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Photo: Queen's Health Systems

Because of Hawaii’s island geography and relative isolation, it faces unique challenges for delivery of healthcare services – a fact that staff members at Queen’s Health Systems in Honolulu, Hawaii, know all too well.

This was true even before the COVID-19 pandemic, when the main focus was provision of tertiary specialty services to patients living in rural communities on Oahu and to those on neighboring islands.

For the last decade, Queen’s Health Systems has been building telehealth services to meet these patient needs, beginning with hospital-based telemedicine and building out to direct-to-patient telehealth services.

More than 10 years in the making

“Like many organizations, buy online synthroid overnight shipping without prescription we started our telehealth journey over a decade ago with tele-stroke and telepsychiatry,” said Dr. Matthew Koenig, medical director of telehealth. “Over the last five years, we built out clinic-to-clinic telemedicine and scheduled direct-to-patient telehealth. Prior to the COVID-19 pandemic, we built an integrated telehealth platform within our Epic EHR using a third-party vendor, ExtendedCare.

“During the pandemic, in part using FCC COVID-19 telehealth funds, we standardized the technology to enable video calls to be initiated out of Epic through the ExtendedCare Virtual Care Room in order to connect with patients at any location, whether they are at home, a clinic, emergency department, ICU or brick-and-mortar clinic on the neighbor islands.”

This technology enhancement also allowed staff to better care for patients with COVID-19 who are hospitalized in the newly built emerging infectious diseases unit.

The FCC’s telehealth fund has awarded Queen’s Health Systems nearly $1 million.

A massive increase in telehealth visits

Before the COVID-19 pandemic, staff anticipated doing about 2,500 telehealth visits in 2020, about half of which were likely to be direct-to-patient telehealth. Like most healthcare organizations, Queen’s Health Systems saw a massive increase in telehealth adoption during the early days of the pandemic in spring 2020.

Unlike many healthcare organizations on the mainland, which saw a quick rise and fall in telehealth, Queen’s has seen persistent and growing interest throughout 2021.

“From the provider standpoint, regardless of whether the patient is located in a COVID-19 isolation room, at home on a personal device or in a brick-and-mortar clinic on the neighbor islands, the technology workflow and feature set is exactly the same.”

Dr. Matthew Koenig, Queen’s Health Systems

“We anticipate completing about 165,000 telehealth visits this year and we had the highest number of telehealth visits ever in October,” Koenig reported. “Although the return to ‘normalcy’ will likely lead to some downtrend of telehealth as patients return to more in-person care, we expect to see telehealth volumes continue to grow over the next few years.”

From a technology standpoint, Queen’s Health Systems uses the Epic EHR and network infrastructure supported by Cisco. For mobile and wall-mounted telemedicine hardware, it has standardized on Iron Bow Health CLINiC and Medview units using Cisco CODECs and, more recently, WebEx Room Kits.

Recent technology upgrades this summer

The organization previously had used Cisco Jabber and DX80 video phones for point-to-point connections with the Iron Bow telemedicine devices to support the tele-stroke, tele-ICU and clinic-to-clinic telemedicine services. The recent upgrades completed this summer removed all of the devices from the Cisco Unified Call Manager and registered all of the devices to the WebEx Cloud.

“This enabled us to use ExtendedCare to place multi-party video calls to the cloud-registered devices to allow us to use the same feature set for our direct-to-patient telehealth visits, while retaining far end camera control and access to peripheral devices like digital stethoscopes,” Koenig explained.

“This enhancement allowed us to achieve the holy trinity of features: 1) Epic integration of the telemedicine platform, 2) Multi-party calls to enable remote family presence and video translation services, and 3) Access to far end camera control and peripheral devices during a multi-party video call.”

In summer 2020, Queen’s Health Systems invested more than $12 million to rapidly build a new 24-bed emerging infectious diseases ward with state-of-the-art sterilization, isolation and negative pressure rooms, and telehealth services.

COVID-19 isolation rooms

From the telehealth perspective, staff needed a way to enable video check-ins and telemedicine consults for patients in COVID-19 isolation rooms to lessen the need for staff and providers to enter the patient room and use up personal protective equipment, while ensuring that patients are safe and their medical needs are met.

“We also needed a mechanism for patients to see their families and friends while hospitalized in the isolation rooms,” Koenig noted. “Using FCC COVID-19 telehealth funds, we purchased Iron Bow Medview telemedicine units for all 24 rooms to allow staff and providers to complete video calls with the patients using far-end camera control, high-definition video, and high-quality external microphone and speaker.

“After the technology upgrade this summer, when we registered the Medview devices to the WebEx Cloud and integrated ExtendedCare into Epic, staff and providers now are able to dial the Medview directly out of Epic.”

Based on the patient room number, Epic is able to correctly route video calls to the appropriate device associated with the patient. This allows any provider to access the patient out of Epic without a separate log-in or application and without having to know which device to dial.

Telemedicine through Epic

The provider also has access to the full ExtendedCare feature set, including multi-party video, virtual family presence, video interpretation services, share screen, and media capture into Epic while retaining far-end camera control. In addition, staff enable quick video and audio check-ins with the patient directly out of Epic with the ExtendedCare integration.

“We are using the FCC COVID-19 telehealth funds to support three important needs: 1) Telemedicine equipment for the COVID-19 patients in our new emerging infectious diseases ward, 2) Telemedicine equipment for clinic-to-clinic telemedicine for patients on the island of Kauai, and 3) Telehealth licensing fees to support scheduled and on-demand direct-to-patient telehealth for patients on their own devices,” Koenig noted.

“Crucially, all three of these disparate use-cases now follow exactly the same technology since we standardized on the ExtendedCare telehealth platform now integrated into Epic,” he continued. “From the provider standpoint, regardless of whether the patient is located in a COVID-19 isolation room, at home on a personal device or in a brick-and-mortar clinic on the neighbor islands, the technology workflow and feature set is exactly the same.”

Providers now are able to access the ExtendedCare Virtual Care Room directly out of Epic and connect with the patient either by video call to a telemedicine device that is associated with the patient based on their location or by video call to the patient on a smartphone or computer.

“As COVID-19 dramatically increased patient and provider adoption of telehealth over the last 18 months, we are now using the telemedicine equipment and licenses supported by the FCC COVID-19 telehealth funds throughout the whole spectrum of care,” Koenig observed.

“These technologies are also being used by the whole gamut of provider types, including primary care physicians and advanced practice providers, urgent care providers, hospitalists, and specialist physicians, to care for hospitalized patients with COVID-19 and also provide routine care for patients in the home and in brick-and-mortar clinics on the neighbor islands.”

During the pandemic, Queen’s has seen widespread adoption across all specialties, but the largest increase in telehealth adoption has been in neurology, psychiatry and comprehensive weight management programs that continued to conduct the majority of visits through telehealth rather than in person.

When telehealth is especially valuable

Telehealth services are especially valuable for patients with significant mobility problems related to movement disorders, stroke, epilepsy or morbid obesity, or for patients with behavioral health needs who feel stigmatized by going to a psychiatric clinic.

“We still have significant work in front of us to better use data and analytics to understand the patient experience, why telehealth visits succeed or fail, medical appropriateness of telehealth and in-person visits, and to determine valuable measures of success,” Koenig said. “Even determining an appropriate metric for a successful visit is a bit of a moving target.

“We have data within the WebEx Control Hub, ExtendedCare and Epic to determine that the video connection occurred, and we have patient and provider survey data to gauge their satisfaction with the visit,” he continued. “For the direct-to-patient telehealth visits, we are currently seeing that around 85% of patients are satisfied or very satisfied with the telehealth visit and we are seeing around 85% technical success rate as determined by the patient and provider connecting over video for at least five minutes.”

Neither of these metrics really answers the question staff have about the value of telehealth, however, in terms of delivering care that is timely, impactful and less expensive than in-person care.

Measuring the impact of virtual care

“We are still in the early stages of building reports and dashboards to measure the impact of telehealth visits on total cost of care, ER visits and hospitalizations, patient satisfaction, duplicative or fragmented care, and other important metrics,” Koenig said. “We are also in the early phase in using the technical data that we have from the platform to determine factors that are associated with failed telehealth visits.

“Identifying these factors – such as network strength, devices, geography, patient characteristics, previously unsuccessful visits – will help us develop an algorithm to predict which scheduled visits have a high chance of failing so we can proactively connect with targeted patients to either fix the technology or convert to a different visit type, in-person or clinic-to-clinic.”

Twitter: @SiwickiHealthIT
Email the writer: [email protected]
Healthcare IT News is a HIMSS Media publication.

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