Article Figures & Data
Figures
- Appendix Figure 1.
Overview of Analytical Approach.
Tables
Limited Use (n = 4) Targeted Use (n = 5) Major Shift in care delivery (n = 8) Virtual primary care services were not expected to have a significant role in their organization. Virtual primary care services were expected to continue in focused, defined areas. Care delivery was expected to meaningfully change because of virtual care models. Administrators noted that they would offer virtual services if a patient requested it, but it would not be their preferred modality for care delivery. Examples included virtual urgent care, behavioral health services, and Annual Wellness visits. Anticipated having a large share of all services into virtual modalities or developing robust, innovative virtual models to offer options to work in parallel to in-person care options. “I would say it's strongly preferred to have an in-person visits over telehealth. But it's a nice tool to have it if you need.” “Of course, we're still doing some telehealth and we're looking at trying to see how we might be able to provide an after-hours telehealth and may, maybe a little bit more so to either help supplement urgent care centers or emergency rooms.” “I think with proper education, every single specialty has a portion of their work that is suited to telehealth.” Motivation Goals Financial sustainability
Administrators believed virtual care services were necessary to ensure the organization remained competitive and financially viable.
Virtual care service options offered by payers and technology-based companies motivated administrators to offer virtual care services within their organization.1. Optimize care delivery
Administrators were exploring which services may be best suited to virtual care. Behavioral health, Medicare Annual Wellness visits, and follow-up visits for some conditions were considered well suited for virtual care.
2. Enhance patient experiences
Offering services that were convenient for patients and that increased access to care 24/7 was a goal for most virtual care programs (this includes options for asynchronous visits).3. Build loyalty
Administrators felt that younger, healthier patients may be inclined to seek out virtual care for their primary and urgent care needs, so they hoped to establish relationships with those patients.Rationale for virtual approach Quote Treatment of Minor Acute Illnesses Allow faster access to primary care with the goals of preventing unnecessary emergency department visits or avoiding care outside of the health system (e.g., a visit to an independent urgent care).
Designated clinicians for after-hours reduces the need for all clinicians to be on call.
Asynchronous services (e-visits) use algorithm-derived questionnaires to assess patient concerns and can be converted to video visits, as needed.
“so for pink eye it's a structured questionnaire that kind of you know describe your eye, describe the discharge, and it gives you options. You know any other symptoms and so you fill out this questionnaire, you can take a picture of your eyes and then send it […] then goes to the nurse practitioner who reviews it […] is able to then determine what the treatment would be so in the case of pink eye, if it's clearly pink eye, then you know, being able to just provide that antibiotic prescription through e-prescribing and then close the loop with the patient to go pick up the medication at the pharmacy always kind of the purpose that that patient did not have to talk to anybody to get their care taken care of.” Behavioral Health Process mirrors in-person, just conducted via virtual modality which means there are no observed clinical downsides.
Does not require touching the patient.
Patient may feel more comfortable.
“Our [behavioral health] therapists are doing 100% virtual care, right now, still now and they report that it's a very successful, you know, tool for them.” Care Coordination Increase interactions between primary care and specialist clinicians.
Facilitates data sharing across care settings.
Provides a financial incentive for collaboration.
Examples included: (1) e-consults (EHR-based tool) which may reduce need for specialist visits, (2) one clinician attended patients' video visits with specialists.
“On a zoom call with the consultant, and the patient in the room and, you know, often the patient will go to the [specialist] visit and they'll tell you something and then you know you might get a note and you might have questions, and you know being on the call and getting paid to be on the call for what you're doing. You know, encourages you to do that stuff and you know you get much better patient care when you're actually collaborating together rather than through letters or emails or things like that.” Care Management Provide the same care management services as previously, but via video.
Allows care management staff to visually assess patients' homes.
“I also think that some of our support and ancillary services will use telehealth also as another way to connect with their patients are in care coordination” Follow-up Visits Alternating in-person and virtual follow up for patients with chronic illnesses can reduce travel.
Virtual visits may make the patient more likely to attend visits due to convenience.
“My plan in the future is to do, alternating telehealth and in person visits, so that that yeah and because of the distance to travel and things like that in a rural community patients really you know they like that not having to drive in and wait and make up ground and do this it's a much too much shorter quick a visit for them.” Annual Wellness Visits Virtual Medicare annual wellness visits ensures the visit is focused on preventive care rather than diagnostic services (which can be addressed in a subsequent visit).
Allows clinicians to assess risks within the home.
“they [Medicare wellness visits] really lend themselves to telehealth because one they can be done with a nurse practitioner, and that allows the nurse practitioner […] because they can't lay hands on the patient into because it's really focused on preventive. And wellness questions to ensure that their visit does not convert to a diagnostic visit, which is so easy to do when you're talking to patients with co-morbidities.” Abbreviations: EHR, Electronic health record.
Increase Access to Care Improve Convenience of Care Administrators described efforts to improve patients' access to care through: Virtual urgent care services to allow patients increased access to care for acute needs.
Asynchronous e-visits where patients complete symptom-specific questionnaires and then receive a diagnosis and appropriate treatment.
Blending follow-up schedules (e.g., mix of in-person and virtual).
Administrators aimed to make care more convenient via: Video appointments to reduce travel burden (which may be particularly useful in rural areas).
Expanded hours through virtual care (e.g., allowing patients to seek care on their schedule).
“We have an urgent care telehealth service. It dominated, 3:1 ratio, female to male. It is dominated by 20, 30, and 40-year-old women. That's who is using it. It makes complete sense. The hours that they want it are completely different hours than what traditional services are. They want the service at 6:00 or 7:00 in the morning because they need to know first thing in the morning, not waiting until 9:00. It's everything Starbucks has always known.”
“Well, this patient is due for an A1C, but we haven't actually seen them in two years. So let's make sure that we outreach to them. And then that conversation's a lot easier because we can say, ‘Hey, well, we do have telehealth available.’”“How do we provide that virtual urgent care in the most simplest fashion possible? How do we make it as convenient 24 hours a day when that night shift worker gets off work, or when that day shift gets off work. We need to be able to provide convenient and accessible care and meet the patients where they are, which is on their mobile devices, which is on the go, which is synchronous as well as asynchronous.”
“However, we need to be thinking about it as a tool to truly be able to deliver on that 24/7 care so one of the things that we have been working with our teams for is to say your traditional clinic is open from 8 pm to four or 5 pm the majority of individuals are working at those same hours, so how do we meet consumer demand as more of a 24 seven approach, because you know when you are seeking care.”Abbreviations: A1C test, also known as the hemoglobin A1C or HbA1c test is a simple blood test that measures your average blood sugar levels over the past 3 months.
Compete with external services Appeal to younger patients Health care organizations aimed to prove the value of seeking virtual care within an established care delivery system: Having both physical locations as well as digital services allowed them to provide better, more comprehensive care.
There were concerns that patients may choose virtual care services from an alternative provider (such as CVS or a telemedicine only company).
Administrators used virtual care to engage with younger patients and foster life-course care. By encouraging the use of virtual care: Administrators hoped to build and maintain primary care relationships with younger patients.
To engage younger patients in preventive care activities.
“the pledge we made is if you come to one of our virtual urgent cares, and we cannot resolve your visit digital, if you come the same calendar day to one of our physical locations, there's no additional charge for that other one. […] Now you're starting to create a value proposition for people. Versus saying, “Well, I went to CVS and they weren't able to resolve my problem. They gave me an antibiotic,” which maybe that's what you wanted and that's what you're going to get. If we can make a deeper connection that we're there to help you with other things that show up and take a Disney approach, sometimes Disney Plus is good enough. You can just watch Moana. But sometimes I need to physically experience Disney. I think that's a recipe for us to potentially succeed.” “One of the areas that that the team is focused on right now is how do we engage those commercial patients, so seniors engage with their care pretty steadily you know, for the most part 80/20 rule there but our commercial patients are younger. They are less likely to engage on a regular basis with their physician. I mean if you just if you feel healthy like what's the point kind of thing, though, where we see video visits really helping with that is it a video visit connection with a commercial patient to their physician is low effort from a commercial patient perspective if they're healthy but allows us to stay connected and ensure that they have that PCP relationship. In the event that something does happen.” “So, as we think about that 24/7, it is creating access. That is always available for patients that can either resolve or then direct them to that next best level of care and not just direct them to it, but actually make that connection for them and guide them there.” “On the patient side, I want it to provide options, so you don't have to call your practice, you don't have to wait for months, and you can receive care the way you want to receive it. So some of our patients really have strong relationships with their PCPs and they want to go in the practice. That's great. I want them to have that option. But I also want the populations that tend to trend younger, that don't really want to go to the practice, that don't want to have to call the office, they want to get the answer, to have that option as well.” Interviewee Categories Description Examples Executive Leader* Individuals primarily responsible for overseeing the operations of the entire organization Chief Executive Officer, Chief Clinical Officer, Chief Innovation Officer Program Management Staff Individuals who oversee specific departments or services Program Manager, Program Director Practicing Clinician Individuals whose primary role was the provision of medical care Physician ↵* Many executive leaders were also trained clinicians. If they had a clinical degree, but spoke primarily about the administrative role, we denoted this by adding their degree type after executive leader.
Organization Interviewee 1 Role(s) Interviewee 2 Role(s) 1 Executive Leader and Practicing Physician n/a 2 Executive Leader and Practicing Physician n/a 3 Executive Physician Leader Program Management Staff 4 Executive Physician Leader Program Management Staff (PharmD) 5 Executive Leader Practicing Physician 6 Executive Physician Leader n/a 7 Practicing Physician n/a 8 Program Management Staff n/a 9 Executive Leader n/a 10 Executive Leader Program Management Staff (RN) 11 Executive Physician Leader n/a 12 Program Management Staff n/a 13 Executive Leader n/a 14 Executive Leader n/a 15 Executive Leader and Practicing Physician n/a 16 Executive Physician Leader n/a 17 Executive Physician Leader n/a Number Region Organization Type* Composition Ownership** Rurality*** 1 West Practice (Federally qualified health center (FQHC)) 1 practice Independent Rural 2 West Multi-practice physician organization, including FQHCs <10 practices Independent Rural 3 West System, includes FQHCs <10 practices Not applicable Urban 4 Northeast System 10 to 50 practices Not applicable Urban, suburban 5 West System <10 hospitals, >100 practices Not applicable Mix 6 South System 10 to 50 practices Not applicable Mix, largely rural 7 Northeast Practice 1 practice System Rural 8 Northeast System including critical access hospitals (CAHs) >10 hospitals, >100 practices Not applicable Mix 9 South System, includes CAHs and FQHCs >10 hospitals, >100 practices Not applicable Mix 10 Northeast Multi-practice physician organization, including FQHC <10 practices Independent Rural 11 West System <10 hospitals, 10 to 50 practices Not applicable Mix 12 West System <10 hospitals, 10 to 50 practices Not applicable Urban 13 South System <10 hospitals, >10 practices Not applicable Mix 14 Midwest Multi-practice physician organization <10 practices Independent Suburban 15 Northeast System, includes FQHC <10 hospitals, 50 to 100 practices Not applicable Urban 16 Midwest System, includes a CAH <10 hospitals, 50 to 100 practices Not applicable Mix 17 Northeast System <10 hospitals, >100 practices Not applicable Urban, suburban ↵* For practices and multi-site physician organizations, we noted if they were an FQHC. For systems, we noted if the system included FQHCs or CAHs, but this not a focus area of our interviews.
↵** We only included ownership for practices. None of the included systems were federally owned.
↵*** Many systems covered large geographic areas and includes practices in a mix of rural, suburban, and urban areas.
Organizational Structure Overview of organization (size, leadership) Overview of patient population Community approach to COVID-19 pandemic Virtual Care Implementation Prior programming? Modality (phone, video) Role of care teams Patient Reaction and Engagement Uptake Patient challenges with use Concerns from patients Financial impacts Reimbursement Provider productivity Questions for leaders Strategy Achieve and maintain clinician buy in Changes to approach during pandemic Questions for clinicians Experience and views of virtual care Relationships with patients Patients without access Internet connectivity Hearing or vision impairment Privacy Patients with social needs Seeing into homes Care management Clinic transformation Lessons we can learn from virtual care Other changes due to COVID? What will stay/go? Next steps? Plans to keep any virtual care services? Support needed from policymakers Process of returning to in-person Will virtual care be part of healthcare forever now? What role will virtual care have in 2023? (post-pandemic)
