How to Make Telemedicine More Equitable

Summary.    One of the risks of telemedicine is that it can reduce disadvantaged populations’ access to health care. But as Harris Health System, which serves metropolitan Houston, found, it also can be a means for expanding such access. Its model entails training clinicians,...

Telemedicine, which provides a way to safely coordinate and deliver care to patients from a distance, has gained popularity in recent years among doctors, patients, and health systems. But its widespread acceptance was dramatically accelerated by the Covid-19 pandemic, which has given patients timely access to care without exposing them to the risk of contracting the coronavirus. However, it also poses a risk of widening inequities in health care in the United States by improving care for those who already have access while leaving behind those who are in need. As the pandemic has highlighted, the disparity is already huge: More than 31 million Americans were uninsured in 2020, limiting health care access during the worst public health crisis in decades. Therefore, it is vital that telemedicine be implemented in a way that closes, rather than increases, the gap.

The approach taken by Harris Health System, the safety-net health care system for Harris County, Texas, can serve as a model for using telemedicine to improve access for disadvantaged populations. Harris County, which encompasses metropolitan Houston, is the third-most-populous county in the United States and has a large indigent, multilingual, and multicultural population — many of whom lack health care insurance. (Texas is the U.S. state with the highest proportion of uninsured residents.)

Harris Health launched its telemedicine service in March 2020; in the first year, we conducted more than 500,000 video or telephone visits. Since the beginning of the pandemic, we have conducted more than 40,000 new patient visits (i.e., those with people who had not seen a provider in our system for at least three years) using telemedicine. Of those, nearly 60% were economically disadvantaged patients who qualified for either charity care or Medicaid. The no-show rate for all Harris Health telemedicine visits was 40% lower than for in-person visits (14% vs 23.3%). Importantly, people of color accounted for a higher proportion of telemedicine visits than for in-person appointments (86% vs 80%).

Here are the crucial elements we think are needed to produce successful results.

Invest in training.

Telemedicine is a fundamentally different way for patients and physicians to experience health care. For example, most physicians do not routinely ask patients at the beginning of an encounter, “Can you see and hear me clearly?” Yet, this is an important first step when conducting a video visit.

It’s unrealistic to expect that physicians will be experts at telemedicine from the start. Therefore, upfront investment in training is critical. Virtual interactions require physicians to be especially adept at the “soft” skills of medicine: empathy, clear communication, and flexibility. It can be challenging to teach even seasoned physicians to adapt these skills into a virtual format. Therefore, a shift to virtual medicine requires such training at all levels of medical education.

At the outset of implementing telemedicine, each department at Harris Health defined the ideal scenarios for virtual care and identified patient needs that were amenable to being addressed via telemedicine. For example, patients in need of chronic disease management are better candidates for video encounters than those in need of well-woman exams that require sensitive physical exams. Our physicians established the optimal virtual care modality (video or telephone encounter) and best-practice approaches for virtual patient examinations unique to their field of practice.

We then developed training videos, tip sheets, clinical practice guidelines, and workflows to assist each department in integrating telemedicine into care. A systemwide checklist helped guide departments; it included items such as identifying virtual care providers, setting training standards, and integrating language-translation services. Training tools are continuously revised and best practices are shared at monthly meetings with all clinics. Centralized staff monitor patient satisfaction scores and work directly with team members when opportunities are identified for improvement.

Telemedicine skills are not yet routinely taught to medical students or resident physicians in training. However, in the past year, our medical school, McGovern Medical School at the University of Texas Health Science Center (UT Health), developed courses to train the next generation of clinicians in this means of care delivery. For the first time, in July 2021, a telemedicine elective was offered to students who then rotated in a myriad of specialties, including neurology, emergency medicine, and psychiatry. In addition to learning core elements of each specialty, our physician trainees are also given the opportunity to develop their “web-side manner” by practicing on-camera etiquette and setting the stage for a safe and comfortable environment for patients. With telemedicine poised to play a larger role in care delivery, we aim to train the next generation of health care professionals to become equally proficient at caring for patients in-person and virtually.

Anticipate patients’ needs.

Before a health system establishes a telemedicine program, it is imperative to understand how and why patients will use telemedicine.

Technology Access

Crucially, health systems must carefully consider their patients’ access to essential technology required for telemedicine encounters, including broadband internet, computers with webcams and microphones, and smartphones with reliable data services. Prior to the large-scale implementation of telemedicine across the health system, Harris Health had experience designing and operating a smaller pediatric tele-psychiatry program; it began operating in November 2018.

With the experience gained from that program’s treatment of a cross-section of the patient population, Harris Health was able to anticipate its overall patient population’s access to internet and camera-capable devices. Building on that foundation, our telemedicine service was expanded first to patients suspected of having Covid-19 and then to the wider community.

Integrated Care

Before telemedicine implementation, health systems should thoughtfully consider how patients will use the service. Is it for routine longitudinal care, “a holistic, dynamic, and integrated plan that documents important disease prevention and treatment goals and plans,” or is it for acute unscheduled care? Will the target patient population already have established primary care providers within the system? Or will telemedicine be their initial encounter with the health system?

An isolated telemedicine visit is unlikely to have long-term impact on a patient’s overall health unless it is integrated within specific services, particularly primary care. But a key benefit of telemedicine is its ability to link patients to longitudinal care within health systems that are often difficult to navigate. Therefore, telemedicine can be a critical entry point to provide comprehensive health care services for patients who have not had regular access to medical care.

One especially challenging population is homeless individuals. Rather than enjoying integrated and continuous care anchored by a dedicated provider, homeless patients are more likely to seek piecemeal and fragmented care from a collection of providers who often are in separate health systems. To address this, Harris Health partnered with community shelters to create telemedicine hubs that are accessible to the county’s homeless population so they, too, could receive the same consolidated care as other residents in the county. More than 130 homeless individuals have utilized this service.

Interpretation Services

Another important consideration is patients’ preferred language for communicating with their physicians. Integration of professional medical interpretation should be easy for the physician and seamless for the patients. This is especially important for areas of the country with large immigrant communities. Given that the majority of our patients speak a language other than English, we made sure that interpreters were readily available for video visits. (Harris Health relies on two sources of interpreters: its own, which it has trained and who have been working from home during the pandemic, and those provided by an outside vendor when demand is high.)

Optimizing this service took several attempts. Initially we relied on the physicians to call the interpreter when needed. However, this created more work for the doctors and sometimes long queues to wait for an interpreter. So we adopted new technology. It allows a member of the clinic’s staff (typically a nurse) to initiate a request for an interpreter just prior to the patient’s virtual appointment with a physician that first is routed to Harris Health-employed interpreters at home. If one isn’t available, it automatically transfers the call to the contracted vendor.  The interpreter logs into the virtual room assigned to the visit and waits until the physician initiates the visit. This smoother process improved satisfaction among both patients and staff.

Pick the most effective types of providers.

Doctors do not always have similar attitudes towards virtual care delivery. Each medical specialty naturally has different proclivities, and some skills more easily translate to telemedicine than others. Using the least costly medical providers may not always deliver the best quality or value to your patients.

Generally, registered nurses, nurse practitioners, or physician assistants — who are less costly than physicians — operate health systems’ advice lines.  Typically, patients call an advice line to find out whether their medical condition is urgent or emergent.

Our health system operates a busy “Ask My Nurse” phone service that’s operated by registered nurses. As part of the care protocol, patients who call in are divided into three categories: low-risk patients who require outpatient follow-up with a primary care doctor or no further treatment, high-risk patients who should call 911 immediately, and medium-risk patients who should proceed to the emergency department (ED) but don’t need an ambulance or can have a telemedicine consult with an emergency physician during daytime hours.

We added the telemedicine option for medium-risk patients in November 2020. We realize that using emergency physicians in this manner is not the approach employed by many health systems; their phone triage services rely on primary care physicians, physician assistants, nurse practitioners, or outpatient sub-specialists to determine whether an ED visit is necessary. But we opted for emergency physicians for two reasons.

First, we realized that many patients being referred to emergency departments could be evaluated via telemedicine and potentially avoid long, costly, and unnecessary ED visits. Second, emergency physicians’ expertise spans the entire spectrum of patient populations, including children, pregnant women, and surgical and geriatric patients. Consequently, they excel in routing patients to the most appropriate types of care such as outpatient primary care, general surgery, or other specialist clinics. This allowed us to reduce ED visits by medium-risk patients who called Ask My Nurse by more than 70%.

This approach also allows us to maximize the efficient usage of our two acute care facilities. Our telemedicine emergency physicians have access to the electronic-medical-records system, which shows bed availability and wait times. They triage patients to both emergency departments based on real-time capacity and capability data. In one instance, when one of our hospital’s MRI machines required maintenance, physicians were able to send patients who might have required an MRI scan to the hospital with the functioning machine.

Always have a backup plan.

Numerous external factors can make video visits challenging. The target population may have financial or geographic barriers to accessing a computer, smartphone, or high-speed internet. Elderly patients may face challenges using new technologies. As part of our workflow a non-physician staff member reaches out and ensures the patient has the proper technology and resolves issues prior to the telemedicine appointment. Additionally, our physicians are trained how to troubleshoot common technological problems. While it is easy to build a one-size-fits-most approach in telemedicine, a thoughtful and flexible approach should be taken in reaching those with the greatest challenges in accessing care.

Separately, since some patients will require an in-person evaluation, care sites for such patients should be identified in advance. Harris Health has 25 outpatient centers, which are spread out over an area larger than the state of Rhode Island. We strive to provide care in a location close to a patient’s home. Therefore, we try to arrange telemedicine visits with staff from the same clinic the patients would see in-person. We believe this improves continuity of patient care.

The Covid-19 pandemic has forced a rapid evolution in technology with the potential to help the most disadvantaged patients. Our experience during the pandemic has demonstrated that telemedicine can overcome access-related challenges faced by indigent populations. By allowing them to access care in their homes or even their jobs, it can help them address health issues expeditiously with minimal disruption to their lives. But telemedicine has to be integrated into the overall health system. When designed in a way that takes into account patients’ needs and limitations and optimizes the strengths of a health system’s capabilities, telemedicine can help make health care in the United States much more equitable.