Telehealth for SNFs – Part 4: How Video Chat Apps Create Chaos and Fall Short of Real Telehealth
By Paul Knight, OT, MBA, Founder, Curatess
In prior articles in this series (see Featured on my profile page), we learned about the why, what, and how of Real Telehealth. Here, we focus more deeply on the inadequacies of video chat applications (such as FaceTime) when used for telehealth visits, particularly in the SNF environment. Improving patient-centered care in this new age of telehealth requires convenient and integrated access to electronic health record (EHR) patient data, real-time diagnostic information, and redesign of clinical workflows in ways that video chat alone cannot accommodate.
“Video Chat Chaos”
The title graphic above represents the conundrum of Video Chat Chaos, i.e. the complexity of trying to perform SNF telehealth with a typical video chat application. Let’s walk through an illustrative scenario in a SNF:
A SNF nurse on the evening shift identifies a sudden shortness-of-breath change in condition of the patient. The nurse logs into the EHR to identify the primary physician and attempts to determine what video chat app that physician uses. Depending upon the particular app, the nurse needs to perform a combination of the following actions to arrange a video session with the remote physician: (1) login to the video chat app, (2) phone the physician, and/or (3) send a secure message to the physician. As the patient’s shortness of breath persists and potentially becomes critical, the nurse and physician spend an unpredictable amount of time connecting, coordinating and finally initiating the video session at the bedside. If the primary physician is not available, then even more time passes as the nurse attempts to contact the next physician on the call tree, or worse yet dial 911 to send the patient to the hospital.
The physician is often using their mobile device, without easy access to a laptop, EHR, nor real-time diagnostic information, and therefore depends upon the nurse to interpret and verbally communicate health information gathered at the bedside. When the physician does have access to a desktop computer or laptop, a persistent and common complaint, in the words of one SNF physician, is that “logging into and accessing information in multiple EHRs in combination with using a video chat application is challenging and wastes time with patients”.
Although it is helpful to see real-time video of the patient, the physician must decide whether to treat the patient in place or refer to the hospital in the absence of much information. Then, after the telehealth session, there is the added burden on the physician and nurse to document the telehealth session in the EHR. Finally, the physician or nurse often must contact the patient’s family to relay what has transpired.
There are too many things that can and often do go wrong in such a complex workflow. As a group of SNF operators recently indicated to us, “the number of video chat applications and mapping of applications to physicians is causing chaos for our staff”.
There are at least three underlying causes of Video Chat Chaos:
- No integration with the EHR
- Lack of real-time diagnostic information
- Disjointed clinical workflows
No Integration with the EHR
Physicians should follow specific standards of practice when evaluating a patient. With regards to conducting a telemedicine visit, the AMA recommends “establishing a diagnosis through the use of acceptable medical practices, including patient history, an appropriate physical examination, and indicated diagnostic studies”. If such clinical information about patients is not easily accessible, how can remote physicians be expected to consistently meet the standards of practice their patients deserve?
Patient information found in the EHR is important for clinical decisions and should be made easily accessible in a telehealth visit. According to the federal Office of the National Coordinator for Health IT (ONC), 66% of SNFs, or over 10,000 facilities, have adopted EHRs. However, standalone video chat applications do not incorporate information from widely-deployed EHRs. As a result, the remote physician must toggle between their video chat app and the EHR during a telehealth session. Often the clinician user experience is so cumbersome that the physician conducts the visit without consulting the EHR. Even worse, sometimes the EHR is not even remotely accessible, such as from the physician’s mobile device, due to IT security and technology constraints. Since critical information must be conveyed to the remote physician, all too often the bedside nurse must consult the EHR and verbally relay it to the physician. When the remote physician has never evaluated or seen the patient before, as has often occurred during the COVID-19 pandemic, then the risks and inconveniences of using video chat without integrated EHR information are even further amplified. Simply put, video chat apps are designed for video conferences, not for leveraging ALL available patient information (beyond just video) to deliver the best patient care.
Real Telehealth at Work: In contrast, Real Telehealth incorporates patient health information from the EHR directly into the telehealth user interface for the remote physician, eliminating the need to toggle between multiple apps. A single login provides access to both live video and critical patient information. In addition, the physician can capture visit notes which are automatically routed to and stored back in the EHR. The scope of EHR patient data needed for Real Telehealth goes beyond just Admit Discharge Transfer (ADT) information and should also include medications, vital signs, laboratory results, and clinical notes.
Lack of Real-Time Diagnostic Information
Important SNF telehealth use cases are enhanced or even critically dependent upon the remote physician having access to real-time diagnostic information, such as stethoscope audio or blood oxygen levels. Video chat apps alone lack such capabilities, and workarounds attempting to combine the use of such apps with unintegrated diagnostic devices can be cumbersome. Consequently, a recent study reveals that 70% of patients had their blood pressure taken during in-person visits compared to 10% in telehealth visits and that cholesterol assessments were similarly reduced by 8%.
Real Telehealth at Work: Real telehealth integrates remote, real-time diagnostics such as Bluetooth-enabled stethoscopes (transmitting diagnostic quality audio to the remote physician) and pulse oximeter readings directly into the SNF telehealth workflow and technology setup. This is particularly important for high-stakes and urgent clinical situations, such as sudden changes in condition of the patient.
Disjointed Clinical Workflows
In order for SNFs to maximize return on telehealth, it is essential to redesign clinical workflows for the patient’s physician, specialty services (like cardiology or wound care), and other providers needed for patient care. As described in the illustrative Video Chat Chaos scenario above, the use of video chat apps for mission-critical telehealth workflows often result in ineffective and inefficient workarounds unlikely to be sustainable in the long term. It should not take multiple phone calls to get a remote physician on an urgent telehealth session. Physicians should not need to have the bedside nurse verbally convey patient medication lists and lab results seen in the EHR. Sophisticated SNFs are moving beyond the COVID-induced adoption of video chat apps for telehealth to better approaches, i.e. Real Telehealth.
Real Telehealth at Work: Real Telehealth contemplates the entirety of the pre-session, in-session and post-session user experiences of physicians, nurses, patients, and families. For instance, in order to shorten the time to identify and contact the best available physician for a telehealth session, a SNF can adopt “intelligent call routing” which automatically and sequentially searches for the most appropriate physicians for different clinical workflows, such as change in condition, cardiology, wound care, and COVID.
Now is the Time for Real Telehealth
The expectation alone that the HIPAA-compliance waiver for COVID will expire and disqualify non-HIPAA video chat apps from being used for telehealth is causing many SNFs to seek better solutions. The right recipe to follow is Real Telehealth, as we’ve described in this series so far.
With the rise of virtual care, SNFs must develop ways to replicate in telehealth sessions, as much as possible, what is normally provided by the in-person visits they are replacing. As Dr. Karim Yunez, a physician leader at one of our customer organizations, exemplifies in this statement, “why would I just want to use audio or video to examine my patient when I could also have access to the health record”.
PS Don’t forget to run your Return on Investment for Real Telehealth. Check out my podcast “Expanding and Improving Telehealth Offerings in SNFs” with Julie Gould of Annals of Long-Term Care to hear more about the Real Telehealth ROI for SNFs.