In 2013, Cincinnati Children’s Hospital wanted to establish a Center for Telehealth.
At the time, the interest in video visits and other forms of telehealth was growing, and the provider organization had a few clinical programs already up and running.
The organization decided it wanted to be able to approach the challenge of meeting patients and families where they are and improving access to care, and telehealth was a tool to do that. Additionally, it was important to the organization that it have a strategic approach to developing clinical programs, using consistent technology, rather than having telehealth done differently in each clinical area.
“At that time, we were already engaged with Cisco as technology partners, and when we constructed the physical center, we were able to upgrade hardware and software solutions to allow our clinical experts to be available around the world,” said Dr. Ken Tegtmeyer, professor of clinical pediatrics, division of critical care medicine, and medical director of the Center for Telehealth, at Cincinnati Children’s Hospital.
“However, as with most large academic centers, each specialty area has different needs and different strengths,” he continued. “Over time, we added additional technology vendors, including Microsoft Teams, Vivify and Teladoc, along with several others. While we would all prefer one platform solution for all of our telehealth needs, each of these platforms has some benefits in specific specialty areas.”
Having a variety of tools available also allows staff to be flexible in the care they can provide, he added.
Each solution offered different benefits, said Jennifer Ruschman, senior director of the Center for Telehealth at Cincinnati Children’s Hospital.
“For example, Cisco products are strong hardware solutions and worked incredibly well in our inpatient facility to allow remote consultations from a specialist to a satellite suburban hospital location and far-end camera control,” she explained. “We primarily used Cisco products, including Jabber Guest, for video visits and to address access initially, as we were doing few visits in the home.”
“We know their platform is strong technically, but we know from over time that often pediatrics is going to have some unique needs. In this case, the vendor recognized that and said let’s work together to figure out those challenges and address them.”
Dr. Ken Tegtmeyer, Cincinnati Children’s Hospital
When the pandemic began, Cincinnati Children’s Hospital needed a scalable solution that could be integrated quickly.
“Microsoft Teams was already a collaboration partner that was new internally, and has been a wonderful tool to utilize for video visits with patients,” Ruschman said. “It allows for multiple party calls and especially made it easy for us to address multidisciplinary visits, as well as adding an interpreter to a visit. The ease of use is critical for addressing access to services.”
As the staff began to look beyond traditional video visits to remote patient monitoring as a tool to connect with patients between visits, it identified Vivify as a vendor of choice.
“At that time, they had the most flexibility for adding in additional peripheral devices on a custom basis, and that was important as pediatric devices are limited,” Tegtmeyer related. “As companies grow, their ability to be flexible or change can be impacted, and that can make it hard to address some pediatric-specific challenges.”
Finally, staff had been evaluating Teladoc for direct-to-consumer telehealth services. The vendor approached the hospital with an opportunity to consult as it developed its platform to meet the needs of pediatrics.
“This was key, as we know their platform is strong technically, but we know from over time that often pediatrics is going to have some unique needs,” Tegtmeyer explained. “In this case, the vendor recognized that and said let’s work together to figure out those challenges and address them.”
Through all of this, the hospital had developed a strong video visit platform as well as remote patient monitoring and direct-to-consumer capabilities. However, the ability to remotely examine complex patients was still a challenge.
Additionally, scaling solutions in house, since so much of the care is multidisciplinary, staff often have hybrid visits that have in-person providers and remote providers. This hybrid workflow was also a remaining challenge.
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MEETING THE CHALLENGE
The direct-to-consumer platform allowed Cincinnati Children’s Hospital to address a problem it was seeing with access to telehealth – the ability for a patient to initiate a telehealth visit request for a minor illness or injury.
“Implementing our Teladoc platform, CincyKids Health Connect allowed for our APRN in emergency medicine to offer a direct-to-consumer service,” Ruschman said. “This is currently not integrated with our EHR or other platforms, and that works as the users are an isolated group.”
In contrast, as the organization rolled out its video visit platform for all specialists, it found that the number and variety of users pushed it to further integration.
“The MS Teams video visit process has been integrated into our EHR experience for providers. They can launch into a video visit from a patient’s chart, join rounds from the EHR home screen, or even conduct inpatient or ED consults remotely.”
Jennifer Ruschman, Cincinnati Children’s Hospital
“The MS Teams video visit process has been integrated into our EHR experience for providers,” Ruschman said. “They can launch into a video visit from a patient’s chart, join rounds from the EHR home screen, or even conduct inpatient or ED consults remotely. Because the vast number of providers – more than 1,000 – and the variety of roles (MA, RN, MD, dietician, therapist, etc.), we knew we needed integration and to simplify how video visits were launched across the organization. This drove our decision for integration.”
Finally, when the hospital added remote-exam functionality, it integrated that into its direct-to-consumer platform.
“The rationale was that these would more likely be visits driven by patients and families,” Tegtmeyer explained. “Further, that platform is designed to support primary care workflow best, and this was the area in complex care where we were launching that remote-exam capability. Eventually we would hope to integrate into our EHR with remote-exam devices, as well.”
However, there can be conflicting resources to get integration into the EHR, and that would have necessitated two platforms in use – remote exam and the TytoCare video platform – and the hospital was trying to limit introduction of any new video platforms, he added.
One metric is overall volume of visits and the geography of patients participating. As has been the case with most telehealth providers during the pandemic, Cincinnati Children’s Hospital has seen its video visits skyrocket – from about 200 per month to more than 20,000 per month – and even higher at times of lockdown.
“We are maintaining approximately 20% of all outpatient visits and those are still being done as a video visit,” Ruschman said. “Our patient and family experience shows 84.7% of families rank these services as nine or higher on a 10-point scale. Many have commented that telehealth has been the bright spot for them during this pandemic.”
These numbers alone are reassuring as the hospital looks at access to services. It also is able to drill down into this data and identify populations that it may not be serving as well.
“An example includes patients who speak Spanish as their primary language,” Ruschman said. “Although interpreter services are available, we still have some work to do in order to create the access this population needs from video visits.
“Finally, we are seeing impact on utilization as we look at outcome measures. In our remote patient monitoring program, we have seen readmissions reduced by 50% in NICU patients who are sent home on remote patient monitoring.”
USING FCC AWARD FUNDS
In mid-2020, the FCC telehealth funding program awarded Cincinnati Children’s Hospital $719,098 to provide telehealth services to the highest-risk pediatric patients with complex healthcare needs, including tracheostomy and ventilator dependence, and gastrostomy and tube feeding dependence, in order to limit their potential exposure to COVID-19 by keeping them out of the hospital and safely at home. That improves their health prognosis and frees up resources to care for children with COVID-19.
“The FCC funds are first being used to obtain remote examination devices through TytoCare,” Ruschman said. “This can be integrated with the CincyKids platform, and we are looking to work with populations to provide care to patients in the home.
“Our technology-dependent patients, with multiple chronic medical conditions, are seen by our complex care team. This team wanted to embrace video visits but, because of the fragile nature of their patient population, were reluctant to do so without the ability to provide some remote examination.”
It is also a patient population where the burden of coming in for a clinic visit is greatest, due to all the equipment involved, she added.
“We had received a demo and discussed TytoCare devices prior to the pandemic,” she recalled. “When the pandemic arrived, our ability to take the very best care of this population became a prominent need. TytoCare and the integration into one of our video platforms, CincyKids Health Connect, allows us to begin to do that.”
Finally, many of the organization’s clinics include multiple disciplines in providers, and through the pandemic and into the future it sees the need to provide this kind of care while also adhering to social distancing.
“We want to allow patients and providers the flexibility to adjust an appointment to telehealth based on illness or weather,” she said. “Thanks to the FCC funds, Cincinnati Children’s was also able to purchase a number of tablet stands that are now available in all outpatient clinics and inpatient units.
“Because of the availability of these devices, our application development team was able to build some key workflows that now allow for easy connection to any outpatient visit, or inpatient, as long as one of the tablet carts is present.”
More than 100 times a day, remote Cincinnati Children’s providers join in for inpatient rounds, she added. Hundreds of outpatient encounters each week include some combination of in-person and video-based care in these hybrid clinics. This has changed how the organization will deliver care to patients and families well into the future, she concluded.