How Cleveland Clinic upholds clinical quality in telemedicine

The Cleveland Clinic has always been a mission-drive organization, striving to be the world’s leader in patient experience, clinical outcomes, research and education.

 

In 2002, when I completed my residency in Internal Medicine at the Cleveland Clinic and was hired as a full-time physician for the health system, telehealth wasn’t something that was on my radar.

Fast forward twelve years, and the Cleveland Clinic began offering outpatient virtual visits for the first time, mainly within the endocrinology, neurology and orthopedic departments. Impressed by the virtual care innovation and strategy, I began offering virtual visits to my patients.  They loved the virtual platform for healthcare.  My practice blossomed.  In 2015, we launched Express Care Online, our on-demand urgent care telemedicine service powered by American Well. Through Express Care Online, we provide patients with 24/7/365 care.

Express Care Online offered our patients incredible access to care, and since launching it in 2015 our virtual visit volumes have increased significantly. However, by giving patients unlimited access to providers, we put a significant strain on our internal infrastructure. We simply did not have the physician capacity to independently support Express Care Online.

To ease the burden, the Cleveland Clinic partnered with Online Care Group (OCG), a nationwide system of physicians who provide care through the American Well platform.  

Through this partnership, OCG board-certified providers would deliver care to patients under the Cleveland Clinic name. As a nationally recognized top medical center in the country, we needed to ensure that OCG physicians met the same high-quality clinical standards that Cleveland Clinic upholds across our entire organization..

While OCG was already monitoring quality with well-established metrics, these metrics required alignment with our existing standards to meet quality goals. Together, Cleveland Clinic and OCG collaborated to create an effective quality improvement plan focused on ensuring visit-type appropriateness, documentation completion and appropriate antibiotic prescriptions. The process and results of this collaboration were recently published in NEJM Catalyst. Below I highlight key steps and results of our quality standards improvement plan:

Establishing guidelines for appropriate telehealth visits

Because telehealth was a new care delivery method for many Cleveland Clinic physicians, we first wanted to determine what visits were appropriate for telemedicine without an in-person referral.  Cleveland Clinic and OCG held monthly quality review meetings, where we reviewed approximately 30% of adult patient visits, and 100% of pediatric visits for clinical appropriateness. Initial audits revealed that up to 67% of the previous month’s pediatric visits were inappropriate for telehealth. At that point, both Cleveland Clinic and OCG made a commitment to drastically reduce inappropriate visits and implemented an intensive program to train physicians on appropriate and inappropriate visits. Within six months, the number of inappropriate visits declined from 67% to 1%. You can read more about how we define appropriate telehealth visits and the program we used to educate physicians here.

Encouraging appropriate documentation of virtual visits

While virtual visits and in-person visits differ in  how they are delivered, the way physicians document during a virtual visit should mirror in-person visit documentation requirements. The Cleveland Clinic team was accustomed to using templates, however, OCG providers were using free-texting clinical documentation. Both organizations agreed to move forward with a template documentation strategy, and over the next two months developed and deployed templates to physicians. The use of templates increased over time, driving the rate of full documentation from 45% to 85% after six months. Today, the rate of full documentation is around 97%.

Practicing antibiotic stewardship during virtual visits

There tends to be a lot of concern around antibiotic stewardship within virtual visits. Both the Cleveland Clinic and OCG developed a coordinated strategy to treat conditions appropriately via telehealth while also minimizing the potential for antimicrobial resistance. Both organizations worked to align their clinical practice guidelines regarding antibiotic appropriateness. After six months of aligning this strategy, we have improved our antimicrobial stewardship from 69% to 97%.

The results of this collaboration illustrate both Cleveland Clinic and OCG’s full committment to becoming the highest-quality medical providers in the on-demand urgent care telehealth space. We wouldn’t have been able to achieve these results if it weren’t for respectful, open dialogue and a clear vision.

As the medical director of Express Care Online, I believe my focus has shifted to aligning virtual quality healthcare and truly collaborating with patients as partners.  How can we, as providers, work with our patients to assure that we provide the right care to the right patient at the right time?  It is with that in mind that I look at what technologies and innovative options can be leveraged to enhance care. With that forward thinking approach, success can be achieved in this collaborative partnership.

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