The Medical Virtualist Comes Of Age With Covid-19

Rarely, do we get an opportunity to directly observe a distinct event, which materially changes standard approaches to healthcare delivery. In 2018, we initially published our first article in JAMA introducing the “Medical Virtualist” and the following year, a subsequent piece regarding formalized training and establishment of core competencies in telemedicine. Since that time, there has been significant growth, nationally and globally, in the establishment of new telemedicine and virtual care programs. (1,2)

None of us could have predicted the magnitude of the Coronavirus pandemic nor could we have projected the impact on care delivery. The healthcare industry is massively gearing up for virtual care on an emergency basis as clinically necessary and mandatory, movement restrictions are introduced. We suggest that this unprecedented expansion of virtual care in multiple modalities, will become our new norm.

A 2019 study by FAIR Health covering the period 2014-2019, showed an increase of 1,393% in non-hospital based, “provider to patient” telehealth visits, based on commercial insurance claims. This still accounted for only 0.104% of all medical claims. Despite the perceived value and convenience of virtual health, the majority of physicians, other clinicians and hospitals remained committed to “in person” encounters for cultural and economic reasons. Rural health and other situations short on specialties leveraged telehealth and the need in behavioral health and chronic disease management became apparent. A myriad of direct to consumer virtual health services, not requiring a physician visit, were also developed for oral contraception, erectile dysfunction, HIV prophylaxis and others.

Contrast that norm with the experience in the past week at some of the nation’s leading Integrated Delivery Systems and Physician Organizations.

In the third week of March, the Cleveland Clinic volume of virtual primary care visits increased by more than 26-fold. Advocate Aurora Health completed 11,000 video visits and 2500 e-visits within 12 days. A symptom checker on the website was completed 4000 times in one day! They will also be implementing an interactive mobile enabled symptom tracker for transition management of COVID and PUI’s (Person Under Investigation) discharged from hospitals and Emergency Departments. Advocate will also be leveraging telehealth in partnered SNF’s (Subacute Nursing Facilities) to reduce the need for provider entry into these facilities.

New York Presbyterian with Weill Cornell Medicine & Columbia Doctors, already had a comprehensive telehealth and digital healthcare program across multiple specialties. Since the start of the COVID-19 pandemic, NYP’s telehealth utilization has increased by 45% over the span of 2 weeks. Over the next weeks, it is projected that over 80% of ambulatory visits will be virtual. New York City has become the epicenter of the COVID-19 pandemic and leveraging telemedicine has shifted from being novel to being an absolute necessity.

The Hospital for Special Surgery in New York, has cancelled all elective procedures and limited in person clinical activity to urgent needs. Office visits and post-operative Physical Therapy (PT) have all become “Virtual”.

On a national scale, the closing of hundreds of PT clinics across the country may be transformational and accelerate innovation in that space.

One prototype, PTGenie.com provides remote, interactive PT, guiding patients through exercises remotely measuring and monitoring movement through sensors applied on the skin. Real time feedback is provided to the patient on a tablet.

Intermountain Healthcare based in Salt Lake City, has had experience with Virtual Health for a number of years. Their Nurse Triage Call Center, Health Answers increased its volume from approximately 50 calls a day to 3000 a day in the middle of March secondary to the COVID-19 pandemic. Nurses were redeployed across their system from other non-critical services. A pool of 6-10 nurses has mushroomed to 70 in the call center servicing the entire State of Utah. Connect Care, their Telehealth Video program was focused on meeting the needs of the non-COVID patients in the Intermountain Healthcare physician organization.

Early in March, medical practices, both independent and part of Integrated Delivery Systems, began to move their scheduled visits to a Virtual medium. Clive Fields MD, Chief Medical Officer and co-founder of Village MD in Houston, reported that they have trained more than 350 providers on a new telehealth platform in the past week and expect 90% of their visits to be “Virtual” within an additional week. Village MD like many others are screening “essential visits” prior to accepting the appointment in an office location.

The major Telehealth vendors have all experienced massive increases in virtual visits, enough to initially cause _delays of hour_s for patients seeking access. This access is being alleviated by the contracting of more providers and vendor clients growing their own internal capabilities.

One major telehealth vendor processed over 100,000 risk assessment screenings for COVID-19 in only a few days last week. To avoid excessive wait times companies are both ramping up recruitment as well as indicating to patients that they have reached their maximum capacity for a reasonable wait time. This is a new healthcare phenomenon of “virtual diversion” akin to the practice historically common in overwhelmed emergency departments.

Teladoc Health (NYSE:TDOC) experienced a 50% increase in daily visit volume week over week in early March. Teladoc provided approximately 100,000 virtual visits in the past week. Chief Medical Officer Lew Levy MD commented “As we saw in the flu epidemic of 2018, a community’s healthcare system can be overwhelmed and virtual care can provide needed relief”.

Remote Monitoring then and with COVID-19

Remote monitoring as part of routine patient care had not previously taken hold on scale. The desire to reduce readmissions prompted development of such programs for transitional care and severe chronic patients specifically Heart Failure. Remote monitoring of heart rate and rhythm expanded with the commoditization of measurement through the Apple watch and similar devices in addition to glucose monitoring in diabetes.

COVID-19 infection and quarantine should precipitate a significant escalation of remote monitoring of oxygen saturation, temperature and blood pressure coupled with virtual visits. This could be adequate for many infected patients if the mechanism for targeted monitoring and feedback to the primary care physician is in place. The capacity to provide these services is limited, largely due to inadequate platform infrastructure and training, and existing vendors are being overwhelmed with requests. There is every indication that this approach will exponentially scale.

More COVID-19 Observations

Medical Virtualists (physicians and other clinicians) keep as many patients as possible away from physician offices and hospitals. This coupled with the deferral of elective cases, is creating capacity for surging of COVID cases while conserving PPE and equipment for the sickest patients.

It is remarkable to hear from multiple centers across the country, about the redeployment of healthcare professionals from services that have been put on hold, to support Virtual Care and Emergency Services. This includes physicians and other clinicians usually active with elective cases, including many from ambulatory surgery centers.

The ability of physicians to use their licenses across state lines may also turn out to be one of the most dramatic changes brought by COVID-19 as it relates to the expansion of virtual health. We believe it unlikely that this will be easily reversed once the value of this method has been utilized on scale during the current crisis.

Virtual Health/The Medical Virtualist: Training and Education

The concept of Virtual Health is not new, but only a few months ago, this massive escalation and diversification of adoption seemed, economically and culturally, unlikely. Yes, it will become an intrinsic part of the healthcare space, which will require all physicians and other clinicians to have some degree of engagement, training and competence. It is not enough for New Medical Virtualists to be familiar or comfortable with the technology—this requires a level of expertise necessitating training and education to develop the skills set to provide high quality and appropriate virtual visits. This essential training includes understanding the importance of the “soft” skill set required to conduct telemedicine visits with a camera, as well as ensuring that providers at all levels are aware of technical and medicolegal standards. Appreciation of these essential training elements yields benefits for both providers and institutions by increasing care proficiency as well as awareness of potential risk.

We believe that in the coming years, there will be a subset of medical graduates who will identify virtual health as a chosen profession within different disciplines and only have a clinical interface with patients through telecommunications.

Beyond meeting consumer needs for value and convenience, this will offer new career options for physicians, with alternate lifestyles. The necessary skills for this role will become increasingly refined with the addition of remote monitoring and testing.

Weill Cornell Medicine, in collaboration with New York Presbyterian has accelerated the creation of a unique Center for Virtual Care (CVC ) under the leadership of one of the authors (RS). The CVC provides training and certification in virtual care for practicing physicians, residents, advanced practice providers and other clinicians in all specialty areas, including “Web-side” manner, remote patient examination skills, and virtual provider to provider consultations. The center has already trained hundreds of clinicians in the last few weeks across the healthcare system during this COVID-19 pandemic.

One should note that virtual health is not restricted to the physician visit or the low acuity illness. In addition to meeting an acute need brought on by the COVID-19 crisis, virtual care delivers needed additional value and convenience to the full continuum of the healthcare system throughout the world.

References:

1. Nochomovitz, ML, Sharma R:“Is it Time for a new Medical Specialty” JAMA. 2018;319(5):437-438. doi:10.1001/jama.2017.17094

2. Sharma R, Nachum S, Davidson KW, Nochomovitz ML: “ It’s not just Facetime: core competencies for the Medical Virtualist” https://intjem.biomedcentral.com/track/pdf/10.1186/s12245-019-0226-y

Acknowledgement: Thank you to the following:

Jane Torres-Lavoro MPH for her insightful editing and assistance in the preparation of this article.

Adam Myers MD (Cleveland Clinic, Cleveland, OH), Carrie Nelson MD (Advocate Aurora Health, Chicago, Ill.), Will Maines MD & Josh Romney MD Intermountain Health, Salt Lake City, Utah, Lewis Levy MD (Teladoc), Ian Tong MD (Doctor on demand), Clive Fields MD (Village MD, Houston, Texas), all for their real-time expert insights at leading edge organizations.

Drs. Peter Greenwald & Neel Naik and David Leyden of the Weill Cornell Medicine, Center for Virtual Care

Rahul Sharma, MD, MBA, FACEP

Professor and Chairman

Department of Emergency Medicine

Weill Cornell Medicine

ras2022@med.cornell.edu

Michael Nochomovitz, MD

Chief Clinical Partnership Officer

mnochomovitz@devoted.com

First Published on March 29, 2020

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