Dr. Russell Libby is the lead physician at Fairfax, Virginia, pediatric group practice and board member of the Physicians Foundation. One of the biggest complaints his practice would get from patients’ families with school-age children is that it was difficult to get appointments that fit into their schedule, and that those times were further confounded by heavy traffic.
THE PROBLEM
Between afterschool activities, homework and limited appointment times with office waits, trying to get to appointments and waiting times in the office were very stressful and dissatisfying. It made getting kids in for needed appointments difficult, especially when they often are for behavioral health issues that need regular follow-up.
PROPOSAL
“I started the telehealth component of my practice to make access easier and more convenient,” Libby explained. “A little over two years ago, I developed the policies and practice around telehealth, but it was not well-promoted or used by many, in contrast to the explosion of use we have experienced since the COVID-19 pandemic.”
Initially, the other clinicians in Libby’s group practice were reluctant to use telemedicine, feeling that the personal and hands-on quality might be lost, something that is ingrained in the work values of most doctors.
It took a while to get their interest and buy-in, but once accomplished, Libby was able to get them all to dedicate a regular part of their office schedule to telemedicine, and for that, it was a limited set of conditions.
“After they became comfortable with the platform and experienced the professional and patient satisfaction around this alternative type of visit, it was embraced and appreciated,” he said.
“As they became comfortable, I was able to implement all of the policies and procedures necessary to get full staff and operational support, and telehealth became a part of the care routines available through the office. This also involved promoting it through appointment options and marketing media like our practice website.”
The group practice also needed payer support to make sure it could get compensated for telehealth visits. Luckily, in Virginia there is par payment policy, which means an audio/video visit is paid at the same rates as a comparable face-to-face in-office visit.
“Telehealth can make visits much more convenient for patients and their families,” Libby stated. “The telemedicine platform we use, Anytime Pediatrics, was selected because it is pediatric-focused and facilitates an encounter that is much like an in-person visit, but without the hassle of travel to the appointment and long waits at busy office times of the day.”
The telehealth platform enables patients to upload pictures or videos that can help with the evaluation, be it a rash that has changed or a swollen knee. And for physicians, it also can be helpful to see the patient in their home environment.
The physical exam is by observation, but can be augmented by having the parent/caretaker perform specific maneuvers to help evaluate specific areas of concern. With older adolescents and young adults, it can be done privately, something this age group values, Libby noted.
“Additionally, if necessary, there are ways to make referrals and connect with our EHR,” he added. “Overall, the technology provides my practice with the tools necessary to provide high-quality care, while alleviating the stressors that my patients sometimes can feel in coming to the office.”
MARKETPLACE
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MEETING THE CHALLENGE
Initially, there was a little reluctance by some of the patients of Libby and his fellow physicians to use the telehealth system for visits, but most had a very positive experience and embraced it as a great option for their care, Libby said.
“We integrated the platform slowly, starting with some set hours for telehealth each week, and gradually getting each of the clinicians to have a portion of their schedule devoted to it,” he explained. “Fortunately, the experience was positive and that eased the transition.”
Even before the COVID-19 crisis, telehealth proved itself to be a practice attribute – it improves care and office operations and even allows the physicians to provide remote care to their college-age patients or to families traveling, he said. It also helps reduce expensive and unnecessary ER and urgent care visits, he added.
“Now, it is extremely well-received by patients,” Libby said. “Our patients can schedule appointments that fit into their schedules, regardless of after-school activities, traffic or anything else that might interfere with getting to our office.”
He noted that a majority of appointments are “triaged to make sure there are no problems that would need a careful physical exam and, possibly, lab work. If there is a concern, we can arrange for an in-office appointment or make the appropriate referral for emergency or other types of care.”
When the COVID-19 pandemic exploded, Libby and his colleagues experienced an acute and dramatic drop in office visits as families feared exposure to the virus. However, they were able to quickly transition to telemedicine. They had what they called a “great platform” that they were by then comfortable using, and the entire office could support patients and clinicians using it.
RESULTS
The effort to limit the spread of the COVID-19 virus and the lockdown imposed on most of the group practice’s community has created a great opportunity to further transition to telehealth.
“In the first two weeks of March 2020, before the virus really hit, we were providing around 10 telehealth visits each week; but literally overnight, that number climbed to 250 to 300 per week for the second half of the month,” Libby reported. “These were mostly acute and chronic condition care visits, not preventive care, which is something we had not planned for.”
During this time – and with the encouragement of public health, regulators and even payers – the group practice has been able to straddle work hours for its clinicians and expand the hours and days for patient access.
It can use its after-hours time and weekends, helping to support its revenue and keep patients out of the emergency room. It also has been able to use its EHR, from Office Practicum, to identify patients who need a follow up but have a hard time getting to the office.
“Another nice feature that has reflected more families being together at home is getting both parents and even siblings into the visit,” Libby said. “It gives clinicians an opportunity to see the home setting and can help support preventive advice on safety and other issues that might affect patients’ health outcomes.
“Sometimes patients are unable to remember the medication they currently take, but the video visits that take place in their house makes it easy for them to show you the medication,” he added.
The physicians feel very positive about the telehealth integration and hope to continue expanding services.
“One area that we believe needs to grow and get the support of our insurance companies is routine preventive care,” Libby said. “Many families still are reluctant to come into the office, at least until there is some confidence that the COVID-19 threat has significantly receded. Along with that, we have started to provide drive-by immunizations, ensuring our younger populations are up to date on their immunizations and well-child care.”
ADVICE FOR OTHERS
The COVID-19 pandemic has catapulted telehealth into a valuable part of healthcare delivery.
“Most physician practices and care settings have started to integrate telemedicine into their practice, but sometimes this has been seen as an expedient and impulsive move, without thinking about the long-term needs of the practice and effective use of telemedicine,” Libby cautioned.
“For healthcare organizations that are considering telehealth, I would recommend researching the platforms extensively to make sure they provide longitudinal relevance for their practice.”
There are platforms that are more adaptable to a specialty, an EHR and a patient mix, he advised. Of greatest importance is to make sure telemedicine technology interoperates and integrates with existing technology, he added.
“Clinicians should also review The Physicians Foundation’s The Telehealth Initiative, which aims to support physicians as they navigate this new care delivery model,” Libby suggested. “The Physicians Foundation in partnership with the American Medical Association, the Texas Medical Society, the Florida Medical Society and the Massachusetts Medical Society have worked together to create extensive resources and guidance on the implementation and use of telemedicine.”
Additionally, physicians in the participating state medical societies can get evidence-based coaching from experienced staff and learn from other practices as they go through the experience, he added. The program, he concluded, helps participating physicians redesign their practices to successfully provide telehealth services to their patients.
