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Population Health

Putting Telehealth Into Practice: Case Study

By Sanjay Upadhyay, MD
Family Practice, Temple Physicians, Inc.

With the COVID-19 pandemic straining the health-care system and testing the mettle of physicians and patients alike, the ability to conduct appointments through digital channels has made a world of difference in maintaining patients’ well-being. 

While telehealth certainly existed prior to the pandemic, it has never been more vital to do it well. And in the time that I and my colleagues at Temple Physicians at Palmer Park have employed remote medicine, I can assure you we have learned a few things along the way. We have continued to shepherd our patients along to good outcomes — but not without overcoming a host of challenges.

Dialing up Telehealth

Very early in the pandemic, our senior administrators met with us to discuss how to keep patients and staff safe amid all the uncertainty surrounding the virus. We are a busy primary care practice that includes four family medicine providers, an internist, a PA, and nurse practitioner; two cardiologists and a gastroenterologist come into the office several days a week. Our patients run the gamut from young to old — newborns to nonagenarians. Our cases run from preventive measures to acute care. 

Prior to COVID-19, we had no telehealth solution in place. When our providers were told we could work from home for a number of days a week, we began switching our patients to phone visits; video consultations were added later.

Our support staff was the main driver in making our phone appointments happen. They informed patients that we would be conducting appointments by phone, then apprised physicians when to call our patients. We asked virus-related screening questions based on templates provided by senior administrators. We asked not only about whether patients had been exposed to or tested for COVID-19, but also socioeconomic questions — for instance, had the pandemic caused them to lose utility access or access to food. 

When it came time to add video, Facetime was an option — but we declined out of concern for contacting patients using private phones and personal numbers. We chose the visitation app Doximity, which lets us send anonymous texts to invite patients to start video visits. To add to its effectiveness, technicians added cameras to our computers and a Wi-Fi extender to strengthen the signal throughout our building.

Clear Benefits

Since using telehealth, numerous positives have emerged. 

  • Over the past 6 months (Apr–Sept 2020) our no-show rate on average has decreased by 5% in YOY comparisons.
  • Likewise, 7-day post-hospital follow-ups are quite easy to do via telehealth, and often are preferable to in-person visits as patients are often no-shows because they're in pain or sick. Since implementing telehealth, our practice has increased the percentage of patient discharges seen within 7 days from an average of 25.6% to 50.2% (April–August YOY). 
  • Without patients in the waiting room, I can call and leave a message if they’re not available; I have spoken with them hours later when we can connect.
  • I’ve been able to reach patients at their convenience, while they’re in town or traveling. 
  • Medicare annual well visits can be done via phone and is a very appropriate type of visit to encourage patients to do over the phone.
  • Telehealth has prompted many patients to join the myTempleHealth portal, which lets them receive their results on demand in a timely and efficient manner.

Making Telehealth Work

Every physician has a different view of how valuable video visits are. Some prefer to rely just on the phone, others will start a video call then return to just audio if a patient has nothing else to show — for example, a rash or bite.

I am really pro video; while it doesn’t necessarily help me make a clinical decision, it does help me determine what state a patient is in. If a patient goes upstairs to show me his or her medications, for example, I might note that the patient has trouble breathing afterward. That said, some patients simply don’t wish to be seen on camera — for instance, I have had several patients start a video call while driving.

Of course, it’s not enough that the practice has the right equipment; patients must also have basic current technology and know-how to use it. Before my telehealth sessions, I call my patients — particularly the elderly — and ask if they have a cell phone with a camera, and if they can receive text messages. If they say yes, I’ll ask them to try it and send them the link to connect us. Most are able to do it, and they’re shocked to see that. Checking digital equipment is a must even with those who know how to use the technology; sometimes a video connection just goes bad, and you have to switch to the phone.

We have certainly tweaked our approach over the past six months, like ensuring our MAs ask all the right questions when verifying appointments and prescreening patients. We have improved our internal communications by learning how to use our telehealth schedule and understand notifications on it.

As we navigate our comfort levels in interacting remotely, our patients are becoming more engaged in making decisions about their care, whether it's about medications, seeing a specialist, planning an ER or urgent care visit, or starting therapy. This is particularly true of patients with anxiety or depression, who might be leery of coming to our office, thus delaying their care. However, for new patients, I encourage you to see them in person first — especially in primary care. Our patients also are more likely to have a supportive member of their care network attend their remote appointments. We’ll often schedule an appointment to coincide with when a home health aide is present, or if a visiting nurse can be there to provide accurate vitals or examine wounds. 

Even with patients trickling back to our office, we’re still seeing most via telehealth; I’m conducting about 70 percent of my appointments remotely.

Next Steps

While we continue to refine our process, from prescreening and scheduling patients to learning how best to interact with them remotely, there is a lot more room to grow with telemedicine.

While the future of telehealth is being shaped, now is the time to get in the game — particularly if you are a small, busy practice with limited infrastructure. I am excited by our successes and the things we’ve learned in our six months of using telehealth outreach, and I am confident of more gains in the near future.

Tips I Learned to Ensure Telehealth Success

  • Ensure provider and patient Wi-Fi signals are strong; use Wi-Fi extenders if necessary
  • Support staff should conduct pre-screening with the patient to ensure they have and can use the proper technology
  • Create and follow a template for pre-visit screening questions
  • Test connection with the patient before the appointment
  • Do not conduct patient calls while the patient is driving
  • If possible, schedule telemedicine appointments when a home health aide, visiting nurse, or family member can be present
  • Patients new to the practice should be seen in person first

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