Connected Health Case Study – The GW Medical Faculty Associates ConnectER Program: Managing Follow-Up ER Visits with Telehealth

Practice Overview: The GW Medical Faculty Associates was incorporated in July 2000 as a non-profit, physician-led practice group that is affiliated with George Washington University Hospital and the George Washington University School of Medicine and Health Sciences. The GW Medical Faculty Associates physicians provide comprehensive patient care, offering one practice for the whole person with 52 medical and surgical specialties.[1] The GW Medical Faculty Associates is now participating in the CMS Medicare Shared Savings Program Accountable Care Organization (ACO), which is designed to provide high level of access and coordination of care that is needed to better care for Medicare Fee-For-Service beneficiaries by; Promoting accountability for the care of Medicare fee for service beneficiaries; Requiring coordinated care for all services provided under Medicare fee for service; Encouraging investment in infrastructure and redesigned care processes.[2]

Important Components of Designing an eVisit Program:

  • Principles of Practice and Licensure Requirements
  • Application of Technology
  • Establishing a Relationship
  • Evaluation and Treatment
  • Privacy and Security
  • Formalized Policies – Prescribing, Operations, and Parity
  • Continuity of Care and Follow Up

 

 

 

 

The Medical Faculty Associates’ ConnectER Program is a telehealth service for George Washington University Hospital Emergency Department follow-up visits. This program is designed to leverage telehealth for increased continuity of patient care, quality of care, patient engagement, and operational efficiency after a patient receives treatment in the emergency room. The consultation consists of a 15 minute online visit for a flat fee of $35.00 for a range of minor illness, minor injuries, and skin conditions. The consultation uses existing technology and platforms like Microsoft Lync/Skype and FaceTime to connect patients to providers. Of note, this fee is set at an affordable rate for patients; as the program serves as a launching point for broader telehealth, remote monitoring, and care coordination initiatives. Additionally, The GW Medical Faculty Associates has had telehealth in place since 1989, providing maritime telehealth services, therefore, the investment was minimal, as much of the infrastructure (both technology and staff) were already in place.

 

 

Patients often seek treatment in the Emergency Department setting, as it is convenient. However, patients with relatively minor complaints may experience long waits when the ED is congested, creating frustration for patients and challenges for the ED. The GW Medical Faculty Associates has created a win-win situation for patients, George Washington University Hospital, and itself by leveraging technology, alleviating the pressure on George Washington University Hospital ED staff, maintaining continuity of care for patients, and increasing satisfaction for all parties by providing an alternative for post ED follow-up visits. In fact, the ConnectER Program was originally launched out of The GW Medical Faculty Associates’ Innovative Practice Section. This section seeks to provide value and efficiencies to the dynamic actors in the healthcare system while fundamentally reshaping healthcare delivery by leveraging telehealth and other health IT. Because patients in Washington, DC often must wait 15-30 days to get an appointment with their primary care physician, ED follow up was considered an optimal place to initiate follow up services using digital technology. Those that return to the ED for follow-up care contribute to congestion which hinders the ability of the ED to serve as an effective gateway for inpatient care and have an increased likelihood of contributing to the Left Without Being Seen rate, which is trending higher, and has patient satisfaction implications.

Although The GW Medical Faculty Associates is located in an urban setting, in downtown Washington, D.C., the use of telehealth for follow-up care provides a convenient means of care for patients at a cost-savings to the organization, and ultimately provides a competitive edge by keeping its patients within its provider panel.

Upon discharge from the emergency room, patients are identified for participation in the program based on a pre-determined list of conditions, the Emergency Severity Index number assigned to the patient, and the provider’s medical judgement. Web and Paper based marketing collateral, as well as discharge paperwork explaining ConnectER is provided to the patient at the time of discharge which the nurse discusses with the patient to make sure they understand that the program is an option for them. Collateral includes information on requirements to participate in the program, the benefits of participation, and information regarding timeframe to follow up with the provider and contact information for scheduling. In order to participate the patient must be discharged from The George Washington University Hospital Emergency Room within 15 days (establishment of the patient provider relationship) and be located in DC, Maryland, or Virginia at the time of the appointment. Appointments are available from 9 am to 5 pm Monday to Friday and the appointments are scheduled to last 15 minutes in duration.

Telehealth technologies used at MFA:

  • VOIP
  • Smartphones
  • Digigone Secure Video Chat and RVS
  • Outlook email, Lync/Skype
  • Allscripts EMR
  • MIE EMR
  • Audiovisual platforms such as Microsoft Lync/Skype and FaceTime

The GW Medical Faculty Associates uses a telehealth call center, called the WECC (Worldwide Emergency Communication Canter) directed by a Paramedic and staffed by EMT operators. Patients contact the WECC via phone or email to schedule an appointment, test their video connection, and receive HIPAA and Consent materials. The Operator staff provides a professional first level screen of patients and an effective communication hand-off to the physicians who are the telehealth providers. Communications with scheduled patients contain a web-link to the browser-based video appointment with information to access the virtual platform in which the follow-up encounter occurs. The center operator also distributes and collects a digital or signed consent form. The consent process also aims to leverage video in the future to cover items included in the consent documentation. The consent document includes language that covers the use of the technology, technical difficulties that may occur, and information regarding the patient that is shared with other individuals for billing or scheduling purposes. The consent document also outlines a course of action should the follow-up visit require returning to the point of care and the ability for the patient to terminate the video consult at any time by right.

 

Physicians and healthcare providers utilizing the Medical Faculty Associates ConnectER platform are issued practice guidelines and training prior to conducting a virtual visit. Guidelines for telehealth visits includes establishing principles of practice, overview of establishing the physician-patient relationship, definitions and terms related to telehealth, guidelines for the use of telehealth, and ethical standards. This policy includes elements of physician licensure requirements and capabilities for providers to write prescriptions (at the discretion of the The GW Medical Faculty Associates provider). In addition the practice guidelines highlight the expectations for continuity of care (patients should see an attending provider from the ER) and requirements for record keeping (communications via email, prior health record, and notes of the telehealth encounter should all be kept per The GW Medical Faculty Associates  Practice guidelines).

Principles of practice for Connect ER include:

  • Place the welfare of patients first;
  • Maintain acceptable and appropriate standards of practice;
  • Adhere to recognized ethical codes governing the medical profession;
  • Properly supervise non-physician clinicians; and
  • Protect patient confidentiality.

From an operational perspective providers are given information regarding the elements of a successful virtual consultation. The timing of the visit is ideally no more than 15 minutes in length, but the visit will not be cut short if a patient requires more time, nor will the price change. Scheduling is handled by a centralized team of staff. Both the physician and patient receive a notification regarding the consultation.   Providers should also sign into the EMR and review the patient’s record prior to conducting the encounter. From a technical and aesthetic perspective, MFA providers are encouraged to consider their surrounding environment when conducting a virtual encounter. This includes ensuring a proper location that is well lit and private. In addition providers are given information regarding “bedside manner” for the visit. Details for how providers can optimize the patient experience when conducting a virtual visit can be found in The GW Medical Faculty Associates Connect ER Operational Guidelines. Providers are also encouraged to arrive early to ensure a working connection to the consultation platform. Providers are also instructed to provide their name, title, specialty, and location. They should also verify the patient’s identity, date of birth, and present location. In the event of an emergency, the provider is instructed to have the patient call 911, have the call center operator call 911 for the patient, or call 911 for the patient themselves. Finally, documentation guidelines from the visit should include an assessment of the patient, both physically, and their capabilities to operate the devices and technology used in the virtual consultation. Support numbers for the providers and patients are also widely disseminated in the event that there is a challenge establishing a connection or technical difficulties regarding the video consultation arise.

Key Components of the Operational Guidelines:

  • Timing
  • Environment
  • Consultation Guidelines
  • Emergency Care
  • Documentation
  • Support

The GW Medical Faculty Associates will continue to assess the effectiveness and impact of this novel telehealth business model. The important components that will be reviewed for modification will include the following:

  • Review of behavior change (both the provider and the patient)
  • Effectiveness of marketing initiatives to create awareness of the ConnectER Program among providers in the Emergency Department and the patients
  • Call center staff following up with discharged Emergency Department patients to ensure they are aware of telehealth as an option for their follow-up care
  • Effectiveness of education for providers (to ensure they are effective in providing virtual care)
  • Assessment of effectiveness of education for patients (to ensure the virtual encounter has the same impact as a face to face visit)
  • Analytics, i.e., a comparison of metrics to determine the number of referred ED patients who engage with the service versus the number of referred ED patients who could have taken advantage of the program but did not.
  • Analytics to determine if the Medical Faculty Associates ConnectER program is having an impact on the Left Without Being Seen rate and the impact on Length of Stay in the ED.
  • Assessment to determine if the ConnectER Program is increasing the patient perception of the GWUH as a whole and the ED, the The GW Medical Faculty Associates, and the ED physicians.

The results of the above will impact the sustainability and scalability of the Medical Faculty Associates ConnectER Program and will allow The GW Medical Faculty Associates to determine how else it can leverage telehealth and remote patient monitoring. It will be key for the future of the The GW Medical Faculty Associates to expand virtual visits for primary care, urgent care, and the patient centered medical home, as well as for specialty consults. As patients who are farther and farther away in Virginia, Maryland, and West Virginia seek services at The GW Medical Faculty Associates, even more opportunities will arise to enhance follow-up care and tele-consultations. Expanding services for remote patient monitoring and care coordination will help existing practices, evolve the ACO, and engage regional hospitals that will benefit from the associated infrastructure. All of which will be especially important as patient engagement and the use of telehealth and remote patient monitoring continue to make their way to center stage on account of the  Medicare Access and CHIP Reauthorization Act (MARCA), as well as MIPS.

Acknowledgements: Neal Sikka MD, Stephen Badger, James Betz, Stella Kim, Brian Choi MD, Gerard Pappa, Nicholas Reed

HIMSS Staff: Thomas Martin, David Collins, John Sharp

References:

[1] http://www.gwdocs.com/about

[1] http://www.gwdocs.com/patients-and-visitors/accountable-care-organization

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Keywords: 
telehealth, eVisit, Population Health