Telehealth The Care You Need—Without Leaving Home

Staying at home has made getting medical attention more complicated. Both patients and doctors are under pressure, and appointment scheduling is a challenge. Many people can’t visit the hospital or their doctor’s office due to concerns about coronavirus.

But there’s been a big game-changer during the pandemic: Telehealth. Using interactive video technology connects patients, doctors and other providers as if they were in the same room. It gives healthcare professionals an effective way to care for patients real-time, while limiting any risk of exposure. When patients and doctors meet by video, many routine issues and concerns can be addressed easily right on-screen. Today, that’s helping thousands of people access the care and expertise they need with peace of mind.

MedStar Washington Hospital Center is using video communications to give patients convenient access and increase efficiency across the Hospital Center.

• MedStar eVisit is the remote version of visiting an urgent care center for a non-emergency illness or injury. Doctors and other staff MedStar eVisit around the clock, providing direct care and advising patients when an in-person visit is needed.
• MedStar Video Visit connects doctors and patients by appointment. This is a remote office visit, useful for staying connected on long-term medical conditions and follow-up care after procedures, as well as routine medical needs. MedStar Video Visit is available according to the provider’s schedule, just like office hours.
• MedStar eConsult connects both providers and patients throughout the Hospital Center, typically for inpatient care. Through eConsult, doctors can tap the resources of other doctors if a specialty consultation is needed. It also puts those clinical resources at the fingertips of nurses, emergency department doctors and long-term care providers. This effective infrastructure increases patient access to high-level care, saves time for patients and the medical team, and helps us allocate resources more efficiently than ever.

For most patients seeking medical attention from home, a visit can be done via any device equipped with a camera. While many use their phones, our system accommodates visits from tablets, laptops or desktop computers as well. A smartphone is particularly convenient because its camera can be easily moved around the environment and, in many cases, doesn’t require WiFi and Internet.

The Power of Video

The great connector here is video technology. Even without the aspect of physical touch, an experienced healthcare provider can learn a great deal from a video session alone.

For example, if coronavirus symptoms are suspected, the healthcare professional will look for labored breathing, noting how the patient moves and any difficulty in speaking. To refine the assessment, we might ask a patient to hold their breath or count to 30 quickly. We can instruct them to take their own pulse, check their temperature with a home thermometer or demonstrate an exam finding.

It’s not unusual for family members and others living with the patient to be involved in these visits as well. At a time when hospital visits are curtailed, video lets family and friends accompany their loved one during the session. This can boost morale, as well as help the patient remember and comply with the doctor’s orders.

For more routine issues, the camera is a powerful tool. We can assess the condition of the skin and look closely at growths or rashes; assess the eyes and eye movement; check for inflammation in the throat; or have the patient stand, sit, walk, bear weight on a joint or change position to assess muscle pain, strain or orthopedic injury. Skin tone also tells a story and we can make accurate assessments of neurological and psychological health. We ask all the right questions to help gauge symptoms and narrow down potential causes. And we can tell very quickly if the patient needs in-person attention—and, if so, help with necessary arrangements.

All the confidentiality rules and regulations associated with traditional care are in effect. We follow established guidelines to ensure each patient is in a private setting where health information cannot be accidentally compromised. It’s also the reason we use our own highly secure system, without relying on outside videoconferencing services or social media.

A video visit may also enable us to assess the home environment: Is it safe? Do you have the supplies you need? Who else is there to help you if you’re ill? The patient can even point the camera at their medicine vials so we can accurately record prescription medications and dosages. Assessing someone in the office may be less useful in some situations than seeing how a patient navigates their home. Can you climb the stairs? Can we talk about some ways to reduce fall risk? For much of the history of medicine, care was delivered in the home. Technology allows an opportunity to return to that traditional practice.

Technology and Social Distancing

Telehealth was taking baby steps before the COVID-19 pandemic. When public officials embraced social distancing and staying at home, its use exploded worldwide.

In February 2020, there were about 240 total patient encounters for MedStar eVisit and Video Visits, but the health system had invested in the infrastructure and knowledge to operationalize at considerable scale. From the early phases of the pandemic and social distancing, MedStar eVisit provided a valuable conduit of care to our patients, without the need for them to leave the comfort of their homes.

Consider this: The average patient comes in contact with five-to-seven healthcare workers during an in-person visit, as well as other patients in the waiting area. So, eVisit was able to have a significant impact during the current crisis. In the first month of social distancing alone, we provided 11,000 eVisit sessions. Of that total, 85 percent of the patients were handled effectively by video. That’s 8,000 encounters that previously might have required a visit to a medical facility, handled with zero personal exposures.

MedStar Video Visit also experienced a big increase in visitors. In the first three weeks of stay-at-home recommendations, we logged 24,000 visits—as many as 3,000 in a single day. These were largely dedicated to ongoing, routine care for diabetes, cardiac conditions, hypertension, and follow-up after procedures. Again, the impact in limiting exposure cannot be overstated and will play a significant role in flattening the curve of infection and easing the burden on the healthcare system.

Streamlining In-Person Visits as Well

It’s hard to be in more than one place at a time. But technology makes it almost possible. Since 2016 the Hospital Center has been at the forefront of a process to improve throughput in the emergency department with a remote-enabled physician being available at dozens of places at once. In addition to the triage area of the ED, the physician is providing consults to urgent cares nearby to facilitate movement to the ED or potentially avoid it all together. The COVID-19 crisis greatly expanded this program which now provides triage and the Evaluate-Treat-Discharge (ETD) workflow at 8 emergency departments. ETD allows a physician to remotely evaluate a patient in collaboration with the in-person nurse and, if appropriate, discharge them without further time in the ED or contact with other patients or health care workers. This limits interactions, protecting patients and the medical team from exposure to illness. It puts qualified crisis care consultation wherever we need it. It reduces consumption of gowns, masks and other personal protective equipment, all in short supply. And it dramatically reduces the time it takes to treat and release patients who don’t need hospitalization—56 minutes in one trial, compared to two and half to three hours under normal circumstances. Each patient could interact with just two people in person, a registration service associate and a triage nurse, compared to an average of seven before.

The emergency consultative role is expanded too, with our ED physicians available to help all 14 MedStar Health Urgent Cares and the MedStar Visiting Nurse Association in the field, as well as MedStar National Rehabilitation Hospital inpatient units.

Healthcare providers are at constant risk of exposure. Without telemedicine, any provider who tests positive would be taken out of circulation to quarantine at home. With it, these providers continue to make a positive impact, using their invaluable knowledge, skill and experience to help others remotely—even as they self-isolate.

In the MedStar Washington Hospital Center critical care areas, technology is being used to allow critical care rounding, ensuring care to our sickest patients while preserving PPE, and our Hospital Center specialists are using it to provide consultative guidance to other critical care providers throughout the system. In those same units, interactive tools are used to allow patients to connect to family members who are unable to visit in the current crisis.

Communication with a patient on a ventilator is very limited. Because the pandemic has restricted visitation, technology is keeping lines of communication open between the team and family. This can be critical when questions arise around extreme measures or do-not-resuscitate orders or to honor patient and family wishes in hospice or palliative care.

The Future

This pandemic has changed healthcare delivery significantly and permanently. I do not see us going back to the way things were, once social distancing and isolation orders are lifted. Interactive capability is limiting travel, wait times and infection exposure. Now that so many have experienced the benefits, it will likely remain a prominent mode of delivering patient care.

Telehealth has been a promise of the future for more than a decade, with suggestions for many years that its time was just around the corner. The present time is demonstrating the safety, quality and efficiency of the care delivery, while supporting the public health need to stay home. With the experience of the present, the next expansion will be to deliver better, quicker specialist access to patients, to connect more data of the patient’s daily life to the care journey, and to create a community of caregivers around a patient who can share that data and quickly and seamlessly coalesce around an issue to help. Patients will want easier, quicker, and less structured access to their doctors. And doctors will want access to their peers, the data they need to provide the best care and the ability to serve their patients’ needs while meeting their own life goals.

Telehealth has features that are different than being in-person, and it’s important to be thoughtful about what is different and what is possible. With the right mix of interactive tools, we can deliver efficient, cost effective care at the highest quality and with the patient as the central focus for better health and wellness. It is an exciting time to be part of it.