Practical Approach to Starting a Telemedicine Program: Lessons From the Real World

Short abstract

Content available: Author Interview and Author Audio Recording

ABBREVIATIONS

COVID‐19

coronavirus disease 2019

CPMC

California Pacific Medical Center

EHR

electronic health record

HIPAA

Health Insurance Portability and Accountability Act

UPHS

University of Pennsylvania Health System

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The coronavirus disease 2019 (COVID‐19) pandemic has resulted in rapid shifts toward telemedicine utilization nationally in chronic liver disease and liver transplantation. ¹ We summarize the necessary components to starting a successful telemedicine program, including an overview of technology, administrative, and regulatory steps required, as well as potential pitfalls. To illustrate these points, we use a case study describing (1) the implementation of a new telemedicine program at a liver transplant center in an integrated not‐for‐profit health care system of 24 hospitals in Northern California, and (2) rapid growth of a telemedicine program with a preexisting infrastructure at a large tertiary care center in southeast Pennsylvania.

Technology: California Pacific Medical Center Experience

With the Department of Health and Human Services COVID‐19 emergency waiver that would not impose penalties for non–Health Insurance Portability and Accountability Act (HIPAA)‐compliant technologies, ² the California Pacific Medical Center (CPMC) rapidly implemented telemedicine without a preexisting telemedicine infrastructure in response to the Bay area shelter in place order. The clinical team used multiple modalities to perform video visits, including Facetime, WebEx, Zoom, Google Duo, Doxy.me, Bluestream Health, and Doximity. These platforms reached patients with both iOS and Android, as well as patients who had trouble downloading an application. In phase 2, we used only modalities approved by our health care system’s security and privacy team.

The primary challenge was meeting the goal of a seamless telemedicine visit. To enable Facetime use, we purchased 10 iPad tablets for shared use in the clinic, set up with anonymized Facetime IDs to protect clinician privacy. For Zoom and WebEx, providers set up their own accounts and provided patients with their individual meeting IDs. Patients were instructed to download the apps on their smartphones or computers prior to the visit. Enabling the waiting room function on these apps ensured that patients would not overlap with one another. Doxy.me, Bluestream Health, and Doximity did not require an app download. See Table 1 for advantages and disadvantages for different modalities.

TABLE 1.

Pros/Cons of Different Modalities Used

	Advantages	Disadvantages
Currently used modalities (phase 2)
Facetime	Easy to use Multiple parties allowed (interpreter or house staff) Nothing to download	Apple products only Can use only temporarily while HIPAA waiver in effect
WebEx (CPMC/Sutter Health has license)	Device agnostic (iOS or Android) Multiple parties allowed HIPAA compliant	Not intuitive for all patients (many buttons to push: unmute, show video, etc.) Patients need to download app
MyChart/Canto (EPIC EHR)	Device agnostic Integrated with EHR HIPAA compliant	Patients need to enroll into MyChart Patients need to download app Patients need to log in to MyChart app Current state does not allow multiple parties
No longer approved at Sutter Health
Zoom (will be approved once enterprise license obtained)	Device agnostic User friendly Multiple parties allowed Familiarity among patients given impact of pandemic	Privacy concerns that arose from “zoom bombing” Patients need to download app
Doxy.me, Bluestream Health, Doximity	Nothing for the patient to download (SMS link sent to patient device)	Does not allow multiple parties Many users described occasional instability with these modalities

As the Department of Transplant implemented the earlier solutions, the health care system was simultaneously deploying its own telemedicine solution in response to the pandemic. The solution uses a video platform on Canto, Epic’s (Verona, WI) mobile app for Apple iPads, to enable video visits. To use this functionality, patients must log in to Epic’s patient portal MyChart, and the clinician logs in to Canto on the iPad.

The medical assistants played an integral role in the telemedicine effort. During appointment reminder calls, they conducted a brief assessment of the patient’s technology, including access to broadband Internet, computer, and smartphone (Android versus iOS). Patients without access to either smartphone or Internet were scheduled for telephone‐only visits. All patients were encouraged to enroll in our electronic health record (EHR) portal to have access to Canto video visits because this was viewed as the solution with long‐term sustainability given HIPAA compliance and integration with the EHR. At the start of the pandemic, 37% (1034/2795) of the San Francisco patient population was enrolled, and as of February 2021, enrollment had increased to 50% (2299/4624 patients). Current enrollment for our patients in more rural areas remains well less than 50%.

Lessons Learned

• It is essential to train both patients and providers on available technology platforms for video visits.

• It is easiest for patients to use applications that do not require additional downloads or log‐in with username and password.

• Trained staff are required to help patients navigate initial use.

• Having a backup modality (other video, telephone) is helpful if one technology fails.

Administrative and Regulatory Infrastructure: University of Pennsylvania Health System Experience

To be successful and achieve longevity beyond the pandemic‐related national emergency, a telemedicine infrastructure must account for multiple operational challenges, such as: (1) limited or lack of on‐par reimbursement with in‐person visits, (2) need for regulatory compliance with state and interstate licensure, (3) variable patient and provider buy‐in, (4) health system and patient technology issues, (5) integration into clinical workflow, (6) and scalability and growth.

In 2016, the University of Pennsylvania Health System (UPHS) established a Connected Health Advisory Group, given the projected future growth of telehealth. Prior to the COVID‐19 pandemic, UPHS had more than 30 telemedicine programs across multiple disease states (including telehepatology); however, the programs were primarily funded through fee‐for‐service business agreements or research grants because of reimbursement challenges for most services and conditions. A preexisting connected health infrastructure helped facilitate rapid telemedicine acceleration efforts across the health system; however, its success still relied on a small group of highly motivated clinicians, early adopters, and staff at the Penn Medicine Center for Healthcare Innovation. ³ Scaling up required a rapid switch of telemedicine vendors, creation of an automated “switchboard” to help automate scheduling efforts, and rapid iteration of processes. Penn Medicine reported positive early clinician and patient experiences during the first 4 weeks of the COVID‐19 response in the academic gastroenterology and hepatology practice. ⁴

Lessons Learned

• A preexisting telemedicine infrastructure allowed for rapid implementation and growth during the pandemic and facilitated long‐term sustainability. See Table 2 for necessary components of a telemedicine infrastructure.

• Key technical functions allowing for rapid ramp‐up included an integrated switchboard to track patient and clinician status, virtual waiting room, integration of translator services, and ability for third parties (e.g., family) to join the video visit or call.

TABLE 2.

Infrastructure Necessary for Long‐Term Sustainability of a Telemedicine Program

Component	Purpose
Legal	To provide guidance on regulatory, legal, and licensing questions related to telemedicine
Clinical	Clinical leads and champions to provide feedback on impact on individual clinical programs
Information technology	To ensure that technologies meet privacy standards and are HIPAA compliant
	To support audio/visual technical needs
Business development	To identify new areas of opportunity
Payer	To communicate on issues related to reimbursement
Administrative	To facilitate the operational aspects of running a telemedicine program

Potential Pitfalls

Although telemedicine offers many advantages, there are some critical potential pitfalls to a virtual practice. Studies conducted early on during the pandemic have shown that health care disparities exist in the utilization of telemedicine, ⁵ , ⁶ as well as in telehepatology. ⁷ The digital divide is most apparent in specific populations, including rural areas, communities of color, older adults, patients with lower socioeconomic status, and non‐English‐speaking patients. ⁵ In telehepatology, disparities were noted in older patients, non‐Hispanic Black patients, and those with Medicare/Medicaid. ⁷ Poor utilization of telemedicine may be because of lack of access to the Internet and/or a smartphone or lack of uptake of an application even with digital access. Although most people now own a smartphone, it is yet another technical skill to download and use an application. ⁵

At CPMC, patients residing more than 50 miles outside of San Francisco had more challenges with technology, which resulted in a greater proportion of phone‐only visits. Medical assistants reported that despite having set up video visits for nearly a year, many patients still require ongoing coaching with their subsequent video visits.

Lessons Learned

• It is important to recognize the time required to do a proper “technology intake” for a patient. Preparation for video visits requires a significant time investment to set up technology and to ensure the patient knows how to use it at the time of the visit.

• To address health disparities, we encourage providers to think outside the box to address lack of technology access. See Table 3 for some practical approaches.

• Offering a variety of modalities helps expand access to virtual visits because one size does not fit all.

TABLE 3.

Practical Approaches to Navigating Health Disparities in Telemedicine

Barrier	Approach
Language barriers for non‐English speakers	Ensuring interpreter services are available at visit. Multiparty applications, such as WebEx/Zoom, can host interpreter and family members. If unable to use multiparty applications, having the interpreter on speakerphone is also beneficial. Video remote interpreter services on an iPad can be wheeled into clinician’s office. Encouraging English‐speaking family members to be present, either with the patient or remotely via video.
Patients who have a smartphone without prior experience using a specific application	This will require additional training by either clinic staff or engagement with a family member who can help with downloading and testing. It is helpful for staff to have an iPad to help troubleshoot issues.
No smartphone access	Borrowing a smartphone from a family member, close friend, or neighbor. Make sure to inquire about other digital devices, including laptop, desktop computer, tablet, or other wi‐fi‐only devices.
No Internet access, no smartphone access	Offer phone visit for patient. For health systems with an existing “outreach infrastructure,” patients can visit a satellite location where a medical assistant can set up the patient with a video visit.

Discussion

We describe a practical approach to starting a telemedicine program vis‐à‐vis two real‐world experiences. The CPMC experience illustrates a start‐up telemedicine program borne out of the urgency of the pandemic, and the UPHS experience reflects on building upon an existing telemedicine infrastructure. Within both systems, access to care improved and wait times were shortened, allowing the health systems to “catch up” on patient backlog while delivery of care for patients with advanced liver disease successfully continued. However, despite the many advantages of telemedicine, it is important for health systems and individual practices to recognize its associated challenges. However, both health systems have observed a lower degree of digital literacy and access to broadband Internet among patients who are racial and ethnic minorities, living in rural areas, of lower socioeconomic status, and older age. The regulatory and reimbursement landscapes beyond the COVID‐19 pandemic remain uncertain, and optimal clinical workflows, as well as patient selection, have yet to be determined.