The coronavirus pandemic has forced U.S. healthcare providers to dramatically increase their use of digital tools, but doing so requires more than just flipping a switch. Organizations are not only challenged with accelerating the purchase and rollout of technology, but also addressing the digital divide that still exists in many areas. As chief digital officer at Prisma Health, a large not-for-profit health system in South Carolina, Dr. Nick Patel has been at the forefront of expanding telehealth services to different patient populations. He spoke with Modern Healthcare Managing Editor Matthew Weinstock. The following is an edited transcript.
MH: South Carolina is a new hot spot. What are you seeing in terms of case loads?
Patel: We were doing pretty good with our overall numbers, but recently we’ve seen a spike—a lot of it with people going back to work and businesses opening up again.
Fortunately, we’re holding on really well. We haven’t filled all our ICU beds, and we still have capacity. We’re finding that a large demographic between 21 and 30 (years of age) has about a 20% positivity rate. The median average is about a 15%-16% positivity rate. But we’re finding a lot of patients are actually pretty stable and we can monitor them at home, which has been great. We do have higher ventilator utilizations than our normal average pre-COVID, but we’re holding on.
Most patients in the younger demographic are going home and that’s great. And like other states are reporting, those people who are sick, it’s very polar—either you have it and you’ve got mild symptoms or little to no symptoms, or you have very, very bad symptoms and require oxygenation and potentially vent utilization.
We have a lot of patients that are also non-ICU who require a little bit of oxygen and support, but not intubation. And then we have a whole bunch of patients that we’re monitoring at home and checking in on them, on day two, five and eight.
MH: Let’s talk about some of the digital tools you’re using. How did you assess what you had and what you needed? One of the things you did was buy a bunch of webcams, as I understand it.
Patel: One of the advantages of this pandemic, if there are any, is you get a warning shot across the bow. You see it going across the country, across the world. Even the United States got early warnings of how it was hitting Asia, then Europe and then hit us, starting on the West Coast.
We got to learn from other organizations how fast this thing was moving, and some of the preparation started immediately.
One thing we knew immediately that we needed to do was stop elective surgeries. Most healthcare systems did that and that was a tough decision … because that’s a large source of income, but we decided to do that early as a precaution and for the safety of our patients.
On the ambulatory side, we pushed to telehealth. I’m an internal medicine doctor and my average patient is around 55, 60 (years old). And they have a lot of co-morbidities—diabetes, hypertension, COPD, autoimmune disorders or immunosuppressants. They have kidney disease.
We wanted to make sure they were protected, and we were doing everything in our practice already to sanitize and temperature check and all those things. But if we had the opportunity to do a video visit, then that’s what we were conducting and started to immediately.
Luckily we were already on the journey for a lot of these telehealth applications. We had a video vendor in place. We didn’t know that we were going to scale it this fast. As you can imagine, the reimbursement landscape was a lot different pre-COVID than it is now. We were concentrating on school-based telehealth and a lot of things on the acute side—for example, our telestroke programs and our mental health programs.
We didn’t do a lot on the primary-care side or ambulatory side, other than the folks who did direct-to-consumer type of things—they got sick, used one of our tools online and paid a fee and got to do that.
But then we had to scale it to everyone. We care for and touch 1.2 million lives a year, and a large portion of volume is within our system on the primary-care side. We knew we couldn’t just close practices. We needed to monitor these patients. We needed to make sure they got their medications. We wanted to make sure we educated folks about it, answered all their questions and concerns. And we didn’t want things to fester.
We found some people were so scared that they were having strokes and heart attacks and worsening of symptoms or not getting their refills or calling us. And they eventually ended up in the emergency room, which is where we don’t want people to go.
So we proactively took that on. We didn’t have every single computer set up for what’s required for minimal video visits, like webcams and speakers and mics; we had to retrofit some and order a bunch of cameras across the whole system, which everybody across the country was doing. And they’re hard to find. You have to think about it with a webcam, you need a speaker, you need a mic.
MH: How has the pace of this impacted your IT governance?
Patel: We had to become more agile. The typical IT infrastructure and governance structure has a purpose, but we had to pivot quickly and we didn’t really have time to have conversations about every single thing.
Luckily the organization and (information technology services) and informatics and digital health stepped up to the plate and made it happen. We already had a lot of things in place like video—a secure chat platform; we were also contracting for automated chatbots and real patient monitoring. They had already gone through the digital steering committee and governance and approval process and got into the contracting phase. All we did then is work with our legal team and accelerated a lot of these contracts to closure.
MH: What about externally, how did you communicate with patients to get them fully engaged in digital healthcare?
Patel: South Carolina is a small state, it’s got 5 million people and (we are among the lowest in the) nation when it comes to healthcare. We have a high number of diabetics, hypertensive, heart disease and stroke.
We’re also a very spread-out state. There’s a lot of rural areas, and in that demographic, there are issues with connectivity and broadband access, access to even a smartphone. Basic things that you and I probably take for granted, and being able to reach out to that very vulnerable population, it really makes you think a lot more about the things that we’ve been talking about for a while, such as social determinants of health.
A lot of the calls had to be just telephone calls. For some (patients), we had to be like a Geek Squad, “OK, click this.” They’ll have the camera on … but you’re not able to see their face.
We had those challenges, but the nurses really stepped up. What you find is how efficient you can become seeing people virtually because you don’t have to worry about the front desk check-in process. You don’t have to worry about the nursing intake process for vital signs and other things.
The nurses were able to call in advance and get some vital signs if they could. A lot of folks have a thermometer; a lot of the folks we found had a scale and a blood pressure cuff. So we’re still able to get those values. Granted, those were not done by nurses. They’re done by a patient themselves, so there’s variability that you have to take in account. But overall, you’re able to be extremely efficient. You also were getting very accurate medication lists because people go to their cupboard and get their meds and put them out and look at them and they were able to bring in family members who typically couldn’t make it to the appointment.
Patients really liked it. The biggest thing I hear from my patients is, “Thank you for being able to even offer this. Thank you for reaching out, having a phone call with us, and not just giving up on us.”
A lot of folks love the video visit and ask, “Can I continue this after this ends?” I hope we can.
We’re working with our revenue cycle people and others to lobby and get CMS and other payers to pay for it.
MH: What do you want to see out of payers going forward?
Patel: I’ve been pleasantly surprised with (Administrator) Seema Verma and CMS. They’ve taken the torch and moved this forward. And to quote Seema Verma, the genie’s out of the bottle. It’s hard to put it back. (Editor’s note: President Donald Trump issued an executive order after this interview took place instructing HHS to look for ways to make permanent many of the changes to telehealth reimbursement).
I think you’re going to find a balancing act because you’re not going to go 100% virtual at this time. But if I see a diabetic, say every three months, I could start doing some virtual check-ins in between that, or using remote patient monitoring, or the chatbot to continuously have a digital encounter with that person in between the office encounters.
I don’t know if the reimbursement is going to stay one-to-one. But even if it’s 80% or better, it helps the patient, and it helps the provider continue to support solutions like this and these types of tools. Many systems are lobbying state and federal agencies to keep this going. And COVID-19 is not going to go away anytime soon. Even if we have a perfect vaccine coming out, you’re going to have to have a large portion of the population get that vaccine, at least 80% or higher are some numbers that I’ve heard, to be able to get out of this crisis.
And it needs to be effective, and the question is how long does the immunity stay around after vaccination? Is it like influenza? Are we going to get multiple strains and you need an annual shot, but you could still get it?