Image by Getty Images
Image by Getty Images

Telemedicine, from both sides now

Hospitalists both give and receive support through the screen.

The typical impression of telemedicine is a doctor on a computer screen remotely caring for a patient. But in 2019, inpatient virtual visits give hospitalists a role on both sides of the screen.

Telemedicine involves the use of technology to deliver health care remotely (a broader term, telehealth, can also refer to nonclinical services). It's becoming more common in U.S. hospitals, with 76% reporting full or partial use of telehealth systems in the 2018 American Hospital Association Annual Survey Information Technology Supplement. In the 2011 survey, just 35% of hospitals reported using telehealth.

More individual physicians are warming to the idea as well. Physician adoption of telehealth increased from 5% in 2015 to 22% in 2018, according to a survey of 800 primary care physicians, specialists, and subspecialists conducted by American Well, a Boston-based telemedicine company. Willingness to use the technology also increased from 57% to 69% during that time.

Improvements in technology are largely responsible for the increased uptake. In the early days of telehealth programs, the technological infrastructure was sometimes unreliable, not to mention expensive, which led to some skepticism, said Todd Czartoski, MD, chief executive for telehealth and chief medical technology officer at Providence St. Joseph Health in Renton, Wash.

“I think as the costs come down and the power and capabilities go up, you're only going to see this grow,” he said. “It's not going to go away, but it's not going to replace bedside care [entirely].”

Across the country, health systems are discovering new ways that telehealth programs can improve care, add value, and make physicians' jobs easier. Hospitalists are increasingly involved, from providing overnight coverage at small hospitals to receiving subspecialty expertise at critical times.

As a result, patients can receive expert care in their home communities without being transferred to larger hospitals—even when the treating physician is on the other side of the earth.

Benefits across the hospital

Providence St. Joseph Health, which launched its telemedicine network in 2018, has built more than 60 virtual programs, including telestroke, teleICU, and a telehospitalist service, said Dr. Czartoski. The last was largely launched for nighttime coverage in resource-limited hospitals.

“What we did was essentially take a hospitalist who worked in one of our large hospitals and spread them across multiple sites,” he said. Currently, about 12 telehospitalists (due to great interest, there's a waiting list) do cross-cover calls, admissions, and medical consults, he said.

Admitting responsibilities distinguish this service line from the other telemedicine programs at Providence St. Joseph Health. “You have to be able to examine that patient thoroughly, listen to their heart and lungs, do an in-depth [history and physical], document that, write orders, answer questions, do all those things comprehensively, just like you would if you were in person,” said Dr. Czartoski.

To make the service operate safely, the health system decided early on that a telehospitalist would need to coordinate with a well-trained clinician, typically a charge nurse or a float nurse, on the other end of the encounter. The telepresenters, as the on-site clinicians are called, are trained to set patient expectations, get consent, and be the “hands in the room” by using a Bluetooth stethoscope and facilitating (but not interpreting) the exam for the telehospitalist, Dr. Czartoski said.

“That has been super important in terms of quality, safety, patient satisfaction,” he said. “It's a little onerous to keep that training up and make sure you've got a nurse available at all times that is trained as a telepresenter, but we think it's worth it.”

While the telehospitalists cover the night shift at small hospitals, the on-site hospitalists on the day shift can use telemedicine to get subspecialty consults. The telestroke and teleICU services started out in small hospitals, and the health system has since expanded them to large urban hospitals, said Dr. Czartoski. Having an expert available for 24 hours a day with a two-minute response time is “just hard to replicate at a local or regional level, even if you have boots on the ground,” he said.

Telemedicine also increases access to other subspecialties, such as infectious diseases. After five years of telemedicine consult pilots at UPMC (University of Pittsburgh Medical Center), a service called Infectious Disease Connect (ID Connect) launched this year to further increase the reach of infectious disease subspecialists. It now serves 16 facilities, about 10 of which are part of UPMC.

The growth of the service is a response to the needs of smaller community hospitals in Pittsburgh and the surrounding region, as well as the shortage of infectious disease physicians, said David Zynn, president of ID Connect. “Our day-to-day customer is really the hospitalist because in these smaller, rural community hospitals, they don't have infectious disease specialists,” he said.

The subspecialty lends itself to telehealth because of worrisome developments in multidrug-resistant organisms, outbreaks, and newly discovered pathogens, said co-founder Rima Abdel-Massih, MD, director of teleID services at UPMC and chief medical officer at ID Connect. “That's why a lot of hospitalists and physicians are recognizing the need, and understandably so,” she said. ID Connect physicians also provide support for antimicrobial stewardship programs and infection prevention and control.

Telemedicine can also offer a solution to hospitals' census problems. At Dartmouth-Hitchcock Health in Lebanon, N.H., the flagship 400-bed academic medical center had to turn away up to 300 patients a month due to capacity, said ACP Member Edward J. Merrens, MD, MHCDS, chief clinical officer for the health system.

Meanwhile, surrounding critical access hospitals had trouble filling their beds. In 2016, one strategy to manage the capacity strain at the medical center was to start a teleICU program at one of the system's hospitals, Cheshire Medical Center in Keene, N.H., which had a dwindling average daily census of 25 to 30 patients and limited critical care staffing. It worked: The average daily census at Cheshire Medical Center increased by 157%, the ICU length of stay decreased from about three days to just under two, and mortality dropped by 34%, said Dr. Merrens.

In 2018, the health system set its sights on establishing its own telemedicine hub in New England, which now includes teleICU programs at four hospitals, he said. As part of the program, critical care subspecialists monitor trends in distant patients' vitals and can make adjustments in real time.

“TeleICU isn't about a camera watching a patient in a room. Actually, most of the care that's delivered is never with the patient,” said Dr. Merrens. While the team in the room is present to handle crises and family situations, he said, “The tele team can be managing everything that might become a crisis and avert that.”

The focus has remained on keeping patients in their communities. “If we can keep them safely getting really good Dartmouth-Hitchcock–level care at a regional hospital, that's a big satisfier,” Dr. Merrens said. “And for us, it means that we can preserve open beds here for the sickest of the sick.”

At Emory Healthcare in Atlanta, the electronic ICU (eICU) service was created to deploy scarce and expensive expertise across a large geographic area, where the distance between the two farthest hospitals is more than 100 miles, said Timothy G. Buchman, MD, PhD, medical director of the eICU. “The hospitalists we work with are very glad for our presence because it frees them up to do things that they can only do on site,” such as fielding a new admission from the ED at 3 a.m., he said.

At the same time, the benefits of the eICU aren't confined to patients. “There comes a point as a professional where the charm of being up at 3 o’clock in the morning loses its luster, but people get sick 24/7,” said Dr. Buchman, who is also founding director of the Emory Critical Care Center. He soon realized that “Once we were talking about remote care, it really didn't matter how remote we were,” even if it meant being on the other side of the world.

Feeling the physical ails of the night shift, Dr. Buchman turned to Cheryl Hiddleson, MSN, RN, director of the Emory eICU Center, and said, “We have to find out how to turn night into day.” Sending some of the hospital's eICU physicians and nurses to Australia did the trick. They cover 7 p.m. to 7 a.m. shifts in the States but can look out the window and see sunshine and palm trees, as they're based at Royal Perth Hospital in Western Australia, which is 12 hours ahead. While the Emory clinicians don't provide care to Australian patients, they participate in the hospital's grand rounds, lectures, and social events.

The perk of Perth means that the critical care physicians and nurses, who rotate as duos for six to 12 weeks at a clip, eagerly fill the unpopular weekend-night shifts in the eICU, Dr. Buchman said. In fact, one nurse didn't want to come back home. “The fact that people want to keep going back tells you a little bit about how their lives change,” he said, adding that experiencing “night work from daylight in a delightful location” has improved his weight and his mood.

Challenges and a look ahead

Of course, not everyone has fully bought in to telemedicine.

Earlier this year, news outlets ran a story about a palliative care physician who had explained, over telemedicine and in a very clinical way, to a dying patient and his family that he did not have much longer to live. While the patient's family members were not surprised at the news, they were horrified at the cold delivery.

Dr. Buchman remembers that story. “In our program, this type of care goes on all the time, but what was reported was an unfortunate interaction, an exceptional situation that made a family member feel uncomfortable,” he said. “It has to do with delivery and perception.”

Tactful end-of-life conversations via telehealth can, in fact, improve the experience for patients and their families, said Dr. Buchman, who has had roughly 85 such conversations in the eICU. The first time it happened, a faraway loved one arrived at 11 p.m. one night and said that the patient would have wanted all the machines stopped. Dr. Buchman excused himself and called the intensivist of record, who said he was planning on having the conversation the next day. Dr. Buchman then returned to the family, who confirmed that they wanted to focus on comfort measures now and did not want to wait until the morning. So he obliged.

After this incident and others that followed, the Emory eICU created protocols that support this unique aspect of teleICU practice, Ms. Hiddleson noted. Dr. Buchman said he lets family members bring up the question; he never asks. “The fact that they can reach out to a highly experienced attending physician at 3 o’clock in the morning their time makes a lot of difference,” he said. The families do not have to wait through what can be an agonizing night of watching their loved one being given treatments that might be painful with no real positive outcome, Ms. Hiddleson added. “This also allows for a reduction in stress and burnout for bedside clinicians by decreasing the delivery of futile care to a patient with a terminal diagnosis and/or prognosis with little chance of recovery,” she said.

While the paradigm shift of telehealth, which involves a physical distance, is uncomfortable for some patients, others are finding it allows closer relations with their physicians. At the University of California, San Francisco (UCSF), a new remote oncology video encounter program, started in 2018, allows patients with cancer to connect with their primary oncologists while on the hospital medicine service, said Priyanka Agarwal, MD, MBA, an assistant clinical professor of medicine at UCSF and clinical lead for telehealth at UCSF's Telehealth Resource Center.

The oncologist joins the patient at the bedside through a mobile iPad cart to participate in important discussions, such as goals of care and code status, she said. “Patients have really loved that. For some of our sickest patients, it's really hard for them to make it into clinic, so I've had patients tell me, ‘Wow, this is so nice to have the input of my oncologist and to speak with them, and it's actually the first time I've been able to see them in some time,’” said Dr. Agarwal.

Other challenges remain, including how to pay for telehealth care. “The technology and our ability to do this has grown way faster than regulation and reimbursement models,” said Dr. Czartoski. However, legislation is starting to catch up, as the Furthering Access to Stroke Telemedicine (FAST) Act went into effect this year. “Now, every telestroke consult that's performed, regardless of where it is, if it's a CMS patient, then it's a reimbursable event,” he said. “That's a big one. We're hoping that's kind of the first wave.”

One final hurdle is getting physicians to think differently about how they care for patients, and there are still quite a few skeptics, Dr. Czartoski said. “One of the challenges of telehealth has been describing the value that's added because a lot of the value that's added is sort of indirect value,” such as costs saved by avoiding a patient transfer, he said.

As the number of Americans older than age 65 increases by 48% by 2032, the U.S. is projected to face a shortage of up to 122,000 physicians, according to estimates published in April 2019 by the Association of American Medical Colleges. Given this, hospital administrators are pressed to find staffing models that extend the reach of physicians and nurses, which will likely include advanced practice clinicians and telemedicine, said Dr. Buchman.

But ultimately, he said, the next generations of patients and families will be the drivers of change. “It's now a social norm to have video conference on demand. . . . Those types of influences fundamentally change the ways we deliver care,” Dr. Buchman said as he prepared for another weeks-long eICU rotation in Australia. “We've only just begun. My only regret is that I'm not going to be around long enough to really see how this comes out. My hope is that I'll be a patient for many years to come and experience where others take this.”