Three years ago, Rush University System for Health in Chicago began a concerted effort to grow a virtual care structure.
We—a team of like-minded doctors, nurses, administrators and other staff—insisted that an organized platform of digital tools must be designed to surmount the challenges of cost, quality and access in our healthcare system. At the time, we thought of these tools as critical to fueling our growth and differentiating our organization from competitors.
Now we know that virtual care is also critical for a public health crisis.
We believe the conversion to virtual care will be seen as one of the most important tools utilized during the COVID-19 pandemic to save lives—and to save healthcare workers from unnecessary exposure to this virulent pathogen.
Before COVID-19, leaders from information services and technology, marketing, strategy and operations focused on constructing a digital front door, mobile app and care options such as chat, e-visits (an asynchronous message-based exchange) and on-demand video visits. After all, consumers expect these kinds of services from almost every other industry. Together, the suite of tools was dubbed Rush On Demand.
In early March of this year, we created a new option.
Patients could request a video visit with a provider about their symptoms and potential exposure to coronavirus. An organized link to COVID-19 testing at Rush was provided for those who met criteria. Since this catastrophe has begun, our team has trained over 200 providers on how to use this new virtual care platform. In addition, our program has expanded from treating only adults to seeing people of any age; increased hours of operation to 7 a.m. to 11 p.m. seven days per week; and accommodated both English and Spanish speakers.
Between mid-March and mid-April, we have spoken to over 2,000 Illinoisans concerned about coronavirus.
Due to the success of this program, we made yet another big decision: to enable all ambulatory providers across disciplines to use telehealth for scheduled appointments.
In a period of just two weeks, we grew to exceed 500 scheduled video visits per day and the daily totals continue to rise. As a result, we have extended care to those who may have delayed it, and we have prevented unnecessary in-person visits to busy clinics and emergency departments—visits that would have exposed and endangered countless others.
The effectiveness of and potential of virtual care has exceeded even the hopes of we early champions. It is especially noteworthy given the obstacles we initially faced: the absence of traditional reimbursement from Medicare and commercial insurance companies, lack of robust studies measuring the clinical quality of virtual care and a general apprehension to clinical assessment in the “hands-off” nature of the virtual world.
These concerns were widespread.
In April 2017, FierceHealthcare reported findings from the 2017 American Telemedicine Association survey where 83% of participating health system executives reported that they planned on making investments in telehealth during 2018; however, most study participants cited reimbursement and resistance to change as major barriers to adoption. At Rush, we weren't able to get the support of any insurers to cover telehealth services, so initially we launched our program to consumers as a cash-only service—$30 for an e-visit and $49 for a video-on-demand visit, with a guarantee to connect patients to a provider in 20 minutes or less.
Now, with a universal coverage mandate for telehealth in place across the country and the need to increase our social distance, health systems are supported with reimbursement for care in their transition to virtual. Reimbursements will not cover the cost of the big technology implementations, but they will allow for much greater adoption of telehealth in the short term for organizations that have systems and technology in place.
It's uncertain at this point how long this reimbursement parity will last. But we hope that enough telehealth programs will be launched to definitely demonstrate they can improve access to care as well as reduce costs. Many studies already performed to date have found that virtual visits cost less than in-person care because they avoid laboratory, imaging and follow-up fees.
As for the paucity of clinical outcomes data, we remain cautious about claiming virtual care is better than or even comparable to in-person care. However, we remain hopeful. In an academic medical center such as Rush, evidence is paramount—and rightly so—when you are looking to change a clinical practice. The idea of not listening to lung sounds for every patient with a cough or not being able to palpate lymph nodes in the neck of a patient complaining of a sore throat leads many experienced clinicians to feel that a virtual medium does not give them the tools to accurately assess patients. But in the case of the COVID-19 crisis, the need to distance and reduce the risk of transmission has helped providers overcome the previous reluctance to make an “imperfect” clinical assessment.
Furthermore, necessity became the mother of invention. Over the days and weeks since we began conducting visits at scale, we have heard of the many innovative methods providers have been using to augment their visual assessment of the patient. These methods include having patients provide a detailed account of their symptoms, asking them to be very descriptive in order for the provider on the other end to get a true sense of their condition. As part of the physical examination, providers may guide patients in counting their own pulses or respirations. For example, patients with sore throats and nasal congestion may be asked to palpate all their sinus cavities and cervical lymph nodes to see whether pain is elicited or may be asked to flip their cameras to the inside of their mouths for the provider to visualize the oropharynx.
We have found that virtual care does not necessarily limit the assessment required, but changes the nature of the assessment and requires new methodology and skills. Providers, once skeptical, are now recounting their saves and cherishing their accomplishments on the virtual front lines. One of our family medicine doctors recently shared the following among a physician WhatsApp chat forum we established to support them during this process. He said, “... It's been amazing to see the gratitude from patients for what we are doing in terms of alleviating real fear, preventing or in some cases managing serious, and complex situations.”
As coronavirus spread continues, we implore you to enable virtual options at your local institutions.
Of course, we know that providing medical care in-person is reassuring and comfortable; however, at this unusual time, discomfort is part of the new normal. As healthcare providers, we are grateful for the smart use of technology to help us identify and prevent the spread of disease, while continuing to be present for our patients at the “webside.”
Meeta Shah, M.D., is an assistant professor in the Department of Emergency Medicine and associate chief medical information officer at Rush University Medical Center. Amanda Tosto, R.N., is the clinical transformation officer for digital health within the Ambulatory Transformation Center at Rush University Medical Center, adjunct faculty at Rush University Department of Health Systems Management. They are both Public Voices fellows through The OpEd Project.