At the time Tennessee’s first case of COVID-19 was reported on March 5, direct-to-patient telehealth visits averaged just 10 a day at all of Vanderbilt University Medical Center’s outpatient clinics; less than a month later, outpatient telehealth appointments had skyrocketed to more than 2,000 per day.
As these visits evolved from a convenience to a matter of critical safety during the coronavirus pandemic, providers and patients not previously convinced of the value of telehealth quickly became converts. From early March until April 30, VUMC providers conducted 58,781 outpatient telehealth visits, more than half of the total outpatient visits.
“Prior to the pandemic, approximately 160 providers were using telehealth in some form or fashion, and only a small subset of those were offering direct-to-patient telehealth, which is most of what we’re doing today,” said Amber Humphrey, director of VUMC Telehealth. “We had to work with Epic (VUMC’s electronic health record system) and My Health at Vanderbilt (the online patient portal) to figure out how to enable telehealth for 2,500 providers essentially overnight.
“This has catapulted telehealth awareness at VUMC, for providers and our patients. Once we are able to look back on all of the things that have happened during the pandemic, this will be seen as one of the bright spots. I’m very proud of the work that’s been done.”
An early focus of VUMC’s telehealth expansion was establishing secure videoconferencing for Vanderbilt Health OnCall, the on-call service operated by nurse practitioners and available to adults living in Davidson County and the cities of Brentwood, Franklin, Hendersonville and Nolensville. With this option, concerned individuals speak directly to a nurse practitioner without any exposure risk. This service proved especially essential in the early weeks of the pandemic when much was unknown about the virus’s transmission and progression. Since March 5, Vanderbilt Health OnCall providers completed 103 telehealth visits, primarily for COVID-19 positive patients.
“We were able to launch telehealth services within a matter of hours,” said Jennifer Mitchell, MSN, APRN, clinical director of Vanderbilt Health OnCall. “I’m so proud of what our group has been able to accomplish.”
Vanderbilt Health OnCall providers were divided into distinct work teams to minimize risk for non-COVID-19 patients and ensure immediate access to telehealth services. One group provided traditional care through telehealth, while another group was able to provide in-home COVID-19 assessments for home-bound patients. A special COVID-to-Home Program was also created in partnership with Vanderbilt Home Care Services (VHCS) to provide regular assessment for COVID-19 positive patients quarantined at home and to provide after care for high-risk COVID-19 positive patients discharged from the hospital or emergency department.
To maintain care for expectant mothers with low-risk pregnancies and minimize exposure for both practitioners and patients, the nurse midwives and advance practice nurses from Vanderbilt-Nurse Midwives & Primary Care for Women at Melrose and the West End Women’s Health Center quickly converted their care model so one group of providers conducted telehealth appointments and another group provided on-site care, said Lori Cabbage, MSN, CNM. From mid-March, 325 postpartum visits and 202 primary care visits were conducted by telehealth.
Additionally, inpatient telehealth options were expedited throughout the Medical Center to conserve personal protective equipment (PPE) and minimize exposure risk during on-site medical screening exams. For example, telehealth is used by providers to evaluate patients who come to the Emergency Department with COVID-19 symptoms who are at low-risk for complications.
Telehealth alternatives for higher-risk populations, such as immunocompromised patients who typically come to Vanderbilt-Ingram Cancer Center (VICC), were also prioritized. During the week of March 16, VICC providers conducted 16 telehealth visits, but by the week of April 13, 655 telehealth appointments were completed for VICC patients.
“Our concern was multifaceted,” said Tom Nantais, executive vice president for Adult Ambulatory Operations at VUMC. “We needed to continue to provide exceptional outpatient care with as little disruption as possible, while at the same time protecting our patients, providers and staff. It was important for individuals to remain safe at home, but we never wanted our patients to feel isolated or without care. We were able to rapidly expand on our existing technology infrastructure to make telehealth available to everyone who wanted to make use of this option.”
Sara Horst, MD, MPH, a gastroenterologist specializing in the care of inflammatory bowel disease (IBD), had already been developing a telehealth initiative with her provider group when the pandemic began, so she stepped in to assist in facilitating telehealth successfully throughout VUMC.
“In inflammatory bowel disease, most of our patients are immunosuppressed,” Horst said. “They need to see us frequently as they’re on medications that need monitoring and they also could have a flare of their disease. However, in order to keep them safe and healthy, preventing them from having to come to the hospital and the clinic was imperative.
“Telehealth has become a vital way for us to continue patients on medications, help answer their questions about their disease in general and especially in these extraordinary times, and also help them when they are having a flare. We have been able to keep in very close contact with patients and avoid Emergency Department visits and hospitalizations by having this new capacity.”
While VUMC HealthIT and Access Change Management worked to make secure telehealth connections possible, a large-scale education effort was also developed for medical providers, many of whom had no experience with telehealth.
The Telehealth department quickly created what Humphrey calls a “do-it-yourself telehealth crash course” offered online through the Learning Exchange. At last count, the course had been attended or completed 3,200 times and special training for schedulers was completed 911 times. Another training module developed to train providers on using iPads for teleconsults was completed 2,502 times.
When all clinical duties for medical students were suspended by Vanderbilt University School of Medicine (VUSM) to minimize students’ risk of infection and reduce PPE use, medical students Kaustav Shah, Austin Triana and Roman Gusdorf worked with Michelle Griffith, medical director of Telehealth Ambulatory Services, and Horst to lead an effort by more than 100 medical students to train both medical providers and adult patients how to use telehealth.
Guided by a master spreadsheet of the approximately 90 Department of Medicine clinics, medical students called patients with upcoming appointments and walked them through downloading the My Health at Vanderbilt and Zoom apps and testing their smart phones, tablets and computers. By the end of the academic year, medical students had assisted with more than 5,300 adult patients.
“Witnessing the Vanderbilt students and faculty rally quickly around this cause gave me hope in a dark time,” said Gusdorf, a second-year medical student whose pediatrics clerkship was cut short. “The gratitude I’ve received from the patients I’ve helped, from the providers I’ve assisted, and from fellow students who were also eager for a way to help in this awful situation has given me the motivation to keep building upon this program.”
Because telehealth visits are conducted through My Health at Vanderbilt, HealthIT had to come up with a new way for pediatric patients and their parents/legal guardians to remotely be granted access to the online patient portal. Two electronic applications were created in mid-March using REDCap, said Deidre Wright, a portfolio and product management manager for HealthIT Portfolio Services.
When an application is received, a Zoom meeting is set up with the parent/legal representative so they can show their identification and verify demographics. If the patient is 13-17, the teen is asked for consent for the adult to have access to their My Health at Vanderbilt account. Since mid-March, 3,200 My Health at Vanderbilt applications have been received for pediatric patients.
Now, patient service specialists and medical assistants are stepping in and not only assisting patients with telehealth connectivity concerns but also gathering additional medical and insurance information to ensure visits are covered by the patients’ insurance and that telehealth is the appropriate match for their needs, Nantais said.
While the adaptability of the providers and staff to new workflows and challenges related to telehealth has been impressive, and the patients’ adaptability has been remarkable as well, said Daniel Cottrell, MD, a physician with the Section of General Internal Medicine.
“Many of our older patients were nervous about the technologies at first but once they realized this is not much different from FaceTime calls to their relatives, they quickly adapted,” he said. “I have had some funny telehealth visits where some patients have been a bit too relaxed about the encounter, such as two patients who thought they could do their telehealth visit with me while they were driving their car. Nope, not doing that!”
Relaxed payer rules on telehealth during pandemic may lead to expanded future coverage
A limiting factor for using telehealth for patient care has been the historically restrictive policies of insurance providers (payers), but health care providers and administrators responsible for ensuring patients and providers comply with all the rules are hopeful that payers’ more relaxed regulations during the coronavirus pandemic will lead to broader coverage of telehealth services moving forward.
Payers have largely doubted the clinical efficacy of telehealth versus traditional face-to-face visits, and often have taken the position that unrestricted telehealth could lead to increasing costs due to over-utilization of services. Medicare has had strict payment requirements for telehealth both clinicians and patients must follow, such as requiring that patients be physically present at a health care facility in a rural area for Medicare coverage to kick in.
Bob Mangeot, VUMC’s Revenue Cycle and Reimbursement Compliance officer, worked with Director of VUMC Telehealth Amber Humphrey and VUMC clinical leaders to interpret and implement rapidly changing billing regulations related to telehealth during the pandemic.
“COVID-19 exposed how far behind our health care system’s payment mechanisms are from our technology capabilities,” Mangeot said. “Without telehealth stepping in, VUMC would’ve had to defer needed visits or ask patients to come in anyway during a pandemic. That’s unacceptable. Payers across the spectrum recognized this and stepped up to relax their telehealth coverage requirements during the emergency period.
“In just the last few weeks, Medicare has transformed itself into a telehealth coverage leader. Among other COVID-19 waivers, Medicare dropped all patient location requirements and expanded the services covered as telehealth. VUMC is, for now, able to use a broader array of real-time interactive platforms. That’s great, because VUMC had thousands of necessary visits daily to shift to telehealth.”
Medicare implemented these temporary rules through wave after wave of new telehealth guidance. For weeks, the regulatory requirements were shifting daily, if not multiple times daily, Mangeot said. The Telehealth team worked with the Office of HealthCare Compliance to digest each new rule change on the fly and quickly determine how to operationalize that within the VUMC environment.
“I won’t say this has been easy, but I’ll for sure say it’s been worth the effort,” Mangeot said. “Our providers and, most importantly, our patients deserve the best and clearest guidance we can provide. I’m proud that VUMC was able to pull this off.”
“The waves of changed regulations are still coming, fortunately with a little more breathing space between them,” Mangeot said. “There are still gaps in coverage for our hospital therapists, dietitians and several other practitioner types. I’m hopeful for good news there soon. I’m even more hopeful telehealth shows its value when it was needed most. That could convince our payers and regulators not to reinstate outdated restrictions once the pandemic is finally behind us.”
Regardless of how payer regulations on telehealth are re-written when a new normal emerges following the pandemic, a lot of work will need to be done to ensure continued compliance, Humphrey said.
“I really believe, however, this has changed the face of medicine,” she said. “Patients nationally have become more comfortable with telehealth and understand that it’s safe and secure. The deciding factor will be how payers feel about telehealth moving forward and if they revert back to their old reimbursement policies. I don’t think they will.
“Payers who were concerned about over-utilization of telehealth can see now that patients are using this appropriately, and it has been very impactful in minimizing patient’s exposure and helping patients feel more comfortable that they are not going to go into a medical center where there may be other sick people and get sick themselves. Peace of mind has been a huge benefit of telehealth, and I really feel that the adoption is going to continue.”
