Transitioning to Telemedicine in Response to COVID-19 Pandemic

When the COVID-19 outbreak exploded in March and hit its spring peak the following month, businesses across the country closed or moved their services online to continue serving their customers. Healthcare providers were no different. Many closed their doors for elective or non-emergent medical services. Others went virtual and had to learn how to care for their patients via new and previously untested telemedicine capabilities.

Lane Regional Medical Center in Zachary, La., is one of thousands of providers that took a crash course on telemedicine. Located 16 miles north of Baton Rouge, Lane is a 139-bed general acute-care facility owned by the local hospital district. The facility runs a primary-care clinic in Zachary—the Lane Family Practice—staffed by five physicians and one certified family nurse practitioner.

In this case study, we spoke with the practice director and patient navigator from Lane whose job it was to ensure virtual care provided by the clinic to patients continued to meet quality standards.

We asked Abby and Amy about how they and their staff managed their clinical documentation, data collection and quality measure reporting responsibilities for clinic patients who no longer received in-person care from the clinic’s physicians and nurse practitioner.

What was the clinic’s telemedicine experience prior to COVID-19 and why did the facility choose to go virtual rather than temporarily closing?

Amy: Our experience with telemedicine was zero. When the stay-at-home order came down, we knew we had to transition as soon as possible. So, we took advantage of the government’s telemedicine waiver that gave us the flexibility we needed. We care for a lot of elderly patients who have one or more chronic medical conditions. It’s not as if those conditions would magically disappear if we stopped seeing patients in person. Doing nothing was never an option.

How did you start connecting with your patients virtually?

Amy: The first thing we did was transition all appointments to telemedicine unless our providers deemed an in office appointment medically necessary. Then, we reached out to the patients to figure out how best to connect with them. Our patient population is definitely older. Many don’t have the latest technology or know how to use it. We figured out what each of them had and could use. The way we communicated was all across the board—FaceTime, Facebook Messenger, Google Duo, you name it. We set each patient up with whatever capability they had so they could keep their appointments.

What did you do if a patient didn’t have any of those capabilities?

Amy: We did a variety of things for patients who struggled with virtual visits for one reason or another. If a patient had no other way to connect with their doctor, we let them come to the clinic parking lot—with all the necessary precautions—and talk to their doctor over a mobile monitor. We also encouraged the families of older patients to assist with the technology needed to connect virtually. If we were unable to provide care through a visit that included video and audio, visits were done with audio only.We did anything and everything that we could possibly do to make patient appointments happen safely.

How did transitioning to telemedicine affect your clinical documentation responsibilities?

Abby:Your clinical documentation of a patient’s visit must be the same regardless of whether it’s in-person or virtual if at all possible. If patients were able to provide biometric data from home, we included that data in our documentation. We’re talking about things like weight, pulse, blood pressure, temperature and oxygen saturation level. We had to get really creative in order to get all of that information to document in their medical records.

What are some creative ways you captured patients’ vital signs during telemedicine visits?

Abby: The first thing we did was figure out whether a patient could take those vital signs accurately themselves and report them to us during a telemedicine visit. Do they have a home blood pressure monitor and know how to use it appropriately? Do they have an accurate scale and thermometer? We talked them through it and recorded the vital signs they reported to us.

Not all patients have home health monitoring devices. What did you do in those cases?

Abby: Again, we had to get creative. We know from our patients’ records if they use a home health service or a home hospice service or get in-home health evaluations from a Medicare Advantage plan. We reached out to those services and asked them to share their visit notes. They collect vital signs during a visit and record them in their notes. We plugged that missing information into patients’ electronic medical records.

Speaking of EHRs…what functions, if any, helped you during the transition to telemedicine?

Abby: We discovered a future tasking feature in our EHR system that we had never used before. You can set up a reminder to collect a missing piece of patient information during a later appointment. It’s great for patient information that isn’t urgent or emergent that we couldn’t capture remotely or via another provider. That would be something like a preventative screening or an immunization that’s due but can safely wait a month or two. It was a great reminder to our staff to go back and close that gap in care and document it when it was safe to do in person.

What other technologies did you use to identify gaps in care that you could fill later?

Abby: We relied heavily on our Medisolv software. We used reports generated by the software to proactively look for gaps in care and reach out to those patients. When our COVID-19 numbers dipped to low levels and we felt it was safe for our patients to come in, we would get the appointments scheduled to do things that can only be done in-person.

What about using technology in creative ways? Did you discover any useful workarounds that you could share?

Abby: We did. We figured out that we could go into our EHR system and look at physician RVUs (relative value units). That’s how we compensate our physicians. Those RVUs are tied to specific CPT (current procedural technology) codes. The CPT codes tell us what services the physicians provided to patients. By working backwards starting with the RVUs, we could find out whether a patient got a specific service, like a preventative service or screening like a mammogram or a colonoscopy. If they didn’t, we flagged that gap in care to fill in later and maintain the continuity of care for our clinic patients.

How has your creative approach to data acquisition from telemedicine visits affected your quality improvement and quality measure reporting work?

Amy: As you know a lot of that data factors into quality measures that you report to Medicare and to other payers. Because we were able to capture that data in a lot of different ways, and able to track and manage quality gaps in our patient population, we’ve been able to achieve the same, and in some cases exceed quality scores from prior years . It was challenging, but we made it work.

What advice to you have for other quality managers who may be faced with the similar challenge of their hospital or medical practice going virtual overnight?

Amy: For me it would be how you think about the visit. You have to address visit documentation just as if the patient is in the office, where possible. And you have to have a great deal of flexibility. We were able to offer virtual visits on several different technology platforms. Patients can come to our parking lot where they can connect to our wifi, if internet service was an issue. We even bring them one of the practice’s mobile devices to use if they need it, and, if necessary, offer an audio only visit. One way or another, we were going to find a way to give patients access to their healthcare team.

Abby: The ability to stop and pivot is essential. Everyone must be onboard—from the front desk to nurses to the doctors to the lab technicians. Everyone must be willing to do whatever it takes when you need to do it. One of our physicians was in full PPE at our picnic table doing physical exams for patients who needed to be seen in person.

Amy: Being flexible is key. For virtual visits, that means identifying the communication tools they have and are most comfortable using. It’s not like one telemedicine app fits all. You must figure out how to accommodate both types of patients to do your job.

Clearly, the staff at the Lane Family Practice was able to do its job with the help of both Abby and Amy. We at Medisolv would like to thank Abby and Amy for the dedication they showed to their patients and their willingness to share insights and experiences with their peers.