key: cord-1033856-va2e029z
authors: Hoffman, Pamela E.; London, Yollanda R.; Weerakoon, Tasmeen S.; DeLucia, Nichole L.
title: Rapidly scaling video visits during COVID-19: The ethos of virtual care at Yale Medicine
date: 2020-10-01
journal: Healthc (Amst)
DOI: 10.1016/j.hjdsi.2020.100482
sha: 5f345d8e2a04fea48358fb9cc4f596ab3f64198e
doc_id: 1033856
cord_uid: va2e029z

Lesson 1: The loosening of federal government regulations enabled the rapid scaling of telehealth, as it enabled providers to be reimbursed for video visits at the same rate as in-person services. Lesson 2: While resistance to change was the norm, the COVID-19 crisis motivated improvements to four major internal operational workflows (scheduling, appointment conversions, patient support and Virtual Rooming Assistants) for video visits, which were met with acceptance by both clinical and non-clinical staff. Lesson 3: Leveraging prior intraorganizational relationships and active collaboration between different stakeholders, helped drive rapid operational change. An ongoing centralized communication and support strategy, ensured all stakeholders were informed and engaged during these uncertain times. Lesson 4: Regular electronic health record (EHR) training and educational material increased end-user knowledge of video visits and helped ensure the visit was safe, medically effective and maintained patient-provider relationships. Lesson 5: A clearly defined intake and evaluation process to filter out technologies that do not integrate with the patient portal or the EHR, ensures operational consistency and long-term sustainability. Lesson 6: Personalized support to patients of different levels of technical literacy with using the preferred patient portal and application, was vital to its use, adoption and overall patient experience.

telehealth, as it enabled providers to be reimbursed for video visits at the same rate as in-20 person services. 21 22

• Lesson 2: While resistance to change was the norm, the COVID-19 crisis motivated 23 improvements to four major internal operational workflows (scheduling, appointment 24 conversions, patient support and Virtual Rooming Assistants) for video visits, which 25

were met with acceptance by both clinical and non-clinical staff. 26 27

• Lesson 3: Leveraging prior intraorganizational relationships and active collaboration 28 between different stakeholders, helped drive rapid operational change. An ongoing 29 centralized communication and support strategy, ensured all stakeholders were informed 30 and engaged during these uncertain times. 31 32

• Lesson 4: Regular electronic health record (EHR) training and educational material 33

increased end-user knowledge of video visits and helped ensure the visit was safe, 34 medically effective and maintained patient-provider relationships. 35 36

• Lesson 5: A clearly defined intake and evaluation process to filter out technologies that 37

do not integrate with the patient portal or the EHR, ensures operational consistency and 38 long-term sustainability. 39 40

• Lesson 6: Personalized support to patients of different levels of technical literacy with 41 using the preferred patient portal and application, was vital to its use, adoption and 42 overall patient experience. While telehealth promised benefits such as ease and convenience of patient care, prior to 58 COVID-19, it was not readily scalable across health systems. This was largely due to the 59 restrictive state and federal regulations as well as inconsistent practices by commercial payors 60 which limited telehealth reimbursement to select patient populations in rural areas. The 61 mainstream adoption of telehealth was further compounded by the challenges of integrating 62 virtual care technology with the electronic health record [1] . 63 64

However, recognizing the need for continued patient care amid social distancing guidelines to 65 slow the spread of COVID-19, in March 2020 the government introduced waivers under section 66 1135(b)(8) of the Social Security Act to vastly expand telehealth services [2] . CMS subsequently 67 relaxed COVID-19 telehealth reimbursement guidelines; they removed geographic restrictions, 68 relaxed technological restrictions for both providers and patients, and reimbursed video visits for 69

both new and return patients at the same rate as in-person visits for over 80 services [3] . As 70 commercial payors followed suit, this propelled the rapid adoption of telehealth. In response, 71

many Academic Medical Centers (AMC) who had previously only piloted telehealth programs, 72

were now tasked with rapidly converting and scaling thousands of in-person visits to video visits. Accountability. It helped them problem-solve together on operational requirements for telehealth 150 success such as educating patients, obtaining devices and ensuring provider punctuality. 151

Moreover, these workshops helped build positive relationships between the Telehealth team and 152

Operational Leads early on, which were vital to the later success of the program. Additionally, 153

although there were few champions prior to the pandemic, this same process was later applied 154 during the crisis to quickly identify such individuals from each specialty, pilot the video visit 155 workflow and rapidly deploy telehealth across the entire specialty. The YM Telehealth team hoped to promote cooperation and resource-sharing as opposed to 313 competition, to continue to provide high-quality patient care and access during the crisis. 314

Therefore, based on the pre-existing centralized workflows and structure of the access center, a 315 third managed entity-the Telehealth Conversion Center (TCC), was established early in the 316 crisis to offer scheduling support to 22 decentralized Epic departments. By building on existing 317 centralized workflows from the access center, the TCC could rapidly deploy scheduling 318 workflows consistently and efficiently for multiple departments. 319 320

However, many individual departments chose to continue to self-schedule throughout the 321 pandemic (defined as the self-scheduling departments in Fig. 4) . Even then, their scheduling and 322 conversion process was guided by ongoing interactions between the YM Telehealth team and 323

Operational Leads, contributing to system-wide workflow and process consistency. The YM Telehealth team provided centralized operational guidance on the conversion process in 357

Epic. Physicians were advised to notate patients eligible for video visits on their Epic schedule or 358

to send a list of patient names to the schedulers. The schedulers would then convert the 359 appointment and make patient contact. Detailed workflows for the exchange of this information 360

were developed and implemented with rapid Plan-Do-Study-Act cycles. 361 362

III. Patient Support 363

The YM Telehealth team recognized that helping patients of all levels of technological literacy to 364 become comfortable with MyChart and troubleshooting technical issues, is essential to the use, 365

adoption and success of this application [12] . Two layers of support were offered during 366 COVID-19: (1) MyChart support, whereby a dedicated group of scheduling staff and volunteer 367 managerial staff were trained to call and assist patients prior to their scheduled visit, to help them 368 sign up for MyChart, download the application to a smartphone or tablet and then test the 369 internet connection. If a patient did not have the technology needed, they were offered the option 370

to complete a telephone consult. (2) Together, these lessons suggest that while the implementation of telehealth was largely 451 successful during COVID-19, in future, additional efforts must be dedicated to continuously 452 improve patient/provider accessibility, technological literacy and satisfaction to ensure the long-453 term sustainability of telehealth. 454

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The views expressed in this article represent the authors' views and not necessarily the views or 2 policies of their respective affiliated institutions

This statement accompanies the article RAPIDLY SCALING VIDEO VISITS DURING 14 COVID-19: THE ETHOS OF VIRTUAL CARE AT YALE MEDICINE authored by Pamela E

Below all 17 authors have disclosed relevant commercial associations that might pose a conflict of interest: 18 19 Consultant arrangements

Stock/other equity ownership: None 22 23 Patent licensing arrangements

None 26 27 Employment: None 28 29 Speakers' bureau: None 30 31 Expert witness

The authors would like to thank Lynne Midolo and Dr. Howard Forman for their contributions to 34 the development of this manuscript. 35 36