Maintaining the human connection in telehealth: NYC Health + Hospitals chief population health officer

While the shift to telehealth during the COVID-19 pandemic has transformed the physician-patient relationship from in-person to virtual, the experience has also ushered in unexpected human benefits, according to Dave Chokshi, MD.

Dr. Chokshi, who serves as chief population health officer of NYC Health + Hospitals, told Becker's Hospital Review that ramping up the New York City-based health system's telehealth program allowed him to connect not just with his patients but also their families, as COVID-19 can affect entire households.

"Telehealth had some of the benefits of doing a house call; because patients were in their own homes, we were sort of meeting them on their terms, so it was a bit more natural to talk about things like cooking, grocery shopping and exercising as ways of protecting themselves but also staying healthy during COVID-19," Dr. Chokshi said.

As chief population health officer, Dr. Chokshi leads the system's ambulatory care transformation, care model innovation, population health analytics and social determinants of health initiatives. Here, he discusses how NYC Health + Hospitals was able to rapidly scale telehealth at the start of the pandemic and why it is important to keep supporting human connections in care.

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

Question: How were you able to rapidly scale your telehealth program?

Dr. Dave Chokshi: There was so much that we did that was very rapidly turned on in the course of days or weeks starting in February or March. But that belies we had spent years laying the groundwork for our telehealth approach. About five years ago we had done some rigorous planning around what would make the greatest difference for our patients with respect to telehealth interventions. In 2017, we had our first enterprise-wide telehealth strategy for NYC Health + Hospitals, so we've had a chance to iterate on the technology as well as the clinical models over those years, and I think that's a big part of what allowed us to snap into action when we started to see the surge in patients in March.

Q: What is something small that ended up making the biggest difference in your telehealth program?

DC: We appropriately think a lot about our patients and the services we're delivering through telehealth. One of our principles in telehealth during COVID-19 has been to keep patients safe but also to keep our staff safe. This was a sort of unexpected benefit of being able to use telehealth during stay-at-home orders. First and foremost, it meant we were able to deliver care to patients without them having to use public transportation or otherwise put themselves at risk of exposure by coming into our clinic or hospital, but also for our staff in the same way it minimized some exposure for them. We found ways to use technology, particularly in our emergency department and in our hospitals that, for example, allowed patients in our ED to be triaged using a video connection so that our staff were safer and we could conserve PPE for them as well. We always think about telehealth as the tool to improve access, but in the context of COVID-19 it was also a tool to improve patient safety as well as staff safety.

Q: What has surprised you about the shift to telehealth?  

DC: One of the things I wanted to highlight from my own clinical experience was some of the unexpected, very human benefits of telehealth in the COVID-19 era. What I remember from my own telephone calls to patients in March and April was how much anxiety and uncertainty there was, and how a simple phone call from someone they trusted, who had the medical expertise we're able to bring, has made all the difference in the world to be able to answer their questions and help them out in a time when there was a lot of fear and uncertainty.

One of the other things I really appreciated was that I was able to talk to my patients but also their family members, often in a way that was difference than before COVID-19, because so much of what had to be done during COVID-19 sort of affected the entire household and not just an individual who happened to be my patient. It also had some of the benefits of doing a house call. Because patients were in their own homes, we were sort of meeting them on their terms, so it was a bit more natural to talk about things like cooking and grocery shopping and exercising as ways of protecting themselves but also staying healthy during COVID-19. Those were some of the unexpected benefits on this shift to telehealth and I think they're going to be really important for us to maintain some of the human connection that can be lost if you're not meeting in person.

Q: Moving forward, what are some of your top concerns heading into the next month or so?

DC: We're focusing on building on the remarkable foundation that our team and clinicians have built over the course of really just two to three months. We are going to continue to scale up our services. We went from doing about 500 visits in February to more than 50,000 in March. For May, we finished around 100,000. We want to continue to scale that up so that we can serve as many patients as possible.

I think the other piece we will really be focused on is ensuring the policy environment and reimbursement also helps to continue this support of the expansion of telehealth services. That's a really important piece of making sure that telehealth does remain here to stay and we can continue to deliver patient services and meet the demand of our patients. When we talk about the patients we serve at NYC Health + Hospitals, it is always important to highlight that since we are the public system for the city we serve poor and working class New Yorkers across the five boroughs. We're always thinking about putting health equity at the center of all our efforts, and telehealth is no exception to that. We've been very deliberate in making sure that interpretation services were widely available for any telehealth tool that we roll out and we often had to push some of our vendors and other partners we were working with to ensure they had taken interpretation services into account. Equally we had to think about making sure that our patients who may have a harder time accessing internet connectivity or the right technology are appropriately supported in our outreach to make sure we stay connected to them as well.

Q: How did you troubleshoot technical issues such as internet connectivity?

DC: We actually did a survey of our patients in 2019, so even before the pandemic happened. It revealed that more than 65 percent of our patients were interested in telehealth, including 40 percent of respondents over the age of 65. We found that 75 percent of respondents owned a cellphone, and 60 percent of them used their phone to access the internet. I always cite that because those numbers are maybe higher than people expect, so I do think there is a real demand and appetite for accessing care using technology. However, we always have to look at the folks who are not part of that proportion, and one of the benefits of the way we had set up our telehealth efforts was even if we used a video channel for certain visits, we have the telephonic channel as a backup. I do know anecdotally and through my own clinical care that sometimes if there are glitches in terms of getting the video set up that we can just convert it to a telephone visit, so there's still a conversation and ability to deliver care through another channel. We try to build those fail-safes in for any of the services that we deliver.

Q: You mentioned that your telehealth platform works in conjunction with the EHR. Have you been using any of the platforms that are now HIPAA compliant, like Face Time or Zoom?

DC: We felt strongly that our video efforts needed to be integrated with our EHR, so we have primarily been relying on that. We do have an enterprise-wide partnership with the Cisco WebEx platform, so we did pilot a few of our video use cases with the WebEx platform as well, which is also HIPAA compliant. We're still trying to figure out for the various use cases what is the best mode of technology to match up to that. I'll say one of our general principles is that technology should be subservient to what we're actually trying to accomplish on the behalf of patients, so we always start with the problem we're trying to solve, the service we wish to deliver and then we wrap around the technology to be able to serve those needs.

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