Rachael Zimlich is a freelance writer in Cleveland, Ohio. She writes regularly for Contemporary Pediatrics, Managed Healthcare Executive, and Medical Economics.

Rachael Zimlich, RN, BSN

The health care industry has for years been trying to figure out how to get people to buy into telehealth services. Were users concerned about security? Was it too hard to use? Would older patients be comfortable seeing their doctor online? It turns out that a pandemic was the catalyst no one saw coming.

The Centers for Disease Control and Prevention reports that telehealth usage increased 50% in the first quarter of 2020 compared with the first quarter of 2019, with a 154% increase noted by the start of the second quarter of 2020 from the prior year.1 Changes in how telehealth visits were reimbursed helped make this happen and encouraged vendors and health care providers to offer increased support for virtual platforms.

The problem became how providers could quickly pivot to provide services their patients needed without seeing them in person. According to a Kaiser Family Foundation (KFF) report,2 many providers at the beginning of 2020 did not have the capacity to offer telehealth at the level the pandemic required. Regulatory changes brought a new influx of cash to health care systems to create or upgrade telehealth systems. KFF revealed that although 50 of America’s largest health systems already had telemedicine programs in place, only about 15% of physicians in those systems used the platform.

The explosion of demand for telehealth services and new financial support for this channel meant many health care systems had to consider revising or replacing their platforms and offering support and education to providers and patients. Health care systems that did not have platforms already in place quickly learned that there is much more to telehealth than a virtual connection.

When it comes to telehealth platforms, there is no such thing as a one-size-fits-all approach. Patients and providers have unique needs, and there is a wide range of services offered in every health system. Organizations need a flexible vendor partner that can satisfy different preferences among physicians and patients, says Dan Olson, senior vice president of provider solutions at Amwell, a Boston, Massachusetts–based telemedicine company.

“We find that our customers have a wide range of needs and many want an integrative solution,” Olson says. “But they also have providers that really want fast, easy, and simple.”

Early in the pandemic, some health care providers resorted to private systems like Zoom and FaceTime to see patients if their systems were not ready to meet virtual needs. But these platforms raise privacy concerns, and there is no consistency throughout the health care system. The focus should not be just seeing a patient over a video stream but also providing them with a safe, secure space that will allow providers to integrate care with their electronic medical record (EMR). Just putting a screen between patients and providers is not enough.

“Everyone ran out with COVID-19 and tried to do video visits. The market is kind of paused now as vendors look at enabling virtual health throughout the entire care continuum,” says Patrick Rainville, director of engineering at Iron Bow Healthcare Solutions, a telehealth firm headquartered in Herndon, Virginia.

Health care systems should be looking for enterprise platforms that do not need to be developed from scratch. Software platforms that can be configured for individual workflows at the use level—not coded—are in high demand, Rainville explains.

“A vendor should offer something that can scale from home use and wellness to ambulatory, skilled, acute care, and more,” he says.

A vendor must be able to evolve with your needs and scale across an enterprise, too. Many technology solutions can connect people, but delivering care is different. A vendor partner should have a record of success and be able to prove it.

“You need a partner that has done its due diligence and vetting,” Olson recommends. Experience matters when it comes to telehealth platforms, he adds.

A good vendor will be able to demonstrate success elsewhere and be willing to create work-arounds and flexible solutions where needed. They should share where their gaps are and what they are planning to be able to move forward. Telehealth is not a static platform.

“Ask for 2 or 3 references in a similar specialty,” Chad Anguilm, vice president of in-practice technology services at the Michigan-based health care consulting firm Medical Advantage, says. “If it’s taking a long time to find those references, that should be a red flag.”

Health care systems will also want to make sure their vendor partner is prepared to stay around and help long after a contract is signed. “Choosing a partner that has done this before or who has a customer base where they have demonstrated success is important,” Olson says. “A lot of people claim they can do things, but they might not be health care specific. It’s important to have that experience in health care because workflows and all the different systems you work with are very different than turning on a web meeting. You need account management and support teams that will walk you through it and build trust.”

The biggest question, says telehealth expert Joseph Brennan of Moonshot Health Consulting in Grand Rapids, Michigan, is how the system and patients will be supported after the health system signs on. “When implementing a technology that is in health care, whoever is supporting you—the relationship is critical,” Brennan says. “So I would ask [the vendor], ‘What is your model for support and what do I get with what I’m buying?’ ”

It is helpful to have a dedicated project manager or support team from start to finish, Anguilm adds. Sustainability is also key. If waivers and reimbursement change once the pandemic subsides, you should not need to find a new platform. A good partner will have a full implementation plan laid out, detail how you will reach out to and educate patients, provide reimbursement information, and more. Avoid long-term contracts, he adds, because there is not much information yet on what reimbursement for telehealth will look like a year from now.

“Simply put, a good vendor partner program should feel like an extension of ongoing operations. Health care organizations looking for a strong partner for telehealth should expect a level of support that maximizes opportunity and minimizes headaches and interruptions to current workflows,” adds Roland Therriault, president and executive vice president of sales at InSync Healthcare Solutions, a Tampa, Florida–based health care technology company. “Vendor partners should take on the heavy lifting of implementations, technology adoption, and optimal use of a telehealth solution. In addition, the best relationships ensure ongoing success by keeping providers apprised of evolving regulatory movements, ensuring infrastructures align with the most advanced security functionality and ongoing support and oversight of end-user education.”

When it comes to telehealth, the big challenge seems to be on the technology end. But solutions that focus only on technology are not enough. Telehealth platforms must have a deep understanding of health care and the needs of patients and providers. When searching for a telehealth platform, there are a number of things to watch for, including vendors that overpromise, Olson warns.

“That should raise a red flag, in my opinion,” Olson says. “A vendor saying that it can do anything a customer wants is not practical in the real world.” Ask vendors for references from providers that use their system already. They should be willing to share success stories, Olson says.

Anguilm adds that it is also important to look for glitches and delays during demonstrations of the program. If it happens in a demo, it will happen live, he warns. Make sure the company can support the technology it promises.

Brennan suggests that part of the vendor partner selection process should include a discussion of failure and connection rates. Where are people dropping off and what can the vendor do to help address this?

“When you’re looking for a partner, look for someone who has been around and has a full-service offering,” says Kevin Greene, director of business development at Iron Bow. It is not enough for a vendor to supply a product. There needs to be operational and clinical support with an understanding of the outcomes you are trying to reach, he adds.

Overall, Brennan says, understand that not every solution works for every system, and that there is a big difference between technology and health care. The key is finding someone who understands your goals and knows what it will take to get you there.

“It’s all the same thing. It’s videoconferencing bolted onto your EMR,” he says. “But if the person you’re talking to doesn’t have any health care references, that’s a big red flag. They’re either brand new and you’re going to be their first customer, or it’s not going that great. Many tech people don’t understand how intricate every aspect of health care is. This isn’t a retail shopping experience; this is health care.”

Koonin LM, Hoots B, Tsang CA, et al. Trends in the use of telehealth during the emergence of the COVID-19 pandemic — United States, January-March 2020. 

 2020; 69(43):1595-1599. doi:10.15585/mmwr.mm6943a3

Weigel G, Ramaswamy A, Sobel L, Salganicoff A, Cubanski J, Freed M. Opportunities and barriers for telemedicine in the U.S. during the COVID-19 emergency and beyond. Kaiser Family Foundation. May 11, 2020. Accessed April 6, 2021. https://www.kff.org/womens-health-policy/issue-brief/opportunities-and-barriers-for-telemedicine-in-the-u-s-during-the-covid-19-emergency-and-beyond/

Articles

COVID-19 helped to speed up adoption of telehealth. When it comes to telehealth platforms, though, there is no such thing as a one-size-fits-all approach.

Your Future Telehealth Program Starts Now

Routine annual tuberculosis testing may be on the way out, following a new recommendation published in the Center for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.

, a culmination of extensive research, reveals that tuberculosis (TB) rates have become so rare among healthcare workers that it may not be worth the time and expense to conduct routine testing.

“We were doing, as a country, tens of millions of TB tests annually on a population that doesn’t have TB,” explains Wendy Thanassi, MD, MA, chief of occupational health at VA Palo Alto, associate professor at Stanford University, and co-author of the guidance.

Thanassi and several other authors who worked on the guidance presented their findings and answered questions about their research at the 

Association of Occupational Health Professionals (AOHP) National Conference

Routine TB testing stems from the century-old fear of the infection, which-thanks to successful public health programs in the United States-no longer appears to be warranted, she says.

“Tuberculosis is still an incredibly dangerous infection. In the United States, it was the leading cause of death in 1915-16,” Thanassi says. “But in the last 100 years, there has been incredible progress in treatment and environmental controls.”

Nutrition and living conditions have improved to the point that the United States now has one of the lowest rates of TB infection at about 2.8 cases per 100,000 individuals-lower in healthcare workers at approximately 2.5/100,000. This represents a 73 percent decrease in TB prevalence from 1991 to 2017-and a 42 percent drop from 2005 to 2017, according to the report.

With roughly 18 million healthcare workers in the United States, Thanassi says the healthcare cost-as well as the environmental cost related to unnecessary transportation of testing supplies and medical waste-is huge.

“When I look at the sweeping change this can make-we are saving tons of medical waste per year,” Thanassi says. “It all came together to mean we have to stop doing these tests every year on healthcare workers. It doesn’t make sense to do tens of millions of tests looking at the population where TB isn’t.”

The research contained in the MMWR report was based initially on more than 1,800 studies conducted since the last guidance on TB testing in healthcare workers was drafted in 2005. The final report was focused on 36 of the most relevant studies, all of which pointed to the conclusion that routine TB testing of healthcare workers is no longer needed. In fact, prevalence of TB among healthcare workers was so low in the data that Thanassi says workers were more likely to have a false positive result than a true positive one.

Thanassi says extensive databases developed over the last decade enabled this level of research and estimates that 96.6 percent of TB tests on the VA’s own 400,000 healthcare workers test negative on annual screening negative. She said the new recommendation means that public health efforts can now be turned to more at-risk populations.

“We want to divert the focus and spending to treating latent TB in the United States and focus our energies on those who still suffer from this disease,” Thanassi says.

Not all states or all healthcare facilities require annual TB screening for healthcare workers, and even some that do have considered discontinuing the practice, Thanassi says.

This report may give those states and institutions the data they need to support a policy change-although the decision to stop routine TB testing ultimately will be made at the individual healthcare facility level. California is one state that has debated abandoning routine TB testing for healthcare workers, considering the 1.4 million healthcare workers in the state, just 92 cases of TB were identified in 2016. The healthcare savings and positive environmental impact of such a change could be monumental, she says.

A companion report on risk assessments and facility-level recommendations that is forthcoming, and will be published in the 

Journal of Occupational Health and Environmental Medicine

Thanassi was also clear that the recommendation in MMWR does not impact post-exposure TB testing for healthcare workers, a practice that she said should continue without question. Routine pre-employment testing of healthcare workers for TB, as well as testing and treatment of workers with TB, also should be continued, according to the report.

New Report Suggests Abandoning Routine TB Testing for Healthcare Workers

When it comes to treating contagious and easily transmissible diseases-particularly at pandemic levels-healthcare providers are the first line of defense. But are they ready?

As the flu season approaches, it is a good time to review infection control procedures within a healthcare organization, especially related to protocols, isolation, and personal protective equipment (PPE).

Federal guidelines exist, but how well healthcare providers understand and enact those guidelines is sometimes underestimated.

“Any hospital or healthcare organization needs to make sure that what they are doing is completely consistent with the gold standards published by the 

Occupational Health and Safety Administration (OHSA)

Centers for Disease Control and Prevention (CDC)

,” says Tener Goodwin Veenema, PhD, MPH, RN, FAAN, and international expert on disaster preparedness and containment of outbreaks and a professor at Johns Hopkins University.

“The key is how do we made sure that we create an infection control program and have personal protection equipment (PPE) plan that is consistent with national guidelines and positions us to keep our patients, staff, and visitors safe.”

Having a basic and clear policy based on national standards is a good start, she says, but it’s not enough. Healthcare organizations need to make sure they are structured in a way that allows them to have real-time surveillance of disease activity and respond quickly when necessary.

“Healthcare organizations that are forward-thinking to seasonal flu and pandemic levels must begin to think, do we have a robust infection control program where there is adequate surveillance, detection, and oversight of the implementation of infection control standards and the use of PPE,” she explains. “One of those key components is daily surveillance with situational awareness reports to all relevant healthcare and administrative staff so that everyone is aware of where we stand in terms of spread and outbreak.”

David Avalos, MSN, RN, AOCNS, CIC, a member of the Association for Professionals in Infection Control and Epidemiology (APIC) and an infection preventionist at CaroMont Regional Medical Center in Gastonia, NC, says when considering infection control programs, it’s also important to consider travel and not just focus on what is going on in your area.

“We implemented a travel screen and posted a map of global hot spots to identify patients who may have traveled to countries with pandemic outbreaks,” Avalos says. “We realized that not everyone was following the same procedures, and there is a need to standardize the process between inpatient, emergency department, urgent care, and community practices.”

Having systems like these in place help administrators and front-line caregivers make the best decisions on how to triage patients and control spread of infection, Goodwin Veenema says.

When considering PPE programs in particular, healthcare organizations must be sure to review their policies and supply levels.

“For seasonal flu, we are concerned with airborne transmission and droplets. We need respiratory protection for all healthcare providers,” she says, noting that healthcare facilities must recognize that protection is needed for other staff that may come in contact with patients, including security, housekeeping, and nutrition services staff. “Is there enough PPE to cover everyone who could potentially need it? Keep in mind that the flu and certain epidemics and pandemics would come in waves.”

This means that healthcare facilities have to be prepared to have enough of the right types of PPE to last for several weeks or even months, she says. The next challenge, Goodwin Veenema says, is making sure that staff are using PPE correctly.

“Donning and doffing is critically important,” she says, adding that caregivers are often exposed from self-contamination from improperly removing PPE.

Some big mistakes when it comes to PPE include placing N95 respirators on patients instead of surgical masks, reusing isolation gowns and not understanding that they are one-time use items, Avalos explains. Don’t assume caregivers know the policy or understand how to use PPE, he adds.

“I had an issue with a physician using the same gloves and disinfecting the gloves between use. Do not assume they understand all the information provided. We tend to provide a lot of information, but do not assess their level of understanding,” he adds.

Education about PPE for support staff is just as important as having adequate standards and supplies. Healthcare facilities must stress the need for caregivers to protect themselves at all times, but especially in times of an outbreak.

“Remember to create a program where we are really stressing personal preparedness and personal safety,” Goodwin Veenema says. “Encourage all healthcare providers and anyone who works within the hospital to make sure they have a flu shot annually, and to remember that the number one best strategy for infection control is adequate handwashing.”

When it comes to less common or highly contagious disease outbreaks, like Ebola and measles, facilities have to quickly move from standard infection control measures to a higher level of protection.

“With Ebola and measles, we implement incident command,” Avalos explains. “There is a 2:1 ratio-two nurses to one patient-for Ebola patients. We stabilize the patient and prepare him or her to transfer to a treatment facility. With Ebola and measles, we limit healthcare workers’ exposure by minimizing amount of staff involved in patient care.”

Other policies that stress employee safety and health are important, too, he says. Caregivers-particularly nurses-should know the differences between seasonal and pandemic influenza, because they are usually the first line of contact for patients. They also need to be supported in maintaining their own health and have the flexibility to stay home and care for themselves when they become sick themselves, she says.

“Talk with the nursing leadership and make sure everyone understands the infection control program and what their role is,” she says. “We as nurses are all so committed to our patients and our families and try to render high-quality care in any situation. But should there be a pandemic influenza outbreak, all healthcare systems would be challenged to the fullest extent due to the volume of patients needing care. Nurse safety and taking care of ourselves and our colleagues is going to be critically important.”

Rachael Zimlich, RN, BSN

Articles

Your Future Telehealth Program Starts Now

New Report Suggests Abandoning Routine TB Testing for Healthcare Workers

Preparing for a Pandemic