COVID-19 accelerates the adoption of telehealth

At the beginning of 2020, Children’s Wisconsin anticipated it would hold roughly 1,500 virtual appointments with patients by the year’s end.

The pediatric health system has offered telemedicine for the past year, but leaders set conservative targets for virtual visits this year with the assumption that it would take some time for patients’ families to warm to the format.

But those early-year projections didn’t anticipate the disruption of COVID-19 and how it would alter health systems’ delivery of care within just a matter of months.

In April and May alone, the health system held 30,000 virtual visits across its locations.

Children’s is among health systems across the state that quickly pivoted from providing primarily in-person doctor’s visits to offering remote phone and video appointments during the COVID-19 crisis.

Now, as clinics and hospitals reopen their doors, health care providers say telehealth is more than just a stop-gap measure in response to the pandemic.

“The general belief is that the genie is out of the bottle,” said Christopher Neuharth, executive director of digital health and experience at Children’s Wisconsin. “...There’s a preference for more convenient and digital channels for these things. Once you remove those barriers, it’s hard to put them back up. We see video as the tip of the iceberg.”

Before the COVID-19 outbreak, telehealth had been gaining momentum in the state. In November 2019, Wisconsin Gov. Tony Evers signed legislation that required Medicaid to reimburse for some telehealth services, joining a growing number of states to adopt similar practices. In recent years, each of the region’s major health systems has rolled out and promoted its own version of virtual visits.

Still, the practice of consulting with a doctor by phone or video hadn’t quite hit the mainstream.

“Many major systems have used telehealth, especially those delivering services over a wide geographic area for consults and follow-up,” said Mark Kaufman, chief medical officer for the Wisconsin Hospital Association. “What’s changed with COVID-19 is both patients and providers have been forced to leverage telehealth and have realized the benefits that it offers. In the past, it was more of an option, especially with geographic distance, but now people, with COVID-19, have understood the power of telehealth.”

At Ascension Wisconsin, the number of providers using the system’s virtual visit platform has grown from 10 to more than 1,000 in under a year.

For physicians who had been hesitant to transition from providing in-person to virtual care, COVID-19 shortened the learning curve, said Dr. Patricia Golden, an osteopathic physician with Ascension Wisconsin.

“If you ask clinicians now, we are in a much different place than we were even four months ago,” Golden said.

As of early June, Ascension Wisconsin had completed 120,000 virtual provider visits to date this year, far surpassing the system’s goal of 20,000 for the fiscal year.

“The door had been there, cracked open slightly. But now the door is wide open,” said Dr. Dirk Steinert, an internal medicine and pediatrics provider with Ascension Wisconsin. “Physicians are feeling much more comfortable with (virtual care).”

Insurance companies’ coverage of phone and video appointments during the crisis has helped enable the wide-scale use of telemedicine in recent months.

Prior to the pandemic, Ascension Wisconsin utilized telehealth, particularly for specialist appointments with patients who live in rural areas – a service that is paid for by Medicare and Medicaid.   

As health care providers reopen, questions remain about insurers’ willingness to cover telehealth more widely moving forward. Steinert said the health system is negotiating with insurance companies to “allow improved engagement with our patient populations and communities, including secure telehealth visits.”

“It appears as if the payers are very interested in supporting this,” he said.

Kaufman said it is yet to be seen how government sources will choose to reimburse telehealth services moving forward.

“It depends a lot on whether state and federal agencies are going to revert back to previous restrictions on telehealth or keep … the expansion of coverage and payment per services that were created related to the COVID-19 epidemic,” he said. “... It’s a little bit unknown going forward.”

Patient satisfaction surveys and appointment cancellation rates suggest patients are generally pleased with the shift to virtual care, Kaufman said.

“(Patient) satisfaction has been high,” Kaufman said of WHA’s member hospitals’ survey results. “Cancellations have actually been lower than for in-person visits.”

Though promising, telehealth is not a silver bullet. Any appointment that requires an in-depth examination, for example, won’t translate to a virtual format.

“The limitation with this is if the physician or provider needs to examine a patient,” Kaufman said. “That’s the physical exam and that’s key to diagnosis. … That’s not going to happen with any telehealth platform. (But) a great percentage of health care can be delivered safely and adequately through talking with a patient.”’

In particular, Kaufman noted virtual visits are helpful for patients with chronic illnesses that need to be monitored continually.

“Going forward, it’s part of the solution, but certainly there are many procedures and visits that are really enhanced by in-person interactions.”

In general, virtual care is more convenient for patients, caretakers and those accompanying their loved ones to visits, health care leaders said.

It also provides physicians with a better view into a patient’s home life, giving insight into the social determinants that may affect their overall health.

During the COVID-19 crisis, Steinert and his team have been reaching out to at-risk patients, inviting them to do virtual visits to check in on their mental and physical health.

“It’s been an eye-opening experience for us as clinicians,” Steinert said.

For example, Steinert has offered nutritional recommendations after seeing the contents of a patient’s refrigerator and helped patients dispose of outdated medication after looking inside their cabinet.

“You can kindly support them in cleaning that clutter out and decrease potential errors in the future,” he said. “For patients to allow you to come into their homes, it is a precious gift – and one that we respect and honor.”

Leaders of Children’s Wisconsin – which is in a multi-year $150 million initiative to expand mental and behavioral health care for Wisconsin children – said telehealth has been key to expanding access to health care for its patients, particularly in the area of behavioral health.

“That’s one of the things our mental and behavioral health team is most excited about,” Neuharth said. “We’ve been looking for every angle to expand access. Before, it’s meant having to pull a kid out of school or parents to get off work early. That’s now removed.”

Of Children’s 30,000 telehealth visits held in April and May, about 9,000 of them were for mental and behavioral health services. That particular category of services has seen a 98% conversion from in-person to virtual visits, Neuharth said.

Physicians have found the format eliminates some barriers of a traditional clinical environment, helping put patients at ease more quickly.

“For some of our kids with developmental delays or feeding problems, it can sometimes take an entire clinic visit to make them feel comfortable, but in their homes, we are getting much better information right away,” said Dr. Kimberly Cronsell, medical director for digital health and experience at Children’s Wisconsin. “One of those components is, when children are at home, you can see specifically what their physical environment looks like and do exercises and other things with them in their home. … You can get a much more authentic view of the child and their family and get to the heart of the matter more quickly.”