PRIMARY CARE | PRECISECAREMEDICAL

 While remote cardiac device monitoring isn’t without its technological challenges — including getting knocked offline by weak cellular service — it has been credited with improving patient health through earlier detection and treatment of heart rhythm problems.

 According to position statement (PDF) released by the American College of Rheumatology (ACR) in 2020, the ACR supports the role of telemedicine as a tool that can potentially increase access and improve care for patients with rheumatic diseases, but it should not replace critical face-to-face assessments conducted at medically appropriate intervals.

 Virtual visits can be a great choice for migraine care, particularly when you’re seeing a physician or other healthcare provider with whom you already have a relationship. This is true both because you’ll likely feel more comfortable talking to a professional you already know, and because an in-person physical examination can be an important part of determining the cause — or causes — of your symptoms and the best way to treat them.

 Telemedicine allows post-stroke patients and their doctors to continue meeting for post-stroke rehabilitative and preventive treatment visits.

 But even before the pandemic, one type of remote stroke care for doctors was already well-established: In-hospital telemedicine for stroke care, called telestroke, has been around since the late 1990s. Telestroke describes an arrangement by which remote stroke experts help local emergency physicians assess patients with suspected stroke and decide how to manage their care. The practice helps ensure that people experiencing stroke will receive appropriate care, even if they don’t go to a hospital with its own on-call stroke team.

 As long as you have a good internet connection, adequate lighting, and space to lie down, walk, stretch, and turn around while on-camera, you can likely benefit from a virtual physical therapy visit.

 Much of what a physical therapist does is analyze how people move and prescribe stretches or exercises that can make moving more efficient and more comfortable. And it turns out, that can be done pretty well remotely, using telemedicine instead of in-person office visits.

 Are telemedicine virtual visits worthwhile? According to experts and recent research, the upsides include the following:

 They save time. “A lot of people don’t have time to drive to an appointment and then sit in a waiting room for 10, 20 minutes or longer,” says Bishop. “We have patients who use Houston Methodist Virtual Urgent Care at work, going into a private office and shutting the door for their appointment, or using it from home.”

 They save money. While the cost of a virtual visit varies widely depending on your health insurance coverage, choice of provider and type of service (read on for details), it’s likely to cost less than a visit to an in-person urgent care center or hospital emergency room for the same problem.

 For example, you could spend as little as $0 to $82 for a virtual urgent care visit. That’s a wide range, but it’s less than the average $176 price tag for a visit to an in-person urgent care center or the $350 to $600-plus you could spend for treatment of an earache, bronchitis, or strep throat at a hospital emergency room, according to Dignity Health, one of the nation’s largest healthcare providers.

 Then there’s the cost of transportation. You won’t have to shell out money for gas and parking or for a taxi, train, or bus. “For someone who’s driving an hour and a half and paying $25 for parking for a routine checkup after a successful knee replacement, a virtual visit can be a big savings,” Carr notes.

 Bishop adds childcare costs to the savings, too. “You won’t have to pay a babysitter while you go to the doctor,” she notes. “Just find a quiet spot in your home, tap on the app, and get started.”

 You avoid exposure to infectious germs. Virtual visits keep you out of settings where you could be exposed to the flu or other infectious viruses, bacteria, or other germs, Bishop notes. “That can be important if you have low immunity, if something is going around in your community, or at times like this when coronavirus is spreading,” she says. “It can help you stay healthy if you’re not sick, but just need to see the doctor for something minor or for your annual well visit or for a routine visit to manage a chronic health condition such as high blood pressure.”

 Covid-19 has sped the adoption of virtual care, or the provision of health services remotely in a synchronous or asynchronous fashion. No longer just a convenient enhancement to in-person clinical care, virtual care is needed by patients, clinicians, care teams, and health systems alike. But the gap between the promise and the reality of virtual care is substantial: The stakeholders often don’t get what they need while trying their best to navigate a new paradigm.

 We aim to close this gap by helping health systems refine and reimagine their virtual care journey while prioritizing the needs of the people who get and give the care. Our guiding principle is a needs-based approach that retains the best practices of in-person visits while sensibly adapting to the unique characteristics of a virtual setting.

 The recommendations presented here are the result of a collaborative effort by University of Texas MD Anderson Cancer Center (MDACC) and Texas A&M University’s Mays Business School. We integrate insights drawn from our experience implementing a broad suite of virtual care services at MDACC with operating procedures and virtual care guidelines identified at other institutions, such as the University of Pittsburgh Medical Center and Jefferson Health. We also leverage our collective expertise in health care innovation, health services research, digital transformation, and clinical care — and did informal interviews with telehealth experts.

 The result is a framework we call DIBS for “Documentation, Integration, Best Practices, and Support.” All four of our DIBS categories have potential benefits, to varying degrees, for all stakeholders in virtual care. Everyone gets “dibs” on optimal design, and no one gets overlooked.

 Health systems should identify and document in detail the activities and interdependencies of everyone directly or indirectly involved in providing, receiving, and designing virtual care. Toward that end, we recommend that health systems create a service blueprint that reflects all the unique activities of health care personnel for a typical virtual care encounter (see the exhibit “A Blueprint of an Outpatient Clinic Visit at MD Anderson Cancer Center”). Health systems should tailor blueprints to reflect their specific strategies for implementing virtual care.

Telemedicine

 A comparison of the in-person and virtual processes allows a health system to identify the elements of a care encounter that should be reproduced, removed, or enhanced in the virtual environment and helps plan the transition of key processes.

 A comprehensive service blueprint should directly compare and contrast in-person and virtual care contexts, which can differ substantially according to the reason for a patient’s visit. This side-by-side presentation can help uncover process complexities that may arise unexpectedly when health systems transition from in-person to virtual care. This will allow a health system to identify those elements of a care encounter that should be reproduced, removed, or enhanced in the virtual environment. The blueprint should categorize care-related activities temporally (i.e., before, during, and after the visit) and guide the technical assistance process for patients who have specific visual, auditory, language, technology literacy, or technology infrastructure needs.

 At a nuts-and-bolts level, the blueprint should describe each element of the care infrastructure, such as technology for remote patient monitoring, software for patient scheduling, screening tools for assessing patients’ needs, and educational materials for patients and caregivers. It also should identify the billing and reimbursement mechanisms that may differ for virtual care visits, if any. A well-developed service blueprint can facilitate implementation by naming accountable departments and individuals within them and anticipating potential barriers to and facilitators of adoption. To monitor the trajectory and success of virtual care, leaders should develop key performance indicators (KPIs).

 MDACC, for example, implemented a remote monitoring program for patients undergoing immunotherapy. The program was associated with significant reductions in emergency room (ER) visits and improvements in patient satisfaction.

 The dissemination and scale of this initiative was guided by KPIs that reflected three areas of strategic focus: stakeholder buy-in (“traction”), operational efficiency, and improvements in health-resource utilization. Measures of traction included utilization by eligible clinicians, percentage of approached patients who consent to participate, and patient-satisfaction scores. Operational efficiency was quantified by volume of patient calls on the platform, rates of patient adoption, and clinical satisfaction with workflow. Health resource utilization focused on patients’ rates of avoidable emergency room (ER) visits and length of hospital stays. Year-end performance, relative to preintervention baseline measures, guided decisions about scale and program iteration.

 Optimizing the virtual visit means making the overall patient-clinician experience as seamless as possible by integrating its component parts. Start by preparing patients and clinicians to use the required technology. Specifically, educate them on how to look at the camera during conversations, choose appropriate lighting and audio equipment, identify a secluded space with minimal distractions, and select a virtual background (if desired). These features, while seemingly minor, can greatly influence the overall experience of this relatively new way to deliver service.

 Integration also means streamlining all ancillary logistics that complement a virtual visit, including but not limited to making future appointments, facilitating prescription refills, and incorporating personal health information captured on in-home devices (vital signs, medication administration history, and patient reported outcomes). Health systems also should design a suite of services that can be combined, as needed, for a given patient (in-person, remote monitoring, hospital-at-home, video visits). The entire service continuum should be modular, when feasible and appropriate, so that patients get care from the right person at the right time in the right modality.

 Integration also means streamlining all ancillary logistics that complement a virtual visit, including but not limited to making future appointments, facilitating prescription refills, and incorporating personal health information captured on in-home devices (vital signs, medication administration history, and patient reported outcomes). Health systems also should design a suite of services that can be combined, as needed, for a given patient (in-person, remote monitoring, hospital-at-home, video visits). The entire service continuum should be modular, when feasible and appropriate, so that patients get care from the right person at the right time in the right modality.

 For example, the University of Pittsburgh Medical Center (UPMC) encourages virtual care use among health plan members by offering $0 copays for virtual visits, compared with a higher cost share for an in-person encounter. The health plan app also facilitates digital onboarding for a broad range of integrated virtual services, including virtual primary care, behavioral health, wellness checks, and urgent care.

 Continuity of care is key. Prepare patients and their home caregivers for self-monitoring and self-care with educational materials (tip sheets, links to training videos) on the proper use of in-home devices (blood pressure cuffs, pulse oximeters, tablets). To gain trust and buy-in, ensure that all communication is culturally and linguistically competent and clear.

 Clinicians and support staff should also be taught how to use broad-based communication platforms (“omnichannel”) to engage patients (e.g., correspondence via online patient portals, text messaging, phone calls) to proactively initiate contact (to remind, inform, and encourage), not merely to react to patient-initiated messages. Ideally, this platform should be unified such that all communications are integrated and visible across the different modalities to optimize patients’ and clinicians’ experiences.

 Ensure that virtual care visits and systems make full use of prevailing best practices for in-person care, sound principles of clinical engagement, and sensible goals for organizational alignment. First and foremost, use evidence-based decision criteria to guide the appropriate use of remote care — for example, lower-complexity and lower-emotion visits. Virtual care is simply not appropriate for all visits.

 Best practices for executing the visit itself are essential. Encourage clinicians to become familiar with patients and their health records before virtual encounters — and ensure, to the degree possible, that records and notes from other treating clinicians are available before and during the visit.

 In addition, like a health system does for in-person visits, it should involve the whole care team (e.g., nurses, medical assistants) in preparing for the virtual visit (gathering records, prepping the “virtual room”), connecting during the visit, and closing at its end (e.g., scheduling next appointments). This step minimizes the additional work (“friction”) associated with virtual care that can be time-consuming and frustrating for physicians and below their level of training; it also enhances team coordination and cohesion.

 Jefferson Health established the National Center for Telehealth Education and Research (NCTER) to “advance the use of virtual health services.” Clinicians can receive certificate-level training on all aspects of optimizing a virtual care encounter, including an overview of the technical, clinical, and operational aspects of common telehealth technologies, instruction on how to conduct a telehealth physical exam, coaching on how to serve as a telemedicine facilitator within the context of an inter-professional team, and general trouble shooting tips.

 Prioritize best practices that enable clinicians to adopt and sustain virtual care. Ideally, virtual care should substitute for, not add to, in-person encounters on clinicians’ schedules. Benefits to clinicians may include greater efficiency, improved outcomes and patient experience scores, and an intrinsic sense of mastery or autonomy. To preserve these benefits, codify virtual care workflows, when feasible, and refine them as new service-line-specific needs emerge.

 Systemwide best practices also matter. Use clear institutional and professional society standards to inform infrastructure and technology design, expectations for patient and provider conduct, and clinical workflows. The American Society of Clinical Oncology has issued practical guidance on integrating virtual care into clinical practice such as outlining appropriate care encounters where telehealth can substitute for an in-person visit, specifying the supporting documentation that is necessary for a virtual visit, and advocating for the use of standard operating procedures to guide a care team’s response to symptoms and side effects reported by patients virtually.