Published in the June 2017 issue of Today’s Hospitalist
HOSPITAL MEDICINE is primed for its close-up in telehealth.
Hospitals and hospitalists have seen the success of telemedicine in more focused types of care; think tele-ICU and tele-trauma. Now, they want to branch out into tele-hospital medicine and replicate the same upsides: improved access for remote populations, 24/7 care, reduced costs and better patient outcomes.
Related article: “The doctor is (plugged) in: embracing telehealth,” May 2016
Why now? Given the inroads that telemedicine has made in other specialties, medical staffs and patients alike have fewer concerns about doctors who appear on a screen and not in person, says Talbot “Mac” McCormick, MD, president and CEO of Eagle Telemedicine, which provides services to hospitals nationwide.
“Telemedicine is just a set of tools and capabilities that can integrate with clinicians on the ground,” says Dr. McCormick. “Telemedicine is still medicine.”
Tele-hospital medicine is carving out several new niches. One is providing a virtual hospitalist presence in rural hospitals that can’t support full-time, on-site physician coverage. Telehospitalists are also helping small hospitals share the costs of night coverage, covering several hospitals simultaneously where nurses are the main on-site provider.
Or telehospitalists take floor call from nurses in larger hospitals so an in-house nocturnist can focus on admissions. Or they bolster staff in hospitals experiencing a patient surge. Future possibilities include assisting with post-discharge visits and skilled nursing facility rounds.
“Try not to use term ‘robot’ for the physicians because it sounds like artificial intelligence, like a machine is doing the thinking,” Dr. McCormick says. “You can call us telehospitalists, but hospitalist is the title we like best.”
WHAT ARE THE BIGGEST misconceptions about telehealth in hospital medicine?
First, both physicians and nurses initially believe telemedicine will be inferior care, says Susan Willis, PhD, PA-C, vice president of clinical program development for iNDIGO Health Partners in Traverse City, Mich.
“There’s nothing different about the level of care doctors are able to provide.”
iNDIGO provides telehealth night coverage for six hospitals, with two iNDIGO hospitalists covering up to four hospitals from 7 p.m. to 7 a.m. Some work on a full-time basis, while others take just a few tele-shifts a month.
“At first, physicians wonder how could they possibly get a good history and provide medical care that’s equivalent to in-person care,” Dr. Willis says. “But other than physically touching the patient, there’s nothing different about the level of care doctors are able to provide.”
The carts’ high-definition camera can zoom in from 15 feet. That allows the telehospitalists to view the fine print on prescription bottles as well as monitors and drips. The physician’s face on the screen is roughly the same size as it would be in person.iNDIGO gives physicians two laptops (one is typically used for the encounter, while the other is used to access the hospital’s EHR) and the hospitals two video carts that doctors use to visit patients. There’s triple redundancy for Internet connectivity in the hospitals, as well as a 90-minute battery backup if power goes out.
Still, telehospitalists need to learn how to create the same kind of doctor-patient relationship they would in-person. And nurses initially worry that telemedicine will disrupt their workflow more than going down a hallway to talk to an onsite doctor.
Dr. Willis points out, however, that communication is just a point-and-click away once the video cart is wheeled to the patient room and plugged into a wall socket. Outside the actual patient encounters, nurses have the physician’s cell number for urgent issues, and they participate in a nightly huddle with the telehospitalist when their shift starts.
And nurses find that they’re now more involved in patient care than before. For example, the nurse may assist in performing pupillary exams with a flashlight in the cart drawer. Further, the telehospitalist relies on nurses to place the stethoscope for heart and lung exams, and may ask them to palpate for lymph nodes, abdominal pain or masses. The documentation will reflect that the nurse did that part of the physical exam.
Another big misconception: Patients, especially the elderly, are not tech-savvy enough to accept tele-hospital medicine.
“That’s categorically false,” Dr. Willis says, pointing out that such a view of- ten reflects physicians’ own concerns. Nurses at hospitals using iNDIGO telehealth introduce it as a cutting edge tool that mirrors familiar technology like Skype or Facetime. The response, she says, has been overwhelmingly positive.
In fact, several patients have asked to delay the physician encounter until family members are present to see the technology in action. Some patients even prep for their screen moment.
“We’ve had several female patients put on lipstick and fix their hair,” Dr. Willis says. “They want to look nice for the camera.”
Paving a new career path
ACCEPTANCE OF TELEMEDICINE has come a long way since the Atlanta-based Eagle Telemedicine started providing services eight years ago.
“When we started, most physicians had another practice and did this as a second job,” says Dr. McCormick. “I’m increasingly seeing physicians leaving their on-the-ground practice and moving to a full career as a telehospitalist.”
Eagle Telemedicine has helped on-site hospitalists at several partner hospitals when those facilities are experiencing volume surges. At such times, the telehospitalists typically take some admissions for the on-site providers.
“I’m increasingly seeing physicians leaving their on-the-ground practice and moving to a full career as a telehospitalist.”
And Eagle now has 20 hospitalists working with 15 hospitals to provide night coverage. Teams of five or six physicians cover one to four hospitals in 12-hour shifts. Physicians work from their homes, but they are licensed in the state in which patients are being seen and credentialed in those hospitals. Telehospitalists are all boarded in internal medicine or family practice and have hospital medicine experience.
The physician takes the sign-out from the day physician, then fields secure texts from nurses. Patient conditions range from low potassium to a status change. If the physician is on another call, the nurse can say, “This is a 911 case” to indicate it’s a priority. The response time is typically less than five minutes.
Eagle provides nurses a script they use to introduce the telehospitalist to patients. They explain that the physician is part of the team and will address the patient’s condition, get care started and, if needed, admit the patient.
The hospital provides its own technology, including an InTouch robot and an Avizia or Cisco cart, which has a stethoscope, screen and camera so patients can see the physician. Before starting the telehealth service, the hospital’s Wi-Fi is evaluated and broadband access is boosted, if needed.
Eagle hospitalists providing night coverage need to be comfortable working on a Windows computer and with multiple EHRs. The laptop that Eagle provides gives them EHR access, as well as operational tools and the telemedicine technology.
Doctors use cameras to zoom in, then document care in the hospital’s EHR and enter orders. “Just like if we were there,” Dr. McCormick says.
Telehospitalists attend rapid response calls and codes, admit patients from the emergency department, and make handoffs to the day physicians. The few things that technology won’t allow include placing chest tubes and central lines or intubations. In those cases, the telehospitalists partner with someone from the hospital, usually the ED.
While Dr. McCormick has a waiting list of hospitalists eager to fill a telemedicine slot, those doctors might not have long to wait. Eagle is continuing to add practices—the company has handled 15,000 telehospitalist admissions—and he fields calls nearly daily from programs looking to integrate telehealth into their hospital medicine programs.
Bringing tertiary care to communities
AS THE ONLY TERTIARY CARE hospital in Iowa, the University of Iowa Hospitals & Clinics in Iowa City has long taken transfers from critical access hospitals. But one 25-bed hospital wanted to figure out a way to keep local patients in the community instead.
“It was really inconvenient for patients and families to travel to Iowa City,” explains Ethan Kuperman, MD, medical director of the hospital’s virtual hospitalist service. Yet there was no way for that facility, Van Buren County Hospital in Keosauqua, to provide round-the-clock physician care.
Dr. Kuperman did a site visit to Keosauqua, which is nearly 90 miles away, to understand what tests and resources were available. He then interviewed staff before setting up protocols, creating a handbook that outlines how to handle handoffs and communication. The telehospitalist program was launched last November.
“We want to be complementary and not replace on-site staff.”
Here’s how it works: Six university hospitalists work in three-day shifts during either their administrative or comanagement time because the hours are complementary. (Telehospitalist shifts are not combined with general medicine ones at the academic center because the higher-acuity patients there are more time-consuming.)
The hospitalists in Iowa City communicate using the Vidyo app on their personal phone, iPad or desktop computer. Staff at Van Buren use iPads to communicate with the telehospitalists, while the telehospitalists go on to talk to the patients through their iPads as well.
The telehospitalist meets with the hospital’s on-site providers at 8:45 a.m. and again at 4:30 p.m. to discuss all patients. Each telehospitalist electronically pre-rounds on patients to review vital signs, medications, labs and nursing documentation, “just as we do here in Iowa City,” Dr. Kuperman says. The advance practice provider on-site sees all patients prior to those virtual meetings to report any acute event that hasn’t been entered in the shared Epic EHR.
The patients at Van Buren skew older with typical conditions such as acute heart failure exacerbation. Dr. Kuperman says he has seen everything from alcohol withdrawal to diverticulitis and sciatica.
For patients with more complicated conditions or who need monitoring or tests not available at Van Buren, the telehospitalist sets up a direct admission to the university hospital. That hospitalist then sees those patients when they arrive to ensure a smooth transition.
Dr. Kuperman, for example, recently transferred a patient with cellulitis of the hand. Concerned it might be septic arthritis, he arranged a same-day infectious disease consult, which isn’t available at Van Buren, and the patient was in surgery within 12 hours.
Van Buren is responsible for the work order and billing and pays a subscription fee to Iowa Hospitals, which covers operational costs. Dr. Kuperman says a moonlighting bonus is taken from that fee for the hospitalists.
Results have been encouraging. The telehospitalists confirm the Van Buren plan 80% of the time, Dr. Kuperman says. “We’re there for the 20% when the patient is more complicated, has red flags or a less common disease,” he says. “We want to be complementary and not replace on-site staff.”
Satisfaction scores indicate that patients like all their doctors working together. And “almost everybody is happy to get University of Iowa care without leaving Van Buren county,” he says.
Other hospitals are hoping for the same. According to Dr. Kuperman, six other critical access hospitals are interested in connecting to Iowa Hospital’s telehospitalist program. He expects to expand the program and add a full-time telehospitalist by the end of this year.
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.
Unfortunately, the “telehospitalist” part of that picture isn’t here yet. But a telehealth operations center has been up and running at the Westchester Medical Center Health Network (WMCHealth) in Valhalla, N.Y., a 1,700-bed health care system, since 2015.
The center provides 24/7 tele-stroke, tele-psychiatry and tele-ICU services to five of the network’s 10 hospitals from a 5,500-square-foot operations hub with 24 workstations. The health system has also added telemedicine capabilities to its critical care ambulances, and an e-trauma program will be up soon.
“The telehealth physicians are a member of the staff. They’re just sitting somewhere else.”
In each 12-hour shift, an eHealth team of three critical care nurses, two data specialists and a physician work with specialized ICU-specific software to take care of patients at WMCHealth hospitals. That team enhances the work of critical care providers in each hospital’s ICU, tracks safety issues and best practices, and uses alerts to head off problems before they occur.
eHealth team members all have experience working in the ICU at the Westchester Medical Center, WMCHealth’s flagship facility and a regional center for advanced care. In addition, the center has a full-time administrative manager.
Sometimes WMCHealth provides the telemedicine technology; other times, the receiving hospitals provide their own, says Corey Scurlock, MD, MBA, medical director of WMCHealth’s eHealth Center. In addition, some facilities have hard-wired ICU rooms, while others use carts. Cameras in patient rooms are turned away from patients when not in use to protect privacy, Dr. Scurlock notes.
In the hub, one screen may show X-rays, while another is open as a physician talks to patients and yet another shows telemetry. While hospitalists in the system can tap into the telehealth network, telehospitalists may one day play a central role, says Paul Llobet, MD, chief medical officer of HealthAlliance of the Hudson Valley. HealthAlliance is a member of WMCHealth that operates two urban community hospitals in Kingston, N.Y., and one critical access hospital 60 miles west in Margaretville.
There’s clearly a need for telehospitalists, particularly in rural areas where physician assistants may be standing in for hard-to-recruit hospitalists. HealthAlliance’s Margaretville hospital, for example, has been recruiting for a hospitalist for five years—and has garnered only one applicant.
“It’s very difficult to get a hospitalist there,” says Dr. Llobet. In the future, a PA in Margaretville may be able to do telerounds with a telehospitalist in Valhalla. “The technology is there.”
So is the start-up strategy. Dr. Scur lock says that establishing the center has meant developing work flows, agreeing on best practices and starting first with simulated patients to increase clinicians’ comfort levels. He says it takes about six months for everyone to get completely comfortable with a program once it goes live.
Now that staff are familiar with telehealth in general, there may be fewer challenges to accepting hospitalists as part of the mix. “Nurses and other ancillary staff were concerned that we were replacing a physician with a monitor,” says Dr. Llobet. But they quickly realized the technology was a tool, not a replacement.
“The telehealth physicians are a member of the staff,” says Dr. Scurlock. “They’re just sitting somewhere else.”
Look into the camera and other tips
CREATING THAT ALL-IMPORTANT physician-patient relationship as a telehospitalist means recognizing and adapting to the nature of the medium.
“Just because you know how to behave with a patient in a room doesn’t mean you know how to behave with a patient on a screen,” says Susan Willis, PhD, PA-C, vice president of clinical program development for iNDIGO Health Partners in Traverse City, Mich. Here are her tips:
- Find a well-lit space to use your laptop.
- Wear your name badge.
- Look at the camera above the screen and not at other things (including the computer screen), or patients will think you’re not looking at them.
- Set the stage by introducing yourself and establishing the physician-patient relationship.
- Make sure to ask the patient who else is in the room.
- Don’t mumble or roll your eyes.
- Remember, the patient can see anything you do, including hand motions.