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Patient Access and Telehealth Begins with Registration
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Patient Access and Telehealth Begins with Registration

By Brenda Sauer, RN, MA, CHAM, FHAM; Jane Torres-Lavoro;
Peter Greenwald, MD, MS, FACEP; Rahul Sharma, MD, MBA, CPE, FACEP

 

The use of telehealth services to deliver medical care is increasing rapidly in many healthcare settings, including urgent care and the emergency department (ED). Despite the passage of the Affordable Care Act (ACA), ED visits continue to rise, forcing healthcare systems to develop innovate ways to provide high-quality, efficient emergency care.1 NewYork-Presbyterian  hospital is one of the nation’s largest and most comprehensive hospitals and is a leading provider of inpatient, ambulatory and preventive care in all areas of medicine. With over 2,600 beds and more than 6,000 affiliated physicians and 20,000 employees, the hospital receives more than two million visits annually. The NewYork-Presbyterian Weill Cornell Medical Center ED treats over 90,000 patients annually and is a comprehensive trauma, stroke, chest pain and psychiatric receiving facility. The staff consists of over 60 physicians, 48 residents, 30 physician assistants and nurse practitioners, 150 nurses and 25 registration and Patient Access staff.

 

NewYork-Presbyterian/Weill Cornell Medical Center developed the ED-based telehealth Express Care Service, the first service of this kind at an urban academic medical center. In parallel to the launch of the Express Care Service to treat patients physically in the ED, NYP On Demand Virtual Urgent Care Service was launched for patients to speak with an ED physician while at home.

 

Two major goals were established prior to launching the Express Care Service. Our primary goal for the Express Care Service was to improve the efficiency of ED visits for low-acuity patients without compromising patient experience. Our second goal was to improve the comfort level of physicians and staff in our academic practice with providing care in the telemedicine setting. For the On Demand program, our goal was to expand the availability of our emergency medicine services to the time and place most convenient for our patients, allowing them to be seen from the comfort of their home or office.

 

The ED Express Care service focused on the low-acuity patients who physically present to the ED. Minor ailments such as a rash, upper respiratory infection, wound checks, suture removal, contusions and sprains were targeted. We believed that if we could care for these patients more efficiently, it would improve overall efficiencies and the patient experience for all other patients in the ED. We believed that implementation of the ED Express Care Service would decant these patients from the typical ED workflow, and allow ED staff members to focus on the higher acuity patients.

 

In order to successfully launch both programs, we needed physicians who felt comfortable with not only the technology but also speaking and caring for patients remotely via video monitor. In addition, support staff, mainly patient registrars, needed to be comfortable with changes to patient flow in the ED, as well as new technology and registration processes in order to guide patients through the required steps to allow these visits to be possible. Since the implementation of these initiatives we have seen over 2,600 patients through the two programs. The length of stay for our ED Express Care patients is approximately 35 to 40 minutes, compared to the typical 2- to 2.5-hour stay for patients who go through our traditional ED workflow pathway (see Figure 1).

 

 

Length of stay for all low acuity patients vs. ED telehealth Express Care patients, 2016-17

 

As part of our ongoing quality assurance program, we monitor ED 72-hour revisit rates for our ED telehealth patients. Currently, the number of patients who revisit the ED within 72 hours of their virtual visit is 1 percent, lower than reported estimates of 72-hour returns in traditional ED settings of 3-7 percent.2,3 Moreover, we have not had a single admission to the hospital following 72-hour return visits for patients seen in the ED Express Care Program. Patient satisfaction for our ED Express Care patients has been uniformly high, with satisfaction measurements consistently in the 99th percentile. This has also had a positive impact on our overall patient satisfaction scores in our low area, with 2016 being the highest score to date (see Figure 2).

 

 

Patient satisfaction scores (percentile rank compared to 70,000+ hospitals across the U.S.) for low acuity area

 

Teamwork is key

 

For both of the telehealth services we provide, teamwork and communication are crucial components for improving both efficiency and patient experience. For the Express Care program, when patients arrive to the ED they are triaged by the nurse, and a physician assistant or nurse practitioner performs a medical screening exam. If the patient is appropriate for ED Express Care and consents, they are seen immediately by the registrar. The registrar then collects the essential information, such as email and pharmacy data, that is required to successfully complete the visit. After registration, the patient is then escorted to a private room equipped with a video monitor and comfortable lounge chairs so they may speak with a physician.

 

The registration process is critically important in order to ensure high quality medical care.  Accurate registration ensures that prior prescription information is readily available to providers, that recent records form visits elsewhere in the institution can be easily reviewed, that data obtained during the visit will be readily available to subsequent providers, that prescriptions can reach the patients pharmacy without errors, and facilitates follow-up contact for results of testing that are not available during the course of the visit. In our On Demand Urgent Care program, patients call in via a smartphone app or on their computer in order to see an ED physician.  The Registrar continuously monitors the software platform on which these calls occur for notifications that a new patient is waiting.  The Registrar then initiates the registration process, using the app by texting or calling the patient for further demographic information.  Once the registration is complete the Registrar notifies the telehealth physician via text or phone call and places the patients in a “virtual waiting room” where the physician will then see their patient. Just as is the case for Express Care, high quality registration information is absolutely essential in order to allow care to be delivered by the On Demand program and to ensure the patient may receive other care within the institution at a future date.

 

 

 

Continuous feedback from the entire team has been essential in developing these processes.   Physicians, Registrars, Nursing, and Information Technology staff work together to improve processes in order to ensure the highest quality and most efficient care possible.  The registration staff provides valuable insight into navigating the software platform and this information is being used by the developers and IT staff to improve processes.  The physicians have collaborated with registrars to make the notification system more robust.  Initially patients in the “waiting room” were occasionally not immediately identified by either registrar or the attending if their attention was diverted elsewhere. Two way communications between the registrar and the physician has eliminated this occasional occurrence (each calls the other when they note a new arrival).  The increased communication has also increased the speed with which inaccuracies in the registration process are identified and corrected. 

 

Technical challenges

 

Like with any new program, there were challenges the team had to tackle. The team had to learn a new technical program and technology for completing their tasks. The registration staff had to learn how to manage patients from different sources. As Miledy Corsino, a patient registrar said, “I needed to learn how to manage a patient in front of me, a patient on the phone, and possibly one on the computer.” 

 

The physicians also had their own challenges in learning to manage the equipment – from operating the camera and microphone to learning to instruct the patient on what to do and how to practice medicine virtually. Improvements still need to be made in regards to how physicians manage patients presenting from different locations and with variations in workflow that result from these different locations for the Express Care and On Demand programs.

 

Limiting interruption and distraction

 

In today’s world, technology may be seen as potentially providing a lack of intimacy in patient contact.  Staff members are constantly distracted by their cell phone ringing or beeping signals from a phone call, email, text or alarm monitors. Frequent disruptions have the potential to diminish the quality of the patient/staff encounter. The virtual visits we are conducting use technology to the opposite effect. Patients receive the undivided attention of the healthcare providers they come in contact with. When the physician evaluates the patient on their computer screen, distractions are limited, allowing the doctor to give the patient their undivided attention. They can focus on what the patient is telling them in a way that is difficult to do in a conventional ED setting. Our patients routinely comment that these telemedicine evaluations are more intimate and personal than any other ED visits they have had. The ED physicians and registrars also agree that a telehealth evaluation allows them to form a bond with a patient that they usually would not be able to in the traditional ED workflow pathway

 

What are the patients saying?

 

Our ED Express Care program has been highly successful from a patient experience standpoint. Our ED Press Ganey scores for our telehealth patients have been in the 99th percentile. The Press Ganey scores for 2016 were the highest in the history of our ED, and the overall scores for registration also increased from the past. Contrary to our initial belief that only younger patients would prefer to participate in a telehealth visit, almost 20 percent of our patients agreeing to this type of visit are 60 years old or older. We have treated not one, but two patients who have been 99 years old! As we have transitioned to the ED CAHPS survey from Press Ganey, we have found that patient experience results continue to be high with great feedback from our patients.  

 

Next steps

 

The implementation of our ED-based telehealth programs have been a success. This success would not have been possible without strong communication and streamlined processes between our clinical providers and registration staff. While we continue to innovate, we feel it is equally important to maintain standards and continue to provide the highest level of quality of care. The technology used to provide these services is not novel or unique, nor is it an end onto itself – it is the people, processes and systems that allow for the highest quality patient experience and outcomes that guide our digital healthcare implementation strategy. We are pleased that our telehealth programs have been featured in various media outlets, such as The Wall Street Journal, Crain’s and Health IT News, and we are inspired that 20 different healthcare systems and hospitals have consulted with us to learn about our processes. However, the fact that we are able to provide high-quality healthcare in ways that meet our patients’ needs and increase patient convenience and overall healthcare experience has been our greatest return on investment.

 

While ED telemedicine programs are in the early stages of implementation, we are confident that we will continue the expansion and build upon our initial successes. At NewYork-Presbyterian Weill Cornell Medical Center, we are currently looking at other ways to expand our telehealth portfolio. In the near future we will be offering services in collaboration with nursing homes and retail pharmacies and coupling emergency medicine telemedicine care with community paramedics for support of patients following hospital discharge. Telemedicine will be a tool to provide better Patient Access and convenience and will allow us to expand the availability of hospital care beyond the hospital walls. High-quality management of patient registration processes will allow the provision of this care and facilitate the integration of medical care provided through these novel systems with the remainder of the medical care environment.     

 

References

 

  1. Gindi, RM, Black, LI, and Cohen, RA. “Reasons for Emergency Room Use Among U.S. Adults Aged 18–64: National Health Interview Survey, 2013 and 2014.” National health statistics reports, National Center for Health Statistics, 2016, no. 90.
  2. Cheng, J, Shroff, A, Khan, N, and Jain, S. “Emergency Department Return Visits Resulting in Admission.” American Journal of Medical Quality, 2016, 31(6):541-551.
  3. Nunez, S. “Unscheduled Returns to the Emergency Department: An Outcome of Medical Errors?” Quality and Safety in Health Care, 2006, 15(2):102-108. doi:10.1136/qshc.2005.016618.

Brenda Sauer, RN, MA, CHAM, FHAM, is director of Patient Access at NewYork-Presbyterian – Weill Cornell Medical Center and past-president of NAHAM. She currently is serving on the Government Relations and Special Projects Committees for NAHAM.

Jane Torres-Lavoro, is program coordinator, emergency medicine, at NewYork-Presbyterian – Weill Cornell Medical Center.

Peter Greenwald, MD, MS, FACEP, is the co-director of emergency medicine telehealth services and assistant professor of Clinical Medicine, at NewYork-Presbyterian – Weill Cornell Medical Center.

Rahul Sharma, MD, MBA, CPE, FACEP, is emergency physician-in-chief and associate professor of clinical medicine and clinical healthcare policy and research at NewYork-Presbyterian – Weill Cornell Medical Center.

 

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