Merging COVID19 virtual hospitals for the future

In mid-March federal and local governments announced a state of emergency in response to the Covid-19 pandemic. Almost overnight, hospitals across the nation halted elective procedures and outpatient diagnostic testing, transitioning familiar in-person encounters to telephone calls and virtual visits. It became apparent that even as we continued to care for the very sick at the bedside, constructing a parallel virtual medical center, designed to minimize the spread of Covid-19, would be essential–and doing so quickly to ensure the ongoing care of our patients would be of paramount importance.

As it did for many medical centers, the Covid-19 pandemic inspired a vision of a virtual hospital for Beth Israel Deaconess Medical Center (BIDMC) in Boston. This vision included the transition of all possible in-person encounters to virtual visits, thereby encouraging social distancing, protecting our patients and staff, and maximizing safe and uninterrupted care. To the US health care system, telemedicine was the ultimate PPE in the fight against Covid-19. 

We first launched an existing telemedicine program, BIDMC OnDemand, as a free video-based telehealth program staffed by emergency medicine physicians to address urgent needs for anyone living in Massachusetts. Covid-19 quickly accelerated and expanded our use of the program, and during the state of emergency, our goal was to make medical care accessible to all, regardless of health system affiliation or ability to pay. With the closure of PCP offices, lack of coronavirus testing and initially limited information available to the public, the aim of this service was to diagnose and manage common medical conditions, and educate patients by answering any questions they had about Covid-19, while keeping them out of the hospital if possible. Patients who, upon virtual evaluation, required in-person or emergent medical care were referred to their local emergency department. If there was clinical suspicion for Covid-19, patients were asked to inform EMS or emergency departments ahead of time so that medical personnel could prepare accordingly. Interestingly, 65 percent of BIDMC OnDemand virtual visits were for medical concerns not related to Covid-19. The program also saw an increase in calls asking for help with anxiety, and for medication refills; these were rather new reasons for visits compared to calls the program received in the pre-Covid era.

Rates of physician adoption of telemedicine have been high at BIDMC. Although the state of reimbursement was initially uncertain, we made reasonable assumptions and physicians at the medical center made every effort to incorporate video visits into their practices. The Department of Psychiatry, for example, quickly identified that their most vulnerable patients could benefit immensely from virtual visits. Within a few days, we were able to leverage Google Meet for clinicians so that they could offer continuity of care as well as evaluation and treatment to new patients during a time when an interruption of care could have been devastating. The launch of telepsychiatry outpatient services was subsequently mirrored by the inpatient psychiatry consult service. We allowed many platform adoptions by our clinicians so that we could learn from these efforts, coordinating efforts across the medical center with daily updates. In a matter of days, the number of ambulatory virtual visits increased from just a few to more than 1300 per day. We gradually permitted virtual consultations between physicians, leveraging our widespread and remote expertise to support front-line workers in the Emergency Department and hospital, in addition to our satellite sites. As the implementation of telemedicine continues to flourish across the US health care system, we must look forward to the parallel innovations that such disruption permits. 

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Innovation across BIDMC has been impressive, and it provides a substrate for further digital health advancements. An iPad donation program at the medical center allows for intimate patient connection with loved ones, despite a ‘no visitors’ policy. Within days of request for more materials by BIDMC, the US Army and Harvard partnered to study, design and test 3D printed nasoparhyngeal swabs as supplies ran low. At the medical center, the Emergency Department deployed a self-navigating robot that moved from room to room facilitating virtual evaluations and minimizing exposure to Covid-19. Pulse oximeters and at-home monitors were donated and given to patients upon discharge from multiple hospital and ambulatory services, allowing more vulnerable patients to be safely monitored remotely. BIDMC’s latest endeavor, MYNA voice dictation, allows healthcare providers to use their own mobile phones to dictate HIPAA secure patient-care notes on the go into a patient’s direct record. MYNA can also be used as a scratch pad, allowing for more flexibility in where and when physicians complete their work, and minimizing transfer of materials from room to room as the only item needed for notes and patient record updates is a smart phone. The pace of innovation has been swift and effective, and it is clear that health care delivery will continue to digitally evolve. 

There is no doubt that Covid-19 has challenged the previously well-established health care delivery model, but this challenge has also brought unprecedented innovation by physicians, health care systems, and the private sector. It is our hope that such innovation will lead to more comprehensive care for our patients, who are at the center of the health care we deliver. Many of the innovative programs that have stemmed from the Covid-19 pandemic will become a mainstay of the care we deliver at BIDMC. Video visits for post-hospital discharge care, telecounseling for behavioral health, and at-home vital sign monitoring are among the newer practices that we intend to continue to develop at our institution. As Covid-19 remains at the center of our “new normal,” the innovation behind the emerging strategies to health care delivery will continue to work to meet needs created by these new and often uncertain times. 

As leadership and steering committees now work to return our hospitals to the pre-Covid era, including opening much needed in-person evaluations and procedures at medical centers, the parallel world of telehealth must continue and be integrated into the mainstream. Health care has been changed forever: we are now evaluating, diagnosing, and treating patients outside of hospital walls. We found that launching telemedicine in a HIPAA-secure way that connects the patient to their own physician within their health care system, rapidly enabled by the change in payment structures, was straightforward; this was fueled by a reduction in regulatory burden and an urgency to connect.

This new world should be encouraged, as we can open accessibility of in-person clinics to many more Americans. The skyrocketing demand for telehealth is ultimately finite, and although unprecedented, this innovative experiment by health care systems encourages a focused adoption of telehealth parity by payers. Ultimately, in order to integrate this parallel health care system, the challenge is on the payers to continue the access to medical care via telemedicine in the United States. If virtual care continues to be accessible to Americans, hospitals will continue to innovate to find ways of delivering it post-Covid-19. 

Oren Mechanic, MD, MPH is the Director of Telehealth for HMFP at BIDMC, an emergency medicine physician at BIDMC in Boston, and is on faculty at Harvard Medical School. Richard Wolfe, MD served as Chief of Emergency Medicine at BIDMC and Associate Professor of Emergency Medicine at Harvard Medical School. Alexa B. Kimball is the President of Physician Performance LLC (PPLLC), the CEO of Harvard Medical Faculty Physicians (HMFP) at Beth Israel Deaconess Medical Center (BIDMC) and a Professor of Dermatology at Harvard Medical School.