A Unique Approach to Introducing Consumer Telehealth Pays Real Dividends

Located in North Carolina, Cone Health is one of the region’s largest health networks. The nonprofit employs 1,300 physicians across more than 100 locations, including 6 hospitals, 3 medical centers, 4 urgent care centers, 95 physician practice sites, and several Centers of Excellence.

Over the past few years, other competing health systems in the area have deployed and aggressively promoted direct-to-consumer (DTC) telehealth offerings, making remote care services available to all patients in the region, including Cone Health patients. DTC telehealth options are also proliferating in the region independent of health systems—via retail clinics, employers, and telehealth vendors.

With consumers expressing high interest in this low-cost, affordable form of care delivery, Cone Health leadership recognized the need to develop its own telehealth program, both to keep its patients from leaving the system and to attract new patients. In early 2015, Cone brought ECG Management Consultants on board to help plan and implement a telehealth strategy that was both competitive and provider-friendly.

What is telehealth?

Telehealth is commonly defined as the use of remote healthcare technology to deliver clinical services. Put more simply, telehealth expands healthcare delivery beyond the traditional brick-and-mortar office setting by connecting providers and patients via the web, phone, or other technology when they are not in the same physical location.

• Some insurance companies cover telehealth visits, with a patient co-pay similar to an office visit.
• Some employers offer telehealth as a benefit, either free or at a low per-visit cost.
• Direct-to-consumer offerings allow patients to bypass insurance and pay a nominal per-visit fee directly to the telehealth provider—health system, vendor, or other.

ECG worked with Cone to develop a phased approach to establishing its telehealth program. Phase I—the focus of this case study—introduced telehealth to the organization through a small-scale pilot program offering asynchronous eVisits through Epic. In addition to launching telehealth, Cone wanted the Phase I program to engage with and respond to the needs of impacted stakeholders, particularly providers, and build a culture conducive to change man-agement. The outcomes of Phase I built a foundation for a second phase in which Cone is deploying a larger-scale competitive program that adds a live video platform and expands use cases.

Key components of the Phase I strategy included:

• Identifying a simple point of entry into telehealth.
• Creating work groups to represent impacted organizational stakeholders.
• Building clinical support for the new delivery model.
• Piloting with a small, yet representative, patient population of Cone Health employees.
• Designing an effective marketing and communications plan.

There are two types of telehealth visits—synchronous and asynchronous. Synchronous visits are real-time interactions between providers and patients, similar to traditional in-office visits except that they occur over phone or video instead of in person. Asynchronous telehealth visits also offer an option for remote consultation, but instead of connecting with providers in real time, patients submit information for providers to review and respond to at a future time.

1. Identifying a Simple Point of Entry Into Telehealth

Cone wanted a provider-friendly solution that complemented its current competencies and patient offerings. Since Cone was already using Epic’s EHR for health records and documentation and MyChart for its patient portal, ECG suggested using Epic’s asynchronous eVisit module as an easy entry into telehealth. The familiar Epic platform ensured ease of use for providers and patients and alleviated integration concerns. Cone uploaded clinical questionnaires for a small number of conditions into the eVisit module. Patients with these conditions who were interested in remote care could fill out the appropriate questionnaire and receive a treatment plan from a provider post-submission, all within the MyChart portal.

ECG worked with Cone to add a notification system that alerted participating providers to new eVisits coming into the system through a shared email mailbox, so providers weren’t tethered to their computers during eVisit shifts. As strong process and protocol users, advanced practice providers (APPs) were selected as the primary providers for the Phase I visits, with the expectation that they would train additional providers during Phase II.

Conditions treated include: cough, sinus pain, back pain, urinary symptoms, red eye, diarrhea, flu-like symptoms, vaginosis, contact dermatitis, sunburn, swimmer's ear, and tick bites.

2. Creating Work Groups to Represent Impacted Organizational Stakeholders

“One of the first things we noticed about telehealth was just how many areas of our organization it impacted,” said Dr. Jenkins, a provider champion who now holds the title of Vice President of Telehealth. Cone established project work groups for each function impacted by telehealth, including operations/revenue cycle, IT, marketing and change management, and clinical standards. A number of the APPs who were actually treating patients via asynchronous telehealth visits were members of the clinical standards group, closing the loop on the development of telehealth-specific clinical protocols.

These work groups were established pre-implementation. They met often (at least twice a month) and maintained oversight of the functional scope even after the initial asynchronous visit telehealth program was implemented.

An executive-level steering committee was also formed to facilitate access to the various subject matter experts within each of the work groups and to identify and communicate gaps in resource needs as well as ensure quick resolution.

3. Building Clinical Support for the New Delivery Model

Having a clinically focused work group gave the organization an opportunity to develop the tools participating providers needed to easily deliver care through the telehealth program. The APPs in the clinical work group provided valuable commentary on the appropriateness and efficacy of telehealth-specific clinical protocols based on their experience treating patients. “When it came time to develop and test clinical protocols, our providers were immensely involved,” Dr. Jenkins said. “They had veto power and the ability to modify the clinical protocols we used—it really increased their buy-in and excitement.”

Cone also appointed provider champions like Dr. Jenkins to evangelize the initial telehealth program to other providers. They utilized existing provider communication channels to advocate for the program and cement support. The provider champions were able to share firsthand accounts of ease of use and integration with existing workflows. “By automating the care plans and clinical protocols as much as possible, we were able to solve for clinical variation and time spent documenting visits—also major provider satisfiers,” stated Dr. Jenkins.

In addition, Cone made sure that providers felt supported at the point of care. When APPs identified workflow issues, they were addressed promptly. Suggested modifications to clinical and operations protocols were communicated directly to the clinical and operations work groups, and they were typically approved and implemented within days.

4. Piloting With a Small, Yet Representative, Patient Population of Cone Health Employees

The reimbursement landscape for telehealth is complex. Specifically, North Carolina does not require commercial insurance plans to cover services delivered via telehealth modalities. Individual plans have discretion to make coverage decisions, and these vary widely. Medicare and Medicaid also have complex regulatory requirements and reimbursement practices for telehealth. Parity between in-person doctor visits and telehealth visits is not yet commonplace.

Cone Health didn’t want its providers to be discouraged by the limited reimbursement opportunities in the state, especially during this important introductory period, so Phase I asynchronous telehealth visits were only offered to Cone Health employees who belonged to a Cone Health insurance plan. This gave the health system complete control and created a cost savings opportunity—employees who may have otherwise presented at urgent care centers or even the ED with low-acuity medical issues could now receive high-quality, personal, and cost-effective treatment through the eVisit experience. Participants in the health system’s high-deductible plan were charged $30 per visit, while employees enrolled in the Choice plan had no cost associated with visits.

Another advantage of introducing telehealth to the employee population first was the opportunity it afforded to solicit honest feedback, which could then be incorporated into Phase II of the program. Regular communications developed by the marketing work group touted the benefits of the eVisit program and created a dialogue between the developers of the program and the Cone employees participating in it. The constructive feedback received from the employees, who were generally representative of the surrounding Greensboro community, helped Cone refine the eVisit program before it was rolled out to the larger patient community.

5. Designing an Effective Marketing and Communications Plan

Cone Health’s marketing and communications plan included internal and external activities to promote the new telehealth program. The marketing work group defined the overarching strategy and also monitored key results.

Internal communication included having the provider champions on the agenda for medical staff meetings and committee meetings across the organization. Early exposure to the new technology, as well as a thorough discussion of the clinical tools and related considerations, helped to prepare the provider community for a larger telehealth deployment in Phase II. In addition, information-sharing about the Phase I pilot ensured that providers would not be blindsided by any telehealth data or documented follow-up needs communicated by the eVisit providers.

Marketing efforts also targeted employees via benefits sessions and email blasts. As Cone began to conceptualize the second phase of its telehealth deployment—making eVisits available to a larger patient population and introducing video visits—marketing efforts expanded to include flyers at clinic sites, social media content, web marketing, and even radio spots.

Phase I

This first phase of Cone Health’s telehealth program—asynchronous eVisits through Epic, offered to Cone Health employees—went live at the end of 2015. The asynchronous visit model succeeded in easing internal stakeholders’ concerns about telehealth, and the simple setup helped achieve the goals of provider buy-in and engagement.

Results of the automated patient survey sent one business day after an eVisit include:

• 96% received care within 1 hour
• 262 number of patient survey responses
• 95% received expected level of service
• 92% net promoter score
• 61% would otherwise visit urgent care/ER or walk-in

Patient engagement was high as well. Within 6 months, 700 eVisits were conducted. Even with limited hours of operation (4–9 p.m. on weekdays and 8 a.m.–8 p.m. on weekends), Cone was able to deliver care in a timely and convenient manner that satisfied patients and reduced acute care costs. Key metrics were collected through an automated survey sent to patients 1 business day after their eVisit.

The ROI of Phase I is well demonstrated through a comparison of the cost of asynchronous telehealth visits to other care settings. Here are comparative wait times and visit costs for alternative care settings:

• $370 ER: Extensive testing costs, high wait times, 5-hour visit, follow-up referrals common
• $150 Urgent Care: Up to 1-hour wait time, 3-hour visit
• $100 Office: 2-day wait, 1- to 2-hour visit
• $59 Retail: walk-in
• $49 Video: minutes
• $30 Asynchronous

Phase II

The success of Phase I allowed Phase II to begin as soon as the pilot program ended. In May 2016, Cone expanded the population served to include the general public and extended the hours of service and provider pool for asynchronous visits. Cone also added synchronous visits through a partnership with a well-known telehealth vendor. To properly oversee the telehealth program, Cone established centralized governance, with a new assistant director of telehealth supervising the expansion of the program to video and phone visits. This put Cone on track to meet the Phase II goal of building a competitive and robust telehealth offering. “Our gradual transition into telehealth offerings is something I would recommend to most organizations,” said Dr. Jenkins. “Being able to look at subsets of data and patient testimonial allowed us to solve for technical and operational issues that needed to be perfected before rolling out our offering to a larger population.”