Editor’s note: Joel Willis, DO, PA, MA, MPhiL is a Family Physician practicing primary and urgent care in Washington, D.C. He is currently serving as a Health Policy Fellow affiliated with the American Board of Family Medicine (ABFM) and the George Washington Medical Faculty Associates. Neal Sikka, MD is an Associate Professor and Attending Physician at George Washington Medical Faculty Associates. He also serves as the Chief of the Innovative Practice and Telehealth Section of the Department of Emergency Medicine. We discussed with them how telehealth at GW is helping to protect patients and providers during the COVID-19 crisis. Their experiences with the sudden rapid expansion of these services may provide insights for other facilities making the transition to use telehealth more extensively.

In his professional role, Dr. Willis has engaged in special projects as a special guest researcher with the National Institutes for Health (NIH) and as a guest researcher at the Agency for Healthcare Research and Quality (AHRQ). Dr. Sikka is the Founder and Chief Medical Officer of SonoStik, LLC and advises Emergency Medical Innovations, LLC.

Dr. Kendall Hall: Could you please introduce yourself, describe your role, and describe the telehealth system capabilities at GW?

Dr. Joel Willis: This is Joel Willis and I am a family medicine trained physician and I just completed residency at the Cleveland Clinic in June. I am doing a health policy fellowship with the ABFM [American Board of Family Medicine] here in DC and I have a clinical relationship with GW [George Washington] as a primary care physician. I was a Physician Assistant (PA) before I went back to medical school. As part of my role at GW, I have been working to put in place the system’s telehealth program. Additionally, I have been supporting some projects at AHRQ [Agency for Healthcare Research and Quality].

Dr. Neal Sikka: I am Neal Sikka and I am an emergency physician. I have been at GW since 2003. I did my residency here and joined the faculty there after. Early on in my career at GW, I got involved in department telehealth programs, which were probably ahead of their time. In addition to working in the ED, I lead our Innovative Practice and Telehealth Section, which is a group of like-minded individuals who seek to leverage emergency physician skills outside the hospital setting in unique and interesting ways that we think are the future of healthcare. Really thinking about how population management is going to be done, how telehealth can be integrated, how we can shift our roles into care coordinators.

Since 1989, GW has focused on maritime and aviation telehealth, as well as supporting remote research stations and remote teams in a variety of austere environments. We are one of the only academic centers that provides support to those industries. In these services we have used whatever technology was available, originally telefax and phones, now phone, email, and video, as per the client need. Over the last 5 years or so, we’ve really made an additional effort to leverage our remote medicine experiences to help our specialists. At GW, the Innovative Practice and Telehealth team is part of the largest multi-specialty group practice in DC, with over 700 physicians. We’ve made it our task to support those specialist and primary care providers in the development of telehealth programs.

Before COVID, while there was interest there were many barriers to implementing telemedicine services. Uptake was slow, but we found physician champion pockets here and there and worked on small projects with them individually. In 2016, we received a CareFirst foundation grant to develop a medical specialty telemedicine service from our academic health center to a DC-based FQHC [federally qualified health center]. We established a partnership with Unity Healthcare, which is an FQHC in DC, and started providing cardiology, nephrology, and endocrine telemedicine services right in the community. We’ve also supported other small programs here and there among various specialists who were early adopters.

In growing the business line in maritime and aviation telehealth, we built a 24-7 telehealth command center. That command center is uniquely staffed with EMTs and paramedics who serve as operators, but also serve as scribes for us when we are doing phone- and video- based teleconsults. They are excellent at screening medical data and following protocols. They have developed the familiarity with our clients’ needs and understand the workflow to deliver the medical services effectively in collaboration with our clinicians. They also handle the basic technical support component of connecting people to telehealth.

At the originating site where the patient is, whether in DC or in the middle of the ocean, we need to extend our eyes, ears, and hands to evaluate the patients. We have developed training for telepresenters to help them best serve in that role, as well as the patient’s advocate to help us complete those consultations. Beyond that, we have also developed residency training and a dedicated fellowship training program for emergency physicians who want to become telehealth leaders in their future carriers.

KH: It sounds like you have a lot of experience in telehealth. So it’s not that you are working to establish GW’s infrastructure, you are just using it in new and different ways?

NS: Yes and no. Yes, we have this infrastructure but because of the existing regulatory and reimbursement barriers, our model did not fit traditional insurance-based care. In maritime and aviation telehealth, we’re using a subscription model and fairly straight forward video platforms. We also have special requirements for some of our maritime and aviation clients who are in very low bandwidth environments. Our command center can support telehealth requests or concerns from the maritime and aviation clients since the program is moderate in scale without many of the barriers incurred in traditional medical practice paid for by a third party. Now when you look at what we are trying to do with a physician group of 700, with hundreds and thousands of patients and thousands of visits a day, we need to consolidate and use a single platform and manage the requirements under our payer contracts. We must train all the physicians, train all of our staff, and make sure that this regional telehealth that we are providing to our patients domestically stays consistent. Our experiences apply, but the model has to be quite different.

JW: Neal had mentioned that there are these pockets of interested parties that they were working with within the GW medical system prior to COVID. One of those pockets would be the primary care clinic I work in. Neal has this excellent and overarching view of where telemedicine has come from at GW, where they are going, and how accelerated it has become. I am on the ground, at a facility that wasn’t using telemedicine 6 months ago and is now suddenly using it quite extensively. Ironically, at my facility the idea of using telemedicine came about pre-COVID but the pandemic accelerated the adoption. I was the initial person at the facility trained to use telemedicine and that was only a couple weeks prior to COVID arriving in the area. One of the challenges that I’m experiencing with implementing the technology is that it is being rolled out in an almost “wild west” fashion because we have to get it up and running so quickly.

KH: Let’s talk about the use of telehealth as a patient safety tool during the COVID crisis, particularly in places like the emergency department (ED).

NS: We started thinking about how to ramp up our telehealth capabilities to improve safety early. We knew we were going to have issues with an unknown “hot zone” in the ED where the risk of transmission from infected individuals is highest and then a cold zone, or clean zone, and that we would need to minimize the interactions between the two. However, interestingly enough, the accelerant for our telehealth systems actually came from our outpatient providers who care for immune-compromised patients. I got emails from a rheumatologist and an allergist and they said it’s too dangerous for their patients to come to the clinic, and they had to go online immediately. Within about a week, they were our first specialists who took their care online. They were aggressive and proactive about it because they were really worried about their patients. These specialists that initially reached out to us trained the rest of their colleagues under a “train the trainer” approach. We were able to learn from their experiences and then expanded across the entire organization from the outpatient perspective.

From an ED perspective, I was struck by how difficult it is for providers to have to get in/out of PPE countless times a day to go see patients. That’s when we started looking at how we can use telehealth to protect our providers within the hospital space who are taking care of patients who are potentially infectious. Now, if you come through our ED, all of the crash carts, respiratory care supplies, all of this equipment that used to live in the rooms now stays outside and gets handed in to the hot zones as you care for the patients. Then we started to think about how we could implement video conferencing to help us communicate provider to provider. For example, thinking through how we could have a specialist do stroke telemedicine in much the same way they would from outside the hospital, but in this case from just outside the patient room, so that only one person has to put on the PPE. We are evolving that approach in multiple different areas.

The next phase that I am starting to work on now is remote patient monitoring. If we suspect you have COVID, and you are not sick enough for inpatient care, in many cases we want to send you home. However, how do we keep tabs on you? We know that with this virus you can have a decline in your function and we want to make sure that we recognize that as early as possible so that care can be escalated.

KH: How do you continue to provide high-quality care when it’s now more hands-off?

NS: I think you can definitely do things to optimize care. Some of the strategies we focus on are really basic. How do you provide an engaging experience that reflects your excellent bedside manner through video? Lighting, pacing, your volume of voice, eye contact, camera positions are all basics and part of our core training. There is something called, “the master interview rating scale” that we’ve done some working on adapting to telehealth. Some faculty at Old Dominion University have done more extensive work with these skills and using that as a tool to give people feedback on how to improve on their telepresence, specifically for telehealth type of care.

In the hospital setting, there may be opportunities to reduce use of PPE and infectious exposure, but the patients still need an exam. For example, let’s say there is a possible stroke. It’s imperative that emergency physicians evaluate that patient because there are many conditions that mimic stroke. Our focus is the evaluation of the unscheduled, undifferentiated patient, and if needed we bring in the right consultant. We want to make sure we maintain this evaluation model in the ED even when using telemedicine. So in this example, under one of our new telehealth protocols maybe you will have the ED resident, the ED attending, neurology resident, and the stroke nurse all seeing the patient at the same time. However, there’ll be only one person that has their hands on the patient but everyone else will be observing through video and able to give feedback. The hands-on person becomes the telepresenter as well as the treating clinician. We will probably become even better at doing our exams because under this protocol we receive real-time input and feedback on the physical examination and how the information is gathered by the telepresenter. I think there are going to be some potential improvements for patient safety from that perspective. We have to get good at observing some of the other cues from the hands-on exam. Is the patient wincing, for example? If we are not comfortable with the way the exam is done, we have to direct the telepresenter to do it better and, in turn, they will get better at it over time and improve the accuracy of those exams. I think when we come out of all this, you might see thinking evolve around which providers need to be in the patient’s room when one person can do the exam and rest of can observe and provide input.

JW: Bedside manner is even more important in telemedicine, at least in my experience. Your ability to connect with the patient, to communicate with the patient. If you’re bad at that in person, you are going to be worse with telemedicine. So it’s important to find ways to train providers to be thinking about that and to be establishing a connection because now you are going to be doing that at a distance, whether that is with audio, or with video and audio. With regards to the no-touch physical exam, from a primary care world/outpatient primary care perspective, you are used to laying hands-on patients. However, now given our situation with COVID you don’t want to be too close to that patient and we have to think creatively about how you can do some of the physical exam remotely. The current situation is evolving so quickly and forcing us to use telemedicine, we find we need to consider workarounds regarding how to provide a physical exams. 

NS: Just last night we were recording a video showing how a clinician can walk a patient through an Ottawa ankle rules evaluation to determine if they need an x-ray. We were also walking people through a brief neurologic exam, giving different types of pointers on how you might assess strength, or thinking about when on video you sometimes have mirror imagining. You have to be cognizant of that when you are directing people to look to the left or right, it can be confusing.

KH: Can you talk about how are you training your staff so quickly? Are you using simulations?

NS: I think if we had more time, we would definitely use simulation and mock patients. The initial training is all about the webside manner, or telepresence, that’s critical to getting patient engagement. It is focusing on the cognitive consults and having a really good conversation with the patient and coming away with a good understanding of what is going on. We know that 80% of what is going on with the patient is in the medical history. In the near future, I would love to get people to do mock or standardized patient encounters and get feedback from standardized patients. That’s something we’ve been trying to develop for nursing students, medical students, and PA [physician assistant] students. Everything was moving along at a slow pace, and suddenly there is COVID. So the pacing for training has slowed down but everything else has accelerated.

KH: As you’re implementing this system, are there any patient safety concerns that this is raising for you?

NS: Some of the concerns have been around patients not being able to connect and that they are then not getting care because of technical challenges. We are trying to figure out a workaround to help onboard the patients sooner, like having someone call ahead of time and make sure the patient can connect. We do have an escalation protocol that we put out as guidance. If you are concerned about a physical exam finding or a history finding, you need to triage that to an urgent in-person visit, could be the same-day or next-day clinic visit. It could be that the person needs to go to the ED. There is a protocol around how you use the patient or the family caregiver to get that person to the ED, and then notify the ED. Lastly would be how do you escalate that to 911 if there is something you’re really concerned about and making sure you convey that information to 911, while still supporting the patient.

JW: I think it is a little bit different from a primary care perspective. If I was a provider that had 1500-2000+ patients and I had started some on new medications and I’m waiting on labs, I would be nervous. You don’t really want patients coming in for unnecessary blood work, but at the same time you know there may be something you need to follow-up on because it’s more urgent and you’re worried. On some level, it’s going to be practice dependent and provider dependent. But like Neal was saying, I think that this may be pushing us to pay more attention to medical histories and conduct a deeper analysis of a patient’s chart before we see them. For example, tomorrow I have clinic and I have already looked at all my patients to decide who I actually need to physically see, who can be transitioned to telemedicine, what labs does this person need that can wait, and what labs might they need to have now. Some providers do that anyway, but this current milieu has forced providers to think more strategically about upcoming visits. The goal at our clinic, like that of many all over the country I’m sure, is to lower exposure risk by keeping people from coming in unnecessarily and handling things remotely when we can.   

However, I do worry about patient safety and the diagnostic errors that could result. Staying in communication with your patients and tapping into your medical assistants and nurses for follow-up care can help troubleshoot potential errors. Another area of concern I have is for our elderly patients who often have the most co-morbidities and medications to manage and may simultaneously have the most difficulty transitioning to this new technological world we find healthcare using.

KH: Let’s talk about patient safety from an information security perspective. What about HIPAA requirements? Do you have patients on a secure platform?

NS: Before COVID, you were required to have a HIPAA compliant video platform, encrypted video, and you needed to have a BAA [business associate agreement] with your vendor. These requirements were definitely a barrier to setting up a system and it was often a challenge to get that BAA executed. Under the CMS emergency declaration waivers, you actually don’t have to use HIPAA compliant video [a video that is not encrypted] and you don’t have to have a BAA in place. That being said, I think it is still incumbent on us as healthcare providers to prioritize patients’ safety, security, and privacy. Therefore, while we have the option to use non-HIPAA compliant video, we have made it our organizational priority to stay within our HIPAA compliant platform. That way we will also continue to meet all the HIPAA requirements after COVID.

JW: There are also simple things you can do to ensure you remain HIPAA compliant. For example, if I am calling a patient through telemedicine, I don’t want a whiteboard in the shot behind me with patient names on it. Having a dedicated space for telemedicine visits can help to avoid making small mistakes that break HIPAA rules.

NS: Absolutely, we put those considerations into our training – what can go behind you, using headphones to keep conversations private, things like that are important.

KH: What kind of advice do you have for the facilities ramping up their telehealth services? Are there any lessons, pointers, or best practices you can share?

JW: Certainly going through some telehealth provider tutorials, like the one that they offer here at GW, and familiarizing yourself with some of the basic concepts. These include making sure you have a good audio/visual connection with the patient as well as making sure you are talking to the right person and that they can see you. As a family medicine physician, I call my patients all the time to discuss their lab work and what is going on with their overall care. Although in the past I wasn’t necessarily seeing them, billing them, or creating a telemedicine note during such communication, I do feel I was performing a derivation of telemedicine for a long time. Realizing that this type of communication isn’t foreign to a primary care practice can help with understanding and utilizing telemedicine to its fullest potential. The realization that you probably already have many of the skills you need to incorporate the new level of creativity being demanded to serve your patient panel can help ease the transition. 

NS: You need to have processes and procedures in place to manage registration for patients who are not coming into the office. There is a workflow change there. How do you confirm their insurance? How do you potentially collect their co-pay? That may or may not be available within the video platform you purchased. You need to have a mechanism to get consent from your patients. Many states require a separate telemedicine consent. You absolutely need to walk them though a consent statement and verify a phone number you can call them back on if there is a technical difficulty. You need to have an emergency escalation plan. You should probably write out a security and privacy policy that addresses the things that we discussed as well as where and how people are going to conduct telemedicine. These don’t have to be books, they can be  one-page documents. It’s a reminder that’s written, it’s the policy and procedure that everyone can be held accountable against. I think you should have a quality assurance plan as well, just like we have M&M [morbidity & mortality] and patient safety conferences for cases that have both good and bad outcomes. It’s important to have the same policy and procedures in place for in-person care as you will for telemedicine care. When you look at implementation of a telehealth program, with both small and large practices it typically takes months to a year to develop. Therefore you need to be thoughtful when you’re doing multiple months/years’ worth of work within a few short weeks. Having a really good team is of critical importance and you need to be working collaboratively with the CMIO [Chief Medical Information Officer], the informatics team, and IT folks as well as your practice administrators. You need to think about how you’re going to re-train your support staff, rethink your workflows, train your providers, identify the champions, reallocate the technology that’s available to you. You need to get buy-in from the larger organization, the executive leadership. That is critically important for any large cultural and technological change.   

JW: I would look over your schedule frequently, I would make sure the technology works, I would create a workflow like Neal mentioned for support staff. Those are some basic things you could do. And the final thing, which is communicate with the patients themselves. I think the key is communication at this point, now more than ever.

KH: Is the anything that we have not discussed that you would like to add?

NS: This is an incredible time to try telehealth services in your facility. Especially with social distancing, we have to prioritize patient access and patient and provider safety right now anyway. Additionally, the regulatory environment with regards to licensure, privacy, security, and payment, all of these barriers have been reduced and patient interest in telehealth is at its peak. This is an opportunity to try telemedicine, to see how it works with your patients. It’s an opportunity for practices to attempt to provide care in a new way that they were maybe afraid to do before.