RAPID DEPLOYMENT OF TELEMEDICINE DURING COVID-19 HOSPITALIST STAFFING SHORTAGES: AN INITIAL PILOT MODEL AND QUALITATIVE STUDY

As COVID-19 cases surge, some physicians may need to be quarantined, resulting in hospitalist staffing shortages.

ABSTRACT: As COVID-19 cases surge, some physicians may need to be quarantined, resulting in hospitalist staffing shortages. Of those quarantined, some can work remotely due to minor or no symptoms. Four remote hospitalists performed telemedicine encounters and telepresenter encounters on admitted patients. The telepresenter hospitalist mobilized the two-way audiovisual telemedicine cart into the patient room and assisted performing physical exams. At completion, all four hospitalists were satisfied with their ability to evaluate and communicate with patients using telemedicine, and felt confident knowing that the physical exam was performed by a hospitalist colleague. Patients found the encounter to be positive and enjoyed continuity of care.

CURRENT EXPERIENCE AND MODELS PREDICT a surge in COVID-19 cases which may further exacerbate staffing shortages and add to the current instability.1-3 On several occasions, our community hospitalist group in Washington state was short-staffed as some physicians quarantined at home due to COVID-19. Similar to other hospitalist groups around the country, our group began exploring current literature to look for solutions and guidance.4-6 After concluding from a literature review that the use of telemedicine can be a solution to mitigate staffing shortages, we decided to explore this further for our group.4-6

We wanted to develop a backup telemedicine system to meet the unique needs of our hospitalist group. As hospitalists, we understand our hospital culture and the needs of our allied health staff and our community, and believed it crucial to lead the development of this work ourselves. Because we are a community hospital, our experience will be valuable to many other community hospitalists7 across the country.

Although evidence supports telemedicine use, if our hospitalists did not believe they could safely assess or communicate with a patient using telemedicine, this technology would not be suitable for our group. Furthermore, frontline hospitalists are in a consequential position of responsibility and stewardship8,9,10 over this profession, and therefore our views and experience using telemedicine are valuable to this discussion.

We are a group of 20 hospitalist physicians at a community hospital in the Puget Sound area of Washington state. Like most hospitalist groups in the United States, we use a seven days on/seven days off working model.7 We staff five rounding teams per day and three admitting teams per day (day, swing, and night). The rounding teams participate in late call from 6 to 11 p.m. once or twice per week, during which the entire hospitalist census is cross covered.

Of our 20 hospitalists, 13 are rounding physicians and seven are admitting physicians. For this study, we explored the suitability and feasibility of telemedicine for the rounding portion of our work. We did not explore its use for admitting or new consults. Our goal is to use telemedicine for hospitalists quarantined at home.

PAIRING HOSPITALIST AND TELEPRESENTER

On Aug. 10, 2020, the CDC (Centers for Disease Control and Prevention) advised both symptom- and testing-based guidance for healthcare workers returning to work after SARS- CoV-2 infection.11 Based on this guidance, we identified the following groups who may need to quarantine and may be able to participate in remote hospitalist rounding if they have non-debilitating illness:

1. Hospitalists who have mild to moderate symptoms.

2. Hospitalists who were asymptomatic throughout their infection.

3. Hospitalists who need to care for family member(s) at home.

The remote hospitalist who is quarantined at home is paired with a telepresenter hospitalist who mobilizes the telemedicine cart into a patient room, performs the physical exam, and relays findings back to the remote hospitalist.

We also aimed to create a staffing model to support the use of telemedicine for remote hospitalist rounding. We discussed how to fill a telepresenter role and explored working with allied health and mid-level staff, especially given the impact on costs. However, the need for rapid deployment of telemedicine within 12 hours of being notified of a staffing shortage became increasingly important and was unavoidable because little notice is available when a hospitalist physician is instructed to quarantine.

We determined the telepresenter role should be filled internally by a hospitalist in our group because it decreased involvement of third parties that requires further debate and buy in, delaying program implementation and therefore inhibiting it from being rapidly deployable or even cost effective, at least in the short term.

This pilot study fulfilled criteria for a quality improvement project in our health system and therefore Internal Review Board (IRB) approval was not necessary. The study was per- formed under the supervision of our hospitalist medical director and chief of staff as a quality improvement project.

METHODS

We paired four remote hospitalists with a telepresenter hospitalist — also a physician employed in our group. For the purposes of this pilot study, the remote hospitalists were asked to situate themselves in our hospitalist office. The four remote hospitalists were asked to complete 10 total remote telemedicine encounters each on admitted patients and 10 total telepresenter encounters each. The participant hospitalists were asked to fill out a brief timesheet noting the start time and end time of the encounter.

Two hospitalists were recruited for each seven-day period and partnered so they could reverse roles, experiencing the role of telepresenter hospitalist (n = 10 encounters) and remote hospitalist (n = 10 encounters). It was important that the remote hospitalist understand the telepresenter hospitalist role and vice versa so that each may understand how a patient is assessed in the telemedicine environment. Tiger connect communication systems and EPIC EHR (electronic health record) are used at our facility.

Encounters were primarily daily progress visits. If the remote hospitalists felt comfortable, they could remotely perform discharge-related activities and new acute symptom assessment. We did not provide any further direction to our hospitalists as our goal was to immerse them into an open environment and allow hospitalists to work through communication challenges and navigate situations that developed within the telemedicine encounter.

At the bedside was a tablet-holding stand on wheels to which a speaker was attached (see Figure 1). The remote hospitalist had a tablet or smart phone.

Data Collection and Analysis

The four hospitalists who served as both remote hospitalist (n = 40 encounters) and telepresenter hospitalist (n = 40 encounters) were interviewed. The interview was qualitative12 and semi-structured, focusing on key areas of interest (see Table 1).

The structure and content of the interview was developed by a hospitalist experienced in conducting qualitative research and interviews.

We performed one-on-one interviews, providing interviewees an opportunity to answer every question completely rather than a group interview where all views may not be equally presented and some participants might succumb to groupthink.13

Each interview was audio recorded on a digital recorder and transcribed. Both the audio recordings and transcriptions were qualitatively analyzed by two hospitalists in our group (Dhamija and Geyer). The hospitalists first evaluated the content of the interviews on their own (individual analysis), making notes and coding key areas of interest (see Table 1), feedback, and themes in the interviews. We used a top-down approach in extracting and coding information on the four key areas of interest with quotes and themes categorized by key areas of interest.

Subsequently, both hospitalists met face to face (group analysis) to discuss their notes, cross tabulate findings, and clarify any disagreements. When disagreements or areas needing further explanation emerged, the analyzers contacted the participating hospitalist(s) for clarity.

RESULTS AND DISCUSSION

Group Descriptive Variables

Three of the four hospitalists had trained in internal medicine residency; one also completed fellowship training in geriatric medicine. The remaining hospitalist trained in family medicine residency with added fellowship training in hospital medicine.

One of the four hospitalists had some familiarity with tele- medicine work. During residency training at a Veterans Affairs health system, the hospitalist participated in outpatient telemedicine encounters during a geriatric rotation lasting two months. The other three hospitalists did not have prior experience with telemedicine.

The four hospitalists completed a combined total of 40 remote encounters. Of these, 37 were routine daily progress note encounters, two were discharge-related encounters, and one was a new acute symptom evaluation encounter.

The mean duration per remote encounter was 10.5 minutes (see Figure 2 and Table 2). The encounter duration is total time spent conducting an audiovisual telemedicine encounter and does not include time spent on chart review or documentation.

Qualitative Data Analysis

See Table 3 for the qualitative data matrix.

Telemedicine Rounding

Remote hospitalist experience: All four hospitalists were satisfied with their ability to communicate with and evaluate a patient remotely and perceived no differences in how they conducted the subjective and medical decision-making portions of the telemedicine encounter.

Most remote hospitalists reported no difference in how they developed rapport with patients; however, one hospitalist reported decreased opportunity to develop rapport or appreciate patient mannerisms. Differences in how one conducts physician/patient conversations using telemedicine were felt by all four remote hospitalists, but these differences were noted to be subtle and did not affect the hospitalists’ medical decision making or communication goals.

Overall, remote hospitalists stated that patients understood the plan of care and had enough time to ask questions. However, their experience was that the delivery of bad news was impersonal using telemedicine. They reached a ceiling in how much they could support and console a patient due to the limitations of a telemedicine encounter, most notably, “not being able to hold the patient’s hand or offer a comforting touch.”

Hospitalists found it helpful that they could simultaneously use the EHR order entry system on a computer screen during the audiovisual encounter, allowing for rapid order entry. Fewer orders, therefore, were forgotten or delayed.

Our remote hospitalists also noticed that the attention of the patient tends to divert toward the telepresenter hospitalist during the encounter. The remote hospitalists advised that the telepresenter hospitalist may repeat what was said for clarification or redirect the patient. If the patient asked a medical question after the encounter was completed, the telemedicine encounter was rapidly restarted, giving the patient the opportunity to speak directly with the remote hospitalist.

There was no change in how remote hospitalists structured the encounter. They discussed subjective assessment, updated with new results and imaging, and described a plan of care as they would have done at bedside.

Outside the door conversations: In their interviews, remote hospitalists advised a brief conversation should take place outside the room between the remote hospitalist and the telepresenter hospitalist before the patient encounter and should include discussion about how the patient likes to be addressed (first name or last name, etc.), gender preference, whether they are located in the bed by the door or by the window, a brief reason for admission, known impairments (example, hard of hearing), and what to focus on for that day.

How to start a telemedicine encounter: Our hospitalists thought that a brief and simple greeting should be provided by the telepresenter hospitalist. This may sound like, “Hi, I am Dr. X. I have your regular rounding physician, Dr. Y, on the screen and s/he would like to visit with you.” From there, the on-screen remote hospitalist should explain the rationale behind the telemedicine encounter and provide reassurance about patient care and continuity.

Our remote and telepresenter hospitalists learned that it is important to turn on lights and make sure noises in the room are decreased to allow for maximal visualization and reduced patient distraction.

Telepresenter Hospitalist Experience

All remote hospitalists reported a high degree of satisfaction with the involvement of the telepresenter hospitalist in the encounter. They said it was easy to communicate with telepresenter hospitalists for two reasons: (1) familiarity as colleagues and (2) similar training. Given the telepresenter is also a physician in our hospitalist group, both parties were familiar with each other’s style and practice.

Due to the shared methodology in medical training, most of the reported findings were intuitively presented and well understood. As an example, telepresenters immediately showed the opposite extremity for comparison without being asked. A level of confidence and experience was brought to the bedside exam that was informative and valuable to the remote hospitalist.

Our hospitalists suggested that the tablet stand should be placed at the foot of the bed and the telepresenter hospitalist should stand or sit on either side of the patient. For patients who were delirious or drowsy, more interpretation was required at the bedside from the telepresenter hospitalist, which the remote hospitalists found invaluable.

Patient Experience

Most patients were understanding of the need for a telemedicine encounter and did not express feelings of discomfort about communicating through a tablet, as noted by our hospitalists. These findings are also corroborated in the current literature that suggests that telemedicine encounters offer enhanced convenience and patients themselves would recommend these visits highly to their family and friends.14,15 One patient commented to our remote hospitalist, “I really liked to see you through the computer. That was great,” and our remote hospitalist noted that “for a patient who is sick, it means a lot to them to see their regular doctor.”

Areas Without Change

During pre-rounding, hospitalists review vital signs, overnight events, progress or consultant notes, and labs and imaging studies in the EHR, and participate in discharge discussions. During post-rounding, remote hospitalists participate in multidisciplinary discharge planning meetings, complete a progress note, enter additional labs or imaging studies, initiate a new consult or speak with consultants, and update families.

None of the hospitalists reported a difference in how they conduct the pre- and post-rounding activities with regard to telemedicine use. Cellular technology, Tiger connect applications, Webex communications for discharge planning meetings, and EHR allowed for such work to proceed smoothly even while the hospitalists worked remotely.

Backup Systems

The two key areas in which all four hospitalists requested implementation of backup systems were rapid responses and the late call structure.

1. Rapid response or acute deterioration in condition: If a rapid response is needed during a telemedicine encounter, our remote hospitalists believed that the bedside telepresenter hospitalist should take over. The on-screen remote hospitalist can offer rapid insight, enter orders, and write an encounter note into the EHR. The two hospitalists may also team up to make decisions.

2. Late call structure: Ideally, if the remote hospitalist was pre-assigned to late call, the schedule could be swapped with an onsite hospitalist. If not feasible, all cross-cover events during late call can be handled by the remote hospitalist using Tiger connect and remote access to the EHR. If a patient needs acute assessment, the remote hospitalist participating in late call would need to contact the onsite admitting hospitalist working the swing shift for assistance.

Impact on Day Structure

Broad variations exist in how rounding hospitalists structure their workday. We found that the remote hospitalists’ workday would need to be restructured to suit telepresenter hospitalist availability. Our hospitalists suggested that the remote hospitalists participate in pre-rounding activities and then schedule all remote rounding encounters to be completed consecutively during telepresenter hospitalist availability.

After all remote rounding encounters have been completed for the day, the remote hospitalist may choose how to organize their time to complete post-rounding activities.

Billing, Documentation, and Regulation

The declaration of national emergency related to the COVID-19 outbreak in the United States16 has created greater opportunity to compensate for telehealth services. The Centers for Medicare and Medicaid Services (CMS) has created both out- patient and inpatient telehealth billing codes.17 The overarching goal of the Coronavirus CMS waiver using section 1135 of the Social Security Act18 is to protect the health of all and to limit the spread of infection.

While CMS has confirmed in its FAQ Document19 that the remote practitioner may provide services from home, there is no distinction of whose risk of exposure prompts this change in practice — the physician or the patient. Employing a practice that aligns with the overall goal is considered enough justification for billing for telehealth. The utility of telehealth codes after the national emergency ends is unknown at this stage.

We recommend partnering with your own billing department to create guidance for hospitalist use in this area and recognize that methods of reimbursement for care are vastly different across nations.

Regarding documentation during our pilot study, the remote hospitalist was the attending on record. The phrase “this is a virtual visit” was included at the top of the progress note. The physical exam section included the statement “the following findings were reported by the telepresenter hospitalist.”

For a routine progress encounter, billing is done by the remote hospitalist only. However, if bedside critical care becomes necessary and is provided by the telepresenter hospitalist, the telepresenter can bill for critical care time.

Lastly, it is prudent to review telehealth use rules and regulations specific to your country and state20, 21 before proceeding with this venture.

Technological Considerations

We did not struggle with technology use in this study. The four hospitalists used an app called Lifesize, which is currently used within our health system largely for outpatient telemedicine encounters. Other audiovisual communication apps exist and may be explored. The addition of a speaker system below the tablet allowed for enhanced volume and an overall better audio experience. Remote hospitalists thought that a tablet, rather than a cell phone screen, allowed for a better clinical encounter due to better interpretation of events in the room. Remote hospitalists noted the added advantage of hearing-impaired patients to read the lips of an unmasked remote hospitalist on screen.

PLANS FOR THE FUTURE

Our vision is to create a five-hour telepresenter hospitalist voluntary moonlighting shift to be filled as needed. This will allow predictable and reliable telepresenter hospitalist availability. In our assessment, the reimbursement for the telepresenter hospitalist shift should be comparable to our current hourly hospitalist rounding rate. The telepresenters’ physical exam, their availability to take over a rapid response, and completion of nursing home and advanced directive forms justifies the reimbursement.

If the telepresenter hospitalist shift cannot be filled, the remaining four rounding hospitalists onsite may take on the role of telepresenter hospitalist and divide the five moonlighting hours among themselves. The telepresenter role can be fulfilled by a moonlighting physician or by the remaining onsite hospitalists and is therefore flexible and rapidly deployable within minutes with minimal additional resources.

Without the use of telemedicine, the quarantined hospitalist is unable to work and therefore a moonlighting hospitalist will need to be brought in to fill that staffing shortage. Instead of bringing in a moonlighting hospitalist onsite at emergent rates for 12 or 16 hours, a telepresenter hospitalist can be brought in for five hours at non-emergent rates. There will be more interest in participating in a five-hour telepresenter shift due to its short duration and significantly less clinical and documentation responsibilities. Moreover, our backup telemedicine model allows us to utilize the salaried remote hospitalists who are quarantined but assigned to work onsite, as they may continue to provide care while quarantined using telemedicine.

In our estimation, utilizing a five-hour telepresenter shift at non-emergent moonlighting rates offers 64 percent cost savings when compared to bringing in a moonlighting onsite physician for 12 hours at an emergent moonlighting rate and 73 percent savings when compared to 16 hours at an emergent moonlighting rate when late call participation is required for that day. We were able to leverage these estimated cost savings when planning our discussions with hospital leadership.

From an administrative standpoint, the key benefits of creating and supporting a voluntary telepresenter hospitalist shift internally are that such a model is rapidly deployable and does not require buy-in from third parties. In low-census situations, we can choose to collapse a rounding panel and redistribute patients based on internally established volume criteria, thereby using our backup telemedicine system only when needed. If a health system chooses to develop and maintain a full-time telemedicine presence, the resources involved in creating contracts, onboarding processes, training, and validation skills pay off with the lower cost of such a system in the long term. Such programs need to be kept up and running and are not suitable to be switched on or off rapidly.

In addition, it should be noted that the quarantined hospitalist is a salaried physician scheduled to work and will continue to be reimbursed while under mandatory quarantine by utilizing sick leave. In fact, our backup telemedicine model was developed in response to COVID-19-related work absences to address an unusual increase in sick leave while awaiting test results and to allow for isolation when testing positive.

Before the COVID-19 pandemic, sick calls among physicians in our group were a rare occurrence. We consistently used fewer than 10 sick days per year for our 20-physician group. This changed with mandatory isolation, significantly impacting our operating costs.

CONSIDERING A NON-PHYSICIAN TELEPRESENTER

Non-physician telepresenters such as allied healthcare staff or mid-level practitioners may be considered. However, using a non-physician telepresenter poses certain challenges.

Hospitalist groups considering a non-physician telepresenter would need to have such members on staff and credentialed with hospitalist privileges. Groups would need to explore the long-term impact of this proposition. Our hospitalist group does not employ allied healthcare staff or mid-level practitioners.

In addition, we believe it is paramount that any such staff undergo a training and orientation program in which their physical exam, case presentation skills, medical decision making, and critical thinking during acute clinical deterioration events are assessed. In addition, such staff would need Advanced Cardiac Life Support and Basic Life Support certification. They would need to be able to successfully take over during acute clinical deterioration. To this end, we also believed that such staff will benefit from participation in a longitudinal training program with mechanisms for ongoing evaluation and improvement.

To entrust a non-physician telepresenter to respond successfully in a rapid response or cardiopulmonary arrest requires significant deliberation by individual hospitalist groups and credentialing committees; therefore, this decision will need reflection and individualization among groups. For our group, we opted to utilize our hospitalist physicians for the telepresenter role because building consensus within our hospitalist group allowed us to rapidly implement our backup telemedicine system rather than try to build consensus among various third parties.

Our hospitalist group is a low-turnover group with a highly developed work culture among our physician staff members. We learned in the chaotic environment of the COVID-19 pandemic that a certain operational cadence is required to handle surprises. In our high-functioning team, we understand each other’s styles and can achieve our goals in times of stress. We understand each other’s patterns of thinking in our group and how to operate with each other. It is for this reason that we decided to retain the telepresenter role within our group so that we may easily communicate and partner with each other in times of surprise.

LIMITATIONS OF THE STUDY

Out of 13 currently employed rounding hospitalists in our group, we conducted our pilot study with four. However, we felt sufficient saturation22 was achieved during the qualitative interviews to understand our key interests, allowing us to proceed with confidence in planning broad-scale use. We will have the opportunity to reassess and tailor our work following full-scale implementation.

Currently, we plan to use telemedicine for quarantined hospitalists who are absent short term but can work. Other solutions will need to be explored for long-term absences.

We plan to explore the use of telemedicine utility for our admitting hospitalists in the future.If a language translation service is required, this will warrant additional service integration, which we have not explored in our pilot study.

Our current model proved most valuable as a backup system for continuing care but is not efficient in the long-term given we required an onsite telepresenter(s) hospitalist(s) who may already be carrying a full panel of patients when the voluntary telepresenter hospitalist shift cannot be filled.

CONCLUSION

We found the pilot study to be both suitable and feasible for our hospitalist group. In this time of rapid pandemic-related change, we wanted to share these findings with the field at large so that those considering adding telemedicine service may examine our experience and the reduced instability it offers. Future research in this area should focus toward exploring other types of telepresenter staffing models and studying the impact of telemedicine on patient outcomes.

Overall, we are pleased that we proceeded with a pilot study despite a narrow scope of use as we now see the advantages and limitations of use. We understand from our hospitalist experience that a “one-size fits all model” to solving problems at community hospitals does not work. We therefore conducted this pilot study for the benefit of our group and for our experience to be of benefit in advancing this conversation for other community hospitalists.

Sue Dhamija, MD, is a hospitalist with the Multicare Inpatient Specialists at Multicare Auburn Medical Center in Auburn, Washington and is a clinical instructor in medicine at the University of Washington. sdhamija@multicare.org

Bradley Geyer, DO, is a hospitalist with the Multicare Inpatient Specialists at Multicare Auburn Medical Center in Auburn, Washington.

Monica Sethi, MD, is a hospitalist with the Multicare Inpatient Specialists at Multicare Auburn Medical Center in Auburn, Washington.

Tomas Ricalde, MD, is a hospitalist with the Multicare Inpatient Specialists at Multicare Auburn Medical Center in Auburn, Washington.

Gunjan Dalal, MD, is a hospitalist with the Multicare Inpatient Specialists and former chair of medicine at Multicare Auburn Medical Center in Auburn, Washington.

Asra Khan, MD, is a hospitalist with the Multicare Inpatient Specialists at Multicare Auburn Medical Center in Auburn, Washington and is a clinical instructor in medicine at the University of Washington.

Rajendra Suvarna, MD, MSM, is a hospitalist and medical director with the Multicare Inpatient Specialists, chief of staff at Multicare Auburn Medical Center in Auburn, Washington and a clinical instructor in medicine at the University of Washington.

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This article was published in the March/April 2021 Physician Leadership Journal.