Telehealth and COVID-19: Time to innovate, not merely adapt

The great telehealth scramble of 2020 — spurred by federal waivers to increase reimbursements and provide HIPAA oversight discretion during the COVID-19 public health emergency (PHE),1 has left medical practices with a loose patchwork of web conferencing and other virtual workforce solutions. These new technologies, processes and workflows strained practice operations as they were rushed into use with little planning and even less lead time.  

Fortunately for practices, implementing virtual technologies allowed them to mitigate the other federal mandates that canceled elective procedures and brought in-office visits to a halt. Though telehealth helped fend off some degree of deferred or denied medical care for patients with non-emergency and non-COVID-19-related issues, the healthcare industry is still coming to terms with the financial and clinical outcomes of the pandemic shutdown.

Many people expect the Department of Health & Human Services (HHS) to permanently extend expanded payments supporting telehealth visits. Patients have embraced these virtual visits, with nearly 60% now viewing telehealth visits favorably.2 This means telehealth and other virtual workflows are likely here to stay for many healthcare episodes. However, 26% of patients in the same study expressed concern about privacy issues relating to telehealth,3 and the HIPAA discretion from HHS explicitly expires when the PHE expires.

This leads to two major effects of the ad hoc technology implementations related to the COVID-19 crisis that practices should immediately address:

1. Operational issues: More robust tools and workflows are needed to accommodate telehealth visits, alongside in-office visits, including all the requisite pre- and post-visit processes. In addition, many non-clinical functions may shift to a teleworking workforce.
2. Privacy and security issues: The rapid deployment of new devices, tools and processes that were created on the fly represent new locations where electronic protected health information (ePHI) may be lurking. This specifically includes issues associated with new technology platforms such as Zoom, Doxy, Google Meet, etc., as well as associated operational workarounds (calendar invites, emails, text messages, downloaded reports, etc.). This also very likely includes employees’ personal devices that may not belong to or have previously been part of normal practice operations. 

Most practices seem intent on dealing with these issues as quickly and as superficially as possible, and technology vendors seem bent on selling yet another siloed, bolt-on product or solution merely to achieve “HIPAA compliance” for telehealth and other virtual workflows.

However, there is a danger that practices may take shortcuts and merely duplicate their in-clinic patient processes or, worse yet, create parallel and non-interacting ones, as well as add these new telehealth tools to what is already an almost unworkable technology landscape. This is true whether IT is done in-house, through an outside company or a combination. This will only permanently increase practice overhead, add more complexity to the patient/provider relationship and create another potential technology integration failure point, along with possible increased HIPAA risks. 

Historically, every time a new healthcare technology requirement or opportunity has arisen, such as with ARRA and the HITECH Act,4 or patient portals or e-prescribing, there has been a tendency for practices to just “put it in and fix it later.” Indeed, much of the engineering and operational effort of Meaningful Use MIPS/MACRA and the new interoperability rules associated with the 21st Century Cures Act,5 have focused solely on achieving compliance rather than gaining the efficiencies and improvements in patient care envisioned by the architects of those initiatives. In addition, mobile healthcare technologies, which have mainly been an afterthought to the digital health landscape, now need to be embraced strategically as part of a holistic, telehealth-enabled technology plan, rather than as bolt-on products with extra steps in clinical workflows and additional integrations in the technology stack.  

To make matters worse, many “temporary” processes or workarounds tend to become part of practices’ ongoing workflows and take on a life of their own. This increases practice overhead and inefficiency, which manifest in two main areas: 

1. Healthcare hiring has actually increased during the past decade, in spite of pressures to reduce costs and maintain profitability, yet the number of patient-facing providers has held fairly constant.6
2. Numerous areas of practice management remain reliant on paper, scanning and faxing for exchanging patient information.7  

In fact, in spite of the explosion of EHRs and other technologies, healthcare isn’t paperless — there’s more paper than before.  

Now it looks as if the post-crisis mode of COVID-19 may follow the same, unfortunate course of “ready-fire-aim” on the healthcare technology journey, but it doesn’t have to be this way. 

With reduced patient volumes, the timing is perfect for practices to take a holistic look at operations and technology, and create more robust processes to optimize their workflows, while increasing the strategic value of technologies, with the goal of reducing costs, improving patient care (and patient experience) and in the process adding more value to their practices. 

Making technology strategic

There is never enough time, money or resources for every healthcare technology initiative to be executed. Plus there is always something new on the horizon, whether it’s a new technology product, a new business opportunity or an external factor, such as a new compliance requirement.  

What is needed in medical practices — and what is almost always lacking — are processes and tools to build out and execute a holistic technology plan that fits long-term needs and can also address short-term issues, such as changing needs and emergencies.  

This may seem daunting, especially with an ever-growing list of needs from every department or constituency within the practice, coupled with so many vendors promising that their product will transform your practice.  

The process begins internally, and can be broken down into three broad activities:

1. Build a team: Get appropriate representation and buy-in from all stakeholders, especially physicians. More specifically:

• One or more physician champions, representing both clinicians and ownership
• Stakeholders, or “the customers” of the initiatives who know the business and clinical requirements
• Executive champions, negotiating priorities (frequently a director, vice president or C-level executive). 

2. Create one master list: Collect all technology initiatives from all business and clinical stakeholders.  
3. Design and create a scoreboard: Set up parameters to rigorously and objectively determine: 

• Strategic prioritization: Measure and rank the relative importance and timing of different technology initiatives. 
• Tactical execution: For a given technology initiative, pick the option that best meets the practice’s needs.

Making technology valuable

The concepts and processes mentioned will help you build a good strategy and a flexible framework to support rational planning and successful execution as you navigate changing priorities and emergencies. However, to add value to the practice, you need to shift away from products and vendors to true technology partnerships.  

Many practices already do this with real estate, as they assess paying rent for office space versus owning things outright to fit their culture and values. It’s also relevant for investments in ancillary service lines (e.g., physical therapy, imaging, ambulatory surgery centers, etc.) that allow practices to diversify their revenue streams by building assets (increased book value) as well as direct positive cashflow impact (increased incomes and/or reduced expenses).

Increasing practice value through technologies is also possible, which entails avoiding siloed products that bolt onto your EHR and increase process steps and integrations. Instead, take a holistic view of what you want to accomplish in your practice and then find a technology partner to help you build it.

What is a partner? You can determine this by analyzing what happened to your practice during the COVID-19 crisis: 

1. Did you have to get out the contract to see what was/was not included in scope? Were you presented with an additional statement of work (SOW) or a scope-change document? 
2. Did you have to pay a premium for emergency or after-hours service?  
3. Were you steered away from free/open source web conferencing and virtual workforce solutions such as Zoom, FaceTime, Google Meet, etc. (which were explicitly mentioned by HHS) and instead toward paid, proprietary or “EHR-integrated” platforms, often paired with claims of being “medical grade” or required because of HIPAA?
4. Did you have to buy extra-cost module(s) or add-ons for any existing hardware or software systems? Is it “free” for now and then you have to start paying for it?
5. Are you now getting pinged with proposals to buy more tech “stuff,” either to make your temporary telehealth solutions more robust and/or HIPAA compliant, or to replace them entirely with a more costly solution?

If you answered “yes” to any of these, you have a technology vendor — not a partner.  

A partner will work with your practice to develop solutions that you have prioritized that improve patient care and lower costs. Such a partner will demonstrate — through conversation, contracts and actions — that they want to:

1. Understand your short-term and long-term technology road map.
2. Help you with your technology needs, whether or not they align with their product road map, and proactively bring in other technology and solutions if/as needed.
3. Help optimize processes and develop systems for you.
4. Suggest free or open-source systems (provided they satisfy HIPAA and other requirements) or recommend systems from others whether they directly benefit or not.  
5. Allow you to invest with them, so you can benefit in the actual intellectual property as you help shape the healthcare technology of the future.  
6. Go at-risk with you, meaning you can end the relationship at any time you feel it is not adding value to the practice. 
7. Create and implement a “virtuous value” cycle to help you:

• Identify and optimize flawed processes to reduce operational costs
• Automate with better technology incrementally (avoiding “big bang” initiatives)
• Use cost savings to continuously feed the process.

Telehealth and virtual workforce technologies are here to stay. Simply adding them into existing practice processes is not enough, and is likely to increase costs. Creating collaborative partnerships that create technology value is not impossible; however, it is certainly not the norm when the whole industry seems focused on just selling more siloed add-ons. The key for next-generation healthcare leaders is to get out of the mode of picking products, tweaking workflows and adding integrations, and instead form collaborative relationships with innovative technology companies that share the vision of truly improving patient outcomes while lowering costs. 

Notes:

1. MGMA. “Medicare Telehealth/Telemedicine Waivers During the COVID-19 Public Health Emergency.” Available from: mgma.com/covid-tele-waivers.
2. Sykes. “Survey report: Americans’ Perceptions of Telehealth in the Era of COVID-19.” Available from: bit.ly/2U44OHy.
3. Ibid.
4. “ARRA, The HITECH Act, and Meaningful Use — An Overview.” Excite Health Partners. May 7, 2012. Available from: bit.ly/301G9r1.
5. Gans D, Jenkins M. “21st Century Cures Act: After 10 years of broken promises, is EHR interoperability finally at hand?” MGMA Connection. September 2019. Available from: mgma.com/21stcenturycures.
6. Gans D. “Staffing evolution: Responding to a new environment.” MGMA Connection. March 2018. Available from: mgma.com/data-mine-evolution.
7. Seib C. “Healthcare can no longer afford to resist the digital revolution.” MGMA. Aug. 13, 2018. Available from: mgma.com/paper-digital-seib.