Where: Thomas Jefferson University Hospitals, a system of hospitals with 951 beds in the Philadelphia region.
The issue: Communicating with inpatients' family members when they cannot be physically present.
When it comes to treatment plans, a lot of information can get lost between early-morning rounds and visiting hours. “We have found that communication between health care professionals and families about the patient getting the care is less than optimal, so we created this program called virtual rounds,” said Judd Hollander, MD, an ED physician and associate dean for strategic health initiatives at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia.
How it works
Using videoconferencing software similar to a webinar, the program allows family members to virtually join the health care team at the patient's bedside during rounds. The family members connect using their own devices, and the inpatient clinicians and patient can use either the patient's smartphone or one of the tablets kept on units that participate in the program. “I think the most family members we have engaged is four at once, all from different states,” said Dr. Hollander.
The program is offered to patients as part of admission instructions, and they can then opt in or out. Patients schedule virtual rounds with the hospital's telehealth team, either in advance or on demand, and about a handful occur on a given day, said Dr. Hollander.
So far, the postanesthesia care unit (PACU) has seen the most success with the program, said Dr. Hollander. “When people come out of surgery, the family is always antsy, they're not always there, and even when they're there, they can't go in and see the patient for a couple hours,” he said. “So we're now able to connect that patient with their loved ones right as they come out of the OR.”
In addition to making families feel better, the system can potentially improve postdischarge care. “That way, the family or caregiver who is not sedated and has not just woken up from sleep gets a chance to listen to that interaction, be part of the discharge process, and hopefully be able to better help coordinate care when the patient goes home,” said Dr. Hollander.
A minority of patients take the offer to be on camera. “I think our percentage of people that take it is around 10%, but those who take it generally love it,” said Dr. Hollander. He recounted a story of two brothers who hadn't spoken to each other in six months. “The brother who was actually on hospice care and dying wanted to do this, and his other brother agreed to do it. . . . The hospitalized patient couldn't speak anymore, but he was able to give his brother the thumbs up,” said Dr. Hollander. The next day, the patient's brother wanted to connect again, he said, but the patient had died overnight. “It was a little bit embarrassing for the telehealth coordinator, but when they called the brother at a distance back to inform him, the brother stated that he had interpreted the thumbs-up sign as ‘All is forgiven’ and was totally at peace with their six months of not speaking,” Dr. Hollander said.
Challenges to the program have been on the physician end. “Some doctors spend a lot of time with patients and are really, really happy to do it and love this,” Dr. Hollander said. “Some doctors are in and out of the room, and if the video's not set up at the exact minute they're going to be there (which is, of course, hard to coordinate), they don't tolerate that terribly well.”
There can also be difficulty finding a time to talk that fits families' schedules and physicians' workflows. “With many things in telemedicine, it's not actually about the technology; you could use a million different technologies to do this. It really is about the workflows and the human factors,” said Dr. Hollander.
It also took time to find the best setting for the program. It first launched in 2015 on a comanaged hospitalist and oncology ward, but that wasn't a perfect fit. “Although we thought they were people in the hospital for a decent duration of time and there would be more confusing decisions being made. . . it turns out oncology patients are getting chemotherapy and they're sick and vomiting, and they don't really want to be on video,” he said.
Jefferson's telehealth team is deciding which units should be next to implement the program, with the ultimate goal of allowing all willing patients to participate whenever they want, he said. “What we really need to do is embed it. . . in [each] unit's workflow so that a device can be stored there, so that the software is licensed there, so that it can be used when it needs to be used,” Dr. Hollander said. “Some of the self-contained units, like the PACU and some of the ICUs, are where we've revamped to target now,” since it can be more difficult for physicians to coordinate with patients who are spread out over multiple general medicine wards.
Words of wisdom
Those who want to initiate a similar program should first find hospital units where there are interested clinicians—and not just the doctors, Dr. Hollander suggested. “Where are the unit clerks and nursing staff going to be most interested in helping you champion this initially? Because once you win in some areas, everybody else wants to play in the pond with you. But if you go to the wrong place first, it's a lot harder to get people to jump in,” he said.