Telemedicine: From Perpetual Pilot to Full-Blown Transformation in Three Weeks

Steven Z. Kassakian, M.D., M.S., F.A.C.P.

COVID-19 has brought, and continues to bring, a tremendous amount of suffering and anguish. However, the acceleration of telemedicine clearly will be one of the silver lining stories to emerge. Like many healthcare organizations, Oregon Health & Science University (OHSU) has experienced a transformative acceleration in the use of telemedicine during COVID-19 (check out the following article from Willamette Week: The Future of Telemedicine Just Arrived at OHSU. Steve Kassakian Is Helping to Drive the Project). While telemedicine is a broad umbrella term, the term I think that resonates most with patients and provider is the ambulatory video visit where instead of going through the hassle of traveling to a clinic, being subjected to interminable waits (surrounded by other suffering folks and only dated copies of People or Golf Digest to tide you over), your visit occurs via video within the comfort of one’s home or wherever you choose. To give some sense of scale of change we at OHSU have seen in the months before COVID-19 caused profound disruption in the U.S., we averaged around 75 total video visits delivered per week. That number has now been over 5300 video visits per week for the last 4 weeks, an over 7000% increase. These kinds of numbers are echoed by colleagues around the country. To say it has been profound would be an understatement.

Prior to COVID-19, my experience with telemedicine has been typical for both my provider & informaticist roles. I helped lead our initial launch of virtual visits (aka, video visits) for our ambulatory care environment about 2 years ago. We had 3 phases: 1. development of an urgent care video visit; 2. primary care; and 3. specialty care offering.  Urgent care made sense, many others had already gone down that path. While primary care seemed to intuitively make sense as it seemed that much chronic disease management could utilize the platform, I recall distinctly in my time spent talking with colleagues around the country the one thing I heard repeatedly that even once you built the platform, there was just no demand. In fact, I fell victim to the cobbler’s kids have no shoes scenario and in my provider role as a primary care doctor, I didn’t really see a compelling reason to use telemedicine. My patients were not clamoring for it, the hassle of interrupting my normal in person clinic workflow to see the odd video visits and the attendant hoops required to get credentialed-enabled just seemed too much. Plus I had the convenient excuse that I was too busy helping others.

When COVID-19 arrived, we were fortunate that we already had a platform in place. While we never really received a formal request from leadership to enable telemedicine for all faculty, it became obvious pretty quickly that telemedicine was what we had to do as the volume of calls, texts and emails from desperate providers, practice managers became completely overwhelming. Like many organizations, OHSU was actively trying to reduce the volume of patients being seen in person in addition to the concerns and fears from patients looking to avoid physical contact with healthcare but still in need of help. Telemedicine was exactly what was needed. It was such a profound shift from the prior state where we literally had to try to sell skeptical colleagues on the idea of telemedicine and benefits it would bring, to now a scenario in which the customers were lined up at the door ready to buy your goods that previously we had trouble giving away. Perhaps it will be looked back upon as telemedicine’s Black Friday Sales Event. To facilitate the rapid scale required we developed an agile approach with our newly formed video visit “baby tiger team” and anointed a “baby tiger tamer,” aka “scrum master.” The team included all the needed resources from clinical informatics, telemedicine, revenue cycle, EHR analyst, integration engineers, compliance, scheduling.  In a matter of three weeks, we enabled the entirety of our ambulatory clinical faculty to use telemedicine. This required non-stop work and in those three weeks we met daily, weekend included and calls, texts, ad-hoc meetings took place constantly.

As the enormity of what has occurred with telemedicine starts to sink in, there is lots of conjecture about what’s next. Clearly, we aren’t going back to where we were but how does telemedicine shift from a necessity service during COVID-19 to being just the way we do business and what are the impacts both desired and the unintended consequences. As mentioned before the prior selling points on telemedicine were really about convenience and avoiding hassle. While those are still apparent, I’ve had numerous patients tell me they will never come back to the office unless I insist on it, and I’m starting to see there is perhaps a more compelling value proposition for telemedicine. I am hearing stories and personally experiencing with my own patients that the ability to be invited as a guest into their homes, and see the intimate portions of their lives both the positive, negative and in between, is providing a much deeper picture of who they are as a person, their values, their challenges, successes and failures, than we’ve ever been able to glean before from short office visits. One incredibly touching story from a pediatric neurologists involved in caring for a foster child with profound neurologic issues: this neurologist was finally able to see the things that concerned the foster parent, and to see the child interact in the natural environment, the home, with the siblings and caretakers and the video visits provided more insight than any office visit ever had. Further on the provider side colleagues have shared with me that when they are able to finish with their last patient on time, close their workstation down, and walk from their home office to their kitchen, it marked the first time they have been home for dinner with their families in years.

That said, there are likely challenges. Much of this was made possible by suspension of an arcane patchwork of regulatory requirements from Centers for Medicare and Medicaid Services (CMS), which if any of those previously stifling regulations will come back is an open question. As well, there exists a digital divide in the nation (smartphones, PCs and broadband access), some view it as so profound as to label it a social determinant of health. We must be honest and acknowledge this inequality and work diligently to ensure that technologies like telemedicine do not exacerbate it and strive to help overcome it. Educationally it is a challenging moment, as we work simultaneously to both use and understand the implications of this profound digital switch, while at the same time rapidly needing to teach the next generation of providers how to care for patients digitally.

Prior to COVID-19, I think many in health IT may have seen telemedicine as part of the tired theme of technology trying to find a problem to solve. However, with COVID-19 there is a real problem and telemedicine is clearly one of the solutions. The question is will telemedicine outlast the current crisis? For me, the answer is a resounding yes and the truly exciting part is it may actually turn out to be part of the solution for many problems in our healthcare system for which we did not even consider.

Posted by:
Steven Z. Kassakian, M.D., M.S., F.A.C.P.
Associate Chief Health Information Officer, OHSU
Assistant Professor, Department of Medical Informatics and Clinical Epidemiology