How Telehealth Has Changed the Hospital, a Medical Office and a Clinic

Just a year ago, telehealth was a niche service.

Indeed, Jesse Wolff – who last year was the managing director of the HealthSpark health-tech incubator at 20Fathoms – said that 85% of hospitals had “some kind of telehealth platform,” up from 35% a decade previous in a TCBN story on the steady rise of telemedicine in northern Michigan.

Wolff predicted at the time that telehealth utilization would be ubiquitous in the United States within a matter of years.

Wolff’s prediction was right, except for one detail: Ubiquity took only a matter of weeks shortly after the pandemic shut-downs began.

 

‘High Level of Urgency’

Chelsea Szafranski had started a job in mid-February as Munson Healthcare’s first-ever system director of digital health. One moment, she was a new hire learning the ropes in a relatively low-stakes role. The next moment, she was in charge of implementing a service that was urgently needed.

Chelsea Szafranski

“We had been working on a multi-year plan for telehealth strategy, just looking at the whole healthcare system and where we’d be prioritizing it,” Szafranski said. “And then COVID came and quickly changed that. It went from a multi-year strategic plan to ‘We don’t have a vendor for video visits and we need to get one implemented within a couple of weeks.’”

The good news was that most of the technologies necessary to execute telehealth services already existed. The bad news was that healthcare systems like Munson weren’t ready for a quick pivot to telehealth, in part because of regulatory and billing restrictions.

“Pre-COVID, there wasn’t a ton of telehealth being done in our provider practices,” Szafranski explained. “There were actually a lot of federal restrictions that said you couldn’t provide that (type of care) to a patient in their home. And also, a lot of payers weren’t even reimbursing for video visits at that time.”

Once a federal public health emergency was announced, these roadblocks “changed very quickly,” she said.

“(The announcement) temporarily alleviated all those restrictions that we’d had,” she said. “It allowed us to provide video visits to patients in their homes. And Medicare and Medicaid began covering telehealth visits, and then all the other commercial payers followed.”

Working with “a high level of urgency,” Szafranski rallied IT resources and training teams within the Munson system, with the goal of getting video telehealth services rolled out to all Munson provider practices. Within a matter of weeks, Szafranski says that Munson was “at about 60% virtual visits across all of our practices.”

That percentage dipped to “around 10% in the summer,” as COVID-19 precautions in Michigan eased and Munson caught up on in-person services that had been delayed by the statewide shutdown. When area coronavirus cases increased in the fall, the rate of virtual visits went back up, sitting at 25% by the end of the year.

Szafranski notes that some healthcare specialties have higher telehealth utilization rates than others, simply because certain services are easier to provide that way. Behavioral health services, for instance, are “between 95 and 100% virtual,” while specialties like endocrinology and nephrology are “at about 80% right now.”

Behavioral Health

Behavioral health is certainly one of the biggest adopters of telemedicine. Pine Rest Christian Mental Health Services is a nonprofit based in Grand Rapids with a clinic location in Traverse City, and is the fourth largest behavioral health provider in the country.

Jean Holthaus

According to Jean Holthaus, Pine Rest’s southwest regional director for outpatient and recovery services, the organization increased from “about 400 or 500 (virtual) visits a month” before the pandemic to doing “thousands a week” once COVID hit in March.

“We’ve kind of adopted the philosophy that anything that we can do in person, we really want to be able to do virtually as well,” Holthaus said.

While some services like play therapy for small children can’t be translated to a telemedicine model, Holthaus said that most can effectively be delivered virtually, with no apparent loss in quality or outcome.

“If you look at national studies, they will show that you get as-good-as and sometimes better-than results from using telehealth,” Holthaus said. “Anecdotally, we haven’t found that our results are different, and we don’t feel like we’re not providing the same level of services. But feeling is different than fact, so we’re going to obviously want to study our own outcome data to know (for sure).”

Holthaus concludes that it’s ultimately “too early to tell” whether telemedicine is a 100% effective replacement for in-person care. Pine Rest, for instance, is still working to make it easier for patients to access virtual appointments via their online patient portals, to remove potential technical difficulties that can delay or derail scheduled appointments.

“We’re asking, ‘How can we smooth this out? How do we make it as easy as possible for patients?’” Holthaus said. “Because currently, they’ve had to download an app (for a video appointment), and get an invite in their email, and there’s a lot of places where that can go wrong.”

‘Trial and Error’

Courtney Whinnery, a licensed professional counselor at Traverse Health Clinic, reports a similar ongoing learning curve for telemedicine. Whinnery says she had “never done telehealth before COVID.”

Courtney Whinnery

She’s not alone. Mi Stanley, Traverse Health Clinic’s communications and marketing manager, says that the clinic had been “100% face-to-face” for both behavioral health and primary care services up until last March. Now, Traverse Health Clinic is doing more than 95% of its behavioral health work virtually, as well as the majority of its primary care.

While Whinnery notes that she’s had a small handful of in-person appointments over the past year, it’s now been long enough in the behavioral health cycle that she’s never met the majority of her current patients in person.

That transition has involved a change of tactics, because being a virtual counselor is not exactly the same thing as being an in-person counselor. In particular, phone appointments – a common piece of the puzzle for Traverse Health Clinic, since many of the patients it serves don’t have internet access – have been especially challenging without facial expressions and body language.

“It was trial and error,” Whinnery said of the adjustment to telehealth. “It’s a lot more asking questions, rather than intuitively knowing by looking at (the patient) that their moods have shifted. So, stuff like ‘You sound like maybe you’re irritated by that,’ versus, ‘You look upset.’”

Internet Accessibility

In northern Michigan’s rural landscape, the internet accessibility factor is one of the biggest stumbling blocks to widespread adoption of telemedicine. At several Munson practices, for instance, Szafranski says there is a new pilot program in place where patients can do virtual visits in their cars if they don’t have the ability to do them from home.

“If (the patient) is suspected to have COVID but needs to get in touch with a provider, we’ll have them actually drive to the practice, and we’ll hand them an iPad in their car, and they’ll complete the virtual visit in the parking lot outside the practice,” Szafranski explained.

Amidst all these efforts to improve telehealth delivery, there’s also one overarching question: Will digital health continue to matter after the pandemic? The challenge, according to Holthaus, is that healthcare providers likely won’t be the ones to make that decision.

“The insurance companies will have to decide, and Medicare and Medicaid,” Holthaus said. “They originally were mandated by the government that they had to allow for (telehealth) service.”

Whether insurance companies and Medicare/Medicaid continue to reimburse for telehealth will make all the difference, she said.

“We’re seeing some of those mandates expire, and as that happens, people are going to need to continue to advocate that their insurance company cover telehealth service if they still want it,” she said.

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