JUST ABOUT every health care forecast for 2020 says that the boom times in telemedicine will just get bigger. And while hospital medicine has seen its growth in telemedicine hamstrung by archaic reimbursement policies, hospitalists are encouraged by interest in niche areas like telenocturnists and surge capacity.
The boom times in telemedicine reflect not only a chronic shortage of clinicians, particularly in rural areas, but to what some say is this domino effect: The good outcomes that hospitals achieve in one area of telemedicine are spurring adoption of others.
Take Atlanta-based Eagle Telemedicine, for instance. The company established itself more than 10 years ago by providing telenocturnist services to small hospitals. While that business continues to grow, Eagle’s partner hospitals have asked for so many other service lines that the company has since expanded into 17 different medical telespecialties. Those specialties now make up 40% of its business.
“Could you not see a direct-to-consumer telehealth option for Amazon Prime members for a couple of dollars a month?”
~ Nitin Sawheny, MD
The nation’s largest virtual health network, Avera eCARE in Sioux Falls, S.D., provides e-emergency medicine services to nearly 200 hospitals across 30 states. It has likewise expanded into many different telespecialties. In addition to moving into new outpatient telemedicine options such as schools, employers and correctional facilities, the Avera eCARE Hospitalist program is up and running in more than 20 sites.
And TeleHealth Solution, a pioneer in providing night and weekend virtual coverage to SNFs, was able to parlay its reductions in SNF return-to-hospital rates last year to jump into tele-acute care, a service line that includes hospital medicine. That’s in addition to more than 10 telespecialty lines.
One of the company’s telehospitalists, Nitin Sawheny, MD, predicts that the continued evolution of both his company and the telehealth industry in general will be into direct-to-consumer care.
“Could you not see a direct-to-consumer telehealth option for Amazon Prime members for a couple of dollars a month?” asks Dr. Sawheny, the company’s national director of acute care services. “That could put a real dent in both family medicine and urgent care.”
In the midst of all this tele-morphing, the growth of e-hospital medicine is still hampered by reimbursement policies that lag behind the times.
Thirty states have passed private-payer parity laws, and Medicare now reimburses for several telespecialty services. But the CMS by and large doesn’t pay for virtual general medicine services such as histories and physicals, only for services provided by attendings on the ground.
Like just about everyone else in telemedicine, Jessica Schlicher, MD, MBA, medical director for CHI Franciscan’s Virtual Hospital and Mission Control in Tacoma, Wash., looks forward to Medicare reimbursement catching up with real-world needs.
“We derive an immense benefit from having the people who work onsite at night feel supported.”
~ Jessica Schlicher, MD, MBA
But she quickly adds that she doesn’t see payment issues hurting the growth of telehospital medicine, at least not in her health system.
“Payment policies aren’t really a barrier because we derive an immense benefit from having the people who work onsite at night feel supported,” says Dr. Schlicher. “There’s also a safety benefit to having patients get their needs addressed rapidly, rather than an onsite person having to get through all their pages.”
While much of telehospital medicine is driven by meeting the needs of low-volume hospitals, Dr. Schlicher points out that CHI Franciscan’s virtual hospital medicine program is “responding to patient needs in a very high-volume situation.”
The program has a telenocturnist team—a hospitalist, an advanced practice clinician (APC) and an RN all working together in a virtual hospital hub—take all non-critical issues via a text-based system from five CHI Franciscan hospitals. The team then triages those patients to “whoever can address them most appropriately and quickly.” That allows the onsite nocturnists to focus on admissions and decompensating patients.
“The telenocturnists can get back to all cross-coverage calls within two or three minutes,” Dr. Schlicher points out. “That’s reduced the overall number of pages by 42%.”
Like many other telehealth providers, Talbot “Mac” McCormick, MD, president and CEO of Eagle Telemedicine, says his company is likewise seeing sharp growth in nighttime cross-coverage services in large hospitals.
Another growing area of demand in high-volume facilities: surge capacity. “That tends to be in larger, urban hospitals that are being overwhelmed with admissions every third night,” says Dr. McCormick. “Telemedicine allows us to provide fractional physicians on standby at more than one place. We sometimes provide both call coverage and surge protection.”
The growth of telespecialties
Still, much of the growth in telehealth including telehospital medicine continues to be driven by the needs of small and rural hospitals that want to stay open, transfer fewer patients and boost their revenue.
“Telemedicine allows us to provide fractional physicians on standby at more than one place.”
~Talbot “Mac” McCormick, MD
Saurin Patel, MD, is chief medical officer of the Dallas-based Access Physicians. The company, which started in 2011 providing house physicians and rural hospitalist programs, is now one of the country’s largest for inpatient telemedicine with services in more than 150 sites, both rural and urban, and a network of more than 600 physicians.
Not surprisingly, Dr. Patel says the telespecialty lines experiencing the strongest growth are ones the CMS has agreed to reimburse. At the top of that in-demand list is acute stroke.
“Every hospital out there wants to get a stroke accreditation,” he points out. “You can’t do that without a quality stroke neurologist and neurology program.” Other telespecialty lines that small hospitals want are infectious diseases, pulmonary/critical care, and maternal/fetal medicine.
“Maternal/fetal medicine lends itself very well to telemedicine because it’s a very imaging-heavy field,” Dr. Patel explains. “If you can work collegially with local ob/gyns and keep patients who are very high-risk pregnancies in a community, that’s a massive game-changer for patients.”
And hospitals in small communities appreciate the higher reimbursement that comes from not transferring such complex patients. That is likewise driving telespecialty growth for Eagle, which operates in more than two dozen states. Dr. McCormick says it’s also spurred a new demand for virtual outpatient services.
“With success on the inpatient specialty side, patients now staying in the community need outpatient follow-up, so that’s a new demand being generated,” he explains. “More hospitals are asking, ‘Can you give us a half-day clinic a week for telecardiology or tele-ID?’ ”
A consult model
Eagle is also seeing strong growth in daytime telehospitalist services, often in collaboration with APCs on the ground in referring hospitals.
“This work has restored my passion for practice.”
~ Ellie Basaly, MD
That’s also true for the Avera eCARE Hospitalist program, according to its medical director, Amy Evjen, MD. She is one of 12 physicians in her 30-member group who maintains a combination practice of both telemedicine and in-person hospital shifts at Avera McKennan Hospital & University Health Center. Like her colleagues, Dr. Evjen divides her telehospitalist time between day and night shifts.
Given the restrictions on reimbursing telemedicine services, she notes that most of both her day and night tele-encounters are consults, either from APCs or physicians in client hospitals.
“We have different arrangements based on what the referring site has established,” says Dr. Evjen, “but the consults are often for patients about to be admitted.” Her eCARE consults also take place when a local doctor or APC has rounded on patients and seeks further advice or interpretation of results. Or the consults serve as second opinions or answers to questions about guideline recommendations or up-to-date practice patterns.
According to Dr. Evjen, local hospitals derive many downstream benefits from telehospitalist services, including better local recruiting and retention. They also enjoy increased revenue because physicians and APCs can bill as attendings.
The Avera eCARE Hospitalist program, meanwhile, does not bill insurers for consults and is instead being paid a subscription fee from client hospitals. That’s currently the payment model for many telehospitalist programs.
However, TeleHealth Solution, which is based in North Carolina, has opted for fee-for-service charges instead. “There are so many provisional barriers to getting paid from insurers that we’ve decided to set fee-for-service charges for an admission or a consult,” says Dr. Sawheny.
“This is a way to not only connect with smaller communities, but to support rural physicians.”
– Amy Evjen, MD
The company bases those fees on a hospital’s number of service lines and volume. “The clinicians on the ground may, as attendings, bill insurers, or they may just reap the revenue and patient-satisfaction benefits from keeping more patients in their community.”
Wanted: telemedicine physicians
What is also growing, says Eagle’s Dr. McCormick, is interest among doctors in doing telemedicine.
He chalks that up to the fact that telemedicine now is “not quite as cutting-edge as it was 10 years ago and is more generally accepted and understood.” Many doctors, he adds, start out with telemedicine as a second job. “Then it becomes their full-time clinical practice, and they leave their job on the ground.”
Ellie Basaly, MD, signed on as a full-time telenocturnist with Eagle four years ago after spending three years as an onsite hospitalist.
Dr. Basaly readily ticks off the advantages of working in telemedicine: the ability to respond almost immediately to patients and spend more time at the bedside, the variety of patient populations she treats around the country, the chance to take skills acquired through meeting challenges and quality metrics at one hospital and introducing them at others.
Perhaps the biggest benefit for her right now is the ability to work from her Florida home with two children under the age of five. “This work has restored my passion for practice,” says Dr. Basaly. “It is satisfying to care for patients who would otherwise not have access to care because of their rural location.”
The CHI Franciscan telenocturnists work a different model. For one, instead of doing telemedicine full time, they must maintain a hybrid schedule that combines virtual shifts with onsite work in at least one of the five hospitals they provide telecoverage for at night.
“We find that it’s important to have a hybrid schedule,” Dr. Schlicher says. “That allows our telemedicine team to monitor the needs of the onsite team in real time.”
And all of CHI Franciscan’s teleproviders work in its Virtual Hospital, a hub that has about 150 clinicians and IT staff rotating through. Those clinicians don’t have the option of working from home.
“The virtual ICU is right next door to the telehospitalists, as well as the virtual sitter program and virtual telemetry,” says Dr. Schlicher. “With just a few steps, the telehospitalists have any resource they need.” Plus, keeping all their telehealth lines co-located “has proven to be very helpful when processes change.”
That’s the same model used by Avera eCARE, Dr. Evjen points out. Currently, only one telehospitalist works per shift, fielding consult requests from any of the service line’s more than 20 sites. As it grows, the service continues to add more physicians on per shift.
Helping rural physicians
According to Dr. Evjen, offering a combination of both telehealth and onsite shifts has been a boon for hospitalist recruiting.
She also finds telemedicine to be a welcome break from practicing in a tertiary care facility. In their on-the-ground practice there, she points out, “hospitalists care for virtually all hospitalized patients. That includes very complicated management of patients with bone marrow and solid-organ transplants coming out of critical care.” By contrast, her virtual hospitalist work with smaller community and rural hospitals serves much less complex patients with fewer comorbidities.
“It is,” she says, “a nice change of pace.”
Dr. Evjen also notes how gratifying she finds it to work with rural doctors. Having grown up in South Dakota and attended medical school there, “I spent a significant amount of time training in rural settings. This is a way to not only connect with smaller communities, but to support rural physicians.” Telemedicine, she adds, helps rural doctors “feel less isolated and, hopefully, more job satisfaction by having colleagues they can rely on.”
For Eagle’s Dr. Basaly, staying connected to rural health care is likewise a big draw of telemedicine. While she trained in a tertiary center, her hospitalist work after residency was in a rural hospital.
“I enjoyed that front-line work, intubating patients and putting in our own central lines.” She now continues to manage those procedures at night with onsite physicians. “That’s the type of medical practice I enjoy.”
What can go wrong?
WHEN SMALLER community and rural hospitals make the jump to telemedicine, what mistakes do they make? Hospitalist Saurin Patel, MD, is chief medical officer of the Dallas-based Access Physicians, which has set up telehospitalist and telespecialty lines around the country. He points out the following potential pitfalls:
• Ordering “the whole enchilada.” According to Dr. Patel, hospital executives in smaller hospitals can be so eager to reduce transfers and boost revenue streams that they want to ramp up a full menu of telespecialty lines—cardiology, pulmonary, infectious diseases and neurology—all in the same quarter.
“You have to be able to decrease what we call ‘the time to therapeutic relationship.’ “
~ Saurin Patel, MD
“That may be great in theory, but it’s a suboptimal way to launch programs,” he says. “You really need to be thoughtful on the front end and design sustainable workflows at the hospital with the existing nursing staff and physicians. If you don’t do a good job with that first service line, it won’t go well.”
• Using “one and done” consulting. In telemedicine, it’s good to try to replicate what works in traditional practice as much as possible. When it comes to consults, “we’re going to see the patients until they no longer need to be seen,” Dr. Patel says. That means a telespecialist shouldn’t just check in once, offer a game plan and then disappear.
“Our consultants will check in tomorrow and then stay in touch via text or phone until the patient is discharged,” he points out. His company typically staffs its telespecialty service lines with a rotating group of about eight specialists working blocks of three to seven days.”That way, the teleconsultants have more continuity with both patients and nurses,” he explains. “That diminishes early barriers to the acceptance of the program and builds a higher-quality long-term operation.”
• Ignoring virtual personalities. Perhaps the “biggest failure point” in telemedicine, Dr. Patel says, is taking physicians who don’t have a great bedside manner and putting them behind the screen.
“You not only have to be a great physician, but you have to be able to quickly connect with patients and decrease what we call “the time to therapeutic relationship,” ” he says. “In telemedicine, physicians have a very short window to build trust and have patients buy into the game plan for their care.”
To that end, Dr. Patel says his company has developed its own internal mechanism to identify physicians who have high emotional intelligence and the ability to deliver care virtually. And this year, Access Physicians plans to begin using artificial intelligence to see “more personable characteristics” among possible recruits. “When patients are sick and about to be put on a ventilator, they want—and deserve— a physician who cares and who can communicate clearly and with compassion.”
Published in February 2020 issue of Today’s Hospitalist