“You Don’t Start by Worrying about ‘What If'”: Liz Johnson on the Rise of Telehealth

During the Covid-19 pandemic, the industry has seen a significant spike in the use of telehealth services. According to a CHIME survey, the majority (84 percent) of healthcare organizations are conducting more than 50 virtual visits per day, with a third of those scheduling more than 250 per day. For some, including Stanford Children’s Health, have seen 2,000 percent increase.

The numbers are undoubtedly high; we know that. But what do healthcare leaders really know — does telehealth lead to improved outcomes, or higher patient satisfaction? Which groups are most likely to respond positively, or negatively?

That, according to Liz Johnson, is what CHIME is trying to determine. Throughout the pandemic, CIOs have been too busy fighting fires to analyze the data, which is precisely why more time is needed. But of course, that isn’t the only reason why the organization is advocating for an extension of the regulatory flexibilities around virtual care. For the industry, the pandemic has presented a long overdue opportunity to determine telehealth’s effectiveness and prioritize digital health.

In a recent interview, Johnson, who serves as chair of the CHIME Education Foundation and vice chair of the Policy Steering Committee, talked the extensions the organization is asking for — and why, and how CIOs “have stepped up” during the crisis.

Part 1

Part 2

• Measuring patient satisfaction – “It needs to be done in a consistent & reliable way.”
• Dealing with anecdotal information
• Reimbursement parity – “This isn’t about being greedy; this is about being economically sound.”
• Cross-state licensure
• “I’m excited about the potential of creating a world where we can give care across boundaries.”
• Zoom – “It’s become a critical tool.”
• Testimony from CHIME members
• CIOs: “Their plates were full and they stepped up and make it happen.”

Bold Statements

We know from satisfaction surveys that come in from CIOs and their provider organizations that the response has been positive, but it needs to be done in a consistent and reliable way so that we can use the data.

They have to be able to run their business, and if they’re not able to do it without a loss ratio that isn’t acceptable, they can’t do it. This isn’t about being greedy. This is about being economically sound.

I’m really excited about the potential of creating a world where we can provide care across boundaries, because it might be much faster for you to drive 5 miles across the state boundary than to drive 25 miles to a metroplex.

There are always going to be concerns — is your glucose monitor calibrated correctly? Is your blood pressure monitor calibrated correctly? We’re going to have to deal with that. But you don’t start by worrying about the ‘what ifs’ — you do it, and then react when you need to.

Gamble:  You mentioned being able to get good data on telemedicine and establishing some type of barometer — are you looking primarily at things like outcomes and whether patients would be affected by not having an in-person visit?

Johnson:  Yes. We think the use of telehealth had a significant impact on the spread of Covid-19. We really believe that, just as with social distancing, it makes a difference when patients aren’t being exposed. So if you were to study patients who use telehealth, particularly those with underlying conditions — even advancing age — you’d see that those who weren’t exposed to Covid-19 were better able to take care of their chronic illnesses or acute episodes during that time.

We also want to look at patient satisfaction. A lot of people would prefer not to drive in for an appointment and have to sit and wait in a provider’s office; when those dissatisfiers get removed, it makes a difference. But we don’t want to just make an anecdotal observation; we want to be able to ask patients, ‘Do you like this? Does this work well for you?’ We know from satisfaction surveys that come in from CIOs and their provider organizations that the response has been positive, but it needs to be done in a consistent and reliable way so that we can use the data.

Congress is very interested — and appropriately so — on using data to look at things from an objective perspective and look at economic and health quality measures to determine that it’s the right thing to do, and should be part of our future healthcare options. And so we’re looking at outcomes, we’re looking at satisfaction, and we’re looking at the economics of it.

We want to explore the cost. What does it cost to deliver care this way? Is it an economic win for Medicare if we’re able to deliver quality care using telehealth? What does it mean in terms of how care will be delivered in the future? Is it going to be a hybrid model?

It’s an interesting time. Unfortunately, so much of the information we’re getting is anecdotal right now. People don’t have time to sit down and fill out surveys and do that type of work, because they’re still fighting Covid-19. But the data will be there, and eventually we’ll be able to make better decisions about how to move forward.

 

Gamble:  Let’s talk a little more about reimbursement parity. I would think having data could affect that conversation as well.

Liz:  It will. You’re exactly right. And from what I’ve heard, people are being very rational about it. They’re not asking to match dollar for dollar; they’re saying it’s an economic burden, and providers aren’t able to run their practices. They have to be able to run their business, and if they’re not able to do it without a loss ratio that isn’t acceptable, they can’t do it. This isn’t about being greedy. This is about being economically sound. They just want to make sure they have the right information so they can be economically sound going forward, using telehealth as a tool.

 

Gamble:  And as far as state licensure regulations, what do you think we’ll see going forward?

Liz:  There are some states that allow reciprocity. I’m licensed as a nurse, and I know there are places where I can apply for a license, and others where there are varying requirements.

I’m sure there were valid reasons at the time. But the reality is that we no longer think about the United States as independent pods. Dallas-Fort Worth is not the state of Dallas-Fort Worth or the country of Dallas-Fort Worth, it’s part of a nation. I’m really excited about the potential of creating a world where we can provide care across boundaries, because it might be much faster for you to drive 5 miles across the state boundary than to drive 25 miles to a metroplex. And then there’s subspecialty care. Super specialists can’t be everywhere, but they can certainly advise people if they’re allowed to. That’s very exciting. We’ve been pushing this for a while. The VA did it, so we know it can be done, we just haven’t done it for everybody.

 

Gamble:  Right. I’m sure it helps to be able to point to a successful model.

Liz:  Absolutely. Our veterans are everywhere. And it makes sense, but in the world we lived in prior to COVID, we were everywhere too. People no longer spend their whole lives in their hometowns. If I’m traveling to Europe or Washington or California, and something happens, I want to be able to get care from the right people. It’s time. That’s what we’re hoping will happen, now that we’ve had an opportunity to really test it.

 

Before, nobody was really picking up on telehealth in a big way. What’s happening is terrible, but we’ve been incredibly fortunate to have the opportunity to test the concept on a large scale. The providers did a remarkable job of getting it up and moving so quickly to take care of patients, and the government did a great job of backing us up and removing the barriers. It’s a pretty remarkable story, and now we have a chance to keep it going.

 

Gamble:  When things really started to ramp up, did you have concerns about security? Were you ever worried that these issues were going to derail the progress that had been made?

Liz:  No, I don’t think so. There was a time when we were worried, but we knew CIOs were working with their security officers to determine which platforms were safest and what needed to happen to get them up and running, and to ensure they were promoting safe platforms to providers.

They also were able to quickly identify platforms that weren’t as safe, such as Skype and FaceTime, and said, ‘these are not okay.’ That’s why so many organizations switched to Zoom. To their credit, Zoom got on board quickly and expanded capabilities, which was critical because it became a common method of communication, along with Microsoft’s solutions.

So many of us did it, both from a personal and a professional perspective. All of a sudden we’ve gone from a WebEx mentality to a Zoom mentality. It was amazing; we all became Zoom experts very quickly.

 

Gamble:  For sure. We actually had just started using Zoom about two months prior to Covid, which was very fortuitous timing.

Liz:  Right. It’s the same with teachers. One of my daughters is a teacher, and she had to learn to use all types of mediums, literally overnight.

 

Gamble:  We went through that. My kids adjusted pretty well — better than me, in fact.

Liz:  It’s incredible, right? Our standard joke is when I can’t figure out how to use something, one grandkids hops up and comes over to fix it for me.

 

Gamble:  They’re so comfortable with technology. It’s amazing. Now, in the discussions you’ve had with CIOs and other leaders about their experience with telehealth, is there anything that surprised you?

Liz:  No, although none of us expected the ramp-up to be so fast. Ed Kopetsky (CIO at Stanford Children’s) told me they had a 2,000 percent increase in the use of virtual care. It exploded. People who had been completely resistant to it got on board. I wouldn’t say that surprised me, but it’s always refreshing to see people step up and step out of their comfort zone during tough times. My hat goes off to CIOs, because not only were they dealing with the surge in telehealth, but they were also standing up temporary tents and getting the infrastructure in place to screen and care for patients. Their plates were overrun and, just like always, they stepped up and made things happen. They have a lot to be proud of.

 

Gamble:  Agreed. No one wanted this to happen, but I think a lot of leaders were glad telemedicine was able to take off — and that their organizations were ready for it.

Johnson:  Absolutely. One comment that stood out was from someone who said they were so excited because telehealth had helped their practices stay viable. Without the use of telehealth, what would they have done? You can’t go several months without any type of business and stay viable, so that was big.

Telehealth just wasn’t on a lot of peoples’ radar, then all of a sudden it becomes part of the normal daily care of patients. To witness that has been incredible.

 

Gamble:  And now the concern is having to roll back, which no one wants to see happen.

Johnson:  Right. It’s interesting because my husband sees a group of physicians from the University of Texas Southwest in Dallas. He had his first tele-visit recently; they had asked if he wanted to come in for his annual visit and he said, ‘No, I don’t. What are my alternatives?’ They said he could do a telehealth appointment, and so that’s what we did. I can’t wait until we can get to the next phase, which is remote monitoring. It’s still an evolution in getting to some of the diagnostics, but a lot of people with chronic illnesses that need a certain physiological parameter measured can do it at home. It would be great if we could get to a place where those results can be sent directly to the provider. Wouldn’t that be cool? There are always going to be concerns — is your glucose monitor calibrated correctly? Is your blood pressure monitor calibrated correctly? We’re going to have to deal with that. But you don’t start by worrying about the ‘what ifs’ — you do it, and then react when you need to.

 

Gamble:  True. You have to keep an eye on the future, but you can’t let it slow things down, especially now.

Johnson:  Exactly. Again, as a clinician, I was thrilled out of my mind to see this. When I left Tenet to retire, we had been trying to get telehealth up and running for stroke and mental health. It had some good successes, but the overall buy-in just wasn’t there.

Based on what I hear from friends who are still there, it has just exploded. They quickly got on the bandwagon, and the leadership immediately started making sure the appropriate tools were available. It’s been remarkable.