Network Director of Telehealth Services
The University of Vermont Health Network
With 29 years’ experience in healthcare and information technology, the expert can comment on an extensive range of technical and operational aspects associated with the buildout of electronic healthcare record systems and personal/telehealth programs. They are currently responsible for overseeing the telehealth program of a network of six hospitals.
Section 1: Pre-COVID-19: Establishing a Baseline
1.1. How would you describe the US telehealth industry before the outbreak of COVID-19?
It was still nascent. Before the outbreak of COVID-19, we didn’t have much telemedicine rolled out in our smaller areas as the uptake of telemedicine there was slow. What happened, though, is that we had to go from 0 to 100 in two weeks
1.2. What did the usage of these services look like?
Around 60 visits/week was where we were before. Now, come three weeks ago when we decided that all our providers needed to do telemedicine, we went from having 150 providers to about 1,100 providers using telehealth, and we’ve gone from 60 encounters a week to doing about 2,000 in one day, according to numbers I saw yesterday. Two weeks ago, we did 4,000 calls in a week. Last week, we did 8,000. This week we’ll do North of 8,000 – it is just incredible.
1.3. Before the COVID-19 outbreak, what represented the largest opportunity for telehealth providers? What were the most significant use cases?
The biggest opportunity – and it still the biggest opportunity – is providing specialty care to patients in our rural locations. That is what I was fighting for before the COVID-19 outbreak. I was trying to get more of our specialists up and running so that we could better serve those rural areas. We have a lot of rural hospitals that are part of our system. Of course, we have our location here in Burlington, which functions as our central academic medical center that has nearly all the specialties. Contrastingly, we also have areas in rural New York and Vermont, that offer very few specialties. At most, they might have a cardiologist and an endocrinologist, but they wouldn’t necessarily have neurologists, nephrologists, or psychiatrists for example. Over the past two weeks, we have enabled every one of our specialty clinics to have telehealth capability.
Our challenge now is to make all those services available throughout our whole network and to ensure that patients aren’t coming to Burlington for follow-up visits unless they truly need to. For a new patient visit? Yes, they should still come. For a follow-up visit for someone that might have had a mild stroke or needs an endocrinology follow-up to get some labs taken in their local area, why not just have a quick call at home or one of our facilities? That still is the greatest opportunity that we have for telemedicine.
In short, we call that “access” over here, that we’re providing access to the care out in these remote facilities.
1.4. Who are the major players?
Companies like American Well.
Section 2: COVID-19 Outbreak: The New Normal
2.1. How would you describe the impact of COVID-19 on the telehealth industry in the US?
The impact has been remarkable.Throughout this entire process of responding to COVID-19, the emphasis for us has centered on the need to put the right team together to enable mass roll-out. Two weeks ago, my team consisted of four people covering six hospitals.
To enable mass roll-out, the first thing I did was to leverage a group within our medical group called the hiCOlab, or the Healthcare Innovation Collaborative. They are a design thinking group, which uses human-centered design to work on hospital processes. Rollout and expansion were topics I had already started working on with this group before the COVID-19 situation. For example, we took one of our primary care projects that had been going on for two years but that hadn’t seen the usage or reached the volumes we expected and worked with hiCOlab to carry research on the design of the program itself, identifying all potential barriers and opportunities. It was really lucky that I had already trained up that team to understand the problems with telehealth as this allowed us to more easily overcome some of them at pace.
When we decided to build our telehealth task force to do this rollout to provide services to 2,500 users in 10 days, I took the hiCOlab and a group of project managers that we grabbed from various parts of the organization, and we did a build-the-factory design session the first day. It was half education to educate all the project managers about what we were about to do because none of them were trained on telemedicine, but they were project managers.
hiCOlab helped us use design thinking strategies to plan, prototype and build our factory over 10 days. That was one of the smartest things that we could do. For those 10 days, we took that group of project managers, part of IT, part of Medical Education, part of compliance and billing (this was necessary given all the changes that were happening with all the payers), and also part of our EMR team, and went from a team of four to a team of about 30 overnight. This is how we were able to roll out and train the team so quickly to meet the demand resulting from COVID-19.
2.2. How has uptake and usage changed?
I’ve been the network director of telehealth here at UVM since 2017. Since then, we had success with, and have gotten up and running, around 25 programs, although we only had about 150 providers, and this was over six hospitals. We were averaging somewhere around 60 visits a week with telemedicine, anything from ambulatory care, primary care, telestroke, to some e-visits with our patient portals. I use the term “success” in this instance due to the fact, at that time, we were able to get the infrastructure up and running within the past three years. We went from using Polycom codecs for technology to using Zoom and cloud-based technologies. Within the telestroke program, we used American Well and their carts et cetera.
2.3. What opportunities exist for companies not directly in this space to support telehealth and virtual health providers with this increased demand?
Another area that has been challenging has been the sourcing of headsets. You simply can’t find Logitech headsets that are USB-connected anywhere. This is another example of what everybody went out and grabbed, which has been a major supply chain issue.
This supply issue has also occurred with medical carts. Indeed, we’ve had had to rely on local vendors to retrofit devices and other things, including building brackets that would go on to IV carts so that we could enable double use. We have a number IV carts and have been working with one local mechanical service provider to see if we can’t build a bracket that would take an iPad and put it on IV carts as we can’t enough get medical carts.
There are, of course, a lot of examples in the news, but I don’t see this as having specifically occurred within telemedicine, other than what we’re doing with Zoom and local providers.
2.4. What challenges have arisen? How are these being addressed?
We faced one challenge after another with the mass rollout of telehealth services across all our facilities, but we still kept to our deadlines. The medical group gave us to the 13th to be done, although we had pretty much finished the rollout in about seven to eight days, rather than 10. In answering your question, the first thing to mention here is that we had our share of barriers before COVID-19, of course. Foremost amongst these would be the payment. It was one of the aspects, especially with Medicare, that got blown out of the water three weeks ago with policy changes.
Secondly, the other major issue was patient willingness. Even though we have been trying to engage patients for the last two years, not a lot of them when given the opportunity was taking advantage of it because people like the physical interaction and want to come into the office. You had some that wanted to use telemedicine, but now they have been forced to, which is going to have an impact.
Thirdly, aside from patient willingness and engagement, the staff themselves and the scheduling component of the work has been challenging. The office managers weren’t necessarily that receptive to change initially, although they have now been forced to. Believe it or not, our barrier here has never been with the physicians even before COVID-19; they have always been our easiest path.
Fourthly, there are a lot of different workflows occurring simultaneously, which is challenging to address remotely. We are not just using telehealth for ambulatory-type visits out to patient’s homes. We are also doing a lot of things right in our facilities. For example, we have installed iPads in all our COVID-19 rooms, allowing the nurses to video in to save PPE and lessen their exposure to the virus. This also allows our physicians who normally do rounds to go into those patient rooms using that same device.
We are also expanding telehealth into other areas. Emergency departments are coming to me wanting to do home visits to patients calling in. We are setting that up this week. We are also engaging areas of medicine that you thought would never come to you before to talk about telemedicine. Ophthalmologists, for example, are being set up to do video visits. We were doing retinopathy screenings in our clinics, but I didn’t think that follow up surgical visits from an ophthalmologist would be something that we would do remotely…but we are.
Another challenge we ran into was the training of this new workforce we had created on all things telemedicine. All these providers hadn’t used it before. Usually, this would not be an issue. However, it’s one thing to go and be able to train people where they are working, but another altogether as soon when the workforce instantly goes remote. This change to remote working occurred even as we started the roll-out project. As a result, we had to rapidly transition from training everybody on-site to training everybody on webinars. We had to build all the training we wanted to roll out as webinar-based, and then all the at-the-elbow support has subsequently happened remotely as well.
Since then, the hiCOlab and I have been carrying out research to evaluate the rollout itself, as we have done previously with primary care projects. We are looking at all our support tickets and conducting interviews with providers, patients, and staff in an attempt to figure out what is going well and what is going badly so we can make adjustments to ensure we come out the other side of this with people feeling really good about providing care this way.
We’re focused on not losing the momentum around telehealth because we think that we have this opportunity to change how healthcare is delivered post-COVID-19.
2.5. What new technologies are being leveraged to ensure that increased demand is met and that providers ensure both COVID-19 and non-COVID-19 (chronic, routine) patients receive the same level of care?
Zoom has been a godsend. I started our first Zoom contract back in 2017 when Zoom was still pretty new. That was probably one of the best decisions I’ve ever made, especially given the ubiquitous situation with the different types of devices that people can use to access telemedicine services. It has been interesting to see the way that Zoom has propagated throughout not just healthcare, but into other areas – people are using it for exercise, for faith, or to have cocktail hours with their friends. I don’t know if it’s dumb luck or just me being a little insightful three years ago, saying, “Hey, this is going to be our platform,” that that’s made a big difference.
One of our biggest challenges, though, has been with the devices themselves. Some of the big health systems, like Partners HealthCare in Boston, can put an order in for 6,000 iPads and simply suck the supply chain clean of devices. That’s been one of our bigger challenges, namely being able to get our hands on enough devices to hit all the use cases.
We managed to get around 300 to 400 iPads two weeks ago. However, we have had to essentially do the same thing that New York has done with PPE. We have had to say, “We have to ration this – this hospital gets this many; this hospital gets that many.” This feeds into another challenge, which was to make sure that we had a good coverage plan – we, and others doing the same thing, have had to be thoughtful about how we deploy our plans and resources. To be honest, we have had to make several hard decisions. For example, we have also had to ration access to this technology by the specific specialty areas we want to support. Another issue with the iPad project was that although we had the iPads to roll that across the floors where we wanted them, we couldn’t get carts to put the devices on. Consequently, we are now clamping the devices onto food trays.
For ear, nose, and throat (ENT), I had some scopes and other diagnostics devices that were brought in to enable ENT doctors to look in ears, mouths from anywhere. We have deployed some of these at some of the clinics, but this hasn’t occurred at all of them yet. These devices have come from Welch Allyn. I would say that the increase in the need for these devices reflects the increased technology requirements resulting from COVID-19 for providers.
The last thing on this is that we had stroke carts, or American Well carts, at two of our EDs. On March 9th, I put an order to American Well to make sure that we had carts in all our EDs because our telestroke program was new. We only had two sites up, but we wanted for our critical care and ICU teams to be able to help with ventilation and incubation procedures and stuff in those small EDs where they don’t do that too often.
Another point here is that Zoom has a feature where if you put two devices in a group you can get Zoom to do an auto-answer on the device. We have set up nursing stations with devices and then put a device in each of the rooms and patient beds. We clamp them on a patient’s food tray to enable the nurse to just beam in to have a discussion with the patient to see how they’re doing without the need for the nurse to put on PPE. It also allows them to tell the patient to put on their mask because the nurse is about to enter the room.
2.6. What impact has COVID-19 had on telehealth policy? (E.g. reimbursement, licensing, etc.)
It has had a massive impact on payers and patients, alike. It will be interesting to see what happens post-COVID-19 and what the government, and payers, will do..
Section 3: Post-COVID-19: A Lasting Legacy?
3.1. What lasting impact(s) will COVID-19 have on the telehealth industry in the US for all stakeholders? (For patients? For providers? For payers?)
I think we are going to hear a lot of great stories on those on the winning side of telemedicine just because of where we are at with technology, but we still have some of the same barriers that we have always had, including that rural areas just don’t have the infrastructure they need for telemedicine to be as widely used as it should be.
The one thing that we’re trying to do there is to tell patients, “Well, if you don’t have the internet at home, you can go to the library. You can come to our facility out in Malone, New York. There are always places you can go to connect.” I think that’s one of the things we have been saying for years, but the difference now is that patients have to listen.
At times, my job has been frustrating. My role has been frustrating here as we never got achieved the success that I wanted or thought we could with telemedicine. Even at an organization like ours where our senior leaders – Dr. Brumsted, our CEO, and my boss, Howard Shapiro, the chief population officer – have always actively supported me from the get-go and have allowed me to budget and spend on infrastructure ahead of our demand. Thank God they did, or we would have been in a heck of a spot trying to rollout to meet the COVID-19 demand. The one thing I haven’t been able to do in the last three weeks because I’ve been working 12 to 18-hour days is to look at what has been happening with my colleagues around the country to see. I have a core set of colleagues from other health systems that I interact with quite a bit around telemedicine. I can’t wait to be able to sit down with those folks in a few weeks just to ask “Okay, so what did you do?” We have exchanged a few emails about different things but have yet to have that deep discussion. I do want to see who failed and who succeeded, and why people failed and why people succeeded, just to see how that goes.
3.2. What new players, business models, and/or technologies will emerge strongest as a result of the acceleration of the industry in the wake of COVID-19?
I think it has been the springboard for telemedicine to realize its value and be respected.
3.3. Does it become business as usual once the pandemic has cleared? Will there be a continued desire for treating at a distance?
Some of it we can control, and some of it we can’t. What we can control is providing a great experience as well as the tools our users and patients need to make this a reality. What we can’t control, at least right away, is if the government decides to roll back some of the changes they put in place around payment, as well as the activity of the payers themselves. If this changes, then we’re going to be screwed, and we’re going to roll back to what we were. Hopefully, they don’t do that, but I think that’s one of our biggest risks.