By Bill Siwicki
Everyone in healthcare is well aware of the specialists shortage crisis in the industry today. There just are not enough physician specialists to treat all the patients in need, especially ones in rural areas.
One solution to this pressing challenge is telemedicine. This technology – which has finally gone mainstream, thanks to the COVID-19 pandemic – can spread the expertise of specialists far and wide.
SOC Telemed is a large, multispecialty acute telemedicine practice. SOC Telemed, whose clients include 19 of the 25 largest health systems in the nation, has enabled nearly 1,000 facilities in 47 states to manage complex, acute workflows and provide life-saving care.
Dr. Chris Gallagher is CEO of SOC Telemed and a physician who works in internal medicine and cardiovascular disease. We interviewed him to talk about the landscape of specialty care in telehealth, which medical specialties lend themselves well to telemedicine, and what CIOs and CMOs at healthcare provider organizations today should know about delivering specialty care via telehealth.
Q. In this new era of telehealth where the technology has finally gone mainstream, what does the landscape look like for specialty care via telehealth?
A. I’m bullish on the specialty telemedicine landscape. Even before the pandemic accelerated the growth of virtual everything, I saw the power of telemedicine to change patients’ lives and make a real difference to hospitals’ bottom lines.
As hospitals and health systems look at myriad challenges confronting them, specialty telemedicine can be a forefront solution. We know that specialty telemedicine can be deployed today to solve some of hospitals’ immediate challenges – physician shortages, nurse burnout, patient retention, financial stability, reducing readmissions. The list is long and varied. So, from that perspective, the landscape is blue ocean.
However, we have to be mindful not to dilute the core value of telemedicine and simply put a “doc-in-a-box” in a patient’s hospital room. For telemedicine to have long-term staying power, and not just be today’s short-term fix, it must be deployed not as a commodity or as just a technology platform but as a holistic model of care with its own distinctive set of skills and attributes.
Telemedicine is not simply the replacement of in-person care. There are practices and behaviors unique to telemedicine that must be learned, practiced and honed. Because they are virtual, telemedicine physicians need a very high level of emotional intelligence and different tactics from their brick-and-mortar colleagues to connect emotionally and personally with patients, their families and caregivers, and other health professionals.
Telemedicine specialists need to be effective at minimizing the physical barriers to interpersonal connection and maximizing the integrity and effectiveness of the patient-physician relationship.
Successful specialty telemedicine also depends on an ongoing collegial, collaborative relationship between the virtual physicians and the on-site healthcare professionals, whether that’s other physicians, nurses, respiratory therapists or pharmacists.
The remote physicians need to become part of the care team, even though they are not physically present. There needs to be a high level of trust and reciprocity between the on-site team and the telemedicine physicians.
There’s never been a bigger window of opportunity for the practice of specialty telemedicine to be in every hospital in every city and town in the country. I’m optimistic about its future – especially when everyone involved deploys it intentionally, with an eye to what goals they want to accomplish, and communicates those goals with internal and external stakeholders so they are shared and collectively owned.
Q. Which medical specialties lend themselves well to telemedicine, and why?
A. All the “cognitive” specialties are perfect for telemedicine. These are specialties that aren’t procedure-based. Psychiatry, infectious disease, cardiology, hospitalist, maternal-fetal medicine [MFM], nephrology, endocrinology, pulmonology and critical care all can be delivered via telemedicine in both the inpatient and outpatient settings.
The keys are having a high-quality specialist trained in the practice of telemedicine – delivering care over a screen, having a commitment to creating a connection with the patient and their family or support network, and building a collaborative relationship with on-site nurses and other clinicians.
In addition to these specialties being “cognitive,” they are also the same specialties that are in short supply. We know there aren’t enough psychiatrists, enough infectious disease specialists, or enough MFM specialists, for example, to care for the population.
About 80% of counties in the U.S. have no infectious disease specialists. Of the country’s only 1,800 maternal-fetal medicine specialists, 96% practice in major urban areas, leaving vast areas of the country without access to their expertise to consult on high-risk pregnancies – those where the pregnant individual is older; carrying multiples; or has a chronic condition, such as diabetes or hypertension, for example.
The need for specialty care, fueled in large part by a growing and aging population, exceeds the available supply of physicians. The results will be delayed or forgone care, leading to poorer health outcomes.
Telemedicine offers an immediate solution because it distributes the available supply of specialists more equitably and puts physicians where they are needed without limiting them to a specific geographic area or facility.
And it does today. Increasing the number of physicians takes years and requires taxpayer investment in creating new residency and fellowship positions. These are important policy questions that merit debate and analysis, but hospitals have patients to care for now. With specialty, high-acuity telemedicine, they can.
Q. Please share an example from your experience as a cardiologist practicing telemedicine where the technology really proved its worth.
A. The practice of specialty telemedicine proves its worth every day because it’s not just technology. It’s harnessing the power of technology to put highly skilled, highly trained physicians where they are needed, when they are needed.
Here’s one example. One of the first hospitals I worked with as a telecardiologist was able to significantly reduce the time to surgery for its patients because we were able to do the preoperative cardiac workups to clear patients for surgery much faster because the patients didn’t have to travel to an urban center to get the workup.
We could do it through telemedicine within one or two days, instead of weeks or months. We had the relationship with the on-site surgeon, so care was coordinated.
The patient wasn’t left to themselves to find a cardiologist, make an appointment, travel to the appointment, and make sure the results were shared with the surgeon. It sounds like a small thing, but getting patients the care they need more quickly has a significant impact on their outcomes, not to mention their anxiety and stress levels. And the impact for the hospital is significant as well because it reduces inefficiencies.
A second example is managing cardiac arrest through telemedicine. It’s hard to imagine a more dramatic moment in a hospital than a “code blue” event. And everyone pictures a hands-on response.
But the evidence-based guidelines from the American Heart Association tell us that the manager of the response shouldn’t literally be hands-on. The guidelines stipulate that the physician in charge of managing the event should not also perform the associated procedures, i.e., airway device placement or defibrillation.
Instead, the physician should have a 360-degree view of what’s happening and coordinate simultaneous responses from the respiratory therapist, nurses and others in the room, rather than performing any of the procedures himself or herself.
In hospitals where we’ve implemented telemedicine cardiac arrest programs, the physician managing the code blue is entirely remote. The only hands that touch the patient are those of the nurses and respiratory therapists. The respiratory therapist handles airway device placement. The nurses insert any intravenous lines needed for fluids and emergency medications.
This setup, however, doesn’t mean the physician isn’t present. The physician has a bird’s-eye view of the event from a large, high-definition screen, and directs and manages the multiple responsive actions in parallel.
The nurses act while the respiratory therapist acts. Rather than a single person administering each procedure one at a time in a series, the whole event is managed in parallel, each team member owning their role and practicing at the top of their license. This reduces the time to effective resuscitation from minutes to seconds.
In the aggregate, the telemedicine model for code blue events has reduced the time to effective resuscitation from 7-10 minutes to 90 seconds and reduced relative mortality rates by 17% and absolute mortality rates by 1.8%.
Q. What should CIOs and CMOs at healthcare provider organizations today know about delivering specialty care via telehealth? What does the nature of healthcare today require them to know?
A. I’d offer three suggestions.
One, there are essential differences between direct-to-consumer telehealth and facilitated, managed specialty telemedicine that are important to keep in mind:
Telemedicine augments and enhances, not replaces, in-person care.
Telemedicine reduces access-to-care disparities and evens out geographic imbalances in physician supply and availability. Direct-to-consumer telehealth typically gives additional points of entry to the healthcare system for those who already have them. Facilitated and managed specialty telemedicine puts physicians in places where they have traditionally been missing to provide patients care they have traditionally lacked.
Telemedicine helps hospitals, clinics and physician practices achieve financial, patient care and quality goals.
Telemedicine’s use in hospitals is not new, and some of the most forward-thinking hospitals early on recognized its value.
Two, telemedicine isn’t the future. It’s here. It’s how we solve access to care problems, and it’s how we support hospitals, particularly those in rural areas, so they can keep their doors open and care for their communities.
Hospitals today are challenged to be efficient and lean, yet also prepared and equipped to handle any patient with any condition or need at any time. For most hospitals, having a full medical staff with every specialty and subspecialty represented is pure fantasy. The cost is prohibitive, and there are simply not enough physicians to make that possible.
Although this was the case before COVID-19, the pandemic has pushed into the spotlight the challenges hospitals have long dealt with of maintaining readiness while keeping costs down.
Traditionally, hospitals unable to care for a patient’s particular condition or need must transfer or refer the patient elsewhere. The repercussions are immediate (lost revenue for the hospital and delayed care possibly for the patient) as well as downstream (loss of patient loyalty and loss of adjacent services, such as physical therapy or swing bed).
High-acuity, inpatient telemedicine solves these problems. Specialty physicians can be in any hospital, in any state (assuming licensure) within minutes as hospitals require based on patient need.
This means a patient presenting in the emergency department with stroke or cardiac symptoms, for example, can be triaged, admitted, diagnosed and on a treatment regimen in less time than it would take to transfer them out. And a patient seriously ill with COVID-19 or an end-stage disease can receive critical care in their local hospital, close to family, friends and support.
Three, telemedicine isn’t only a technology play. It’s a cost-effective way for hospitals to add new service lines, such as cardiology or neurology, that were previously out of reach because of the inability to recruit and retain on-site physicians. And it’s a way for hospitals to augment existing service lines, such as hospitalist, by enhancing physician capacity, reducing on-call costs and alleviating physician burnout.