Based on an American Medical Association news article published May 18, 2020 and Sara Berg's interview with Kevin Hopkins, MD, Family Physician and Primary Care Medical Director, The Cleveland Clinic, Cleveland, OH.
Learn how ambulatory primary care at Cleveland Clinic pivoted from a rate of 10% virtual visits to 80% virtual visits in 2 months.
Kevin Hopkins, MD, returned from vacation on March 9, 2020, which was the day the first 2 COVID-19 cases were diagnosed in the state of Ohio. That weekend, leadership at Cleveland Clinic worked together to completely redesign workflows for scheduling and evaluating patients virtually and in person. Within 72 hours, a plan was created for kickstarting telemedicine within their health system.
“We've been trying to get our physicians and APPs (advanced practice providers) to really embrace telehealth options for the last 3 years. I joke every day it's taken a worldwide pandemic to get us to do it. Prior to this, less than 2% of all ambulatory volume at the clinic was completed by virtual platforms.”
—Kevin Hopkins, MD
Developing the Intervention
Prior to COVID-19, one of the 2020 goals for Dr Hopkins' team had been “to get to 10% of all ambulatory primary care encounters completed virtually by the end of this year,” he said. “There's been some things that we can't control that have held us back, like coverage by insurance companies is a big one, but 3 days earlier in March we went from 99% in the office to about 50% virtual.”
“For the month of March and April, we were at about 70% to 80% of our patient encounters being completed virtually. Now we want to try to shift that back, but we don't want to go back to what it was before,” he said. “Trying to define that new normal is really part of what we're working on now—designing what's the right mix of in person versus telehealth or virtual encounters."
At Cleveland Clinic, the volume of COVID-19 hospital admissions has been flat for 24 days in a row, but telehealth remains top of mind. As Ohio works through reopening, Dr Hopkins shared further insight into Cleveland Clinic's digital health playbook for rapid transition into telehealth across ambulatory patient care in response to the COVID-19 pandemic and beyond. These are the elements of the plan.
Expanding digital platforms
Cleveland Clinic needed to transition 19 clinical institutes that represent almost 4000 physicians to digital care. In just a few days, virtual care daily volume rose 10-fold.
“We had some technology challenges because we have a virtual platform that we've used for the last 3 years for our express care on demand, which is basically a walk-in urgent care clinic that you can do from your mobile device 24 hours a day, 7 days a week,” said Dr Hopkins. “That platform had worked just fine for what it was being used for, but when we were trying to throw tens of thousands of ambulatory visits a day on that virtual platform, it just didn't have the bandwidth.”
“We had to quickly find and identify other virtual platform options for how to complete those virtual visits,” said Dr Hopkins, adding that right now they are using about 5 different platforms, but will condense it to 1 or 2.
Training and reorganizing the workforce
To provide patient continuity and meet the increasing demand for care for those exposed to or infected by COVID-19, primary care and subspecialty teams were quickly trained.
“One thing I've learned is we can actually pivot and shift and change things a lot quicker than we thought we could when the need arises,” said Dr Hopkins. “There are certain things and processes within our system that in the context of a health organization that have historically taken weeks or months to get approved have now taken place within minutes and hours, which is awesome.”
“We've also learned that people are more willing to embrace technology than we thought they were—again, that's in the context of a worldwide pandemic,” he said. “A lot of people are afraid and didn't want to come into our health care facilities physically, so they were much more comfortable with a virtual encounter.”
Developing a standard playbook
Key to the success of Cleveland Clinic's telehealth rollout was the creation of a unified dynamic playbook that lives on a central COVID-19 internal website. The availability of this playbook improved the use and efficiency in a platform that physicians and other health professionals did not previously engage with.
“We're going to move past COVID-19, and virtual visits are here to stay,” said Dr Hopkins, adding that it is important to house a playbook or a similar resource that health care workers can look back to for guidance.
“Not everybody's going to remember everything that we're trained on,” he said. “They're going to remember the things that they do every day, but they might not remember how to flag a patient chart for something in particular that gives them a resource to be able to look back to.”
“This is something that then you can sort of point to and show them and say, ‘Well, I don't remember all the details, but based on what we have documented in our playbook, here's what we did,'” said Dr Hopkins.
Maintaining open communication
To launch telehealth, leadership at various levels huddled daily across workgroups and translated key points to the front lines regularly. Transparency allowed for innovation, quick iteration, and early success of telemedicine.
“Communication was huge for our organization because we're 70 000 employees. The ability to pivot and shift in minutes and hours, as I pointed out earlier, it doesn't happen without effective multi-directional communication.”
—Kevin Hopkins, MD
Leadership set up 5 touch points throughout the day to share important information. Daily huddles began at 7:40 AM and continued at several different times with the last occurring at 4:30 PM. At noon, a question-and-answer session with primary care leaders allowed all physicians and APPs to ask questions and learn more. As of May 11, 2020, the touch points per day are being reduced to minimize any redundancy in topics.
“In the beginning, we thought it was important to have a lot of opportunities for caregivers to communicate in multiple directions in order to give and receive information and feedback in a timely manner,” said Dr Hopkins. “By being able to field questions as a group on a call with 200 plus primary care doctors from 12 to 1 PM daily, it helped us to disseminate that information more quickly.”