Journal of the American Medical Informatics Association, 0(0), 2020, 1–6 doi: 10.1093/jamia/ocaa067 Perspective Perspective Downloaded from https://academic.oup.com/jamia/advance-article-abstract/doi/10.1093/jamia/ocaa067/5822868 by guest on 01 June 2020 Telehealth transformation: COVID-19 and the rise of virtual care Jedrek Wosik,1 Marat Fudim,1 Blake Cameron,2 Ziad F. Gellad,3,4 Alex Cho,5 Donna Phinney,6 Simon Curtis,7 Matthew Roman,6,8 Eric G. Poon ,5,6 Jeffrey Ferranti,6,8,9 Jason N. Katz,1 and James Tcheng1 1Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA, 2Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA, 3Division of Gastroen- terology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA, 4Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, North Carolina, USA, 5Division of General Internal Medicine, De- partment of Medicine, Duke University School of Medicine, Durham, North Carolina, USA, 6Duke Network Services, Duke Univer- sity Health System, Durham, North Carolina, USA, 7Private Diagnostic Clinic, Duke Health Access Center, Durham, North Carolina, USA, 8Duke Health Technology Solutions, Durham, North Carolina, USA and 9Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA Corresponding Author: Jedrek Wosik, MD, Division of Cardiology, Department of Medicine and Division of Cardiology, Duke University School of Medicine, 2301 Erwin Road, Durham, NC, USA; [email protected] Received 14 April 2020; Editorial Decision 15 April 2020; Accepted 17 April 2020 ABSTRACT The novel coronavirus disease-19 (COVID-19) pandemic has altered our economy, society, and healthcare system. While this crisis has presented the U.S. healthcare delivery system with unprecedented challenges, the pandemic has catalyzed rapid adoption of telehealth, or the entire spectrum of activities used to deliver care at a distance. Using examples reported by U.S. healthcare organizations, including ours, we describe the role that telehealth has played in transforming healthcare delivery during the 3 phases of the U.S. COVID-19 pandemic: (1) stay-at- home outpatient care, (2) initial COVID-19 hospital surge, and (3) postpandemic recovery. Within each of these 3 phases, we examine how people, process, and technology work together to support a successful telehealth trans- formation. Whether healthcare enterprises are ready or not, the new reality is that virtual care has arrived. Key words: telemedicine, telehealth, COVID, pandemic The novel coronavirus disease 2019 (COVID-19) pandemic has tunities and limitations of each type of telehealth encounter is of- altered our economy, society, and healthcare system. While this fered (Table 1). crisis has presented the U.S. healthcare delivery system unprece- Telehealth programs overcome physical barriers to provide dented challenges, it has catalyzed rapid adoption of telehealth patients and caregivers access to convenient medical care. Health- and transformed healthcare delivery at a breathtaking pace.1,2 care systems with telehealth sustain the continuity of outpatient pa- The term telehealth refers to the entire spectrum of activities used tient care during this pandemic—in the midst of “stay-at-home” to deliver care at a distance—without direct physical contact orders and physical distancing measures, while reducing community with the patient. Telehealth encompasses both provider-to- and nosocomial spread. Telehealth also proves useful for inpatient patient and provider-to-provider communications, and can take care, in particular to help balance the supply of clinical services with place synchronously (telephone and video), asynchronously (pa- surge in demand across physical or geographical boundaries, con- tient portal messages, e-consults), and through virtual agents serve personal protective equipment, and provide isolated patients (chatbots) and wearable devices. A brief summary of the oppor- connection to family and friends.3,4 VC The Author(s) 2020. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: [email protected] 1 2 Journal of the American Medical Informatics Association, 2020, Vol. 0, No. 0 Table 1. Classification of telehealth encounters Platform Use Case(s) Opportunities Limitations E-consult: Asynchronous During and after initial surge: As- Time efficient for specialists, con- Potentially shifts work to front- clinician-to-clinician sist frontline clinicians with tri- solidates care for patients line clinicians communication based age of urgent patient referrals New inpatient clinician-to-clini- Lack of physical exam or direct on record review (inpa- Assist frontline clinicians with cian billing codes available communication with patients tient and outpatient) management of low complexity Patient-initiated second opinion patients where there is limited requests are possible Downloaded from https://academic.oup.com/jamia/advance-article-abstract/doi/10.1093/jamia/ocaa067/5822868 by guest on 01 June 2020 capacity among specialists Remote patient monitor- All phases: efficient method of Respond to clinical data outside Requires staffing infrastructure ing:Gather patient out- patient care, especially those of regular clinic visits Data ideally is integrated into side traditional with chronic conditions Recordings can be automatically EHR for sustainable workflow healthcare setting via sent to clinicians connected device or pa- Payers support remote patient tient reported out- monitoring activities comes (synchronous or asynchronous) Patient-initiated messag- All phases: time-efficient han- Patient initiates communication Requires technology infrastruc- ing: Synchronous chats dling of straightforward issues. when convenient ture and staffing with automated or live Able to get FAQs and use self- Potential lack of context, agents service tools requires tight integration with Asynchronous patient Live or autonomous text-based the EHR to be optimally useful portal messaging options Telephone visit: Synchro- During and after initial surge: re- Universally accessible, even in Currently devalued by most nous patient-clinician place some face-to-face visits the most ill/low socioeconomic payers, inability to conduct a communication by status patients physical exam, loss of nonver- phone bal cues Video visit: Synchronous During COVID-19 surge: repla- Slight improvement in clinical Technology requirements: patient-clinician com- ces face-to-face visit care (nonverbal communica- Outpatient requires broadband munication with both After initial surge: expansion of tion, physical exam depending Internet, computer/smart de- audio and video, with virtual interactions across all on bedside facilitator and vice; may need digital periph- possible ancillary and sectors of the healthcare sys- peripherals) erals (eg, stethoscope, otoscope) telemetry equipment tem; More favorable reimbursement Most complex/sickest patients unbundling of services through by payers may be least able to partici- technology pate/access care Inpatient requires mobile/zoom- able camera with microphone and speaker Need infection prevention/saniti- zation protocol for devices COVID-19: coronavirus disease 2019; EHR: electronic health record. Using examples reported by U.S. healthcare organizations, in- virus. Adoption of telehealth requires changes in both patient- cluding ours, we describe the role telehealth has played in transform- related and clinical care processes. The target is to dramatically de- ing healthcare delivery during the 3 phases of the U.S. COVID-19 crease the proportion of in-person care, offering in-person clinic vis- pandemic: (1) stay-at-home outpatient care, (2) initial COVID-19 its only for patients who cannot access telehealth technology or who hospital surge, and (3) postpandemic recovery (Figure 1). Within have urgent (but not emergency-level) clinical concerns that require each of these 3 phases, we examine how people, process, and tech- detailed physical examination. nology work together to support this telehealth conversion.5 This Before the outbreak, many health systems had low rates of tele- framework offers health systems integral components for a success- health utilization for routine care.6 Even health systems with rela- ful transformation. tively high telehealth adoption performed fewer than 100 video visits per day.7 Now, many are seeing >600 patients per day via video, with many in-person clinic replaced with video or telephone PHASE 1: OUTPATIENT CARE DURING “STAY-AT- visits. At our institution, the share of telehealth visits has increased HOME” ORDERS within a 4-week period from <1% of total visits to 70% of total vis- Social distancing and “stay-at-home” orders began in earnest in the its, reaching more than 1000 video visits per day (Figure 2). United States in March 2020 and will likely remain for an extended By May 1, 2020, our institution will have fully provisioned and period after the peak surge period. Telehealth services provide the trained all clinicians to provide both inpatient and outpatient tele- opportunity to maintain access and continuity of medical care while health services. To manage this shift, a centralized telehealth call reducing the potential for community and nosocomial spread of the center was created, staffed by newly hired and repurposed