Published in the May 2016 issue of Today’s Hospitalist
HOSPITALIST Sanjay Dhar, MD, is already nostalgic for the future, robot-doctors and all.
Today, when he has a very ill patient who needs an infectious disease consult at Summit Health’s 50-bed Waynesboro Hospital in central Pennsylvania, Dr. Dhar has to transfer that patient to a large hospital a half hour away. But for nearly a year, that wasn’t the case.
Related article: Tele-hospital medicine branches out, June 2017.
Until last May, Dr. Dhar was able to consult with a tele-infectious diseases specialist who, unfortunately, has since changed jobs and no longer tele-consults.
“A telehospitalist almost has to be an actor on camera.”
~ Susan Willis, PhD, PA-C<br>iNDIGO Health Partners
“We realize what we lost,” he says. “We have seen it both ways, and now we are sold.” Practicing without telemedicine, he concludes, is “a huge waste and inconvenience for patients.” Because health care has lagged so far behind other industries in capitalizing on the Internet, he adds, “we have lost opportunities to fix some inequities in health care access.”
If health care has lagged behind, it is catching up. Telemedicine, which has been the next new thing for many years, has already made major inroads in tele-stroke care, tele-psychiatry and tele-ICUs.
And increasingly, hospital medicine is getting involved. While some physicians like Dr. Dhar have come to rely on subspecialty tele-consults, a growing number of hospitalist groups are ramping up virtual hospitalist programs in difficult-to-staff facilities or during hard-to-cover shifts. Some also plan to use those same audiovisual and electronic communication resources to provide post-discharge follow-up to patients at home or in skilled nursing facilities.
While those endeavors range widely in design, they share one intent: to extend the reach of hospitalists into communities that can’t afford onsite service or can’t entice medical professionals to relocate. And all say they are planning to expand. Hospitals are using telemedicine to grow their networks in rural areas, as well as contract with hospitals outside their own health care systems.
In their push to telemedicine, hospitalists are leading the “hospital-without-beds” model. One example is the St. Louis-based Sisters of Mercy health care system’s Mercy Virtual Care Center, which cost $54 million to build and employs more than 300 people. Hospitalists there work alongside other doctors and nurses monitoring inpatients remotely in a program called “SafeWatch.”
The center is the nation’s largest single-hub e-ICU. The virtual hospitalist-and-nurse teams handle hundreds of cross-coverage calls at night and monitor alerts for telemetry patients in both the 700-plus bed suburban Mercy Hospital, just 15 minutes away, and for several smaller facilities. While it may seem counterintuitive to use telemedicine to cover a large hospital that has boots on the ground, telemedicine cross coverage allows those onsite nocturnists to focus on admissions without interruptions.
Having a virtual team also allows onsite nocturnists “to admit more patients before midnight,” explains Brian P. Miller, MD, an onsite hospitalist at Mercy Hospital and Mercy Virtual’s eHospitalist medical director. “Now, when the sun comes up, there are fewer patients who haven’t been seen, and day hospitalists can turn over more encounters.” That in turn, Dr. Miller adds, “leads to better patient care, as well as higher satisfaction for patients, nurses and providers.”
The center is signing contracts with other hospitals and health systems outside the Mercy system to provide virtual care, he says, to “those who don’t have the infrastructure on their own and those building their own, but looking to partner in the meantime.”
Bringing doctors to patients
Hospitalist Mohit Srivastava, MD, moved from Brooklyn, N.Y., to Bunkie, La., population 4,000, 12 years ago. In addition to his internal medicine practice, he has begun taking some of the first-ever telehospitalist shifts for the Lafayette, La.-based national physician staffing company Schumacher Clinical Partners. Schumacher is using the program to cover nights in several critical access hospitals in rural Louisiana.
Seated in front of a computer and camera in the telemedicine service center known as “the bunker,” Dr. Srivastava rounds, admits, cross-covers, transfers, writes orders, coordinates care and even jokes around with the nurses at two small community access hospitals 30 miles away. Sometimes, patients call him Dr. Robot, “the TV doctor” or Robodoc.
“You are erasing time and distance,” Dr. Srivastava says. “You can manage two hospitals at one time.” When the pilot phase ends later this year—once all the kinks are worked out, quality and safety proven, more facilities contracted, and more virtual hospitalists hired and trained—he thinks he should be able to cover “eight or nine hospitals at one time.”
He estimates that as much as 80% of what a hospitalist does happens away from the patient, from reviewing data and records, coming up with a game plan, coordinating with other providers, and charting and documenting. The other 20% requires him to be face-to-face with the patient.
By using the camera and peripherals on the “robot” cart, he can take a history, talk with patients and families, listen to hearts and lungs, look into ears, eyes and throats, and zoom in on wounds, ulcers and rashes. If he wants to find out if a swollen leg is tender, the nurse acts as his hands, and an ED doctor is in-house for an emergency intubation or line placement.
As Randy Pilgrim, MD, Schumacher’s enterprise chief medical officer, explains, tele-hospital medicine can help solve the specialty’s biggest, most intractable problems: recruitment and retention.
“Many hospitals can’t recruit qualified hospitalists despite aggressive recruiting efforts and some pretty significant dollars on the table,” Dr. Pilgrim says. “If you can’t get hospitalists to go to where the patients are, sometimes we need to bring patients to the hospitalists.”
Smooth out staffing
Other hospitals are being drawn to the technology because it can smooth out other staffing issues. CHI Franciscan in Tacoma, Wash., will begin testing a telehospitalist program this summer that will be located in CHI Franciscan’s virtual medicine center alongside an e-ICU, a virtual sitter program and remote telemetry.
Kimberly Bell, MD, CHI Franciscan’s associate vice president of hospital medicine, points out that the hospitalists at four of her hospitals are not equally busy. One hospital may have “four nocturnists with 18 admissions, while another has one nocturnist handling nine admissions,” Dr. Bell points out. “What if we had a nurse- and doc-in-the-box take all those calls and be the point of contact to distribute all admissions for all the hospitals?”
At the same time, a telehospitalist could admit a straightforward, lower acuity “pneumonia or cellulitis patient so the onsite nocturnist can go and see the rest.” As Dr. Bell sees it, the virtual hospitalist team could also expand to take care of post-discharge follow-up calls.
What is different about telehospitalist work is the pace and the flow, largely because virtual hospitalists have to depend so much on onsite nurses or NPs/PAs to facilitate their practice. Doctors need onsite clinicians to—at the very least—roll a “computer on wheels” cart with the monitor, computer, camera and peripherals into patient rooms and turn on the machines. Doctors have to figure out a way to fit their work into the workflow of a nurse or advanced practice partner.
They also need to be able to develop productive relationships and have the kind of personality that works well on teams. Telemedicine is not for everybody.
“A key to success is investing time in your NP or nurse,” says Nitin Sawheny, MD, a former telehospitalist in Oklahoma who, as a regional medical director for TeamHealth Acute Care Services, is developing a telehospitalist program that should begin pilot-testing in five sites later this year. “You have to be patient and specific with how you direct your questions to get the information you need and make the appropriate diagnosis. Being able to trust your partner was difficult at first, but I came to like it.”
Telemedicine also isn’t a good match for someone who thinks that working at home or alone in a bunker is a more relaxed way to practice. “You have to be able to work efficiently because you may be at three hospitals at one time, and you must be available to every single one,” says Jayne Lee, MD, national medical director for telehospitalist services for Eagle Hospital Physicians, a national hospitalist staffing company based in Atlanta. For the past six years, Dr. Lee has been providing remote care to small hospitals throughout the U.S. from her apartment in Paris, France.
A virtual hospitalist also has to be comfortable with technology, Dr. Lee says. Telehospitalists must be able to troubleshoot, help nurses who may be uncomfortable or intimidated, and switch seamlessly among different EMRs in the course of one shift.
In Northern Michigan, the hospitalists with iNDIGO Health Partners, a private group, provide nighttime telemedicine at two rural hospitals and plan to expand to three more by this summer. Some telehospitalists are local—their own hospitalists pick up moonlighting shifts—but others will work from homes across the state or even across the country.
The company is looking to hire telehospitalists to cover critical access hospitals and other rural facilities expressing interest in the program. But finding hospitalists with the right skills and attitudes isn’t necessarily easy.
“We spend a fair amount of time on training, including etiquette,” says Susan Willis, PhD, PA-C, a physician assistant who is iNDIGO’s vice president of clinical program development and is spearheading the telehospitalist program. “We tell them they can work from home, but they need to look and behave professionally. If they don’t, the patient won’t take the program seriously. We let our providers know that they can’t look like they just rolled out of bed to do an encounter.”
A different dynamic
The position also requires media training to help physicians understand the importance of factors like tone of voice and facial expression. “A telehospitalist almost has to be an actor on camera,” says Dr. Willis. “You can’t mumble or roll your eyes, and you have to measure your tone and the words you use.” Messages relayed through body language are lost, she adds, because patients see only a face on a screen.
“The fact that you are not in the room with the patient changes the dynamic, and many don’t realize that until they do some encounters.”
Telehospitalists are also taught to look at the camera, not at the computer screen, “so patients will perceive that you are looking right at them,” she adds. “When you look away, it seems to the patient that you’re not paying attention.” Telehospitalists are told that if they have to review notes, they need to say something like, “I need to look away for a minute to review your labs.”
Telehospitalists must also make an extra effort to know who is in a patient’s room and ask the nurse every time to introduce everyone. “For HIPAA compliance, make sure it’s OK to speak about the patient’s medical condition in front of everyone. That also helps family members feel included in the interaction.”
On the hospital side, Dr. Willis says, expect to need a lot of preparation and education: upgrading wi-fi, credentialing telehospitalists and developing process flow. Hospital administrators and nurse management have to be onboard, and floor nurses need training in how to serve as presenters. “Many RNs are worried that this will create work for them or disrupt efficiencies,” she says. “And nurses don’t want to be embarrassed in front of patients, families and telehospitalists because of not knowing what to do or how to do it.”
According to Dr. Willis, the biggest skeptics are physicians. “I think it’s the fear of the unknown and of change and of potentially being replaced by a ‘robot,’ ” she explains. Doctors may also believe that they won’t provide the same care remotely as they do in person. “And there are always concerns about how to handle situations when something
goes wrong with the patient or the technology.”
Benefits for rural communities
For telehospitalist Ariel Lufkin, MD, who’s with Mercy in Oklahoma City, “the most surprising part of the job has been patients’ acceptance. Obviously, everyone wants to see a doctor in person, but these people live in rural communities, and they understand that it is hard to get doctors out there.”
Moreover, he adds, patients often think—incorrectly, he insists—”that because they are ‘seeing’ a doctor in the city, that I am somehow smarter” than a rural doctor. Dr. Lufkin works as a telehospitalist for three hospitals and does onsite shifts. Occasionally, he transfers a telemedicine patient who’s just too sick for a rural hospital to himself.
He advises skeptics to keep in mind that the benefits to rural communities—where the alternative to telemedicine is no medicine—usually outweigh concerns.
“When census is low, nurses get their hours cut,” Dr. Lufkin points out. “Then they start looking for jobs elsewhere, and you get a brain drain of your best nurses from the town.” Launching telemedicine in one community also helped one small hospital recruit a new primary care physician who was happy not to have to cover inpatients, he says.
In fact, a major reason why Jason Kimball, MD, and his three telehospitalist colleagues in the Lawrence, Kan.-based Sunflower Telemedicine started their company was to support the NPs/PAs who staff most of Kansas’ 84 critical access hospitals.
“To keep critical access hospitals in business, they have to have patients in beds,” says Dr. Kimball. Without doctors backing those advanced practice clinicians, “they have to ship patients out, and we want Kansans to get care as close to home as possible.”
His group has helped cover five different hospitals in the state 24/7 from their laptops or smartphones, using a telemedicine app and mobile hotspot. State laws regulate how often physicians have to supervise NPs/PAs in the hospital in person, and each state is different. In Kansas, Dr. Kimball points out, the state Department of Health and Environment determines how frequently sponsoring physicians must be onsite if a hospital relies exclusively on telehealth supervision of advance practice clinicians. Often, he adds, it’s once a month.
In Tacoma, CHI Franciscan’s Dr. Bell notes that being able to locate telehospitalists and nurses in a virtual medicine center obviates one risk of the job: having to work alone.
At the same time, she points out, telemedicine is the inevitable wave of hospital medicine’s future. “If hospitalists staff ourselves in a way that requires face-to-face contact to manage everything,” Dr. Bell says, “we just won’t have enough people.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
How telemedicine is paid
How is telemedicine reimbursed? The answer varies by payer. Currently, the Centers for Medicare and Medicaid Services (CMS) doesn’t reimburse doctors for many general medicine services such as histories and physicals done through telemedicine, although it does pay for virtual specialty services such as tele-stroke.
As for private insurers, every private payer and state seems to have different telemedicine payment policies and laws. As of last year, more than half the states—particularly rural and Western ones—had enacted telemedicine parity laws, requiring private insurers to pay for the same service provided via interactive audio, video or other media as in person.
Even without such laws, the trend among private payers is to cover an increasing amount of telemedicine, particularly for entities taking risk in bundled-payment programs and ACOs. Advocates claim that it’s just a matter of time before the reimbursement barrier crumbles.