As telehealth proves to be a cost-effective and safe beacon of hope for the patient that would otherwise not receive care, it is also a solution for hospitals to deliver care amidst overwhelming public concern due to the COVID-19 pandemic. Increasing access to care through telehealth seems to be a promising option for hospitals, according to an analysis from Advisory Board, “as many as 20 percent of virtual care patients would theoretically convert to being full-service patients of a hospital or health system at an estimated annual revenue increase of approximately $3,000 per patient.” Despite this benefit, however, there are still several concerns with the efficacy and implementation of a hospital virtual care program.
“Our very survival depends on our ability to stay awake, to adjust to new ideas, to remain vigilant and to face the challenge of change.”
~ Martin Luther King Jr.
Here are previous blogs in this series:
Part 1 of 5: Pre-Registration & Telehealth Consent Strategy
Part 2 of 5: Step-By-Step business Case & Grant Funding
Part 3 of 5: Clinician Champions, Team Structure, & Training
Part 4 of 5: The Best Telehealth Room Design for Your Clinicians
In Part 5 of this series, we will provide solutions to the top 10 concerns of hospitals considering a telehealth strategy. The primary goal is to provide resources and solutions to common telehealth challenges. While there are many advantages to implementing telemedicine, there are some sound concerns as well as several misconceptions. We will help you answer questions such as:
- How can clinicians speak to the patient and not a computer screen during an eVisit?
- How are Medicare, Medicaid, and government regulations changing to increase telemedicine options for hospitals?
- How can clinicians preserve the patient experience when a telehealth visit translates to an in-person visit?
- Does telehealth reduce physician burnout?
Top 10 Concerns & Solutions Challenging Hospital Telehealth
- Patient satisfaction, adoption & retention concerns
- Diagnosis & exam challenges
- Quality of care & continuity concerns
- Clinician burnout
- Medicare & Medicaid reimbursement concerns
- Telehealth restrictions & regulations
- Privacy & security concerns
- Program awareness concerns, sustainability & growth
- Technical training & restructuring responsibilities
- Hospital integration & implementation challenges
1. Patient Satisfaction, Adoption, & Retention Concerns
A common myth among critics is the concern of an impersonal patient experience due to the virtual environment of a telehealth visit. It is often assumed that because patients and providers are communicating through a video screen and that visits are briefer than your traditional in-person visit, a virtual visit will lack a feeling of human connection and cause issues with patient satisfaction. This is a myth; patients often have lesser feelings of human connection during an in-person visit than during a teleheath visits.
According to GlobalMed’s Virtual Care vs. In-Person Visits: Which is Higher Quality?, during an in-person visit, 64% of primary care physicians did not ask why a patient came in, and when they did, patients were interrupted within 11 seconds. American Telemedicine Association CEO Ann Mond Johnson in ATA’s Johnson Looks to Dispel The 7 Myths of Telehealth Adoption, explains a different perspective “virtual visits – especially those used in telemental health – often compel patient and provider to look each other in the eye. As well, the telemedicine platform can improve interactions for patients who aren’t comfortable seeing a doctor in person.”
While there is certainly a distance barrier and looking at a monitor can feel less human, there are a few practices that will help your patients feel as though they are speaking with a person and not a computer. According to Best Practices for Patient Engagement with Telehealth, providers can build rapport with their patients by interacting with them. A simple, “How are you doing?” can go a long way in building a human connection through a computer. Asking patient-centered questions about their goals for care in the beginning of the visit can open a healthy discussion between provider and patient. If the patient is new to the virtual visit experience, providers can educate them by discussing the aspects of the visit and virtual care, so they know what to expect and feel more comfortable. Making direct eye contact, actively listening, and not interrupting when the patient is speaking can all improve the patient experience during a virtual visit. In addition, creating a welcoming virtual care environment with quality telehealth-appropriate cameras, natural lighting, and room aesthetics as outlined in Part 4 Strategic Location, Environment & Hardware Considerations, can also improve the patient experience. If the patient less familiar with initiating a telehealth visit, which is a common barrier for elderly individuals, providers should take extra care to create an inviting environment and anticipate their needs, especially for individuals who lack experience with technology. By following these practices, you will make a considerable positive impact on patient engagement and the success of your virtual care program.
2. Diagnosis & Exam Challenges
While telehealth is suitable for a wide array of care needs-from treating the common cold, flu, UTI, insect bites, sore throats, post-op check ins, remote monitoring and more --there are situations which require an in-person examination. According to a Telemedicine Journal and e-Health study examining the effectiveness of consumer electronics within a telehealth exam, “Elements of the physical examination that are easily observed show high concordance, but posterior structures and elements that are difficult to observe using consumer communications technology limit the utility” of the telehealth exam.
Providers should use their best judgement and follow protocol to determine when and how to schedule an in-person exam. The clear advantage of a hospital- or clinic-implemented telehealth strategy is the readiness to schedule an in-person visit when necessary. To lessen the impact on patients, providers should be prepared to schedule the exam during the telehealth visit. Hospital- and clinic-based telehealth programs should develop protocol for in-person exams, including scheduling, coordination, payment, and a contactless check-in. Providers will need to describe the aspects of the exam that will take place, follow-up considerations, and other preparations. For example, if a patient is coming in for a urinalysis to test for UTI, the provider might collect payment and any other information ahead of time to expedite the visit. Other considerations include informing them of the test that will be administered and roughly how long the visit will take, giving them an estimate of the time it will take to get the test results, and providing instructions for follow-up and prescription procedures. Considering COVID-19 and other HAI exposure risk, clinics should also advise patients to bring a mask and wait in their vehicles if their room is not available upon arrival. While translating a telemedicine visit to an in-person examination is not always ideal from a patient perspective, full communication about the scope of care and easing the check-in process will drastically minimize any negative impact.
3. Quality of Care & Continuity Concerns
According to Beckers Hospital Review, a top patient concern for telehealth is low quality of care. There is not adequate evidence to suggest that the quality of care given is lower for telehealth other than what may be derived from limitations of care, such as visits that require an in-person exam. Given that telehealth increases access to care through lower costs and by “meeting patients where they are,” virtual care improves health care outcomes. Individuals who might not seek care in a timely manner or address medical care at all benefit from the option of telemedicine as a less invasive, less intimidating care option.
However, lack of data for care continuity has the potential to introduce risk as patient records may not reflect outcomes, treatment plans, and diagnoses from outside telehealth providers. This lack of platform integration between providers is common; however, introducing telehealth options within hospitals and clinics where patients receive primary care can eliminate this risk through interconnectivity within the EHR. According to Arizona Telemedicine, “By using a platform that integrates with your EHR, you can record your established workflow and ensure your patients’ e-visits are properly documented and updated for future visits.” In cases where this circumstance is unavoidable, the best solution is to request details of your patient’s last visit and attempt to access their medical records to eliminate misdiagnosis and treatment risks.
4. Clinician Burnout
According to Managed Healthcare EXECUTIVE, a top concern for telehealth is physician burnout due to lack of face-to-face time with patients and increased time updating the patient’s medical records in the EHR.
With packed days, high demand, and increasing burdens and complications caused by COVID-19, clinician burnout is certainly a huge concern for healthcare systems and physicians. However, according to Chief Medical Officer for Greenway Health, Geeta Nayyar, MD, MBA, in Telemedicine Offers New Hope For Burnout Reduction During COVID-19, the incidence of burnout is primarily a result of workflow inefficiencies. Dr. Nayyar says, “When we say digital health and burnout, I think the two things that come to mind are just EHR—it's a burnout associated with the EHR—and the second one, sort of as the dovetail to that, is the clicks. The number of clicks and the excess of inefficiencies created by many of the EHR software out there.” Regarding positive experiences with telehealth, Dr. Nayyar states, “I think those that have had positive experiences have workflows that have been really customized or well thought out for their specialty or per their vendor of choice.”
According to Physician’s Weekly in 3 Ways Telemedicine Reduces Provider Burnout, 42% of providers suffer from clinician burnout leading to poor performance, which can lead to medical errors. Telehealth can create greater flexibility and day-to-day variety through telehealth days. “On telemedicine days, I can see patients from an office in my own home,” says David Shprecher, DO, Movement Disorders Director at Banner Sun Health Research Institute in Phoenix. “This allows me to telecommute and save about an hour of total travel time. This can be a nice break from the rat race.”
5. Medicare & Medicaid Reimbursement Concerns
Cited as a top challenge for telemedicine programs, the applicability of telehealth has been suppressed for years due to state and federal reimbursement restrictions.
Though there has been much progress in recent years, prior to the COVID-19 pandemic, federally run Medicare coverage had many restrictions on how coverage could be applied. In the past, for instance, Medicare billing requirements mandated the telehealth visit must take place within a Health Professional Shortage Area (HPSA) and at an approved originating site, such as a physician's office, hospital, or skilled nursing facility. This completely defeated any advantage of telehealth as a home option, virtual care visit, and reimbursement was only applicable to specific HCPCS and CPT codes.
With the onset of the COVID-19 pandemic, CMS temporarily expanded Medicare reimbursement and applicable services to broaden telemedicine options for all Americans. This expansion now allows for Medicare to pay for visits regardless of location, including within a patient's home, and allows for a wider range of providers to offer virtual visits. Further strengthening the future of telehealth, Congress appropriated $200 million in funding to healthcare providers to rapidly develop and implement virtual care programs. To learn about Medicare reimbursement rates for your area, use this CMS PHYSICIAN FEE SCHEDULE SEARCH tool.
Medicaid has been less restrictive. While most states do reimburse for live telehealth, relatively few states will cover store-and-forward or remote patient monitoring telehealth. It is a good idea to check your specific state laws and policies. Use the CCHP Current State Laws & Reimbursement Policies state search tool to stay informed on your state’s laws, regulations and Medicaid programs.
6. Telehealth Restrictions & Regulations
As mentioned in Part 2 Step-by-Step Business Case & Grant Funding, HHS created immediate flexibility for telehealth? for providers? during the COVID-19 pandemic. Now, according to HHS.gov, “HIPAA-covered health care providers may, in good faith, provide telehealth services to patients using remote communication technologies, such as commonly used apps – including FaceTime, Facebook Messenger, Google Hangouts, Zoom, or Skype – for telehealth services, even if the application does not fully comply with HIPAA rules.” Furthermore, the “established patient with a physician” requirement is no longer enforced, which means a physician can see a new patient and still receive Medicare reimbursement during this public health emergency.
7. Privacy & Security Concerns
As telehealth is a virtual bidirectional communication between providers and patients sharing health information, there is an understandable concern regarding potential privacy breaches, particularly for patients. Despite current HIPAA flexibility, providers should still ensure patient provider trust by maintaining strict standards in safeguarding patient privacy and security. When communicating electronic Protected Health Information (ePHI), it is critical to use a system to monitor these communications and prevent breaches.
Providers should seek a HIPAA-compliant communication platform that has encrypted data transmission and allows only authorized users to access ePHI. It is important to consider all potential threats to the integrity of ePHI, particularly virtual environment changes or end user risks. For example, if a provider or third-party contractor is working from home, connected to a hospital network, it is critical to ensure that they are fully protected against potential cyber-attacks. According to HEALTH IT SECURITY, “VPNs are one of the most common, secure methods for connecting remotely to an enterprise network. However, organizations have been failing to patch core vulnerabilities found in some of the most popular VPNs, despite repeat warnings and available patches.” For patient end protection, consider implementing a two-factor authentication to add more protection against cyber-attacks and have a detailed plan to address security and privacy concerns and take measures to protect patient security and ease potential apprehension.
8. Program Awareness Concerns, Sustainability, & Growth
Growing pains and sustainability are both top concerns for any new hospital venture; however, there are some strategic practices to consider prior to launching a successful telehealth initiative. In Part 4 Strategic Location, Environment & Hardware Considerations, we detail the best methods to establish a virtual care program in an existing hospital, including placement within a specific area if the building, such as near the ER or out-patient check in, to positively impact the promotion of the virtual care program through physical exposure. In Part 3 Best Practices for Building a Telehealth Team Now, we specifically address shared responsibilities among the providers, care managers, nurses, front desk staff, and schedulers in actively promoting telehealth as an option to current patients. The California Telehealth Resource Center also has a great step-by-step guide, Developing a Telehealth Marketing Plan, which contains a marketing plan template that can be suited specifically to your hospital’s telehealth initiative.
9. Technical Training & Restructuring Responsibilities
Restructuring and learning new systems and processes in preparation to implement telemedicine within a hospital is a labor-intensive endeavor, which is why we have devoted an entire blog to give you the insight and outside resources necessary to help you achieve your mission.
In Part 3, Clinician Champions, Team Structure & Training, we outline the characteristics and roles of a clinical telehealth champion who pushes the implementation and virtual care program forward. We detail the four distinct core components and roles of each telemedicine team: Core, Leadership, Advisory and Implementation. Within Telehealth Staff & Care Team Roles & Responsibilities, we outline the five cross-compatible roles among existing clinical staff to structure your new virtual care team. We reveal six training methods to prepare your team and evaluate your program to ensure a smooth patient experience. We also provide a synopsis of online training and continued education programs from Thomas Jefferson University and The University of Arizona designed to prepare various roles for telemedicine.
10. Hospital Integration & Implementation Challenges
Implementing and integrating a virtual care option within a hospital may seem daunting; however, proper structure, planning, and alignment with the organization’s mission will facilitate implementation within a tighter timeline. Providers can start by creating a business plan, as exhibited in Part 2 Step-by-Step Business Case & Grant Funding, that outlines the scope of the project, helps determine its efficacy, and steers next steps. It is important to present your business plan to key stakeholders and discuss the elements and challenges ahead to gain buy-in. Make sure to discuss your service plan assessment, financial plans, marketing and optimal placement strategy, organizational structure, security, patient satisfaction concerns, and training framework openly to address any potential gaps and gather momentum.
During implementation, it’s critical to keep workflow and security in mind by choosing an EHR compatible teleconference software solution so visits are kept within a patient’s chart. Consider compliance and risk, as guided in Part 1 Pre-registration & Telehealth Consent Strategy, by choosing an EHR integrated eConsent solution like, Impression.
Below are a few examples of how to introduce telehealth as an option within patient workflow:
Telehealth Visit Workflow (particularly in reference to COVID-19 and other HAIs)
American Academy of Pediatrics Provider – Patient (after hours)
American Academy of Pediatrics Provider – Patient (during hours)