How UPMC plans to sustain 50% of telemedicine growth post pandemic: Q&A with CMIO Dr. Robert Bart

To help maintain the telemedicine growth achieved during the COVID-19 pandemic, UPMC's chief medical information officer Robert Bart, MD, is focused on opportunities in urgent care, post-operative and prenatal care.

As CMIO, Dr. Bart has helped lead the Pittsburgh-based health system's rapid shift to telemedicine. Pre-pandemic, UPMC averaged about 1,000 patient-facing telemedicine visits per week. The figure quickly rose at the onset of the pandemic, as social distancing guidelines were enacted; by mid-April, the health system was averaging around 47,500 virtual visits per week, Dr. Bart told Becker's Hospital Review.

UPMC's telemedicine increase has predominantly been in the ambulatory space, replacing traditional in-clinic face-to-face visits. This is where Dr. Bart expects to see continued growth, with telemedicine serving as a "modern" approach to home visits.

"If you think about — and this is one of the things I like to think about with some of the physicians who are sometimes a little resistant — physicians and medicine started with home visits," Dr. Bart said. "That's not necessarily practical in 2020, but I can take you virtually into that person's home for a home visit using telemedicine. It's just a modern way of doing what physicians actually started doing when medicine was created."

Here, Dr. Bart shares his takeaways from UPMC's telemedicine expansion and continued growth opportunities at the health system as well as other organizations.

Editor's note: Responses have been lightly edited for clarity and length.

Question: What are the lessons learned or biggest takeaways you've had from the experience?

Dr. Robert Bart: One of the lessons I think is that when there is a need, the desire and adaptation to a new technology and a new way of care delivering is just amazing — both from the patient or consumer side and from our clinicians. I can honestly tell you that some of the clinicians on March 1 said, 'I have no interest in telemedicine' and on March 16, they were like, 'I need telemedicine now, because I need to be able to deliver care.' It's like a light bulb or a light switch was flicked and people's sort of mindset completely changed, both on the care delivery side and on the patient side. The adaptation of our patient community and our clinicians to telemedicine was quite remarkable. I haven't seen this type of change in any of my experience in 20 years in healthcare IT.

Q: What do you need for the telemedicine program to continue moving forward?

RB: Now that we've been doing it for a few weeks, I think the things that need to occur are sort of all of the wraparound services that we're able to provide in a face-to-face clinic setting, we need to be able to provide that with telemedicine. Some of the things I mean by that is, for example, if you're a patient who has an appointment at our multiple sclerosis clinic, in a traditional face to face, you're sent a questionnaire where you answer certain questions about the current state or any symptoms or signs you have related to your multiple sclerosis. Then when you're seen, that's reviewed, and then when you leave, there's an opportunity for education materials to be given to you. That's all based around the type of appointments that individual has. At UPMC, as well as most of the organizations that had to rapidly roll out telemedicine, we weren't able to embed all those features to add to the richness of the visit experience in as quickly a manner, and so we have a list of probably 300-plus questionnaires and surveys, education materials and things that are wrapped around certain specific clinics and/or diseases that people get diagnosed with, that we're digitally embedding now into the telemedicine experience so we can deliver these questionnaires to the patient portal knowing that you're going to be getting a telemedicine visit for multiple sclerosis.

At the end of that visit, the clinician can figure out which of the education materials you need, and those will be similarly delivered to that individual in the patient portal electronically so they can have that. Those are some of the niceties that have been developed over years of delivering face-to-face care that in sort of the rapid expansion of telemedicine; we couldn't do that all at once. Quite honestly, that's going to take us weeks to months to accomplish that for all the different clinics.

Q: Once the pandemic ends and things return back to "normal", how much telemedicine business do you plan to continue supporting?

RB: Our goal is to maintain at minimum about 50 percent of the growth of telemedicine. I'm more optimistic. My leadership says 50 percent; I'd like to maintain probably around 7,500 visits per day, in that ballpark. I picked that number because in a pre-COVID-19 clinical environment, the core part of UPMC, excluding the pinnacle portion, we averaged around 21,000 to 22,500 ambulatory visits per day across our system, and I have the opinion that we can maintain somewhere between 30 percent to 35 percent, or about 7,500 visits per day, virtually via telemedicine.

I think it provides a very good service to our patient population. The feedback we've gotten from patients has been very good. Many of them comment that they actually have better and more face-to-face interaction or eye contact interaction with the clinician. The three of us have all been in face-to-face clinic environments where oftentimes you're seeing the side profile or the back of the clinician because they're actually facing a computer while they're asking questions and trying to either type notes or type their actual note. It accomplishes the job, but you still don't have that interaction with the clinician. With telemedicine, a lot of the feedback we get is about 'I spent more time with the physician, I had more face to face or eye contact interaction with my clinician.' It's all been quite reassuring and very supportive that we can, for a large portion, meet the needs of our patients through telemedicine. Not everything can be done that way, but certainly a large portion of visits and care can be delivered via telemedicine.

Q: Your goal is to get to 7,500 visits per day, which would be about one third of UPMC's typical ambulatory volume in a pre-COVID-19 clinical world. Which patient populations do you anticipate this will work best with?

RB: I think that a lot of the initial screenings, so anywhere from urgent care. If you think about it, for many of the sort of routine, infectious maladies, whether it's the common cold, the flu or some sort of GI illness that we have, in the pre-COVID-19 world, we'd all be in the physician waiting room. Half of the room is there because of some chronic disease that you're seeing a primary care physician for, but the other half of the room might be seeing one of the physicians for something that's an urgent need. Frequently those urgent needs are of an infectious nature. We've all spent time in waiting rooms wondering if we're going to catch the same illness of the person who's across from us who is coughing and sneezing a lot. I think that because of the necessity of the concern around the asymptomatic carrier for COVID-19, telemedicine got pushed to the forefront. I really think going forward, when people have these concerns about, 'I have something I don't need to be in a hospital and I don't need to be in an ED, but I'd like to know what it is and/or I need documentation for my employer,' all of those matters can be handled through telemedicine in the future.

Another category, and this is one that we were focused on at UPMC prior to the last few weeks, is post-operative care. Most insurers reimburse for a procedure or an operation by a 90-day bundled payment. The day of the procedure, you get a bundle of reimbursement for that procedure, and then all of the visits to that surgeon for the next 90 days are covered in the bundle payment you get for the procedure. There's no money collected, there's no copay, none of that occurs. Most of our surgeons, not just at UPMC but also across the country, use resorbable sutures these days. We were rolling out a program with all of our surgeons and procedure lists that the post-procedure visits could all be done via telemedicine. Most of our patients do very well after their procedure or surgery. Pennsylvania is a very rural state, so it's one thing to drive to the medical center or the hospital two hours each way to have your surgery done. You get discharged and go home. But now you're 10 days after surgery, you still have some aches and pains and some incisional pain. Do you really want to have to get into your car, drive two hours in and go through the halls of the facility, get into the exam room for the surgeon just to say, 'How are you doing? Doing well? Eating okay? Any issues? No, let me look at your incision.' Then you drive back home for two hours. All that can be done via telemedicine, and in fact, it's probably a much better experience for most of the people than having to schlep back and forth.

I think those are areas where there's large room for growth for telemedicine, not just at UPMC, but also in other organizations. That's one of the things we're focusing on is what are the types of appointments that we can push this sustainability with telemedicine.

Q: What is one patient population telemedicine has particularly benefitted during the pandemic?

RB: Another area where we have had good success and continued growth during this phase is prenatal care. A lot of women, very early on in their pregnancy or at various stages of pregnancy, didn't necessarily want to come to the physician's office because of the concern of community exposure to COVID-19, but they still wanted prenatal care. Our women's health program worked out a series of which visits they felt would be appropriate for telemedicine, and which visits they felt would be more appropriate for an in-person visit. They developed that, and the uptake within the expecting women has been very big in that space. I think part of it is it's up to us at UPMC as the sort of clinical leaders to examine what we have done traditionally, and where are the places telemedicine can be applied well? And take the experience of our clinicians and our patients really wanting to gravitate toward it, and then making it both convenient and a robust experience that wraps all the traditional things that were good about face-to-face visits into telemedicine while leaving behind some of the things that weren't good about in-person, like having to find parking. That all sort of melts away when you do it virtually.

Q: Is UPMC working on any remote monitoring projects?

RB: We do remote patient monitoring. In fact, that prenatal program that I was talking about, they do some of the remote patient monitoring because blood pressure is one of the things you definitely want to monitor closely in a woman who is pregnant, and recognizing that if you have new hypertension with pregnancy that puts you into a different risk category.

We've been doing systematic and system wide remote patient monitoring for about four to five years. We started with our congestive heart failure patients, and we also started with inflammatory bowel disease patients, and have had good practices working with those two groups and extensive experience with them. With the advent of the current public health crisis that we're in, we enabled our city of Pittsburgh EMS for telemedicine and we also gave them portable pulse oximeters, so that if there were any questions or the patient that our physician and EMS felt was stable but still had a high anxiety level, we could leave behind monitoring with them and get them sort of on-site enrolled into the program and do pulse oximetry monitoring and work with that patient.

Similarly, although we did not see the spike of COVID-19 inpatients that other parts of the country did, we were prepared with remote monitoring. We had sort of a concern that if our hospital use got very high, similar to what they experienced in New York City, that we would have to potentially consider discharging patients sooner. A safe way to discharge patients sooner would be to set them up with remote patient monitoring at home, so if we did have to discharge them with criteria that wasn't like what our usual criteria of discharging a patient, we could at least make sure they were home safely being monitored.

Q: UPMC implemented Abridge's transcription tool to create a transcript of the virtual visit for both the patient and clinician after telehealth visits. What kind of response have you seen to the tool?

RB: One of the main feedbacks we're getting from the patients and physicians is that the patient feels liberated from having to take notes during the visit because they know that they're going to get the information after. They're able to pay attention and be in the conversation, and the physician, similarly, feels liberated from having to take notes. The piece that we're working with Abridge on the physician side is we actually want to take the part that would be the note and actually have that become a sort of a template of our note within the EHR. If you can think of sort of a typical physician's workflow, if I see 20 patients to 25 patients in a day, I might jot some notes on each patient through the course of the day. Then when five o'clock comes, the last patient leaves the office, or the last telemedicine visit occurs, then I would finish all my documentation on all those patients. We think having that parsed medical transcript will improve the efficiency of them completing their documentation on the visits that occur, but we also think it's going to improve the level of detail and the accuracy. This will subsequently lead to improved care all the way around, because the next clinician who comes and reads that note is going to have a better representation of the patient that's in front of them for subsequent visits.

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