For virtual care, the future is now: Telemedicine transforms health systems

Katie Coleman describes how the COVID-19 pandemic ushered in a new normal at Kaiser Permanente Washington and how research is vital to making it thrive

COVID-19 led to a dramatic shift in how Kaiser Permanente and other health systems provide care. To avoid transmitting the coronavirus, clinics restricted in-person visits and embraced telehealth. What will happen after the pandemic? For insights, we spoke to Katie Coleman, MSPH, director of Kaiser Permanente Washington’s Learning Health System Program and director of the MacColl Center for Health Care Innovation at Kaiser Permanente Washington Health Research Institute (KPWHRI).

1. Can you describe the recent transition to virtual care?

Katie Coleman: It is astonishing. Telehealth interventions have been discussed and debated in policy forums for more than a decade. Overnight it was as if a light switch was flipped: We transformed the fundamental way we deliver health care toward virtual care in order to protect patient safety during the COVID-19 crisis. About 90 percent of Kaiser Permanente Washington patient visits are now by telephone or video.

Surveys of patients who received virtual care in March showed that in general, patients had a good experience with virtual care and found it was a convenient way to get care. Members felt comfortable with the interactions, noting  that they felt there was a trusted relationship between them and their care provider.  I think this is due to two unique things about how Kaiser transitioned to virtual care. The first is that peoples’  own care providers transitioned to doing phone and virtual visits, so in many cases people knew who they were talking to.  But, even when they weren’t talking to their own doctors, the providers had their electronic health records readily available. This kind of continuity is different from how virtual care is usually offered. We also found from focus groups we did with members  that patients liked the convenience and the cost: No travel expenses and no co-payments.

2. What have you heard personally about the virtual care?

KC: I’ve heard many positive stories. For example, I was struck by the experience of my colleague whose 13-year old son has a chronic illness that requires seeing his pediatrician weekly. She was nervous about virtual visits and worried that her son would not get the attention he needed. But the first video visit offered a new opportunity: The doctor got to meet the only thing that consistently brings her son joy─ his pet rats!

Although the pediatrician had asked before for photos, the first virtual visit began with an up-close and live action shot of his pets–it was the first thing the doctor saw! The rats are now a standard part of their visits. Her son has gone from dreading appointments to looking forward to them. He is more relaxed at home than he is in the clinic, so the doctor sees his more natural state.

3. How do we capitalize on that sort of response moving forward?

KC: We can learn from these experiences and build on what works for patients and doctors. We can improve how we support virtual care so it’s more equitable and easier for all kinds of people to access.  And, we can think creatively about how to use virtual care as a tool for our care teams to preserve and extend relationships, even those outside of traditional medical services.

Kaiser Permanente National would like Kaiser Permanente Washington to pilot and learn from these novel “virtual first” strategies and then rapidly share them at scale. Susan Mullaney, Kaiser Permanente Washington president, and Paul Minardi, MD, Washington Permanente Medical Group president, have announced plans to strengthen virtual interactions as a first line of care in the coming year. I serve on a group they established–the Business Command Center–that is, among other things, working to develop a new virtual care model.

We are going service line by service line, specialty by specialty, evaluating what percent of each visit could be done virtually – and would be better virtually. There might be an advantage, for instance, to doing virtual video visits with seniors; you can see their home environment and get more information about ways to adapt it to improve their health. No one is suggesting an end to in-person visits: Obviously, procedures such as open-heart surgery and biopsies cannot be done virtually. We are going to have to study what the right mix of on-site and online care should be.

4. What else needs further research?

KC: Kaiser Permanente Washington had about half as many patient visits in March and April as it usually has. As we return to a new normal, we need ensure people are getting the care they need. If there is a backlog of people who need primary preventive care, that's a problem. Our entire model of care is based around great primary care and prevention that keeps people healthy, out of the emergency room, and out of the hospital. With innovative use of telehealth, we can extend this expertise to virtual care. Here’s an example:

Through our Learning Health System Program, we recently used predictive analytic capabilities to rank Medicare members in order of health risk. This work by my colleagues Roy Pardee, JD, Yates Coley, PhD, Emily Westbrook, MHA, and David Arterburn, MD, MPH, allowed clinics to reach out to our most-vulnerable seniors, many of whom have multiple chronic conditions, ensuring that they know how to get care. Sometimes virtual visits were scheduled, or other ways of providing care were found. We need to make sure people who need to come in are coming in, while also providing comprehensive preventive, chronic, and acute care virtually.

5. What can be done to address concerns that virtual care could exacerbate inequities in health care?

KC: Evidence shows that some patients find video visits unsatisfying not because of the medical services but because of technical glitches. Patients rank video visits highly when they can see and hear the provider well, so we need to make that type of interaction readily available. There is much work underway to ensure providers have the appropriate laptops, the right computer programs, and a decent internet connection. But what about the patients? We need to avoid creating new inequities in care by devising ways to serve those who don’t know how to use technology, may lack Internet access and the right device, or perhaps don’t have a private place to talk. We’re at a unique moment to learn more about how virtual care tools like “care chat,” video visits, phone visits, and other things like remote monitoring, can move us forward toward more affordable, equitable, patient-centered care.

6. Given the downturn in the economy, is now the right time to advance virtual care?

KC: As of May 21, more than 1.6 million people had applied for unemployment benefits in Washington. Many of these people will need affordable health care options. Virtual care could help to meet this challenge. Researchers must devise ways to test and evaluate how these types of changes roll out and their impact on cost and health care outcomes. We have to study virtual care’s effect on health equity in specific populations, whether it’s an additive in some situations that leads to medical overuse, and what new services are needed to support virtual care and in-person primary care. There are countless other questions, but one thing is sure. We cannot go back to business as usual.