarelated to the patient’s medical care,all in one place.(Continued on page 37)

13send them home with devices for eight weeksof follow-up? If they don’t have Internet accessat home, is there a library or a police or firedepartment in town that has a private kioskset up for telehealth visits? If there is a culturaldivide, how do we learn to communicateeffectively and appropriately?”NICHOLE PERISHO, BA, BSN, RN, PROGRAM DIRECTOR, NORTHWESTREGIONAL TELEHEALTH RESOURCE CENTER(Addressing the Digital Divide, continued from page 11)Fast being the operative word. InFebruary 2020, about 200 UWMedicine healthcare-system providerslogged about 200 telehealth visits.In May 2020, 3,800 providers in thesystem had 33,000 visits. And thenumbers keep growing.“The genie is out of the bottle,” Dr.Scott says. “People tried it to avoidexposure to COVID-19 and realized howconvenient and easy it is. There’s nogoing back.”The three drivers of future telehealthgrowth, he says, are increasedbroadband access, device access,and digital literacy. The 1 trillioninfrastructure bill that Congress passedin August will go a long way towardincreasing broadband where thereare deficits. Device access is beingaddressed in many different ways—from Medicaid providing tablets torecipients who demonstrate need, tocompanies like Amazon and Microsoftgiving them away as those tech giantslay the groundwork for getting into thebusiness of healthcare themselves.Digital literacy is being tackled at agrassroots level, with opportunities foreducation arising at local libraries andcommunity centers.Where providers are concerned, hesaid, there are three non-negotiablesfor getting patients to use telehealth:it must be private, reliable, and easy touse for both patients and providers.“You need to create an interface withas few clicks as possible,” he says.“We work hard on the back end to dothat.” He says that ideally there’s nodownloading of an app; rather, it’sjust a link, which can be texted to thepatient, where the patient logs in, seesthe visit, and clicks to connect.Contracting with interpreter servicesensures straightforward communicationonce the visits take place. Zoomdoes provide closed captioning,and sign-language interpreters arean option as well.“You can have a very good experienceconnecting with a patient overvideo, but you have to make themcomfortable,” Dr. Scott says.“Show them the actual room, not abackground. Show them your badge,that you really are a doctor. Show themthat you’re writing notes, so they don’tthink you aren’t paying attention. Shareyour screen, and look at labs and X-raystogether. Come close to the camera withyour face. Use facial and body languageto express caring.”TELEHEALTH TOOLKITJust like patients, providers havetheir own digital learning curves tosurmount—and help is out there.Nichole Perisho serves as ProgramDirector at the Northwest RegionalTelehealth Resource Center (NRTRC),creating and disseminating informationand resources to expand and sustaintelehealth in NRTRC’s seven-stateregion (Alaska, Idaho, Montana, Oregon,Utah, Washington, and Wyoming).A 10-year veteran in the telehealthfield, Perisho is working to developtelehealth’s critical role in achievingthe quadruple aim of reducing cost,improving quality, enhancing thepatient experience, and bettering thework life of healthcare staff.Created in 2005, NRTRC is a HealthResources and Services Administration(Continued on page 34)THE PHYSICIANS REPORT FALL 2021“If patients don’t have devices, can providersDr. Scott explains that it’s important toeducate the patient, before telehealthis used, about privacy and how theequipment works. One way to do thatis creating a video with instructions, inthe language that patients prefer.

14OVERVIEWTelehealth’sPolicyLandscapeWhen it became apparent in early 2020that COVID-19 would have a significantimpact on our lives and particularly onthe United States healthcare system,immediate action needed to be taken.As the highly infectious virus had devastating effectson patients, we watched as national economies cameto a standstill and necessary supplies became scarce.Immediately, telehealth was looked to as a tool to helpcombat the pandemic.Telehealth is the use of technology to provide healthcareservices from a distance, when the parties are not in the samelocation. It seemed an ideal tool for the time: patients couldstill receive healthcare services, but physical exposure couldbe limited and precious personal protective equipment couldbe conserved. But as beneficial as telehealth was, why wasn’tit already being utilized? Instead, doctors, hospitals, andclinics had to scramble to set up telehealth programs, oftenliterally overnight. Why wasn’t America ready?Though telehealth itself has been in existence for decades,it was slow to be adopted for a variety of reasons. For one,until recently, the technology was not necessarily at a pointwhere it could be used effectively to provide health services.Additionally, telehealth policy only began to appear on thefederal and state levels in the mid-1990s. Much of thetelehealth-specific policy that had evolved to that pointcentered around reimbursement—what and who could be paidand covered, if healthcare was delivered remotely. Existingpolicies were very restrictive among Medicare an

Playbook," published in 2020, the American Medical Association recommends that organizations work with their IT department and a telemedicine vendor to: Ensure that the telemedicine platform seamlessly integrates with your organization's electronic medical record Assess the platform's impact on your internet and local network usage