As the tsunami of COVID-19 cases began sweeping toward the Midwest, we had to quickly prepare for a surge of COVID-19 patients while continuing to care for everyone else.
First, how do we care for those with COVID-19? They would be part of our critically ill patient population, and there would potentially be more patients than beds. Care needed to meet the highest quality and safety standards and not overstretch our supply of personal protective equipment (PPE). Therefore, specialists needed to provide care while perhaps not physically present.
The second issue was: How do we care for and protect the tens of thousands of other patients outside our walls, many of whom were at increased risk of COVID-19 and associated complications?
All these issues had the same solution—telemedicine.
To support patients in our hospitals, we repurposed 600 bedside iPads inpatients use to order meals and communicate with their care team by adding an app that allows them to communicate with specialists. In two weeks, our hospitalists, intensivists and infectious disease specialists had the app installed, as well as everyone from psychiatrists to oncologists, pharmacists to nutritionists, and even our spiritual care team had the ability to use the app to connect with patients.
We quickly expanded this functionality to multidisciplinary rounds, so one provider could be in the room conducting the exam while others attended via video, conserving PPE and reducing exposure. The care team could still witness the exam, talk to the patient and communicate with each other from anywhere. In our inpatient psychiatric unit, the experience was so seamless our physicians wrote about it for the American Journal of Psychiatry (PDF).
We also had to rapidly expand our eICU capabilities to see more critically ill patients via video, especially if there was a surge of COVID-19 hospitalizations. Our eICU capability initially allowed an intensivist and three critical care nurses to monitor the vital signs and video feeds of about 100 ICU beds in our hospital and at regional community hospitals. To expand that capability, we added 50-plus ICU beds by increasing staffing and the number of video monitoring carts.
We also have a telestroke service that ties rural hospital emergency departments into our comprehensive stroke center. We leveraged this for our eICU staff to help assess and manage COVID-19 patients at rural hospitals.
Even after devising ways for providers to see patients via video, we still needed patients to see loved ones even when visitors were restricted. This isolation was a major source of distress for patients suffering and even dying alone without friends or family present. After exploring several options, we rolled out a solution to link family from home securely with the patient anytime, which will persist long after the pandemic is over.
Caring for patients remotely
We needed to rapidly scale our ability to connect with patients in their homes. For urgent care, we expanded our online service (“Care Anywhere”), increasing staffing and hours following a call volume increase during the first weeks of March.
For general care now taking place via telemedicine, schedulers send a link to patients initiating a video visit using our existing app. Our providers can do this using any operating system and almost any device. This was a game changer. Going forward we estimate half our 35,000 outpatient visits per week could be handled by telemedicine.
Prior to the pandemic, we had several barriers to expanding and accelerating telemedicine. We had separate telemedicine programs that all started a dozen years ago but had not been aligned, making our work difficult to scale.
While we’d started to build a more solid telemedicine foundation recently, it is amazing how fast issues can be resolved when the mandate is there from leadership and so are the resources, both human and equipment.
Together this need, support and foundation enabled us to move faster over the first eight weeks than in the past eight years.
This is just the beginning.
From a payment angle, getting reimbursement for telemedicine has been challenging. In Wisconsin, Gov. Tony Evers signed a law in 2019 that allows full payment parity for video visits, but that law doesn't take effect until 2021. Since COVID-19, we’ve seen accelerated movement by the Centers for Medicare & Medicaid Services, state Medicaid and insurance companies to pay for telehealth visits. While the landscape of coverage is changing daily, most telehealth visits are a covered benefit by health insurance.
Going forward, we need to create a more permanent system of video-based care that is integrated with electronic health records. We’re going to need legislative support for keeping the emergency rules that allow us to see patients via telemedicine and be fairly reimbursed for those visits.
Nationally, this pandemic spurred more telehealth advances in the first weeks than occurred in the previous decade. It forced us all to come up with a new, patient-centered model of care in a time when a patient’s decision to come to the hospital can literally mean life or death. It let the telemedicine genie out of the bottle, and neither patients nor providers are going to want to return to the way things were.
Tom Brazelton, M.D., is the medical director of the UW Health Telehealth Program.