P1020 - Reducing Telemedicine Technology and Process Barriers: If You Build It, They Will Come

Background: Telemedicine is an increasingly-utilized tool for treating patients with decreased access to care, particularly children needing specialty care concentrated at urban referral centers and/or those who are isolated at home. However, barriers have prevented it from reaching its full potential. These include the challenge of efficiently integrating telemedicine appointments into ambulatory clinic schedules, and patient hesitation when faced with new technology.
In our health system, specialists can virtually see patients at home when clinically appropriate, for indications ranging from epilepsy to transgender identity. When the telehealth program launched, telemedicine appointments were kept apart from in-person schedule templates, and video software was run external to electronic medical record (EMR) software. This reduced scheduling complexity and facilitated troubleshooting in the event of technical problems. However, in-home telemedicine adoption was slow, likely related to the multi-step non-integrated processes required to initiate a visit on both the provider and patient ends.
DESIGN/

Methods: To address these barriers, a comprehensive ambulatory scheduling overhaul and EMR/ patient portal/ video conferencing software integration project was undertaken. Workflow processes were streamlined in parallel with the technical changes, with all upgrades going live on the same date. In-home telemedicine visit volume across the health system was evaluated before and after implementation to determine if these technical and process changes resulted in increased utilization.

Results: Weekly in-home telemedicine encounter volumes were plotted on run and control charts (Figures 1, 2) over a 24-week period. Special cause variation was noted following the project’s go-live date (Week 14), indicating that addressing software integration and scheduling barriers significantly increased in-home telemedicine usage. The median rate of in-home telemedicine encounters also increased by 7 per week (from 17 to 24, a 40% increase) in the 2 months following implementation. Because essentially all telemedicine team resources were committed to infrastructure projects at the time and this took place before the coronavirus outbreak, there were no concurrent provider- or patient-targeted change management interventions or significant external factors to confound the data. [Of note, this infrastructure upgrade was an essential foundational component that facilitated our subsequent nearly 50-fold increase in telemedicine volume during the coronavirus pandemic, but the nature of that expansion precludes analysis of individual factors.]

Conclusions: Disruption and change management are key components of health system innovation, including telemedicine adoption. Much emphasis has been placed lately on necessity-driven culture change, but identifying and mitigating technical and process barriers are equally critical for success.