5 Lessons for Achieving High-Quality Virtual Care
October 21st, 2022
A new report presents five lessons to support the long-term use of telehealth services as a tool to deliver high-quality virtual care.
The use of telehealth services to support patient care has rapidly expanded due to the global COVID-19 pandemic. The volume of care provided virtually jumped drastically from approximately 2% prior to the pandemic to highs of 50% or more as the initial wave of COVID-19 swept the United States.
In response, PBGH’s California Quality Collaborative launched the CalHIVE Network, an improvement collaborative focused on maximizing the use of virtual care tools to enhance chronic disease management. Over two years, the seven participating provider organizations adopted and refined telehealth strategies to improve virtual care for more than 715,000 Californians. The lessons presented here are supported by the real-world experiences of providers who participated in the CalHIVE Network.
1. Invest in people and technology
There is not a single telehealth strategy that health care organizations should adopt. Instead, they should examine their overall strategic plan, patients’ clinical needs and projected environment and decide how telehealth can be an integrated part of the overall clinical experience. This requires targeted resource investments.
Desert Oasis Healthcare, a CalHIVE participant, discovered that the shift to telehealth did not equally serve all members of its community, and even created new barriers for some. A mobile health unit was used to expand access to care. The unit provides access to a care team on-site in the mobile unit, or if preferred, patients can speak directly to their physician via the unit’s virtual exam room.
2. Support seamless data exchange and integrated clinical systems
Technology should support a seamless experience for care teams and patients, but this is often not the case because of poor integration into other clinical systems and the overall care experience. One CalHIVE participating organization surveyed network providers and found more than thirty different telehealth platforms were being used across twelve Independent Physician Associations (IPA).
Provider organizations should consider how a virtual care platform integrates with the current technology used by most of their network’s providers and ensure they understand which products are being used in their networks. Organizations may consider peer groups or information and resource sharing based on the most utilized platforms.
Many telehealth technologies are focused on primary care, rather than specialty care. This creates a huge gap when aiming for care integration. Technology and associated resources should be tailored to support as many specialties as possible.
3. Redesign clinical workflows to support telehealth
Effective team-based care has been a key attribute of high-performing primary care delivery for many years. However, when it comes to telehealth, many organizations have not had the bandwidth to redesign their workflows or may not even be sure what needs to be redesigned.
Choice Medical Group used their morning huddles to gather feedback on virtual appointment workflows and to proactively engage staff in problem solving. That feedback supported improvements to training and adjustments to their telehealth platform and workflows.
4. Collect and integrate patient and care team feedback
Understanding how your providers are using telehealth is crucial to achieving high-value virtual care. Organizations should regularly ask providers, care teams and employees about their telehealth experience to determine if workflows, training and functionality can be improved.
In a networkwide survey, PrimeCare found that the majority of its providers were offering telehealth services but were struggling with challenges related to coding, reimbursement and patient education. By using the feedback collected, the organization was able to take action to improve the quality of their virtual care visits, which led to 80% of patients reporting a positive telehealth experience. Efforts to respond to the challenges identified included implementing several centralized support services for its network by developing telehealth best practice guides, educating providers and staff through individualized meetings and adding specific telehealth-focused questions to its annual provider survey.
5. Utilize data to address known health disparities associated with virtual services
To better understand if telehealth is meeting patients’ needs, health care organizations should examine utilization, access, experience and outcomes data by key patient demographic fields to identify improvement actions needed to ensure telehealth is effective for all patients.
In trying to understand why telehealth services were being used less by their non-English speaking patients, Golden Valley Health Centers discovered that their translation service was causing poor audio quality for non-English speaking patients using video visits. Updated workflows, including a new standard work around for the “language line” instructions, and additional training and education for frontline staff have been successful in supporting non-English speaking patients.
More information about each of these lessons and the experiences of CalHIVE participants can be found here. As health care organizations prepare for the future of telehealth, these learnings can inform their decision making and offer a road map to high-quality virtual care. They may also provide insights to other stakeholders, such as purchasers, health plans, technical assistance organizations and policy makers, as they seek to support telehealth moving forward.
Patient Experience and Telehealth During COVID-19: Investigating Key Success Factors and Obstacles
February 26th, 2021
The global COVID-19 pandemic has led to a rapid increase in virtual care delivery that will likely be long-lasting. During the height of the pandemic, fear of infection and stay-at-home orders meant that many practices stopped seeing most patients in person for routine care. Relaxing of government regulations allowed for widespread national adoption of telehealth.
Telehealth holds great promise for improving primary care through increasing access, improving patient experience and enabling team-based care models. Importantly, while telehealth expands access to all patients, it may improve health equity for lower socio-economic patients who may lack transportation or sick leave.
To gather the patient perspective on telehealth, The Purchaser Business Group on Health developed and fielded a telehealth patient experience survey as part of the Patient Assessment Survey (PAS) program. Approximately 12,000 surveys were distributed by email to patients with commercial and Medicare coverage who had a virtual visit (phone or video) with a primary care provider in California; 1,500 email responses are reflected in the research findings.
Key Findings
- Equal satisfaction between virtual and in-person care: No significant differences were found in ratings of patient visits between telehealth and the regular PAS survey responses (which measure in-person care).
- Telehealth was popular: A total of 87% of survey respondents recommend telehealth; of survey respondents, 73% want to continue using telehealth in the future.
- Video visits were favored over audio-only: Ratings of visits and communications were nearly identical in video and telephonic visits, but patients who reported that they would likely recommend telehealth and engage in repeat telehealth visits significantly favored video appointments.
- Provider communication was good: Most patients said the provider with whom they met via telehealth methods explained information in a way that was easy to understand (92%), listened carefully (92%), spent enough time with them (91%) and had relevant patient medical history on hand during the visit (88%).
- Most patients received medical tests: Half of survey respondents had tests ordered by their provider. Most followed up to have the tests conducted (84%), and most patients were able to access their test results (88%). Patients were most likely to get the tests ordered on their behalf while being seen for COVID-19 concerns, whereas patients being seen for chronic health care or other health issues were least likely to have tests ordered for them. Patients who did not receive ordered tests (16%) scored their health care provider lower on communication scores.
Despite these promising findings, PBGH research has been, to date, limited to commercial populations in the state of California. Further research on patient experience and clinical outcomes should be conducted nationwide with more diverse populations, including Medicaid beneficiaries, racial and ethnic minorities and those with limited English proficiency. PBGH will have preliminary results from a survey with a sample of patients with Medi-Cal coverage in Spring 2021 and seeks to expand this measurement nationwide.
Implications
The findings of the PBGH Telehealth Survey are instructive for provider organizations, solution providers and health plans. The survey findings suggest the following four steps can make a meaningful difference in ensuring that patients have a positive experience with telehealth:
- Continue to offer telehealth. Patients enjoy telehealth and want to continue using virtual care in the future.
- Offer video visits. Satisfaction with telephonic and video care was high, but users of video visits were more likely to recommend telehealth and want to continue using telehealth.
- Provide instructions for video visits. Patient satisfaction is highest when clear instructions are provided to the patient in advance of a video visit.
- Offer both virtual and in-person care options. Patients indicated the need for in-person options to evaluate certain physical concerns, such as broken bones or rashes. Patients feel they can determine if an in-person appointment versus virtual care is appropriate for their unique health issues.
Read the full report.
Designing and Offering Responsive Telehealth Support
September 10th, 2020
Since the beginning of the COVID-19 public health emergency in mid March 2020, primary care practices across the nation have adopted telehealth at astronomical rates. Working closely with California provider organizations, the Pacific Business Group on Health’s California Quality Collaborative (CQC) designed technical assistance webinars supporting primary care practices rapidly implementing and optimizing telehealth to care for patients unable to be seen in-person during the pandemic. CQC’s work highlighted significant challenges providers are experiencing, as well as lessons on how to maintain telehealth gains in the future.
What Provider Organizations Need Today
To better understand operational needs and challenges after several months of telehealth use, CQC conducted a survey and interviews with five primary care provider organizations representing 700 providers. Three takeaways emerged:
- Providers reported their top concern for the future is addressing patients’ care deferred during shelter-in-place orders
- 100% of the five provider organizations representing over 700 primary care clinicians surveyed think primary care telehealth visits will increase in next 6 months
- Practices are likely not able to take on “optional” operational improvements this fall as they recover and also prepare for later COVID-19 waves
Lessons from Designing Responsive Telehealth Support
Throughout the early months of the pandemic, CQC hosted regular expert webinars and curated a COVID-19 resource page for primary care provider organizations. Our team observed five key learnings that quality improvement organizations should consider when designing telehealth support, which we shared with national peers on a recent webinar for the Network for Regional Healthcare Improvement:
- Telehealth implementation can happen very quickly.
Most provider organizations who reported launching telehealth capabilities during the months of March and early April had, prior to the pandemic, been delivering very little care virtually.
- Most providers and patients like telehealth.
The rapid adoption of telehealth proved popular with both providers and patients. In a CQC webinar poll, 73% of providers were satisfied or very satisfied with telehealth, and most reported that they and their patients wanted to continue using telehealth into the future.
- Most care can be delivered virtually.
Even before the pandemic, some primary care practices are successfully offering 95% of their care virtually, including for high-risk patients. For recent adopters of telehealth, provider organizations have found that they are able to conduct many types of visits, especially chronic condition management, virtually.
- Billing and reimbursement are challenges.
Providers are worried about keeping up with changing guidelines and getting paid, especially when in-person revenue is down. While there have been promising signals from the federal government, the precise future of telehealth reimbursement remains unclear.
- Providers must ensure patients are equitably able to use virtual care tools.
Providers are concerned about equal access for their patients for technology and broadband. In the course of the pandemic, we’ve seen some viable solutions that clinicians can practice, which include: asking patients their preferences between audio or video visits, using patient advisory bodies to incorporate feedback, and simplify workflows whenever possible.
The Opportunity: Join CalHIVE
Using this feedback, this fall CQC is launching a technical assistance program, CalHIVE, which will support provider organizations as they re-design primary care delivery for people with chronic conditions by fully leveraging the capabilities of virtual care. California-based provider organizations are invited to participate in CalHIVE and can learn more on CQC’s CalHIVE website. Interested organizations can reach out to Michael Au at mau@pbgh.org to learn how CalHIVE can help their organizations improve virtual care to help their patients.
Primary Care Practices Can Engage Patients in Virtual Care
June 6th, 2020
During the most challenging phases of the COVID-19 pandemic, one opportunity for the health care delivery system has been the rapid adoption of telehealth and virtual care by both primary care practices and patients. The Pacific Business Group on Health’s California Quality Collaborative (CQC) has hosted webinars to support and spread successful practices in virtual care for independent primary care practices and IPAs as they rapidly implemented telehealth technology and workflows.
Nationally, the trends reflect widespread virtual care adoption. By one May 2020 analysis, telehealth visits in the US increased 300-fold in March and April 2020 compared to the same time period in 2019 (Epic Health Research Network). Providers have been pleased with their telehealth experience, and patients have too: 88% of patients new to telehealth said they would like to use it again (PwC Health Research Institute). The health system is eager to build on the implementation gains around virtual care made during the public health emergency, especially its ability to improve access to care and reduce costs.
Patient engagement in virtual care
Yet today, more than ever, it’s essential for health care clinicians and care teams to ensure that virtual care being provided is as patient-centered as possible. This topic was the focus of a May 6 webinar hosted by CQC, which highlighted presentations from a number of experts including Dr. Courtney Lyles, Associate Professor, Center for Vulnerable Populations at UCSF; Libby Hoy, Founder & CEO, PFCC partners; and Dr. Fiona Wilson, former Teladoc provider and current Supervising Clinician Specialist, Workers Compensation Division, Department of Human Resources, City & County of San Francisco.
Dr. Lyles shared examples from decades-long research done around patient portals, telephone visits and tactics that help bridge the “digital divide,” even in regions of strong technology adoption, such as the Bay Area. Her advice was not to make any assumptions about what patients do or do not have access to, and establish ongoing trainings, where patients can be assured to get continuous support for the virtual care they are seeking.
Libby Hoy of PFCC partners shared lessons from her organization’s history building patient advisory capacity. She cautioned that the work, especially at this time, is messy, but reminded care teams and providers that involving patients in the design process of the workflows results in more effective care.
Dr. Wilson shared her experience as a telehealth provider during COVID-19 for Teladoc, an organization that provides virtual care for patients all over the United States. Her advice for clinicians was to be an empathetic and engaged listener to patients when they are sharing their health issues, and make sure to ask about non-medical needs that may be even more present today, such as social isolation and economic hardship.
What providers can do now
Today, primary care practices are regrouping after shelter-in-place restrictions lift, adapting to a hybrid of virtual and in-person care, and working to address any care needs of their patients that were deferred during the height of epidemic. Yet even in this time of transition, CQC’s expert panelists shared the following steps practices can take to focus on patient needs:
- Always ask patients their preferences. Ask what technology they have access to, and what makes them comfortable. Make sure your visit builds on your relationship, addresses what device they are using and that you ask how you can be of help during this process.
- Look to your patients and families as resources to designing your telehealth programs. Outside even the visit, consider implementing patient open-ended surveys, focus groups, telephone calls or advisory programs. Tap into the people with the least experience to help you improve your work.
- Make workflows as simple as you can. Technology can be part of the barrier, but at the same time, almost everyone has a phone. Start with the tools that you and patients have. You don’t need a smart phone to conduct these visits.
Access CQC’s May 29 webinar recording and summary here.
Doctors Expect to Use Telehealth More Extensively Post COVID-19
April 27th, 2020
Physicians Embracing Telehealth During Pandemic
Telehealth is quickly emerging as an important clinical tool for physicians scrambling to adapt to the COVID-19 pandemic. Both patients and physicians report being happy with treatment delivered via telehealth, but doctors say barriers to adoption still exist.
Two April surveys conducted by the Pacific Business Group on Health’s California Quality Collaborative, during a webinar with independent physician associations (IPAs), community health clinics and managed services organizations, found that more than 80% of polled physician practices in California are presently using telehealth to deliver care.
Most practices report having launched telehealth services in earnest only in the three-to-four weeks after the pandemic’s shelter-in-place orders rolled out. Providers are using a combination of both telephone and video technologies not only for COVID-19 patient screening, but also urgent care, wellness visits and other clinical services.
Nearly three-quarters of poll respondents said clinicians were satisfied or very satisfied with providing care via telehealth.
Nonetheless, uncertainties remain about payment, policy and patient uptake of this technology. About one-third of respondents said policies on payment for telehealth were confusing or very confusing, and 64% said they need more guidance from health plans on billing.
Notably, about 40% of IPA representatives said they were extremely or very worried about their organizations’ financial health, while another 47% said they were somewhat worried.
During CQC’s webinars, IPAs and small physician practices identified a range of additional barriers to launching or expanding telehealth, including:
- Helping patients adopt telehealth, notably older patients without smartphones or with low digital literacy
- Reaching hard-to-find patients, like homeless patients without phones
- Improving patient acceptance and technical training (providers did note that when patients tried telehealth, they generally liked it)
- Providing staff training
- Documenting and coding for telehealth visits
Despite the challenges, there’s broad agreement that the COVID-19 epidemic has helped to push past resistance to the more widespread use of telehealth; 94% of IPA respondents tell PBGH that they expect to use telehealth differently or more extensively once the pandemic begins to abate.
Telehealth Providing Critical Pregnancy Support During Pandemic
April 20th, 2020
Telehealth has emerged as a vital tool for helping expecting mothers and clinicians manage pregnancy in the time of COVID-19.
That was the overarching take away from a recent webinar on maternity issues and the COVID-19 pandemic held by Pacific Business Group on Health and co-hosted by the Washington Health Care Authority and Washington Health Alliance. Participants included employers who help cover the costs of about 70% of all births in Washington state.
Telehealth’s ability to regularly connect pregnant women and their doctors has become essential in the face of the need to practice social distancing, which keeps expectant moms at home, employers said. An audio-visual link becomes particularly useful as mothers approach their due date or face the questions and concerns that inevitably follow birth.
According to employers, a growing number of health plans are making changes in telehealth coverage due to the pandemic, including waiving costs for patients who access care this way.
Ensuring that both payers and providers continue to support and expand telehealth services after the pandemic eases will be important, they added. On April 14, the Federal Communications Commission (FCC) announced a $200 million program to help non-profit providers establish telehealth services to better connect with patients.
Adjusting to the New Normal
Beyond increased use of telehealth, employers said the epidemic has resulted in a small percentage of pregnant women (5-10%) requesting transfers to birthing centers to avoid the risks of COVID-19 infection by delivering at a hospital. While most women will still deliver in a hospital setting, the current crisis has underscored the need to leverage all available maternity assets in our communities.
Developing a better understanding of how health benefit designs can create incentives for giving birth in settings outside the hospital, when appropriate, will be important for the future, employers said. Some webinar participants suggested that designating specific medical centers or alternative care sites as maternity centers could reduce risk of infection.
Employers also indicated that innovative solutions are needed to provide socially isolated expectant moms and new parents with venues for learning and reestablishing a sense of community. Possible options could include weekly education and Q&A sessions via Facebook Live or regular forums for discussing pregnancy-related issues that could be established through an employer’s human resources department. Group prenatal classes not only engage patients in their care and improve quality, these types of resources provide expectant mothers with necessary support from both peers and providers during this vulnerable time.
Looking Ahead: New Payment Models
Virtually all webinar participants agreed that the current fee-for-service payment structure constrains the way providers can deliver care, and that alternate ways of paying clinicians who provide maternity care are long overdue. New models are needed to support high-quality care that puts the patient’s needs first. Instead of having to ask themselves “can I bill for this,” providers could focus on simply delivering care in the most effective and patient-centered way possible.
Webinar participants echo what PBGH has been consistently hearing from patients and employers: the COVID-19 epidemic is creating an important catalyst for changes across health care and barriers to adopting telehealth more broadly may finally be coming down.