Telemedicine and COVID-19: an Observational Study of Rapid Scale Up in a US Academic Medical System
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INTRODUCTION
The COVID-19 pandemic has challenged health systems in many ways. One positive change may be a dramatic increase in telemedicine use. Health care systems have been moving to provide virtual care for some time, but progress has been slow.1–4 We describe how, in a large academic medical system with a high case mix index and diverse racial profile, we dramatically scaled up our slowly growing telemedicine program within a few weeks. We provide information on lessons learnt and patient experience.
METHODS
We define telemedicine here as synchronous live consultation via video. Keck Medicine of USC, which provides mainly tertiary and quaternary care for East Los Angeles and Southern California, began phased implementation of telemedicine in 2018, aiming for 20 clinics by 2019. With the COVID-19 outbreak, we rapidly scaled up. Declaration of a state of emergency relaxed credentialing guidelines and allowed use of other video-capable platforms in addition to our usual platform, InTouch.5 Telemedicine privileges were granted to all physicians and providers for one year. Each clinic determined their own workflows and received an onboarding packet comprising a training video, guidance for coding and documentation, consenting and prescribing principles, and job aids. Providers had access to a testing site for practice and were offered one-on-one training. The telemedicine implementation team augmented training staff from two to eleven. A command center was established to coordinate workflows and to allow a drop-in point for advice or rapid training.
RESULTS
By mid-2019, we had activated fewer than 15 clinics and delivered less than 400 televisits. By end of March 2020, we operated 110 virtual clinics, completed more than 2000 visits (Fig. 1), and trained 523 new staff. Received April 14, 2020 Accepted May 6, 2020
Results of a patient satisfaction questionnaire from over 470 patients surveyed during the scale up period are shown in Table 1. Many patients included positive comments on avoiding travel, parking, and the risks of attending a clinic, a few patients expressed concern that the visit was charged at the same rate as an in-person visit, and that they missed the physical examination.
DISCUSSION
The novel coronavirus epidemic provided a critical stimulus to transform our telemedicine program in just a few weeks. Challenges created by such a sudden expansion included the need to deliver training remotely and learn a new web-based platform while simultaneously delivering patient care. Providing live coaching and the ability to run test scenarios proved helpful for troubleshooting, and jumpstarted rapid implementation across ambulatory services. To meet demand, switching to other platforms such as Zoom from HIPAA compliant platforms, although allowed within relaxed CMS regulations,5 caused concerns about privacy.1, 2 Before the COVID-19 pandemic, barriers to widespread usage of telemedicine for most health systems included billing, reimbursement, credentialing, and choosing an effective delivery platform.1
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