In This Article
- The COVID-19 pandemic has prompted Massachusetts General Hospital to develop three new telemedicine applications: web-based screening, video "intercoms" in patient rooms and virtual rounds
- The hospital is also rapidly scaling up existing uses of telemedicine: virtual visits for ambulatory patients, virtual urgent care and virtual consults
- There are substantial nationwide barriers to virtual care of COVID-19 patients, including lack of access to technology, inadequate insurance coverage and restrictions imposed by licensing boards and malpractice insurance carriers
Virtual care (also called telemedicine, telehealth and digital health) has proven critically important in the response to COVID-19. Lee H. Schwamm, MD, director of the Massachusetts General Hospital Center for TeleHealth and vice president for virtual care at Partners HealthCare, and colleagues recently published commentaries in Lancet Digital Health and Nature Digital Medicine describing how virtual care is helping Mass General and Partners HealthCare minimize nosocomial infection, reduce the use of personal protective equipment and cope with the surge in demand for its services.
Web-based COVID-19 screening allows patients to use a Microsoft asynchronous tool (called a "chatbot") to answer questions. Providers then remotely evaluate the risk of infection and provide guidance to patients on the next steps for them to take. The clinical algorithms hardwired into the system can be updated nearly instantaneously, and the tool alleviates pressure on the live COVID-19 hotline.
A nurse or consultant can monitor and communicate with a COVID-19 patient from outside the room through a videoconferencing system that connects a personal device or hospital laptop to a tablet computer mounted on an IV pole. The tablets are enabled with Vidyo and SBR Health software.
The tablets auto-answer, so conversations can occur without the patient taking any action. The patient can see the nurse's facial expressions, and the interactions need not be rushed. When physiological monitor alerts require immediate patient observation, nurses can swiftly appear on the screen from anywhere in the hospital. Currently, 600 of these tablets are in use at Mass General, and reports from patients and nurse leaders have been overwhelmingly positive.
As a means of physical distancing, one or two providers are physically present on the ward, while others join remotely from other hospital locations or from home via Microsoft Teams. This approach preserves the intimacy of group work and facilitates task management and image sharing. In fact, more than the usual eight to ten professionals can join in, such as pharmacists, case managers, providers in self-isolation and students who were removed from hospital work.
Expansion of Established Applications
Prepandemic, Mass General had up to 800 providers regularly offering video-enabled visits to ambulatory patients in a program tightly integrated into its electronic health record (EHR) system. To allow rapid scale-up, the program now operates outside the immediate EHR workflow. It's expected that over 11,000 providers employed by Mass General and others Partners hospitals and practices will eventually participate.
Providers can conduct visits on almost any device because central management keeps communication secure. Providers isolating voluntarily at home or assigned to home quarantine due to testing positive for COVID-19 can continue working if well enough. This option is designed for patients without suspected COVID-19 who are at high risk of serious complications if infected or have ongoing medical conditions that will predictably deteriorate if unattended.
Brief, video-enabled urgent care visits are also available 24/7 when patients cannot be triaged adequately by phone or physician offices are closed. All encounters are documented in the EHR.
Additionally, Mass General offers provider-to-provider expert Virtual Consultation to providers at a network of 30 community hospitals, and over 60% of patients remain at their community hospital after the consult rather than being transferred. This solution is being leveraged during the pandemic to provide expert care across all provider types and specialties, especially critical care and infectious diseases, and is offered at additional facilities like skilled nursing facilities and Boston Hope.
The authors urge other health care systems to consider these tactics. They address internal challenges, such as technical support and nationwide barriers to virtual care. Those include:
- Lack of access to technology by patients, including those who are visually impaired or have other disabilities
- Limited availability of medical interpreters for patients with limited proficiency in English
- Inadequate insurance coverage or financial resources to cover copays
- Supply chain disruptions that are making it difficult to obtain webcams and other peripherals
- Requirements that providers be licensed in the jurisdiction where the patient is located
- Concerns about malpractice insurance coverage
All stakeholders including health care systems, providers, payors, government agencies and the public will need to realign their goals and incentives in order to meet the urgent needs posed by COVID-19 and beyond.
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