mHealth

In hopes of sparking renewed commitment to applying improvement science to telehealth, we offer this Telehealth QI and QA Miniseries. Today is the second in the series.

Many people are confused about plan-do-study-act (PDSA) cycles, and I am here to set everyone straight! Dr. Don Berwick has called the PDSA the heart of the Model for Improvement. However, after many years of helping health care organizations build skill around PDSAs, it seems to be a tough nut to crack, despite its being at core of why humans are such a successful species. The more PDSAs and the faster you do PDSAs, the faster your learning and progress with improvement will be. Here are a few pointers.

How much do you love improvement science? I have been an improvement science evangelist and guru since 2007. That was the year I completed advanced training in health care improvement with Dr. Brent James at Intermountain Healthcare in Utah.

I was a practicing clinician, clinical manager, quality coordinator, practice transformation lead, IT support (and more) at a family medicine residency that was participating in the Safety Net Medical Home Initiative. Learning the power of data and the science of improvement was one of the biggest light bulb moments of my life. I often liken it to when Johnny 5 – the robot in “Short Circuit” – throws open the barn doors, seeing the outside for the first time and remarks, “Ahh – input!”. Suddenly I could ask and answer questions, using data and measurement.

Telehealth services depend on quality broadband network communications. Recent legislation, executive orders, and agency funding commitments and grants are set to make a significant impact in terms of expanding and improving telehealth services and broadband availability and reliability in the southwest region and nationally.

At this time of year, I feel it is important to take the time and reflect on what makes us happy, and what we are you thankful for. I am truly thankful for my family and friends. I am also thankful to be working in telehealth with the Southwest Telehealth Resource Center. Through telehealth I’ve met some amazing people and I’ve reached out to some of them and asked them to help celebrate this season of Thanksgiving by sharing what they are thankful for. Hopefully their thoughts will inspire some of you and maybe even make you smile. All of us at SWTRC wish you and yours a wonderful thanksgiving holiday!

Telehealth has many benefits including reduced, or eliminated travel and wait times; decreased exposure to communicative diseases; easier access to healthcare professionals and therapeutic interventions; and greater flexibility. However, for many individuals with disabilities, Telehealth and it's associated benefits may be out of reach due to web inaccessibility. Benefits can become barriers because of websites’ inconsistent compatibility with screen readers, closed captions, magnifiers, speech to text software (used by individuals with limited dexterity), easy to understand instructions and hyperlinks (for individuals with cognitive disabilities), and alternative text formats.

Does it surprise you that some clinicians are NOT all that excited to continue to provide care without being in the same room with a patient? Virtual care includes care by video, telephone, email, text/chat, remote monitoring, social media, mobile apps, artificial intelligence and more! More than a decade ago, when I implemented video visits for one region of a large healthcare organization, one-to-one training was provided to approximately 1000 physicians, Advanced Practice Nurses and Physician Assistants who provided scheduled, outpatient care - primary care, medical and surgical specialties. Each of the trainees was given a webcam. One year after training was completed, only 70 of these trained clinicians had provided care by video at least once. Note that reimbursement was not an issue for these clinicians. They were and still are salaried, with incentives based on clinical outcomes and patient satisfaction.

Let’s do more interprofessional consultations! And let’s start by calling them e-consults.

What are e-consults?

Electronic consults (e-consults) are asynchronous clinician-to-clinician exchanges that are used when there is not a need for a face-to-face (in person or telehealth) visit between a clinician/specialist and a patient. Under the umbrella of telehealth, e-consults are considered a store and forward option that uses telephone, Internet and/or an electronic health record (EHR). Patient information that has been gathered and documented is provided by the treating/requesting clinician to a consultative physician with a request for medical advice and/or an opinion. According to the Centers for Medicare & Medicaid Services (CMS) “…these inter-professional consults are typically initiated by a primary care practitioner to a specialist for a low acuity, condition-specific question that can be answered without an in-person visit. CMS also considers e-consults as assessment and management services.

For many Americans, their first personal experience of being a hospital patient quickly becomes a crash course in the importance and value of having a skilled and dedicated bedside nurse. At a higher level, this points to the importance of a sufficient nursing staff which impacts the entire workflow of the hospital. Without sufficient bedside nurses, patients in the Emergency Room and Intensive Care Units cannot be moved to the floors, resulting in longer waiting times for care for those newly arriving. Beds that cannot be staffed are beds that do not exist for all practical purposes. Unfortunately, a shortage of nurses has long been a problem for hospitals across the United States. The coronavirus pandemic has brought this challenge to an entirely new level, resulting in a request by the American Nurses Association that the U.S. Department of Health and Human Services declare the current nursing staffing shortage a national crisis.

Why am I ALWAYS crying? I swear right when I think to myself… “I got this, I GOT THIS”. Tears, puddles, Niagara Falls… pouring out. Every time I’m asked to share my experience. Why cry? Because of all the LOVE I have as a healthcare provider and the genuine connections I made during our crisis immersion in collaboration with the Gallup Indian Medical Center (GIMC), Gallup, NM.

The United States and the world have seen a dramatic increase in the use of telemedicine since the inception of the COVID-19 public health emergency due in most part to stay at home restrictions for both providers and patients. Prior to this, telemedicine was used in a wide variety of clinical and related patient care applications for at least 30 years, and had been seeing steady but not exponential growth. In many cases programs were initiated quite rapidly using readily available and often low-cost equipment and tools, unless there was already an existing program and platform in place. Further, the use of telemedicine was facilitated at the state and federal levels but widespread waivers and measures being put into place to reduce barriers that were previously in place such as changes in reimbursements, requirements regarding patient and provider locations, cross-state licensure and privacy/security requirements.