CHOC telehealth visits continue at a rapid pace

As the world surpasses the one-year anniversary of the COVID-19 pandemic, the resulting rapid rise of telehealth continues to propel forward in 2021, with CHOC patients consistently reporting a 90-plus percent satisfaction rate in surveys, hospital officials say.

Virtual visits with a CHOC provider via a smart phone, tablet, or computer not only are here to stay, but are expected to continue growing at a rapid pace – not just in Orange and surrounding counties, but nationally and globally.

The rapid growth and acceptance of telehealth is a definite sign that consumers want easier access, convenience, and comfort as they seek medical care,” says Dr. Michael Weiss, vice president of population health. “CHOC is committed to providing the highest quality and service to fulfill these needs.”

Kathleen Lear’s son, Matthew, 18, was diagnosed with intractable epilepsy when he was 6 and the last 12 years have been a non-stop roller-coaster, she says.

In mid-February 2021, Matthew became the first epilepsy patient at CHOC to undergo a procedure called Deep Brain Stimulation (DBS), in which electrodes were placed in his brain to help reduce his seizures by sending electrical currents to jam his malfunctioning brain signals. In another first, CHOC recently conducted DBS on a patient with the movement order dystonia.

Kathleen and Matthew recently have had neurology and hematology telehealth visits with Dr. Joffre Olaya and Dr. Mary Zupanc, as well as a consultation with Dr. Antonio Arrieta and Dr. Loan Hsieh.

“I think it was amazing that we even could have a virtual neurology visit,” Kathleen says. “The doctors were able to assess a lot by watching Matthew walk and run and touch his finger to his nose.”

Kathleen says the telehealth session was especially helpful because her husband is working from home during the pandemic and he, too, could participate.

“It was really nice,” she says.

Growth projections

According to Fortune Business Insights, the global telehealth market size was valued at $61.4 billion in 2019 and is projected to reach $559.52 billion by 2027, exhibiting a compound annual growth rate (CAGR) of 25.5 percent during the forecast period.

The U.S. telehealth market size was valued at $9.5 billion in 2020, up a whopping 80 percent over 2019, and is expected to exhibit a CAGR of 29 percent between 2020 and 2025, according to market research firm Arizton.

Quick pivot

At CHOC, a lot of teamwork was necessary for the quick pivot that began in the early days of the pandemic, says Lisa Stofko, CHOC’s telehealth manager.

“There is a difference between a two-way video and telehealth,” Lisa says. “We are committed to making telehealth a seamless experience for both patients and providers, and ensuring that it replicates the safe, quality care patients are used to receiving in person.”

The information services department, Lisa says, worked feverishly to get technology set up so clinicians could use video conference software that came with extra layers of protection that allowed them to safely consult with patients virtually.

Training videos were delivered to more than 700 providers so they could replicate the in-person visit as closely as possible, Lisa says. And a 20-member steering committee was established from key stakeholders from across CHOC’s health system — including administrative executives and physicians — to further improve the telehealth experience and capabilities at CHOC.

In December 2020, Dr. Robert Hillyard, CHOC neonatologist, and Dr. Kenneth Grant, CHOC pediatric gastroenterologist, began serving as co-medical directors of CHOC’s telehealth program, while each retaining existing clinical responsibilities.

Some statistics

Dr. Weiss tracks telehealth visits daily.

From March 2020 through April 2020, CHOC telehealth visits zoomed to 14,457, from 2,233 prior to the pandemic, he says.

Since the pandemic began through early February 2021, CHOC telehealth visits totaled 95,757. The average number of telehealth visits per month during COVID-19 have remained in the 8,500 range.

Telehealth visits at CHOC have grown dramatically in both primary and specialty care.

In January 2021, the most visits (370) in CHOC’s Primary Care network were recorded at Orange Primary Care, followed by Pediatric and Adult Medicine (338), Clinica Para Ninos (286), Breathmobile (176), Los Alamitos Pediatrics (149) and Boys and Girls Clinic Santa Ana (92).

In January 2021, the most visits (1,498) in CHOC’s Specialty Care network were recorded at Providence Speech and Hearing Center, followed by endocrinology (1,017), mental health (991), gastroenterology (893), neurology (481), pulmonary (450), the Thompson Autism Center (407), and outpatient rehabilitation (301).

Kathleen says she looks forward to continuing Matthew’s treatment at CHOC – in person when possible, and virtually, too. She finds telehealth visits especially useful when doctors want to go over test results.

“There’s definitely a time and a place for it,” Kathleen says. “And I just feel so privileged to have CHOC so close to us.”

Learn more about telehealth at CHOC

CHOC Launches Telehealth Program to Improve Cardiac Outcomes

CHOC Hospital has launched an innovative new telehealth program to help improve the short and long-term outcomes of high-risk patients with complex congenital heart defects. 

Parents of patients in the CHOC Heart Institute’s Cardiac High-Risk Interstage Program are now being issued iPads enabled with Locus Health. This HIPAA-compliant platform monitors vital health data in real-time to be shared with a patient’s care team. The Locus platform is currently used in more than 25 leading children’s hospitals in the U.S. and Canada. CHOC is the first hospital in California to implement the platform.

Patients in CHOC’s Cardiac High-Risk Interstage Program have single ventricle circulation, causing structures on the right or left side of their hearts to be severely underdeveloped. Heart surgery is performed shortly after birth, followed by a second surgery months later. The time between the two interventions is critical due to the baby’s fragile health and risk for life-threatening problems. Monitoring and evaluating a patient’s information on a regular basis has been proven to help with early recognition of possible serious problems and to save lives.

“The goal of our program is to yield the best outcomes for our highest risk heart babies while they recover in the comfort of their own homes,” said Dr. Nita Doshi, a CHOC pediatric cardiologist. “The Locus platform offers our physicians and our patients’ families with an innovative and convenient way to connect and share important information. Our providers have access to data in real-time, providing parents with peace of mind knowing their babies are still under our watchful eyes – even though they are no longer in the hospital.”

Dr. Nita Doshi

The Locus platform is also able to leverage providers’ existing workflows, enabling care teams to more efficiently manage data collected on large groups of patients. This frees up their time to focus even more on direct patient care. Of note, Locus has been proven to reduce the length of a pediatric patient’s hospital stay by more than 30 percent.

“In an era when telehealth has never been more vital, we are thrilled to bring Locus to CHOC. Our platform was designed by doctors and nurses who saw the need to implement remote patient monitoring into pediatric care and has been proven to benefit patients, parents and healthcare providers alike. We are excited to have our first partner in California be CHOC, which has provided incredible care for children in California for more than 55 years,” said Kirby Farrell, Locus Health CEO.

How CHOC transformed its telehealth services during COVID-19

Between July 2019 and mid-March 2020, CHOC had completed 182 telehealth visits. After the onset of COVID-19 and to date? Since then, tens of thousands of visits have provided safe, high-quality care for pediatric patients at CHOC — and that number continues to grow.

So, how did CHOC elevate its telehealth offering so quickly and seamlessly?

It took a whole lot of teamwork, says Lisa Stofko, CHOC’s telehealth manager.

Tech steps

“We collaborated with CHOC’s information services department and had video technology set up within 72 hours,” she says. “This was essential, as we wanted to ensure patients were still getting the care they needed, and clinicians had the technology they needed to carry out appointments.”

To conduct telehealth appointments, CHOC clinicians primarily use a special version of Zoom, a video conferencing software with extra layers of protection. Clinicians also have access to InTouch, Health, PingMD and Doxy.me as well.

Patient safety remains paramount to providers, regardless of whether a visit is in-person or virtual. To ensure the protection of private health information during virtual visits, the telehealth team at CHOC collaborates closely compliance and information security.

“We want to remind families that CHOC’s doors have remained open, whether that be in person or virtually,” Lisa says. “We serve some vulnerable populations and we want to accommodate them safely.”

Increasing physician and patient comfort level

Although telehealth offerings predated the COVID-19 pandemic, some physicians had more experience conducting virtual visits than others. To increase comfort levels with new platforms, training videos were delivered to more than 700 providers.

Many patients and families were new to virtual visits as well. The telehealth team at CHOC wanted to make visits as easy as possible on families, so they prioritized replicating the in-person visit as closely as they could.

For clinic visits where patients are visited by multiple specialties, Zoom breakout rooms are utilized. This complex workflow requires close coordination with compliance and information services to ensure HIPAA compliance.

“Telehealth is not one-size-fits-all. The way one specialty care clinic operates may have a different flow than another,” Lisa says. “To make the process of adapting to virtual visits as easy as possible on families, we have interviewed providers and clinical staff on their typical in-person workflow and done our best to replicate that virtually.”

Before the appointment begins, families receive clear communication from their provider’s office on how to prepare themselves for a telehealth visit. The team recognizes patient-facing tech support as an essential part of ensuring a seamless appointment. Care coordinators empower patients with education and support for the continuum of care. Materials are translated into Spanish and Vietnamese. And just like with in-person appointments, translators are available during virtual visits, too.

Ensuring patient satisfaction

To measure patient satisfaction with the telehealth experience, CHOC’s telehealth team launched a satisfaction survey which is sent to patients within 24 hours after their appointment via text, email or phone. To date, results have consistently hovered around 91%, compared to a benchmark of 86%.

“We continue to monitor survey results and identify opportunities to further improve patient experience,” Lisa says.

Ongoing optimization

A 20-member steering committee was established from key stakeholders from across CHOC’s health system — including administrative executives and physicians — to further improve the telehealth experience and capabilities at CHOC.

Future plans include additional features to further replicate the in-person experience. The team is working toward kicking off and wrapping up a patient’s online appointment with a virtual visit from the same medical assistant. This would provide not only proper intake protocols, but also quality customer service and a personal touch.

Another tactic the team is working on implementing is streamlined notifications for parents – especially those of medically complex children who may have multiple telehealth visits with various specialists in the same day.

“We want to make sure that parents are easily able to keep track of appointments, and that we are not under or over communicating to them, causing additional stress,” Lisa says.

Moving forward, the CHOC telehealth team is doubling down on its commitment to ensuring telehealth remains a safe, high-quality and stress-free experience for providers and patients alike.

“There is a difference between a two-way video and telehealth,” Lisa says. “We are committed to making telehealth a seamless experience for both patients and providers, and ensuring that it replicates the safe, quality care patients are used to receiving in person.”

Learn more about telehealth at CHOC.

A physician shares his best tips for a successful telehealth practice

Ophthalmology might not be the first specialty that comes to mind when envisioning a telehealth practice, but Dr. Rahul Bhola, medical director of ophthalmology at CHOC, has seamlessly integrated the service in his practice, completing more than 900 telehealth visits since March.

In this Q & A, Dr. Bhola outlines his team’s success in transitioning to telehealth, and shares best practices that physicians in a variety of specialties can put into practice: 

What does an ophthalmology telehealth appointment look like?

A synchronous (live audio-video) CHOC ophthalmology telehealth appointment is divided into four components. I call them the four C’s: contact, connect, consult and care.

  1. Contact
    Our front desk reaches out to the family to confirm contact information. We send a Zoom link to the families, along with information about how to connect to Zoom and download the visual acuity app to check vision before the appointment. 
  2. Connect
    As the appointment day approaches, our technician connects with the family to discuss any technical issues that should be resolved prior to the physician consultation. The technician also goes over the at-home visual acuity check and evaluates basic medical history. 
  3. Consult
    On the actual day of the appointment, the physician connects with the families on Zoom to go over the pertinent history and visual acuity, and performs a focused examination including an external and ocular motility exam. If needed, pictures and videos from the family are requested for further evaluation. This enables us to diagnose a majority of anterior segment ocular issues as well as visual acuity concerns like amblyopia, refractive errors and ocular motility disorders.
  4. Care
    We discuss the treatment care plan and review any medical issues or concerns the patient is experiencing. Throughout this process, we can fulfill their needs ranging from prescription refills for medication or broken glasses without them having to step outside the comfort of their home.

Our office will then schedule a follow-up visit depending on the medical necessity.

Dr. Rahul Bhola offers his best tips for telehealth practices
Dr. Rahul Bhola, medical director of ophthalmology at CHOC , has completed more than 900 telehealth visits since March.

How do your patients and families feel about telehealth?

While some physicians may have been wary of telehealth care, I was pleasantly surprised that patients love telehealth.

Telehealth helped our patients and families feel secure, supported and assured that there would be no interruption in the patient’s care plan during COVID-19.  Our families are so grateful that during this time of emergency, their physician was able to connect with them to address any urgent issues and follow them in clinic on a need-to basis.

Due to the positive response we have received from our families, we will continue to offer telehealth visits for our families, when appropriate.

 Does telehealth compromise quality of care?

Not at all. Providers are often able to spend more time with patients during a telehealth visit. Children are more comfortable in their home setting and you can engage more with them and spend more time on-screen with them.

If we felt the urgency to see our patients face-to-face after the initial exam, we schedule in-person appointments.

What makes your telehealth visits successful?

The expression “Necessity is the mother of invention” really is true when it comes to telehealth.  Telemedicine has been around for a while, but it took a pandemic to make it universal and successful. As soon as the stay-at-home orders were announced we knew we had to connect with our patients to prevent any disruption of their care. Our team was not afraid of change and we realized the urgency to adapt to the circumstances right away to provide uninterrupted care to our patients and their families. We reallocated our resources to maximize our outreach; our goal was to connect with each and every patient scheduled to be seen in the clinic.

What advice and tips do you have for other providers to do telehealth successfully?

Being open minded, adaptable to the changing circumstances and embracing technology were a few things that helped us during this unprecedented time. We created a vigorous team of both technical and non-technical staff in a short span of time to enable successful initiation of a robust tele-ophthalmology program. The key was strategizing dynamically in this constantly changing environment and having frequent huddles with the team to address any issues.

Very quickly we realized that telehealth was amazing to address the four-part aim of healthcare: access, cost-effectiveness, patient satisfaction and physician satisfaction.

There will be nuances for specific specialties. In our case the American Academy of Ophthalmology right away provided resources and tools to help us initiate an effective synchronous telehealth portal.

Technological innovations like visual acuity apps and the ocular motility app were phenomenal tools developed to assist effective consultations.

Find other resources to grow your telehealth practice.

6 telehealth tips for providers

For many providers, the COVID-19 pandemic has accelerated the use of telehealth to serve patients and families. With that, this may be a developing skill set for many physicians and advanced practice professionals. Here are a few tips to ensure a successful video visit:

Determine if the patient is a good telehealth candidate

It’s up to each clinician to gather enough information to make appropriate medical decisions. Refer the patient to in-person care if you determine a video exam is not adequate to provide high-quality medical decision-making.

Here are some things to consider:

  • Is the patient in a private location? Do not provide telehealth services when a patient or parent is driving or in a public location.
  • Does the patient or family have access to the internet and a computer or mobile device?
  • Do you have a medical license for the state in which the patient lives? Restrictions during COVID-19 have been waived but this may change.
  • Is the patient and family able to help with the physical exam, testing and vital signs, if necessary? For example, do they have a thermometer and scale? Are they able to count respirations?

Prep your virtual exam room

Take a few steps to prepare your environment for an optimal video experience:

  • Check for clutter and any personal health information visible in the camera frame. Consider activating the virtual background if necessary.
  • Check your self-view and make any needed lighting adjustments so your face can be seen clearly.
  • Be aware of the position of your devices. If you’re using two screens, ensure they are positioned optimally so you can look back to the patient frequently when documenting.
  • Shut your door, if possible, and hang a sign indicating a video session is in progress.
  • Once the visit begins, be mindful that any typing from charting or notetaking will likely be picked up by the microphone.

Perform some housekeeping

Once the session begins, you’ll need to start with a few housekeeping matters:

  • Verify you are with the correct patient and family by using two patient identifiers such as full name and date of birth.
  • Obtain consent for the telehealth visit from the patient and parent.
  • Explain to the patient and family that the video visit is not recorded, meets HIPAA requirements, and cannot be posted or forwarded.

Ensure comfort and privacy

For both the provider and patient, this visit will certainly “feel” different than a typical encounter. Acknowledge that to the family and then take some steps to increase comfort:

  • Your usual techniques to connect with families can translate well on video. For example, help your patient warm up by asking them to show you their favorite toy or book.
  • To help the family feel more comfortable – particularly if the exam will require clothing to be removed – ask non-essential staff and family members to leave the respective rooms.
  • If others are in the room, introduce everyone in the location. Ask the family to do so as well for anyone who is in the room but off camera and in the microphone’s range.

Double down on communication

Communication is always important – but doubly so during a video exam. Be engaging and encourage cooperation from the patient and parent throughout the exam:

  • Be comfortable giving the patient and family direction to improve the experience. This could mean asking them to adjust lights; move closer or farther from the camera; remove objects obstructing your view; or speak more loudly.
  • Let the patient and family know they may hear you typing but this is because you want to accurately document the visit.
  • Make eye contact with your camera, not the patient’s eyes.
  • Do not cover your camera or mute your microphone; this could make the patient and family feel you’re not giving them your full attention.

Ask for assistance from the patient and family

In the absence of physical proximity, you might need the patient and family to help you perform exam maneuvers:

  • Direct them to remove clothing, as necessary, and remember to tell them when it is OK to put on their clothing again.
  • Tell them how to palpate to localize pain.
  • Explain how to perform range of motion maneuvers.
  • Describe the landmarks you use in clinic to find the right location for an exam component, such as ribs or the pelvic bone.
  • Watch carefully and ask them to repeat anything that appears questionable.
  • Verbalize what you think you are seeing, allowing the patient and their parent to clarify as needed.

Find more resources for telehealth services.