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Balancing Virtual and In-Person Health Care
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The 2020 Covid-19 pandemic has seeded the U.S. healthcare system with innovations across the care spectrum, largely focused on outpatient care delivery through virtual care tools. The Centers for Medicare and Medicaid Services reported over an 11,000% increase in virtual visits (i.e., video- or phone-based visits). In our academic health system, Brigham Health in Boston, Massachusetts, we saw an overall increase in virtual visits from pre-Covid-19 to its peak in May of over 20,000% (roughly 80,000 virtual visits that month), offered by nearly all of our ambulatory providers, and representing roughly 70% of all outpatient care from a baseline of less than 1%.
After the May peak, health care facilities began to reopen for more routine care; in-person volume in our system slowly grew while virtual volume fell. While the current surge may reverse that pattern again, as of this writing virtual visits represent about 25% of overall outpatient care – and our clinicians, practices and colleagues across the country are asking common questions about what comes next: How much virtual care makes sense when we do return to a new normal state? What is the best approach to offering virtual care alongside in-person care? How will we know whether virtual care is succeeding, and in particular that it is reaching all patients as safely and equitably as possible?
Before Covid-19 struck, few large health systems in the U.S. offered outpatient telehealth at high volume, and thus it wasn’t clear how much virtual care was appropriate or even possible for many medical specialties. Kaiser Permanente, among the largest users of telehealth in routine care, reported in 2014 that at least 40% of its outpatient care was performed via virtual modalities (including portals, phone and/or video visits, and apps) and then in 2016 that virtual had exceeded in-person outpatient care. These reports became an industry benchmark, though were seen by many as not generalizable given Kaiser’s unique economics as an integrated payer-provider (and thus partly incentivized to offer more unreimbursed, virtual care). Our experience with Covid-19 sheds significant light on this question in a more traditional fee-for-service system.
During the massive shift to virtual care earlier this year, most specialties in our organization found that at least half, and in many cases nearly all, of their care could be delivered virtually. A few specialties with large proportions of visits requiring in-person care continued to offer predominantly in-person visits. Interestingly, our pre-Covid assessment of billing data to determine what proportion of visits would be appropriate for virtual care closely predicted our actual experience during the pandemic. While these data likely overestimates the ideal proportion of care that should be done virtually — both because the billing model does not account for instances when the physical exam was necessary for evaluation or treatment, and because the Covid pandemic induced an aggressive focus on limiting physical interactions and preserving hospital capacity — the data still suggest that, for many specialties, 50% virtual is likely a minimum and some may be able to safely offer a significantly higher portion in the future even as in-person volume grows.
Principles and best practices
Regardless of what proportion of outpatient care at the Brigham is delivered virtually after the pandemic subsides, it will surely represent a significant increase from our baseline, which is likely to be a generalizable trend for other national providers. As we transition to this new normal for healthcare delivery, how do we best continue virtual care alongside in-person care in the era of Covid-19? Based on our experience, we propose the following principles and best practices.
First, practices will need to develop criteria for triaging and scheduling patients for in-person or virtual visits. These criteria may be diagnosis- or symptom-based, or could rely on visit types (post-op, routine physical, etc.) and will likely vary across specialties depending on the clinical needs of patient populations. As “reopening” efforts are staggered and in some cases on hold as we confront a resurgence of Covid, and physical distancing requires that we minimize patients in waiting rooms and hospital common areas, in-person clinic schedules will likely remain under-filled for months to come.
In this environment, clinicians will need to offer a mix of in-person and virtual care from the same clinical session and space, and find new ways to work with practice staff to move patients into and out of visits smoothly. As in-person volume returns, this mixed model will be stressed by the tensions between in-person and virtual care operating under the same roof. We believe a cleaner approach is dedicated sessions of all in-person or all virtual care where the practice setting can be optimized. When offering virtual care, providers will need dedicated equipment, space, and focus to efficiently deliver virtually in a block of time. They can use smart devices (phones and tablets) for virtual visits but when necessary or as a backup, but we’ve found that clinicians have a better experience using webcams on desktop or laptop computers for larger video screen size and simultaneous, side-by-side use of the electronic health record (EHR-integrated video). These sessions can occur from any private, quiet space including home, so clinicians and practices will need to consider varying provider location in scheduling models.
Second, once technical functionality is established, virtual care needs to be optimized to meet other core provider and patient needs. One important function is interpreter service integration, for both phone and video visits. Another is a diversified technology toolbox including phone, EHR-integrated video, and video offered more seamlessly outside the EHR via simple tools like text messages linking to live videos, so that as many patients as possible can participate in virtual care and not just those who are English-speaking with ready access to broadband, connected devices and patient portals. This can help assure that disparities in care are not amplified by constraints on patients’ access to technology. For virtual care to be sustainable and to best meet patient needs, the full care team must be involved. Medical assistants can virtually room patients and perform many of their routine pre-visit tasks. Schedulers can help patients book virtual visits and can be integrated into the post-visit workflow so that follow-up items are completed. Trainees including students, residents and fellows can be precepted virtually depending on their relevant educational and compliance needs. For each of these groups, we have developed and disseminated best practice documents to encourage standard workflows, just as we have for in-person care.
Third, key performance indicators should be designed to assess the effectiveness of virtual care models. Practices will need to understand what proportion of virtual care they are offering and how to quickly adjust it to absorb surges such as the one we’re experiencing now. As virtual visits can improve access and efficiency, monitoring relevant metrics such as the lag times between scheduling and visit date and visit length are important, as well as payment parity compared to office visits as state and federal governments work to ensure comparable payment for virtual care, in the face of some national insurers looking to decrease it. As clinical experience with virtual care has been limited, it will be critical to monitor quality and safety data to identify potential gaps or problem areas.
Finally, we are paying careful attention patient experience of virtual care, in the same ways we do across all our patient populations. Our success will depend on reducing the digital divide as much as we can, and making sure that these visits are provided equitably, particularly to patients with social determinants that can limit access to care.
As we enter a new era of virtual healthcare spurred on by Covid-19, these models will be judged not by their dizzying initial growth, but by their ultimate clinical quality, patient experience, technical reliability, financial sustainability, and health equity. While we hope that this recent digital transformation is a permanent one, hard work is needed to not lose ground, and that work begins now.
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