The value of telehealth and digital health: Key thoughts from Stanford Children's CMIO Dr. Natalie Pageler

Stanford Children's Health has a comprehensive digital program focused on improving the quality of care for pediatric patients. The health system launched a clinic with telehealth visits that saves hundreds of miles in travel for patients who need specialty care. The hospital has also been migrating to home virtual visits in the past few years and has seen a dramatic increase in its technology capabilities.


"We want to make sure we are getting the value out of the program that we need for our patients and understand the effects of telehealth on care utilization," said Natalie Pageler, MD, chief medical information officer of Stanford Children's Health in Stanford, Calif. "We have also been doing work to expand our digital front door with a mobile app that includes access to our patient portal, online scheduling and obtaining second opinions."

Dr. Pageler and her colleagues will present at an upcoming Epic conference on diabetes and digital health, examining how virtual visits for patients with diabetes can ensure they keep up with glucose monitoring and supplement normal office visits.

Question: What metrics do you track to ensure value for your program?

Dr. Natalie Pageler: We started tracking performance metrics for telehealth, including the volume of calls, technical issues with the calls and the number of appointments or cancellations made through virtual visits. We also examined the number of calls that start off virtual and then are transferred to in-person visits for any reason so we can hone in on the quality of our current situation and make it better.

We are working with new technology now and need to make sure we have visibility into how well it works to drive quality. Our next step is looking further into the value equation of telehealth and digital health, including the clinical and technical quality side of care as well as patient and provider experience. Then we will look at the overall costs involved, including those in a supporting role, technology, reimbursement, time saved on facility costs, no-shows and cancellations that don't happen because of virtual visits to quantify the importance of digital health in the value we provide.

Q: I understand you have tracked your progress with the virtual visits for diabetic patients. What successes have you had there?

NP: Patients who would otherwise have to drive to the diabetes clinic can make a virtual visit instead and save hundreds of miles round trip. The time saved at the diabetes clinic for virtual visits right now is about six hours per patient per visit. That means a whole day of school the patient didn't have to miss to travel for their visit.

At a children's hospital like ours, many patients come from far distances to see our specialists. The burden of travel is significant. Offering care virtually can improve care and reduce disruption in the patients' lives.

Q: Have patients been willing to apply the new technology? Do you receive much push back from patients wanting to see their specialists in person?

NP: We are in the Silicon Valley, so we have tech savvy patients and families in our area and they have an affinity for trying new technologies and telehealth. We have been lucky with the number of patients and families willing to try the new technology. There are times when families prefer to come in person, and we develop a plan that works for them. Sometimes after they become comfortable with the diagnosis, they will do more visits virtually.

Q: How were the physicians with implementing telehealth? Did you encounter any challenges with implementing the new technology and workflow?

NP: We have a small but mighty digital health team. They support the first few visits the provider does and show the patients how to use the technology for their first visit. That has dramatically improved the comfort and uptake.

However, some providers are more enthusiastic than others. Our pain service has been a big utilizer of the telehealth visits because they don't need to conduct a physical exam every time. The frequent touches with virtual health visits yield better overall outcomes for their patients. We have also seen services such as reproductive endocrinology have a high uptake in telehealth because they don't need a physical exam; it's largely consultative.

Q: What are you excited about for the future of your telehealth program?

NP: The space will continue to evolve with policy and regulation, but I think it will become easier to participate. For hospitals like us, we are managing patients that come to us from all over the world and as the technology and reimbursement landscape evolves, we will be able to develop programs that are a truly connected care model.

We are also monitoring the patient's data regularly and using advanced analytics and machine learning to identify the issues and reaching out to them proactively to make care changes from a distance. There are some areas where we can engage this more fully, such as with diabetes or cardiac care, and those programs will continue to form into comprehensive care models.

We really take a strong approach to making sure the data comes into our enterprise systems so providers can integrate the data in their workflow. We've used Apple's Health Kit, and our patient portal directly uploads continuous glucose monitoring data into our EHR. We also designed our own analytics tool to process the data and put summaries directly into the provider notes so they have the information they need at the point of care.

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