Telehealth is Improving Access to Health Care

Amy Coyne noticed her 9-year-old son Max wasn’t feeling well and booked a doctor’s visit a week after his Georgetown school closed due to the COVID-19 outbreak. The exam not only produced a diabetes diagnosis, but Max spent two nights in the intensive care unit of UK Hospital. 

A diabetes educator said Max needed a follow-up visit within days, but by that time, the pandemic outbreak was dominating headlines and the Coyne family feared venturing back out to Lexington and to the main facility treating COVID patients for the region.

Instead, for the first time, the Coynes tried a new channel of connecting with health care professionals—a video visit with a diabetes education professional. And it enabled the whole family, including out-of-state grandparents, to be updated about Max’s new health needs.

During the pandemic, health care systems have had to quickly increase their use of telehealth options for patients like Max to keep both staff and patients safe.

The U.S. Centers for Disease Control and Prevention (CDC) touts telehealth as the best method when in-person visits aren’t necessary. It also helps patients who may lack reliable transportation or who live in rural areas with limited health care provider options, particularly specialists.

Greatly facilitating telehealth implementation and growth, the U.S. Centers for Medicare and Medicaid Services along with state government officials issued waivers in recent months that expand how telehealth may be used and how its use is covered for billing.

Shawn Crouch is administrator of the Barnstable Brown Diabetes Center at the University of Kentucky, where the Coyne family sought care for Max. He, along with pediatrician Dr. Carol Steltenkamp, has led efforts to scale up UK’s use of telehealth during the pandemic. Steltenkamp has been a leader in the implementation of electronic health record systems in Kentucky for the past decade.

In April 2019, Steltenkamp said, UK Healthcare had about 100 telehealth visits, using a HIPAA-compliant Zoom platform to ensure patient privacy. In April 2020, that number had leapt to 25,000 visits.

Crouch said a telehealth option had already been initiated for urgent care in evaluating COVID-19 patients. But within a week, officials scrambled to expand that platform so that any clinic in UK Healthcare could use it, even when physicians and staff were in their own homes.

“We were still able (at that point) to get that critical care that those patients needed,” he said.

By June, there were fewer than 20,000 telehealth visits, and in early July the frequency was about the same, while in-person care visit numbers had begun to rebound, he said. 

Plans are to ensure telehealth visits remain an option, and other applications are also being explored, like electronic ICUs.

While there aren’t many silver linings attributable to the pandemic, Steltenkamp said, “The fact that this really ignited enthusiasm around telehealth is definitely a plus.”

Jake Bast is chief operating officer and senior vice president of St. Elizabeth’s Physicians Organization, which has nearly 2,000 associates, 620 of them physicians and advanced practice providers operating about 100 practice locations in Northern Kentucky, southeast Indiana and the Cincinnati area.

The pandemic forced providers with existing telehealth plans to increase capabilities quickly, he said. 

For about five years, St. Elizabeth Healthcare had used “asynchronous e-visits,” in which messages or medical data are sent in online and a medical professional reviews and responds to it later. 

St. Elizabeth planned to roll out real-time video visits this year over nine months, but when COVID-19 hit that process was squeezed into three weeks. Its 2,000 associates conducted about 50 video visits from Jan. 1 to March 14 this year, but has logged nearly 95,000 since mid-March.

Practitioners find “that video visits are effective and appropriate for a far greater number of patient visits than we once thought,” Bast said, and its future use is being explored for remote nurse triage services, employer and school system services and in rural areas.

An e-ICU program has been in place for about six years, he said, and using telehealth, specialty care in rural areas can be performed without patients having to travel or be transferred from one hospital to another.

Though video visits are on the decline for now—accounting for about 16% of total visits, down from a high of 70% in March and April—when it comes to these new technologies, it’s all about increasing access, Bast said.

“The more we can provide convenient primary care for patients … the more we are going to be able to keep people healthy,” he said.

Stressors abound during the pandemic, from homeschooling children while juggling at-home work responsibilities to unemployment to those actually battling the virus and their worried families. Not to mention the widespread fears of contracting COVID-19 while adjusting to sweeping new safety regulations.

Tack onto that society’s existing mental health challenges, and the importance of maintaining mental health care access, even in a pandemic, is obvious. 

Don Rogers is chief clinical officer and Natasha Painter an outpatient clinician and telehealth provider in the Georgetown office of New Vista, which is based in Lexington. New Vista has a staff of approximately 2,000 working across 25 locations to provide mental health and substance abuse services.

About a year ago, Kentucky’s Department of Medicaid began covering telehealth services, which had been piloted at New Vista on a limited basis.

But pre-pandemic, in-person visits were overwhelmingly the norm, Rogers said. The transition to video visits took four or five days and has gone smoothly, he said. Rogers expects a 50-50 mix of in-person and video visits moving forward as clinicians and patients prefer. For now, treatment staff still work from home and in-office on a rotating basis.

Painter said telehealth has decreased patient cancellation numbers, removing barriers for clients like transportation and child care and enabling treatment within the comforts of home. If anyone needs help logging on, she assists by phone.

“Clients who have transportation issues have definitely been able to come to appointments more often than they had in the past because they’re just a phone call away,” she said.

At Louisville-based Kentucky Counseling Center, there are 10 locations and 90 mental health providers in network. Founder/CEO Matt Grammer said telehealth services began in 2016 for medication services only, but now that telehealth therapy is being covered by Medicaid during the pandemic, that’s all changed.

The conversion to telehealth was completed in a whirlwind two days, and was still at 100% usage in mid-July, as offices were closed to in-person visits. 

While some patients with no interest in telehealth have stopped treatment until offices reopen, and older or very young patients may not be able to use it to its fullest, “for the majority of our folks, it’s really well suited for them,” Grammer said, adding that he thinks it will be difficult to return to “normal” once a vaccine is hopefully released.

“We are scheduling more appointments than we were prior to the shutdown so that feedback is telling me it is something people have really been looking for,” he said.

As virtual visits become more commonplace, patients will be able to contact doctors at times that are most convenient for them, using familiar technology, says Dr. Thomas Coburn, a family physician in Wilmore who’s also medical director of application and information technology for the ambulatory market of CHI St. Joseph Health Lexington.

While telehealth may never replace having a physical exam or the desire to shake a physician’s hand in-office, Coburn said he hopes Medicare, insurance and others will continue reimbursing virtual visits as they become a fixture in American health care.

“There’s a learning curve and we’re in the middle of that learning curve, but I do see that this will be the wave of the future for health care,” he said.

Coburn said he’d used Zoom for internal videoconferencing for years but not for seeing patients. COVID-19 necessitated exploring that option, which was rolled out in about five days at CHI St. Joseph Health. They’ve even helped providers in other markets in Tennessee begin providing video visits.

During the height of COVID-19 concerns this past spring, about 65% of visits were virtual. That figure has since dipped to between 15% and 20%, which Coburn says is a sustainable level for the future.

He said patients who request or are recommended to have a virtual visit receive a link to click at their appointment time, then safely wait in a virtual waiting room until time to video chat with a physician. 

Afterward, prescription orders can be sent in electronically and follow-up visits scheduled as needed. If in the course of a video visit a physician realizes an in-person visit is warranted, one will be set up. If it’s on the same day, a patient will only be charged for one visit, he noted.

Video platforms have also been used in ICUs and for specialists who would otherwise have to travel many miles to follow up with patients whose surgeries were performed in Lexington.

Health care providers are also experimenting now with technology that enables them to listen to a patient’s heart with a stethoscope that transmits the heartbeat sounds online to a cardiologist, he said.

Even now, Coburn said, if he has concerns with a patient who he knows also sees a cardiologist, “I can actually consult with the cardiologist in my office through Zoom and they can see the patient while they’re in my office.”

Employing more than 200 providers and 1,000 staff among more than 25 locations in central Kentucky, the Lexington Clinic has also been using telehealth with its patients, CIO Brent Baldwin said.

Along with his staff, Baldwin upgraded network circuits and connectivity in certain offices to handle additional bandwidth of telehealth and meet increasing demand. 

Physicians conducted virtual visits either from home or their offices, following clinical guidelines to determine whether patients needed that mode of contact or an in-person appointment, Baldwin said.

Patient feedback has been positive thus far, he said, and he believes telemedicine will remain a long-term option.

“The telemedicine genie is out of the bottle,” he said. “…Regardless of whether (a vaccine) comes out, we’re going to have to meet the patient’s needs.”

Nick Sarantis, system director for digital health at Louisville-based Baptist Health, agrees. “I think it’s going to be hard for people to just put (telehealth) away” and go back to the way things were before, he said.

There’s been more of a learning curve for some providers, he said, as digital health care delivery isn’t typically taught in medical school. But patients seem to be embracing the changes.

“As consumers, we’ve been going down a digital path in our lives for a long time,” he said.

In three to five years, Sarantis predicts telemedicine will have become routine, and investors will pour money into digital health companies, startups and new products in the telemedicine space. 

“I think you’re going to see a lot of innovations in these devices and peripherals” with implementation moved forward three to five years because of the pandemic, Sarantis said.

Pre-COVID, Baptist Health was in a road mapping and strategizing mode to implement remote patient monitoring and video visits, he said, but that time frame advanced five years and was completed within about six weeks.

Prior to the COVID outbreak, Sarantis said, one provider in an outpatient ambulatory setting performed virtual urgent care visits, with probably five to 10 video visits a day. In the inpatient realm, there were some tele-ICU and tele-neurology functions, monitoring vitals and having remote consultations as needed. But as the surge picked up speed, he said it became clear that rapid systemwide implementation was necessary in case many doctors were lost to quarantine, which thankfully didn’t happen. 

Much like retail companies such as Amazon have thrived by making access to merchandise easier for customers, the health care profession will be able to identify what gaps prevent patients from accessing health care and use telehealth methods as part of the solution, Sarantis said, especially now that more patients and providers have been exposed to this new way of care.

The Coynes’ telehealth experience continues to expand, as other follow-up visits have been done by telehealth. Amy Coyne said she’s glad to have the option, and now even sends in Max’s blood glucose numbers remotely to his physician.

“Overall it was a really great experience and we were really grateful that we could do it that way,” Coyne said. “It was so overwhelming at the time,” but being able to get information at home made it seem more manageable.