Curbside Consult with Dr. Jayne 10/17/22

When I speak with physicians who don’t have a lot of experience with using telehealth for urgent care patients, they’re always concerned about quality. Many of them aren’t aware of some of the different techniques you can use to assess patients, or the ways you can instruct a patient to perform different maneuvers to help in that assessment.

It seems kind of funny at times, because in medical school we were always encouraged to remember that the patient’s story often provides the majority of information needed to narrow the options for diagnosis. Despite what we might think in a world of high-tech diagnostics, it’s not always about doing a lot of tests or even about performing hands-on examination techniques.

In my time as a “fast track” physician in a high-volume emergency department, I’ve seen a lot of patients who did not truly need emergency services. As telehealth expanded during the COVID pandemic, hospitals were looking at different ways to manage increasing emergency volumes and figuring out different ways to care for patients who didn’t need high acuity care. Some organizations turned to telehealth, adding phone booth-style cubicles where patients who met certain triage criteria could consult with a physician. Others moved to a “physician in triage” model to help expedite care, although that occasionally backfired when patients left after being triaged but were still stuck with a bill since they were seen by a physician.

With that in mind, I was excited to see an article last week in NEJM Catalyst that examined this phenomenon. Titled, “Converting an ED Fast Track to an ED Virtual Visit Track,” the case study looks at the Stanford Health Care experience as it substituted remote consultations for in-person visits in the emergency department. The effort started in December 2020, as the organization accelerated an already-approved plan to add virtual visits into the ED’s offerings. As we’ve seen with a number of technology initiatives across the US, the challenges posed by the COVID pandemic led to many different advances in care delivery capacity.

Historically, the goal of a fast-track area within an emergency department is to be able to treat low-acuity patients faster, since higher-need patients will always be prioritized. Typically, the fast-track area has dedicated physicians and nursing staff who can quickly evaluate and manage a variety of non-emergent problems, such as cough/cold, sore throat, ear pain, rashes, nausea, vomiting, diarrhea, low-grade burns, minor lacerations, sprains, lower-acuity fractures, and the like. On any given shift in the fast track, I’d see kids who were sent home from school too late to get an appointment with their primary care physician, people who were injured at work, and those who might not have a primary physician or other access to healthcare but who had run out of prescription medications or had other care needs.

At my hospital, the fast track was staffed by family physicians since the majority of patient complaints were the kinds of things we see in our offices day-in and day-out. That freed the board-certified Emergency Medicine physicians to manage more complex cases, including strokes, heart attacks, major traumas, gunshot wounds, serious burns, etc. It sounds like Stanford’s fast track unit was a lot like mine, with its own physicians, nurses, and ED technicians. However, due to COVID surges, Stanford implemented a Virtual Visit Track in place of its fast track, adding the offering to both adult and pediatric emergency departments. In that program, a physician is seeing low-acuity patients from a remote location, while dedicated support staff in the emergency department provide services that must be done in person.

In the Stanford program’s first year, 2,000 patients received virtual care through the offering. The volume of patients has been sustained, with around 1.5 patients per hour being diverted into the virtual visit track during an eight-hour shift. This metric was tracked closely since 12 patients per shift was the break-even point for the resource investment. The wait time for patients in the virtual track was around 1.9 hours compared to 4.2 hours for patients seen in-person for the same level of care.

Additionally, researchers looked at the quality of care being delivered, comparing virtual care to the standard in-person care normally available. The virtual care was found to be non-inferior. Research also showed that virtual patients had a lower median return visit rate than in-person patients, although the numbers were not statistically significant.

It’s great that this type of research is being performed so that we know whether the interventions we’re applying to the healthcare system are actually effective or if they’re just another shiny object that we thought would make a difference but didn’t. We’ve all seen plenty of the latter over the years, as hospital administrators brought back ideas from conferences and did a lot of “transformation” work without knowing for sure it would work.

I remember when my hospital jumped on the Disney Institute bandwagon back in the mid-2000s. A lot of money was spent on educational in-services, culture promotion, institution of dress codes, and uniformity across patient care units. I’m not sure any of it did much to drive patient outcomes or to retain staff. Frankly, as far as the latter, I think re-engineering the hospital cafeteria’s late-night offerings did a lot more to boost morale than the Disney principles ever did.

I was involved in a “virtual first” offering with one of my clients a couple of years ago, and it was an interesting experience. I know how my visits went, but when we looked at the work of all the clinicians on the panel, there was a lot of variety. Unfortunately, the program was slow to grow, and during my time there, we never had enough visit volume to get to the point where any research would have been statistically significant. Seeing this article makes me want to reach out to my successor and find out what their volumes have been since I left and if they’ve been doing any quality work. It would be gratifying to know that something I helped get off the ground was making a difference.

Has your organization done any work looking at the quality of virtual offerings compared to standard care? Is it a case of the newer offering being merely “non inferior” or does it really shine? Leave a comment or email me.

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