“[With telehealth visits], I have 20 minutes that I am dedicated to talking to that patient,” she said. “We really form quite a connection.”
Telehealth has been around for years, but during the COVID-19 pandemic, it has picked up steam and become a larger part of healthcare culture. The new telehealth norm is partially due to the need for many hospitals to cancel nonemergent procedures to free up space to accommodate surges of patients with COVID-19 and the inability of physician offices to take patients as usual when social distancing practices began. Also, CMS enacted temporary policy changes allowing providers to expand their telehealth offerings.
Now that CMS has proposed a permanent expansion of some of those permissions, physicians, revenue cycle personnel and leaders are looking to shift their mindset from seeing telehealth as a temporary solution to considering it a fixture in the healthcare landscape.a
The challenge of the quick pivot
Telehealth did not have a strong presence at OhioHealth prior to the pandemic, but a team was working to map out a long-term strategy to offer telehealth, according to Nicole Walker, OhioHealth’s director of revenue cycle. When the pandemic hit and people began to move to telehealth visits, OhioHealth leaders created a large, multi-departmental team to make decisions around telehealth and other issues. For 14 weeks, team members including Walker met virtually every day for several hours to work through those issues. A smaller version of that team continues to meet regularly.
“It took a large team to say, what do we as an organization want to offer, what can we offer safely for ourselves and our patients and what is our standard work around that?” Walker said. Some examples of those issues were:
- Issues that are clinically appropriate to address over the phone versus in person
- Prescribing protocols, particularly around controlled substances
- Lack of laptops for providers, who had to use their own personal devices for a time, which introduced risk
- Clinical workflows and privacy issues in pediatrics, particularly when photos are shared
For Walker, pivoting to a telehealth-heavy strategy was not only an administrative challenge, but also a moral one. People who work in revenue cycle typically rely heavily on data, but in a situation where data simply wasn’t available, she had to get comfortable making recommendations and decisions based on estimates and expert opinion. The process also was stressful because she knew the stakes were high, she said.
“As a non-clinical leader, I’ve never had the feeling that I hold someone’s life in my hand,” she said. “I felt like I was working against a deadline that I didn’t really know for sure. And if I don’t pull my weight and do my job to the best of my ability, people could die.”
During that crucial time, team members leaned on each other’s expertise and worked methodically to put workflows in place that could be easily adjusted going forward. (See the sidebar at the bottom of this article, "OhioHealth overcomes revenue cycle challenges posed by telehealth visits.")
For Sinha, the adjustments were more practical. Some patients had trouble with the technology. And patient privacy is now a family consideration, as she must restrict her children’s access to their play area because it’s near her work area.
“They’re really understanding. They know when Mommy is with patients, she needs to be left alone,” she said. “They know when that sign is up on the door, they cannot come downstairs and disturb me.”
The opportunity of flexibility
At Presbyterian Healthcare Services in Albuquerque, New Mexico, the process of moving quickly toward a telehealth strategy included education for providers, according to Alex Carter, a physician’s assistant and innovation telehealth clinical advisor at the health system.
Some providers were hesitant because they weren’t sure how to translate in-person care to virtual and provide the same level of quality. Presbyterian ran a focus group and held an informational session about how telehealth could work well while the provider worked from home, and early adopters were given the opportunity to share their tips and feedback.
“It’s not a one-size-fits-all experience,” she said. “There are some constants ... but we also know that providers have their own style and their own personality.”
Physicians who have adapted to new clinical workflows tend to like the way their days are structured, and many find career flexibility they didn’t have before, Carter said. For example, telehealth at Presbyterian’s urgent care clinics is exclusively asynchronous (that is, care where a patient uploads information and a physician logs on later and responds), which allows physicians to work where they like and, to some degree, when they like. Some physicians do telehealth work in the office between live visits, and some work the entire day from home, focusing only on remote patients.
“There’s a lot of flexibility, and it’s very customizable,” Carter said. It’s also efficient: Presbyterian’s response time is typically less than 10 minutes.
According to Oliver Lignell, vice president of virtual health at AVIA, flexibility and workflows should also take the patient’s convenience into account. For example, there should be a mechanism that allows a physician to convert an asynchronous visit to a synchronous one.
“You need all those modalities,” he said. “You need to be able to move between them and choose what’s appropriate clinically.”
The future of telehealth
Early on, most of Sinha’s remote visits were conducted over the phone (see the sidebar “Telehealth by the numbers” below). But as telehealth becomes a more important component of care, the technology is improving, and on the practical side, CMS’s plan to expand telehealth permanently does not currently include long-term plans for telephone visits to be widely used.
