Curbside Consult with Dr. Jayne 4/13/20

Despite my clinical employer’s failure to get on board with telehealth, many organizations are embracing it. The American Medical Association released a Telehealth Playbook last week. It has a lot of good information for people who might not be sure how to approach the process. It’s a bit lengthy at 128 pages, but don’t let that dissuade you, because the last 40 or so pages are worksheets.

The AMA did a good job gathering information from people who have figured this out in the past, when they weren’t in a rush as people are now. Situations are a little different when you are trying to ramp something up quickly or are using solutions that are unproven, though. Your mileage may vary to some degree, depending on how nimble your organization is and what your tolerance is for just getting something live without achieving perfection.

Not all organizations have done well with trying to manage patients remotely or making sure that the needs of patients with chronic issues are met. I have heard from multiple friends and neighbors who have visits scheduled during the next two weeks (while our state is still under a stay-at-home order) and they have received zero communication from their physicians on whether the visits will happen or how they might be executed. I’m sure some of them might be waiting to see how things unfold since they seem to change from day to day, but especially given the availability of patient portals and texting solutions to communicate with patients, it’s surprising that the practices are running silent.

There’s also an error component as practices shift visits. I have already had one pharmacy error when my primary physician canceled my annual visit. They usually send a year’s worth of refills to Express Scripts when I appear in person. This time they sent an order for a 90-day supply to tide me over until I have a visit, and Express Scripts promptly misprocessed it and sent me 30 pills. Four phone calls later, I still don’t have what I need. Fortunately I’m a bit of a pharmacy hoarder and always stay a month ahead on my refills, and it’s not something that will cause grave harm if I miss it for a few days, but I’m sure patients in those situations are experiencing similar confusion and delay.

The AMA playbook divides the process of implementing telehealth into 12 steps, with the first six being planning. Those steps typically include needs analysis, building a team, defining success, evaluating vendors, gaining buy-in, and contracting. In many organizations, these steps can take 12-18 months, and practices are now trying to do it in a matter of weeks (if not days). The playbook includes a concise “Warmup” section that talks about telehealth and provides some basic definitions, helping people understand synchronous versus asynchronous technologies and how they might benefit organizations. It glosses over some of the barriers to telehealth, though, listing them but not really explaining how much of a showstopper they can be for organizations.

Licensure issues are big, especially for organizations that are on state borders and see patients from multiple states. Although there has been some relaxation of interstate licensure during the COVID crisis, some states have their own regulations around it, where others are a bit more of a free-for-all. Even the big telehealth companies have handled temporary licensure waivers differently. One is requiring physicians to opt in to see patients in states where they are not licensed, while another is just assuming that its providers want to see patients from all states where there are waivers. Some of the waivers are already expiring, causing dramatic shifts in how many patient visits are available for physicians to staff.

Privacy and security issues are also paramount, especially given the recent federal relaxation in the level of security needed for billable visits. Providers can use commercial platforms that weren’t specifically designed for patient care, which may increase access, but also increase the risk of exploitation. Another concern is whether telehealth visits can deliver the same level of care as in-person visits with the same outcomes. Having worked for a telehealth organization that has a strong quality program, and where the antibiotic metrics are higher quality than those I saw in my brick and mortar practice, I have to say it’s more about the organization and its culture than it is about the delivery platform.

Funding a telehealth program is also a big issue. The playbook puts it squarely back on the practice to figure out, although it does define a few examples. Organizations will have to work with their payers to understand how visits might be covered and how they might impact other aspects or practice, including Accountable Care Organization cost and quality attribution. The document makes it clear that practices that go down this road will need to have dedicated resources to stay up to date on the constantly shifting landscape with payers, rules, and regulations.

Several of the steps they identify are being largely skipped over as organizations race to get telehealth solutions live. Some of them include getting feedback from staff on pain points and figuring out how different telehealth solutions might solve those issues, along with evaluating the organization’s readiness for telehealth solutions. It’s clear that whether organizations are ready or not, here it comes, so that definitely shifts the dynamic. Budgeting and identification of funding sources are also being skipped as organizations view telehealth as a way to try to preserve care delivery (and financial margins) versus just closing to patient traffic in the face of an outbreak.

Other pieces that are being skipped over include gaining stakeholder buy-in and identifying success metrics. From a vendor analysis perspective, it seems like many organizations are trying to go with solutions that might be already integrated with their EHR or otherwise using commercial solutions. There are multiple third parties that are offering no-risk or low-cost agreements for 90 days during the crisis, so that’s a good thing for practices who might just want a quick solution without significant commitment.

It’s a risk for vendors to take this approach, but if they have a solid offering and treat their clients well, it’s a great way to prove their capabilities. The contracting piece of the document made some great points about ensuring that clients understand who is going to have access to their patients’ data and ensuring scalability.

Steps 7-12 fall into the “Game Time” portion of the document. Some of these steps — like workflow design, prepping the team, and partnering with the patient — are being done in a matter of days in real life. Many of my colleagues are embracing telehealth. It will be difficult to convince them that they need to return to face-to-face visits for many of the issues they are treating. Patients are also happy with the convenience factor, so I don’t see it going away any time soon.

I’d be interested to hear from people who have rapidly executed a telehealth strategy. What worked and what didn’t? Are patients accepting it? Have you had claims come back and are there issues, or are you still waiting for the other shoe to drop? What would you warn someone who is farther back in the process? Leave a comment or email me.

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