July-August 2020

Telehealth: Integrating Telemedicine Into ICU and ED Workflows
By David M. Fedor, DO, FACP, HMDC
For The Record
Vol. 32 No. 4 P. 30

Last summer, IBM Watson Health and American Telemed released a joint report showing a correlation between hospital performance and the adoption of telehealth strategies in care delivery. The data—part of the IBM Watson Health 100 Top Hospitals 2019 study—identified the US hospitals with the highest balanced performance in quality, financial, operational, and patient satisfaction measures.

Among the findings in the report: Telemedicine is correlated directly with positive performance and the field is growing in acute and postacute care settings. The number of hospitals fully or partially implementing computerized telehealth systems increased from 35% in 2010 to 76% in 2017.

The growth is attributable to the technology; as telemedicine become faster, more economical, and more effective, adoption increases in both acute and postacute care settings. The growth of these programs is tied directly to evidence that telemedicine drives better health outcomes.

Retaining More Patients
Anywhere there’s a Wi-Fi signal, experts in their field can support patients and hospitals. Anywhere a cart can roll, telemedicine can provide virtual services in the same manner as if the doctor saw the patient in person or talked to the emergency department (ED) face to face.

At most hospitals, the process of adopting telemedicine drives transfers down across multiple specialties. By providing expertise on demand, telemedicine helps hospitals keep more patients and manage those patients better. As telemedicine becomes more viable, adoption increases across the health landscape, including high levels of implementation in rural and underserved areas where physician shortages are greatest.

Improving the Patient Experience
By reducing wait times and delays in the both the ICU and the ED, telemedicine improves the patient experience. The technology can also ensure 24/7/365 coverage throughout the ED and ICU by adding specialists during peak hours and off times. Hospital administrators can target the operational and clinical performances that matter most, demonstrating increased throughput, reduction in average length of stay, improved census, and other metrics.

And telemedicine is shown to address workforce satisfaction, helping onsite staff maintain a better work-life balance, which reduces turnover.

In the ICU
As hospitals consider how to roll out a telemedicine program, many organizations choose to use the ICU as a starting point to evaluate its effectiveness before considering other specialties and use cases. Most often, the implementation process begins with the health system and telemedicine provider working together to identify care gaps.

Next, it is critical to build out the custom workflows between onsite staff and telemedicine physicians who will be working side-by-virtual side to provide care.

Reimagining Workflows for Maximum Efficiency
While every hospital and health system is different, there are several established workflows that telemedicine is most likely to improve universally. Telemedicine teams work alongside health care professionals to define tailored workflows.

There are three levels of telemedicine requests (routine, urgent, and emergent), each with a corresponding level of care and a respective “time-to-bedside” goal associated with it.

The time-to-bedside metric is defined as the time from when a hospital requests the telemedicine consultation until the time a physician is on screen ready to provide care. This window can be as short as five minutes for the most critical patients.

In a traditional setting, on-call doctors can receive urgent or emergent calls while at home or a different hospital. Sometimes it can take hours to respond to these requests. One of the largest benefits of telemedicine programs is that providers are continually on call and available for consults within a matter of minutes.

Another workflow that is almost universally improved by telemedicine adoption is transitioning patients from the ED to the ICU and other parts of the hospital. Patients often board in the ED, where they wait for a physician to decide on a care plan. With telemedicine, the decision whether to intake the patient into the ICU or release him to another hospital or to home can be managed almost immediately. This accelerates the process and improves patient throughput.

Telemedicine and EMR Integration
By integrating a single point of contact for the documentation created by patient encounters, nurses don’t need to wait for a fax to scan into the chart. Instead, the telemedicine physicians, who have credentials in dozens of hospitals—each of which may have a different EMR system—need to learn documentation in only one system, with their notes automatically transferred into the hospital EMR to be used for follow-up care.

These platforms allow hospitals to coordinate patient care through embedded workflows to order labs, drugs, procedures, radiology—everything. As a result, seamless patient interactions become the norm.

Collaboration Is Key
The question for hospitals is not whether to change workflows to incorporate telemedicine, but rather how to do so. How do they effectively build programs into departments with as little disruption as possible?

The answer starts with collaboration. Telemedicine companies are not in the business of dictating new downstream workflows to end users. Instead, it is best practice to custom-build workflows together.

To create a customized workflow, all key stakeholders should conduct multiple discussions in which onsite staff and telemedicine teams come together. This allows for detailed analysis about what existing workflows look like, how telemedicine can best fit, and how the two teams can work together to ensure the new workflow conforms to the standard of care.

For example, if during the building of new workflows it becomes apparent that a hospital is not conducting multidisciplinary rounds, the implementation of a telemedicine program can be the perfect time to correct that oversight. Workflow planning becomes the ideal time to identify how doctors from multidisciplinary teams might come together to provide more integrated and efficient rounds.

Continuous Improvement
Telemedicine should be flexible. How one ICU or ED elects to integrate telemedicine may vary from others. As long as the workflow enables the standard of care, each hospital can build custom workflows to fit telemedicine into its unique circumstance.

It’s the job of a strong telemedicine team to come alongside these existing processes, workflows, and game plans to integrate as seamlessly as possible.

An ideal telemedicine partner works tirelessly throughout the relationship, running multiple meetings and mock consults so that when the time comes, the providers on the ground in the ICU—the charge nurse, the nursing staff, everyone—is prepared to enact the new workflows.

These redesigned processes usually lead to marked efficiency gains in the hospital. As a best practice, both parties should commit to revisiting workflows on an ongoing basis. Most telemedicine organizations offer dedicated resources to client hospitals that conduct monthly, quarterly, and annual meetings to evaluate the processes that are going well and those that are in need of adjustment. The assumption is that care can always be improved and that refinements are a regular part of a successful telemedicine program.

The ongoing commitment to continuous process improvement is one of the most essential elements of a hospital’s telemedicine partnership. As processes tailor closer over time to the exact needs of the hospital, tighter congruency between the two teams leads to a higher return on investment by reducing transfers and increasing the case mix index, thereby keeping more patients and providing more effective care.

As illustrated in the IBM Watson Health study, hospitals that implement telemedicine also perform better—from improved workflows to increased patient satisfaction. The correlation between hospital performance and the adoption of telehealth services is measurable and positive.

— David M. Fedor, DO, FACP, HMDC, a telecritical care physician with SOC Telemed, is board certified in both internal medicine and critical care medicine. He serves as the associate chair of critical care and is a member of the Medical Executive Committee.