Healing Heros: Conversations About Veterans’ Healthcare Solutions and Telehealth
In the expansive realm of healthcare, Veterans grapple with a unique set of challenges that necessitate specialized attention. These challenges often stem from many factors, including the aftermath of military service, physical and mental health issues, and the complexities of transitioning back into civilian life.
Many Veterans find themselves facing additional hurdles in accessing the care they urgently require. This impacts not only the individual Veterans but also their families and the broader community, as delayed healthcare could contribute to the worsening of existing conditions and, in some cases, escalate into crises.
David Shulkin, MD
Enter Dr. David Shulkin, the Ninth Secretary of the U.S. Department of Veterans Affairs, whose leadership style proved instrumental in addressing the complex problems afflicting Veterans’ healthcare. Dr. Shulkin, recognizing the urgent need for change, set a visionary goal: to achieve same-day appointments for Veterans nationwide. This audacious objective was not merely an incremental adjustment but a transformative vision that aimed to overhaul the existing healthcare system for Veterans.
As a new member of Caregility’s Board of Directors, Dr. Shulkin endeavors to leverage his expertise to advance the company’s mission of pioneering innovative methods for remote healthcare delivery.
His visionary leadership has left an indelible mark on the landscape of Veterans’ healthcare, and in this interview, we unravel the complexities and unveil the exceptional solutions he implemented.
Dr. Shulkin, can you share your approach to leadership and how you fostered a positive organizational culture during your tenure as Secretary?
In my career, I’ve found that it’s easier to create bigger change than to do change through small increments. One of the issues when leaders try to make small changes is they get frustrated at how challenging it is to change the culture.
Being able to clearly articulate where you want your organization to go, why you want to create this change, how it’s going to be accomplished, a timeline, and an accountability plan are all crucial to effect change. Make sure your organization understands all those factors, that you’re consistent in your messaging, and that you put the resources within the organization behind that change initiative. As Secretary, I ensured our initiatives were Veteran-centric and tapped into the strong commitment to mission within the workforce to foster positive culture and change.
What strategies did you employ to improve the efficiency and effectiveness of the U.S. Department of Veterans Affairs?
When I entered the Department of Veterans Affairs, we had a situation where Veterans were waiting long periods of time for appointments. The clarity I brought was making it our priority to get those wait times down. I was clear that we’d set same-day appointments before the end of that year and the specific ways we’d do that were listed; using telehealth technology was one way, and allowing VA professionals to go across state lines was also part of that. We also gave advanced practice nurses independent practice authority, creating additional staffing opportunities to do that.
Efforts to make everyone accountable for that goal included actually publishing wait times publicly. Everyone could see what our goals were and whether we were achieving them. By the end of 2016, we had same-day appointments across the entire country at every VA facility. I believe we were able to accomplish that great change because there was clarity around what our objective was.
How did you navigate budgetary challenges and allocate resources to ensure Veterans received the necessary care and support?
The easiest answer when things are not performing the way anyone wants is, “Well, we don’t have enough money,” and I don’t think that is usually the answer. There are times that is true, but in my experience with the VA that was not the case. Congress would always allocate the money we needed to care for Veterans. The harder part is designing systems meant to get the results you want that are optimally performing, like finding ways to get your workforce to operate at their highest level of training or licensure and letting others field lower-level tasks or using technology to increase labor productivity but decrease the time to perform tasks to look for new, more cost-efficient ways to practice. That’s hard to do but it ultimately saves money if implemented well.
As a new member of Caregility’s Board of Directors, what specific goals do you have in mind for the company’s role in pioneering innovative methods to deliver healthcare remotely?
Healthcare has been one of the few industries in our economy that has not seen labor productivity improvements over the past decade. Instead, we continue to struggle with labor shortages and increasing costs. For a health system to get real value from technology it must be versatile and integrate into the current workflow. Caregility seeks to be the enterprise solution for health systems that seek to use technology to improve efficiency and outcomes.
Looking ahead, what emerging trends or technologies do you foresee playing a significant role in shaping the future of telehealth, and how can Caregility position itself to stay at the forefront of these developments?
Future strides in telehealth are going to be dependent upon the ability to integrate data sources, personalize care options, integrate care delivery among various disciplines, and use artificial intelligence and large language models to extract information from clinical and administrative data to better inform diagnosis and treatment options for patients.
Homelessness among Veterans is a persistent issue. What strategies did you employ to address and reduce homelessness within the veteran population?
We awarded grants to groups that operated in the communities. We also worked closely with HUD to expand the use of HUD-VASH vouchers for housing, including expanding benefits to Veterans beyond those who were honorably discharged.
How did you ensure and measure the quality of healthcare provided to Veterans within the VA system?
We measured quality using and comparing quality metrics in the private sector. We then published all our quality measures. When you look at the VA’s publicly reported outcomes compared to the private sector, the VA overall outperforms the private sector. This surprises many people. It demonstrates that an integrated system of care that can follow patients longitudinally and has a system based largely in primary care with strong integration with behavioral health does have better outcomes.
That doesn’t mean the VA is best at everything. At the system level, it’s superior because private organizations often experience gaps in care. Care should still be an individual choice though. Sometimes you can get the best care for you within the community you live in. Or perhaps you need a heart transplant, and the best provider is a non-VA facility. You may need a treatment that the private hospital does better than the VA. You want to have a system of care that is transparent enough that you can actually look and see, “Is that the best care for me? Is it VA or a private system?” We need to be educated enough as consumers to make that call.
During your tenure, the VA faced various challenges. Can you discuss a specific crisis or challenging situation and how you managed it effectively?
The wait time crisis was our biggest challenge at the VA. We ultimately achieved same-day appointments for all urgent Veteran healthcare.
There is a lot to be learned from the VA in terms of the integrated system of care, chronic care management, behavioral health integration, incorporating the social determinants of health into care planning, and decreasing access barriers like high copays and deductibles.
Transparency is good for healthcare and it’s good for patients. If we can provide that information in an accurate way, we can improve the whole health system. That was my goal at the VA. Wherever you can shine light on issues, people will make better decisions.
Rural Veterans often face unique challenges in accessing healthcare. What initiatives did you undertake to address healthcare disparities in rural areas?
We had an office of rural health that addressed issues with home-based care, remote monitoring, and telehealth.
Women Veterans have distinct healthcare needs. What steps were taken to ensure that the VA adequately addressed the healthcare and support requirements of women veterans?
We created women’s health clinics in each of our medical centers and initiated new programs and policies and increased funding.
Given the advancements in technology, how did you integrate telehealth services to improve accessibility for Veterans, especially those in remote or underserved areas?
Tech needs to be a big part of a solution in accessing care where you don’t have physical facilities or the workforce distribution. There are other ways of addressing the access issue besides pure tech, but I primarily think that should be the essence of the solution – get people to care wherever the expertise exists.
Other solutions include things like working with educational programs to do workforce training and to promote greater patient and family caregiver training to help people understand how they can be part of improving health in their communities, implementing preventative strategies, using tools like AI to help people get information on when they should access specialty care versus primary care versus urgent care, and the expansion of telehealth and remote monitoring care in the patient home and community. People want care where it’s most convenient for them. To me, that means either care on your phone where it’s mobile or care in your home.
Looking back on your tenure, what do you consider to be your most significant accomplishments, and what lessons did you learn that could benefit future leaders of the Department of Veterans Affairs [or health systems in general]?
Creating a system of integrated VA and community-based care that served the Veteran is what I perceive to be our most significant accomplishment.
My advice for others is that incremental change is overrated. Sometimes big goals, while risky, are the way to achieve great things. It’s important for every organization to ask, “What’s a goal that would make a big difference that would be wise for us to pursue?”
Healthcare organizations have the responsibility to answer that question for their specific communities. Healthcare is geographic. Look at what clinical priorities there are for different patient populations in your community. Certain populations have a higher incidence of diabetes, for example. Look at not only the problems but how you’re trying to solve them. Be more proactive in outreach to solve problems.
Many healthcare organizations still have a model where they wait until a patient has a problem and then schedule an appointment to bring them in. Organizations need to think about how we can reach out to people in the community to intervene and manage conditions better or prevent them from having to come to the hospital.
In the Department of Veterans Affairs, when I became aware of drugs that can cure Hepatitis C, we looked at how many Veterans had Hepatitis. There were 176,000 patients documented in our database. We reached out to all of them to bring them in for the treatments that can cure that disease. By doing so, we were able to get it to less than 10,000 untreated Veterans. That proactive outreach model of intervention is extremely powerful.
Read the Impaakt article where this interview was originally published here.
Hospital Leaders Weigh in on Virtual Nursing
Healthcare delivery is undergoing a transformation and virtual nursing is at the forefront. In a recent webinar co-hosted by Caregility and the American Telemedicine Association (ATA), healthcare leaders from institutions at various stages of implementing Virtual Nursing programs gathered to discuss their experiences.
Virtual care pioneer and Caregility CNO Wendy Deibert led the illuminating panel discussion featuring Tracey Kopenhaver, Operations Manager, Geisinger Inpatient Virtual Care; Christine Coriell, Director of Nursing Operations, OhioHealth Resource Center; and Debra Marinari, Associate Vice President, Hospital Operations, Mary Washington Healthcare.
All panelists pointed to nursing workforce challenges as key motivators to pursue Virtual Nursing, but technology and ROI had to line up.
Addressing Nursing Shortages and Burnout
The virtual nursing model allows healthcare organizations to tackle staffing shortages and burnout by distributing the workload more evenly.
“We were motivated by a few things – primarily the nursing shortage, nurse turnover, nurse burnout, and really looking at our care team redesign. Looking at current state, where we don’t have quite enough nurses to go around, and our nurses are overworked and busy and can’t get to all the things that they need to do in a day… How can we try to future-proof or buffer that?” – Tracey Kopenhaver
Technology Aligns with Strategic Goals
By leveraging existing technology that supports remote patient observation teams and tele-ICU programs, Virtual Nursing programs align well with strategic goals to centralize and scale virtual care.
“When we think about our Nursing strategic goals at OhioHealth, one is having a flexible workforce and second is maximizing the technology we have at OhioHealh. So, this was just a natural next step into the virtual world.” – Christine Coriell
Demonstrated ROI
Panelists addressed the importance of justifying costs, typically vetted through pilot programs.
“It had to be cost neutral – that’s the model that we took. So, we had to make sure that whatever we brought in was going to have a good return on investment – not just the quality metrics, but [improving] satisfaction and decreasing turnover.” – Debra Marinari
Strategy
While there is variation in how Virtual Nursing workloads are assigned within each organization, some standard practices emerged. Each panelist’s healthcare organization uses Epic’s EHR in different capacities for streamlining workflows. Each organization also staffs virtual nurses onsite, with Geisinger employing a hybrid model that also includes nurses working from home.
Getting Started
“The number one recommendation I would give to anybody who is thinking about starting a virtual nurse program is don’t let perfection get in the way of progress. We started very low budget. We repurposed carts. We hired per-diem staff to start with and borrowed some staff from our virtual ICU program. We really went in on a shoestring to get it off the ground. We’ve been able to demonstrate the return and we have the financial support to move ahead with a more permanent solution.” – Tracey Kopenhaver
Staffing Models
Virtual nurse staffing models varied across panelists. Coriell noted that, in their current phase, OhioHealth virtual nurses work Monday through Friday from 7 a.m. to 7 p.m., with plans to extend to 24/7 coverage.
“The virtual nurse will be assigned to patients that all will roll up to the many nurses overseeing that care at the bedside. We’re utilizing a flex team of nurses with knowledge across different care sites for now. A future focus is on having dedicated full-time employees (FTEs) for the program.” – Christine Coriell
Geisinger takes a slightly different approach, with Virtual Nursing overseeing specific tasks.
“There are no specific patient assignments for virtual nurses since they currently focus mainly on admissions and discharges.” – Tracey Kopenhaver
Meanwhile, Marinari and the Mary Washington Healthcare team elected to bring on additional FTEs for virtual nursing from the very beginning.
“The model had to be really such that the nurses at the bedside did not feel like they had less resources, but actually more. We had to balance the FTEs for each of the departments, and what that workload was going to be [in terms of] patient ratios. The virtual nurses are assigned to patients, currently managing around 15 to 16 patients during the day and up to 20 at night.” – Debra Marinari
Goals and Results
Positively impacting nurse and patient experience are core objectives for each organization.
KPIs
“Key outcomes that we really want from this program [include] retention of nurses, decreasing that workload and stress at the bedside, increasing time for the bedside nurses to be able to provide care for their patients, improving nurse satisfaction [and] patient satisfaction, and then some cost savings. Ultimately, we would look at time saved with length of stay and a few other metrics as well.” – Christine Coriell
“We’re looking at our HCAHPS – nurse responsiveness and communication with the nurse scores in particular.” – Tracey Kopenhaver
Time Management & Efficiency
All panelists agreed that virtual nursing significantly improves time management, reducing the workload of bedside nurses.
“The thing that we’ve been able to measure the most is the time saved for the bedside nurses.” – Tracey Kopenhaver
Marinari and the Mary Washington Healthcare team conducted time studies to demonstrate time savings, assessing the time from when the discharge order is written to the time the patient leaves as a metric. Coriell highlighted the role of existing relationships between virtual nurses and unit staff in speeding up tasks and improving efficiency.
Conclusion
Virtual Nursing programs are not just a trend; they are a substantial step toward enhancing healthcare delivery. These programs alleviate staff burnout, improve patient experience, and provide financial returns. With insights from leaders in the field mounting, it’s clear that Virtual Nursing is a viable and vital part of the future of healthcare.
ChatGPT and a plethora of other AI-powered applications are rapidly gaining popularity in today’s tech-driven world. In healthcare, AI and machine learning algorithms are being adopted to drive efficiency in patient-facing and back-office settings alike.
One of the clinical frontiers gaining attention is the augmentation of virtual care programs with AI tools such as computer vision, ambient clinical intelligence, and contactless monitoring. By bringing these AI enhancements into virtual workflows in the inpatient setting, healthcare organizations hope to positively impact patient safety, clinical outcomes, care team experience, and operational performance.
During a recent fireside chat, Caregility President and COO Mike Brandofino sat down with Healthcare Innovation editor Mark Hagland to explore the practicality, best practices, and perils associated with selecting and adopting AI technology to advance telehealth.
AI’s Potential in Acute Virtual Encounters
AI is showing promise in clinical use cases in acute care settings where staffing shortages and burnout are prominent. As Brandofino sees it, one of AI’s biggest benefits is in “augmenting the information that a clinician or caregiver has access to with more clinical insight than they’d be able to gather on their own.” When evaluating tools, he encourages stakeholders to consider the impact: “Is it taking tasks away that can potentially save staff time? Is it a tool that adds to productivity?”
One of the AI functions Brandofino sees potential in is radar-based contactless monitoring. These tools continuously capture patient vitals such as heart rate and breathing rate, as well as track motion in the room. This allows caregivers to see trends over time.
“The AI part of that is the algorithms can detect changes in that pattern that mean something,” Brandofino explains. He offers a practical use case example. “That radar device can tell you, based on telemetry, that a patient is starting to wake up. Now think of a post-op situation where the nurses have to be there when the patient wakes up disoriented. Can you just have a contactless device notify them when the patient is starting to wake up so they can get in there then instead of sitting there for 30 minutes waiting?”
Automated, contactless vitals monitoring also accelerates the frequency and timeliness of clinical documentation.
“If you think about what happens with nurses as they do their rounds and take vital signs, many times they don’t get that information into the EHR until the end of their shift or hours later,” Brandofino notes. AI tools can gather vital signs many times throughout the day and put it through an algorithm to evaluate if the patient is getting better or worse. This allows care teams to intervene earlier and potentially improve outcomes.
Ambient clinical intelligence uses AI tools like natural language processing to draft clinical notes and reports, posing similar efficiency benefits. In care environments where resources are thin and burnout is high, those incremental time savings can add up.
Caveats to Consider When Adopting Health AI
As you evaluate AI solutions to bring into patient care delivery, it’s important not to become enamored with the technology before understanding where it fits into the patient care workflow. Brandofino recommends including all stakeholders—clinical, IT, and operations—in evaluations. “How are you going to support your device fleet? Consider the clinical workflow as well as the experience on the patient side.”
“Think about the operational logistics of supporting what you’re doing,” Brandofino advises. “What we suggest to our customers is to understand the impact that you’re going to have on the staff on the floor and think about what that is going to be like at scale.” Nurses are some of the most interrupted people in healthcare. The last thing you want to do is introduce new tools that add to their stress level, whether that be an overabundance of false alarms or device overload.
Given the newness of many AI tools entering the market, it’s also important to consider who you’re partnering with. Has the tool been implemented in one or two patient rooms or thousands of rooms? Are there examples of in-market success that can offer a roadmap?
Combining AI and Telehealth to Empower Caregivers
By integrating AI with virtual care, healthcare organizations can modernize care delivery with innovative new tools and keep the human element of care intact. AI can drive intelligent clinical alerting, while virtual engagement channels serve as a bridge for immediate staff intervention. When combined, these resources amplify what virtual teams are capable of supporting remotely, doubling down on reducing the burdens on bedside staff.
“We believe that combining that remote nurse with smart technology to help gather telemetry in the room will be really impactful in improving care for patients in the long term,” says Brandofino. “Don’t feel like you have to put in a siloed solution just to get access to AI technology. Look for players that are capable of integrating with what you already have. If you already have high-end cameras and mics in the room with edge processing, what else can you gather in the patient room to give to caregivers?”
Ultimately, healthcare organizations that focus on applying technologies that solve real problems that exist today around the shortage of nurses, productivity, and quality of life for staff will have the most impact.
Interested in learning more about AI-enhanced hybrid care solutions? Contact us today!
Buzz around virtual nursing is building. As telehealth sheds its COVID skin, the virtual care technology is entering a new phase of growth helping health systems advance acute care models to mitigate hospital workforce challenges.
In a recent interview with Commercial Integrator editor-in-chief Dan Ferrisi, Caregility President and COO Mike Brandofino addressed the rise of inpatient virtual care and, more specifically, virtual nursing.
“We lost a lot of nurses during COVID who retired, can no longer work, or just decided they didn’t want to [do it] anymore and we don’t have enough nurses coming in so there’s a huge shortage,” said Brandofino. “Virtual care is being used now to augment that.”
Nursing shortages during the pandemic led to labor cost inflation as hospitals battled for scarce resources. Recent CNBC coverage revealed that the “average pay for travel nurses was $150 an hour in early 2022, which analysts say tempted more nurses to leave staff jobs, increasing turnover and exacerbating shortages.”
That pay rate is three times higher than the national average for full-time staff nurses.
Virtual nursing offers health systems an alternative to expensive contract nurses that not only acts as a force multiplier for care teams but also enhances care collaboration and improves patient and clinician experience.
How Virtual Nursing Can Help Solve Many Workforce Shortage Woes
Healthcare IT News
Virtual care pioneer and Caregility Chief Nursing Officer Wendy Deibert, EMBA, BSN, RN, recently sat down with Healthcare IT News editor Bill Siwicki to offer a deep dive into the benefits of a hybrid approach to nursing that employs telehealth.
Virtual nursing programs are typically campus-based and staffed internally but can also be supported by third-party clinical services or a combination of the two. Workflows vary from campus to campus.
“Some organizations use virtual nurses for patient admissions and assessments or discharge education,” shared Deibert. “Others implement more comprehensive 24/7 patient surveillance and deterioration management programs. The fact that there is no one universal approach is really the beauty of telenursing. Programs can and should be tailored depending on your health system’s specific needs.”
Deibert noted that multiple organizations are actively working with stakeholders within the nursing community to develop virtual nurse certification programs to help establish standards for programs.
Virtual Nursing Programs Adapting to Organizational Needs
HealthTech Magazine
Meanwhile, organizations like Mary Washington Healthcare are forging their own path as early adopters of virtual nursing.
HealthTech Magazine editor Teta Alim highlighted the health system’s journey into virtual nursing in coverage of the 2023 American Telemedicine Association conference. Debra Marinari, Associate Vice President of Hospital Operations at Mary Washington Healthcare’s Stafford Hospital, and Heidi Steiner, MD, Clinical Program Manager at Caregility, were on site to share insight into the nursing workflows the hospital is working to virtualize, including admission assessment, plan of care, patient education, and discharge, to name a few.
Mary Washington Healthcare deployed an Inpatient Virtual Engagement solution to support its new virtual nursing program. According to Marinari, the leadership team will assess nurse engagement, patient satisfaction, the rate of nurse turnover, quality and safety metrics, and readmissions to measure program success.
Experts Weigh in on the Joys and Woes of Virtual Nursing
The Atlanta-Journal Constitution
Given the elevated rates of nurse attrition during and since the pandemic, many care teams are onboarding new hires who have limited field experience. As Atlanta Journal-Constitution writer Hunter Boyce shared, another benefit of virtual nursing is its ability to connect new nurses with experienced remote nurse resources who can help guide and mentor them. That secondary line of clinical reinforcement boots confidence for care team members, improving clinician experience and increasing the likelihood of retention.
As Walsh University nicely sums it up:
“The impact of technology on nursing practice cannot be overstated. When nursing technology takes over time-consuming routine processes, streamlining communication and delivering accurate diagnoses and personalized treatment plans, NPs are freed up to do the work that only humans can: providing one-on-one, compassionate care.”
Hybrid Care: The Future of Telehealth
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Hybrid Care: The Future of Telehealth
Hybrid care is the future of healthcare delivery, combining the best of both worlds — conducting in-person clinical encounters when needed and augmenting care with virtual interactions whenever practical.
Caregility Cloud™ enables you to bring virtual care resources into broader use cases across the hospital enterprise to improve operations as well as patient and clinician experience. Watch the video below to see examples of hybrid care innovation in action!
Lee Health Virtual Patient Observation Program Earns Innovation Award
The award recognizes leading-edge ideas, research, products, and services that are empowering healthcare. Lee Health Advanced Application Analyst Kimberly Gault, RN, and System Director of Virtual Health and Telemedicine Jonathan Witenko were awarded the recognition based on the success of the health system’s virtual patient observation program.
The Problem: Limited Staff to Support Rising Demand for Patient Observation
Lee Health’s virtual patient observation program was developed to address a prevalent issue in healthcare: optimizing patient safety in the midst of clinical workforce shortages.
“We decided to pursue this initiative as we were experiencing staffing shortages with our bedside safety technicians,” explains Gault. As demand for observation of fall-risk and at-risk behavioral health patients rose within the health system, “we were having many patients go unwatched or having to pull clinical staff to accommodate requests.”
Patient fall scores were elevated and care teams were stretched thin as a result. That prompted Lee Health to look for a smarter way forward.
The Solution: Virtual Workflow Innovation
Lee Health turned to virtual observation as an alternative to its in-person sitter model. Using newly procured technology, including Caregility’s iObserver tele-sitting application and telehealth endpoint solutions, the team began developing innovative new workflows to create a sustainable solution that redefined how high-risk patients are monitored.
Running on the same platform the health system uses to support additional telemedicine initiatives, the new program enables two-way audio/video communication between virtual safety technicians, observation patients, family, interpreters, and clinical staff. Lee Health acquired 70 telehealth carts to support virtual observation at patient bedsides across the health system. A PRN-to-FTE model is used to staff the virtual safety technician role.
To implement the program, Lee Health made investments in:
Staff training
Technology (telehealth endpoints, workstation monitors, cameras, and headsets)
Software licensing
Wage increases to migrate virtual observation staff from PRN to FTE status
Internal clinical stakeholders collaborated with technical teams to build workflow and documentation processes. Educators from internal nursing units supported intervention and escalation process training for virtual safety technicians.
The Results: Quantifying the Impact of Digital Transformation
Prior to implementing virtual patient observation, Lee Health relied on baby monitors to support 1:4 observer-to-patient ratios. Under the new model, the health system was able to reach a 1:6 ratio, with plans to scale operations to support 1:8 observation.
“With this program, we are able to watch more patients per safety technician at a time,” says Gault. “We have expanded virtual patient observation to all of our acute care facilities and emergency departments and are now working on our Skilled Nursing and Rehab facilities.”
Minus implementation investments, the team reported a six-month program ROI of $280,260. That number is expected to blossom to $1,705,260 in the years ahead. The new approach allows the health system to leverage virtual staff resources instead of drawing from limited bedside staff.
Gault points to securing CNO executive sponsorship, up-front funding and project approvals, and comprehensive pilot program and go-live support as crucial elements of program success.
Pushback from nursing staff and lack of communication with ancillary departments created some friction during Lee Health’s initial pilot program. To address these issues, the team amplified training and communication efforts to build stronger staff awareness and education prior to implementing virtual patient observation at additional facilities.
Lee Health executives view virtual patient observation as something health systems of any size can benefit from but encourage healthcare organizations to adopt flexible solutions that are easy to use and easily scale depending on program needs.
Caregility congratulates the Lee Health team on their well-deserved SFLHIMSS Innovation Award win! The health system’s virtual patient observation program is a shining example of how hybrid care innovation is enhancing and empowering bedside care.
Telehealth’s Role in Emergency Care
NEJM recently published a case study on Stanford Health Care’s use of telehealth in the emergency department. The widely circulated article adds to a growing body of research examining the efficacy of virtual care programs.
Here’s what the study revealed.
In December 2020, Stanford launched its ED Virtual Visit Track (VVT), with the goal of accelerating the health system’s process of evaluating lower-acuity ED patients using a remote physician. “Supported by virtual visit–enabling hardware, software, workflow development, and training, as well as by VVT-trained support staff,” the remote physician virtually assesses low-acuity patients presenting at Stanford’s adult and pediatric ED sites.
Stanford emergency medicine physicians and research scientists compared the outcomes of 2,232 VVT patients to traditional ED patients over an 11-month period. “In a matched cohort of patients, the median ED length of stay (EDLOS) for VVT patients was 1.9 hours compared with 4.2 hours for patients cared for in the typical main ED workflow.”
Researchers also cited lower return visits among VVT patients, though differences were not statistically significant (6.7% vs. 7.2% for 72-hour revisits and 10.4% vs. 12.4% for 7-day revisits). All VVT physicians rated their ability to provide care that’s comparable to in-person care as very good or excellent.
What the Research Tells Us About Telehealth in the ED
Stanford researchers found that virtual care encounters in the ED were on par with, if not better than, in-person encounters for lower-acuity ED patients. Additional research findings paint a similar picture.
Clinical ED teams often use virtual workflows to screen and stratify patients who are better suited for an alternate care site or do not require in-person engagement. Real-time, video-based telehealth was most frequently identified as the most feasible supporting technology. Researchers also note that proper technical infrastructure to support virtual care, although challenging, is essential to program success.
Benefits of virtual emergency care cited within the 18 studies include:
cost reduction
improved quality of care
decreased patient transfer rate from rural centers to major centers
reduced mortality rate
reduced patient treatment time
reduced ED overcrowding
Additional Use Cases for Virtual Emergent Care
Care teams find similar success with telehealth-enabled EMS. Phone or tablet-based virtual consultations between paramedics in the field and remote emergency physicians can improve the speed of patient triage, diagnosis, and intervention before a patient ever makes it to the ED. By using virtual care to engage physicians while on-site or in transit with the patient, EMS responders can redirect lower-acuity patients away from high-cost care sites like the ED when appropriate.
CMS’ Emergency Triage, Treat, and Transport (ET3) model seeks to extend the applicability of telehealth in EMS. The ET3 payment program, currently being piloted, pays EMS participants for use of telehealth to initiate and facilitate patient treatment in place with a qualified healthcare provider for Medicare patients. It also expands Medicare reimbursement to include patient transports to alternative, lower-acuity care destinations like primary care offices and urgent care centers when emergency care is found to not be required.
We saw telehealth being similarly employed to support patient triage in the field during the COVID-19 pandemic, validating the essential role virtual care plays during public health emergencies. Telehealth-enabled field hospitals and curbside EDs were erected to manage patient surges and reduce overcrowding and exposure.
More recently, telehealth was used to support natural disaster emergency response for patients and clinicians impacted and displaced by Hurricane Ian. Evacuees relied on telehealth to maintain ties to providers, while out-of-state physicians and advanced practice nurses were given temporary rights to fill care gaps in Florida when local resources were impacted.
From emergency medical response in the field to virtual visit tracks in EDs, virtual care’s role in emergency medicine continues to mature. As Stanford researchers put it, “Although typically applied when a patient is outside of the care environment, a [virtual] program can be used in other situations in which options for in-person evaluation are limited.” As care teams manage overcrowded EDs and shrinking staff, virtual emergency care programs can provide much-needed relief.
Providers Weigh in on Digital Health Priorities and Pain Points
Roughly 3,000 healthcare stakeholders recently gathered in Chicago for the 2022 Becker’s Health IT + Digital Health + RCM Annual Meeting. Caregility was on site to join the conversation, which focused on “the future of business and clinical technologies” in healthcare. Here we distill what we learned about the health IT trends that were top of mind among health system executives in attendance.
Managing Connected Health
In an industry where the velocity of digital innovation can be difficult to keep pace with, how do healthcare CIOs and technical teams identify best-fit solutions and prioritize IT initiatives?
Clinical and IT leaders from various health systems shared their approach:
Create criteria to assess the seamlessness of integration during evaluations
Select tools that are scalable over the long term to reduce friction downstream
Consider the level of support that will be needed beyond implementation
Quantify the cost of doing things the old way to understand ROI
Health systems reported having as many as 1,500 healthcare applications in use with well over half of those apps being underutilized. Panelist David Reis, Ph.D., CIO at University of Miami Health System, shared that he works with his team to conduct portfolio rationalization monthly to help determine which apps should be optimized versus sunset. He and his team consider two important factors when making those determinations: 1) Does the app pose a cybersecurity threat? 2) Is there an alternative tool with a broader use case scenario? Risk mitigation and resource consolidation are key influencers.
Migrating to the Cloud
As tech infrastructure gets more complex, health systems are partnering with public cloud hyperscalers like AWS and Microsoft to better support burst capacity, real-time computing, and batch processing. Panelist Andrew Rosenberg, MD, EVP and CIO at Michigan Medicine, noted that as modern methods evolve it can be difficult to find experienced technical staff locally. Hyperscalers have the benefit of offering IT teams dedicated expertise in the areas of resiliency and security.
Many health systems simply “want out of the data center business,” as panelist Neal Patel, MD, CIO at Vanderbilt University Medical Center, put it. He feels his organization is better positioned to manage costs with the cloud. “It’s not cheaper, but cloud metering gives us a better process for allocating where the spend is, which allows us to make more judicious budgeting decisions.”
Integrating Telehealth
Several sessions at the event touched on lessons learned as telehealth becomes further embedded in care delivery. Health systems are leveraging telehealth to provide clinical reinforcement, take tasks off clinicians’ plates, and free up in-person engagement for patients who need it most. This includes a push to build inpatient telehealth into patient rooms to create capacity in acute settings.
“The workforce is shrinking, and we’re saying, ‘do more,’” said panelist Christine Vanzandbergen, VP of Analytics and Research at Penn Medicine. “Where can we use [telehealth] in lieu of one-on-one care? Who are the people and skills we need?”
Panelist Dave McSwain, MD, CMIO at UNC Health, made a call for reimbursement models that incentivize hybrid care that blends in-person and virtual engagement. “We need to avoid silos and stop talking about telehealth versus in-person care,” McSwain explained. “It’s integrated care versus telehealth-only care versus in-person-only care. Which is honestly probably best?”
With the relatively immature telehealth platform market largely still in growing stages, panelists encouraged health systems to:
Identify vendor partners willing to let you influence development
Field proof of concept programs to fine-tune processes and establish baselines prior to broader rollout
Be mindful of legal issues like privacy, patient consent, and clinician licensure
Establish a process for virtual care documentation to flow back into the EMR
When assessing success, at a minimum evaluate call responses, downtime, patient feedback or complaints, and utilization. Some health systems are exploring tech centers to ensure patients are comfortable with home health tools.
Where Does it Hurt?
Of the many challenges healthcare organizations are looking to overcome as part of their health IT strategy, staffing shortages were most often cited. “We have to drive an economic bottom line without burning out our team,” said panelist Anthony Moorman, Director of Solution Marketing at Qventus. This means using technology to automate manual steps wherever possible.
Speakers offered unique perspectives on ways to offset workforce hurdles. “Can we do ‘over the shoulder’ nurse guidance for new hires?” posed panelist Meghan Huffman, AVP of Telehealth Field Operations and Programs at HCA Healthcare. There was also a call for digital program reform to modernize clinical education. And as panelist Mohit Bhasin, MD, Medical Director at Sentara Heart Hospital, observed, our industry “doesn’t just lag in tech – we lag in support resources. The majority of nurses are women, yet no one has onsite daycare. We need to mimic other industries.”
Other pain points cited by panelists included:
Validation and governance of patient-generated data
The emerging need for “explained AI” or transparency in AI algorithms
The need for HIPAA, now more than 25 years old, to be rewritten for connected health to ensure we “balance privacy without stifling innovation”
Panelists also encourage peers not to get bogged down in the idea that they are behind. “Shiny object syndrome” and what is picked up by the media “makes you feel like you’re the only health system without all the stuff,” said speaker Michael Saad, SVP and CIO at University of Tennessee Medical Center. “Innovation is different for each health system. Focus on your personal business drivers.”
Virtual Nursing FAQs
As health systems seek to meet the new demands of today’s healthcare environment, virtual nursing has become a hot topic. Here we address some of the most frequently asked questions about telenursing.
What is virtual nursing?
Virtual nursing is a hybrid care model that partners bedside staff with an experienced virtual nurse resource who works from a centralized hub and helps guide and support care for assigned patients.
Should virtual nursing be staffed internally or outsourced?
Virtual nursing programs are typically staffed internally, but hybrid or outsourced models can provide relief when clinical team resources are limited. Virtual nursing programs seek to support bedside staff, not replace them. In any staffing model, building trust between bedside and virtual staff is one of the most important factors in the success of virtual nursing programs.
What makes a good virtual nurse?
Seasoned nurses with extensive bedside experience are ideal candidates for virtual nursing. Virtual nurses should be assertive yet personable, good at multi-tasking, and comfortable with technology. They should also be good problem-solvers with high emotional intelligence who are adept at picking up on nonverbal cues. Prior experience at the health system or facility will likely be more important than telehealth experience, which is one reason unit managers may encourage bedside nurses who are burned out, seeking a change, or considering retirement to consider a telenursing role.
What virtual nursing programs do most hospitals begin with?
Hospitals and health systems typically start with virtual nursing programs that take time-consuming work off the plate of bedside nurses, such as admissions and discharges. Providing relief to bedside staff early on helps to establish trust and buy-in around hybrid care models. Medication second signature and blood product verification are also relatively easy programs to stand up. Tele-sitting is another workflow many health systems begin with, as it often poses the most immediate ROI.
What staffing ratio is recommended for a virtual nursing program?
Ratios will vary depending on the responsibilities being fielded by the virtual nurse. If the virtual nurse is only doing admissions and discharges, they could take over an entire facility or multiple facilities. When telemonitoring with a clinical decision support tool, virtual nurses may monitor hundreds of patients. 30 to 50 patient beds per virtual nurse is typical of other programs. Time studies can help you determine the average time needed to complete specific tasks and inform your strategy. Consider peak usage times when evaluating staffing ratios, as needs can vary greatly from shift to shift.
What KPIs help assess the value of virtual nursing programs?
Efficiency gains are typically assessed to quantify the impact of virtual nursing programs. Conduct time studies pre- and post-implementation to determine time saved by transitioning processes to virtual workflows and the subsequent labor cost savings. Improvements to clinical measures such as patient falls, patient falls with injury, and average length of stay are other metrics to assess program value.
Want to learn more? Check out these on-demand webinar resources:
Since the tipping point of the pandemic, healthcare organizations have embraced telehealth and virtual care models that bring innovative clinical workflows into patient care. Now faced with a nationwide workforce shortage, many leading health systems are once again leaning into virtual care to reduce stress on care teams and enhance patient coverage and safety, especially in inpatient settings.
Tele-nursing, tele-sitting, and tele-consults represent just a few of the remote workflows gaining prominence in hospitals. Enterprise telehealth is paving the way for inpatient virtual engagement at every patient’s bedside.
Under this new paradigm, healthcare IT teams are understandably looking to drive security standards across virtual workflows. The challenge is that many corporate IT initiatives around network security and performance can disrupt patient care in always-on virtual environments. Some IT standards that make perfect sense for many IoT devices can actually impede healthcare delivery.
Common Network and Security Factors that Impede Virtual Care
Login expirations
It’s common for cybersecurity teams to force users to log out at certain intervals. That means tele-sitters may need to log back in multiple times during a shift, interrupting patient observation.
Device timeouts
To keep unused devices from overloading the network, sometimes idle systems that are on for a certain number of hours are automatically disconnected. If you’re in the middle of observing a patient and that connection drops, that creates a safety risk for that patient.
Firewall port restrictions
Firewall updates frequently disconnect virtual care applications. If you’re a sitter watching a patient, your system disconnects, and you can’t call back in, the time it takes to regain access to a high-risk patient can feel like an eternity.
DHCP registration requirements
When managing IP addresses, enterprises often reset assigned addresses, sometimes as often as every 30 minutes. This can cause disconnects. If many systems are trying to renew their IP lease, it can cause congestion. If you’re a doctor trying to call into a patient room that’s still in queue to get an IP address, that call will not connect.
Wi-Fi over-subscription
You can have excellent coverage when you evaluate your Wi-Fi heat map, but it’s really about network congestion: How many devices are connected to your access points transmitting data? That can really impact care.
Bandwidth restrictions
Most networks are designed for data applications, not two-way video. This leads to bandwidth strain during peak usage times when concurrent session rates are high.
These traditional approaches to security and network management warrant reassessment in clinical environments where devices need to be available 24/7 to support virtual care programs. Spending millions of dollars on your network doesn’t mean your network can effectively support virtual care. It’s critical to ensure that your network is designed to handle bidirectional video communications.
Optimizing Your Network for Always-On Care
As hospitals seek to amplify the reach of staff resources and improve the speed of clinical intervention, virtual care holds immense potential. However, the success of your hybrid care programs hinges on the ability of the network to support uninterrupted, high-quality video communications on a 24/7 basis. It’s essential that clinical and IT teams connect early on, collaborate, and compromise to ensure that security and network support are done in a way that improves rather than disrupts virtual patient care.
Here are network security best practices for virtual care to ensure your organization is optimized to support the critical nature of hybrid patient care.
Compromise on staff login expirations by having automatic logouts coincide with shift changes.
Avoid automatic disconnection of devices used in hybrid care models.
Use static IP addresses for virtual care resources if you can. If not, at least have a reserve of IP addresses designated to virtual care support and set the IP lease to last a full shift.
Measure the experience of your Wi-Fi-connected devices and calculate how many devices are within a wireless access point. How much are they being used? Can they be hijacked?
Calculate your peak bandwidth. Look at your fleet of devices and review your network capacity and give an estimate of the number of concurrent connections that you can comfortably do. Then design your network to what that peak bandwidth threshold would be.
Hardwire virtual care devices whenever possible to reduce the potential for connectivity interruption.
Empower patients to connect with their family, care team, and interpreters but consider that impact on call volumes when multiplied across the entire hospital. Factor this into peak utilization because what you don’t want is to have a lot of patients socializing with their families while your doctors can’t access the tele-ICU because of bandwidth limitations.
Remember that network conditions at clinician workstations will impact virtual session performance as well. Ensure nurses and physicians are allocated enough bandwidth to support multiple concurrent connections.
Isolate high-intensity connections like tele-ICU traffic to a VLAN virtual network where their bandwidth is protected. Leave concurrency available for high-profile locations and only allow so many ad-hoc calls to happen simultaneously to ensure high-priority sessions are maintained.
Isolate video traffic in a VLAN if possible or create a wireless environment that’s only for virtual communications. This is going to become particularly important as health systems deploy video systems in every patient room to support enterprise-wide virtual nursing and patient engagement.
Invest in tools that help you monitor and assess your network to quickly pinpoint and proactively address issues.
Get feedback from your clinical team. The easier you make virtual care to use, the less it becomes technology and the more it becomes a tool for clinicians to provide better care.
Bring the cybersecurity team, the network team, and technology partners in early on. Talk through the impact of virtual workflows on the clinician and patient experience. Understand what you need to do to meet the cybersecurity and network demands within that environment.
The most important thing is to be willing to compromise on new best practices for virtual and hybrid care environments. Whether you’re exploring your first tele-sitting program or building the Hospital Room of the Future, virtual care is a high-demand application that you should take the time to design. One size doesn’t fit all and there’s no silver bullet. Taking a mindful approach to balancing security and new virtual workflows within the hospital environment contributes to greater success.
