Telehealth services are sagging under the weight of an unprecedented surge in patients as hospitals scramble to shift routine care online in response to the coronavirus pandemic. The crisis is stressing major telehealth providers’ technical infrastructure and the supply of physicians prepared to deliver care virtually.
Over the last week, a sudden explosion of demand has slammed into hospitals used to delivering telehealth consults for only a handful of patients a day. Clinicians and telehealth companies, initially thrilled with the uptick in business, are now faced with huge backlogs, several providers and company executives told STAT.
“You can get the technology to support these astounding volumes,” said Roy Schoenberg, the CEO of the Boston-based telemedicine company Amwell. “But you’re very quickly getting to a point where the supply of medical services isn’t there. We need to have enough clinicians to allow us to handle that incoming volume.”
In addition to increasing clinical staffing, the company is racing to upgrade its technical systems to handle the influx of patients, which has led to long delays for patients trying to use the service at major health systems such as the Cleveland Clinic, where there’s been a fifteenfold increase in telehealth visits over the last week. Doctors are expanding the use of phone consults and asynchronous, or recorded, video visits to try to keep up.
At the University of Pennsylvania in Philadelphia, requests for virtual visits are coming in faster than clinicians can handle them. The hospital system has increased the number of practitioners delivering remote consults from six to 60, but it is being forced to schedule telehealth visits several days out to spread the workload.
At nearby Jefferson Health, a twentyfold increase in virtual visits over the last six days has left administrators scrambling to supplement the supply of doctors able to perform services as they fine-tune protocols for dealing with suspected Covid-19 cases.
“You can’t invent a system during a disaster,” Judd Hollander, senior vice president for health care delivery innovation at Jefferson Health, told STAT.
Health systems, it seems, must do so anyway.
The flood of telehealth patients is driven by the health care system’s effort to reserve hospitals and other health care facilities for people seriously ill with the coronavirus or other diseases, and by a crush of people worried they have symptoms caused by Covid-19.
The logjam is only expected to worsen after President Trump on Tuesday authorized a dramatic expansion in the availability of telehealth services to Medicare patients. Until now, only seniors living in rural areas were eligible to have such services covered, but Trump’s announcement throws open the doors to tens of millions of new patients who are entering a system unprepared to handle that volume.
“That’s a giant population of Americans that require a lot of health care,” said Schoenberg. “It may take a couple of hours. It may take a couple of days, but that will further dramatically [increase] demand. We’re beginning to see that this huge hike of 10- or 20-fold growth in a week may become the new norm. That’s a tough thing to plan for.”
Amwell has a workforce of about 10,000 clinicians nationwide. It serves beneficiaries of all the major insurers, including Anthem, UnitedHealth Group, and Cigna, and supports telehealth consults delivered by large health care networks such as Ascension, Community Health Systems, and Utah-based Intermountain Healthcare, in addition to Cleveland Clinic.
Just this week, San Francisco-based Doctor on Demand, another telehealth company, has seen a 50% increase in demand, said its president and chief commercial officer, Robin Glass. “The number of suspected cases of Covid-19 we are seeing doubles each day,” she said, adding that patient wait times have gotten longer but that its “technology infrastructure and service delivery has remained stable.”
Despite the growth of telemedicine companies and rapid technical advances, the nation’s health care infrastructure is still tied to the delivery of services in bricks-and-mortar campuses and clinics. The spread of the coronavirus has made those facilities obsolete and largely unusable overnight to some patients, as health systems must deliver care remotely to prevent transmission of the infection.
The administrative challenges are numerous. They include training doctors to deliver virtual care, working out reimbursement snafus, and trying to integrate telehealth services into fractured electronic health record systems. There are also technology setup challenges for new users as well as a shortage of bandwidth as the internet groans under the strain of increasing use.
Eric Perakslis, a Duke University data scientist who led the technology efforts for multiple Ebola response programs in West Africa, said he’s spoken with clinicians who have decided to forgo video consults for now because of the difficulty of addressing the challenges in their health systems — decisions that could result in more patients and caregivers getting exposed to the coronavirus.
“Most of these [challenges] are the types of growing pains expected when transforming process via technology,” Perakslis said. “Doing this during a crisis is always going to get messy.”
Administrators at Penn Medicine, the health system affiliated with the University of Pennsylvania, are working to upgrade their systems on the fly, said Krisda Chaiyachati, a physician and medical director of the health systems’ telemedicine service. As opposed to using a third-party company such as American Well or Teladoc, Penn Medicine has built its own technical infrastructure which, until two weeks ago, was used primarily to serve employees of the health system.
“We’re watching an exponential curve happen on the use of our telemedicine technology,” Chaiyachati said, adding that the health system is providing consultations via video and chatbot, as well as telephone. “The hospital main lines are incredibly clogged with people trying to get in touch with their providers to ask questions.”
He said the number of telehealth visits increased from about 40 a day to more than 120 before noon yesterday. Another 70 consultations had already been scheduled for Wednesday, and more were being slated for later in the week.
To handle the volume, Chaiyachati said, the health system is repurposing primary care physicians to provide telehealth care and rescheduling appointments that can be delayed to avoid transmission of the coronavirus and free up capacity within its system.
Cleveland Clinic is onboarding its entire workforce of 4,000 physicians to deliver remote consultations via video, and the system is also adding registered nurses and others who can help with the workload.
Matthew Faiman, medical director of the clinic’s telehealth service, called Express Care Online, said the health system created a training video for clinicians on Monday and is constantly updating its instructions for dealing with suspected coronavirus cases, which account for 95 percent of its increase in telehealth visits.
“It’s so fluid that from the time I started talking with you to the time we finish, there will probably be changes in some of the protocols and patterns for what we’re doing,” Faiman said, adding that the clinic is getting requests from across the country for how to diagnose and triage cases as well as how to care for people at home. “This has so many moving parts.”
He said the clinic has to consider how to communicate with patients about negative and positive results, how to reduce the backlog of patients trying to get access to testing, and how to manage employees who are stressed about the outbreak and trying to learn to deliver care in new ways.
Meanwhile, the problems with Amwell’s platform have left patients waiting for a half-hour or more to log into their visits. Even though the company has issued two updates to its systems within the last 12 hours, intermittent delays have persisted, Faiman said. “It’s the last thing you want to have happen when there’s a surge in demand, but they are working around the clock to help us,” he said.
Even as they get stretched to capacity, the telehealth providers are hoping that their ability to help in the midst of the outbreak will demonstrate the value of remote services and result in enduring changes to the way health care is delivered.
“There is an inherent need for us to rebalance the place where Americans are getting health care,” Schoenberg said. “Telehealth allows you to pool together health care resources and drive them to where they’re desperately needed. That understanding has been 100% heard at all levels of government. That is the clarity everyone is beginning to see.”
Clarification: The company formerly known as American Well has changed its name to Amwell, This story has been updated to reflect the name change.