In April 2017 Summit Healthcare started a multi-disciplinary program to treat patients with chronic and acute pain in the White Mountains of Arizona. Our patient service area is HRSA-designated as having a shortage of providers and medically underserved. The area is the size of Rhode Island and includes Native American reservations and other vulnerable populations. Many of our patients live in a high poverty area which makes access to care challenging.
We’ve all seen lots of reports from a variety of source documenting how telemedicine use has skyrocketed during the COVID public health emergency. There have also been many subsequent reports on the significant disparities in access to and use of telemedicine that were revealed and/or exacerbated by COVID. A simple search of Google Scholar brings up thousands of articles from around the world summarizing digital divide and related challenges that have been exposed, and many of them highlight some very creative strategies to help address and reduce barriers to telemedicine care. How can we offer a telemedicine option to someone who does not own a digital device? To someone who does but must choose between using their minutes to support their child’s remote school classes or see their doctor? Or someone who has access to the Internet but at limited bandwidth?
In hopes of sparking renewed commitment to applying improvement science to telehealth, we offer this Telehealth QI and QA Miniseries. Today is the fourth in the series.
Require expertise and excellence in telehealth service delivery. Expertise with telehealth requires deliberate practice which builds on or modifies existing skills, usually with the help and guidance of a coach or teacher with targeted feedback on what to improve and how to improve those skills.
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.
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.
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.
States across the country are proposing or enacting legislation that supports making the increased access to telehealth that occurred during the pandemic permanent. However, many states seem to struggle with how to appropriately regulate remote prescribing requirements as there is wide variation in approaches and priorities emerging in these proposed and new laws.
Telemedicine has for years been touted as providing access to healthcare for everyone, anywhere, anytime and it has been quite successful in doing so in many respects but disparities still exist among a number of patient populations. In particular, those who traditionally have challenges accessing healthcare due to physical challenges often experience similar or even greater challenges with telemedicine. Think about for a minute. Telemedicine is predominantly provided using audio and/or video-based telecommunications technologies. This fundamental fact of how telemedicine visits occur can actually exacerbate digital disparities.
“Take care with telehealth” – it’s an urging not a warning. Unless you have been a caregiver of a loved one, you may not appreciate the potential mental, physical, quality of life and financial impacts. My sister bore the burden of caring for our mother when Alzheimer dementia stole her sharp mind. On the rare occasions when my mother stayed with me for weeks at a time, I was overcome with anxiety, feeling like there were tight bands around my chest, and my normally low blood pressure shot up. This tracks with evidence that female caregivers experience more psychological distress than males (Families Caring for an Aging America. 2016).