Cleveland Clinic Optimizes Telemedicine for Primary Care

Added on Aug 6, 2020

Data-Driven Strategy Helps Cleveland Clinic Optimize Telemedicine for Primary Care
By Audrey Doyle

When the COVID-19 outbreak caused nationwide demand for virtual primary care visits to skyrocket seemingly overnight, Cleveland Clinic was well-prepared to handle the surge. Before the state of Ohio had confirmed its first COVID-positive patient, Clinic leaders had already transitioned the organization’s 19 clinical institutes, representing close to 4,000 primary care providers, to its existing telehealth program; trained these providers and their teams in the delivery of telemedicine; and added additional platforms on which they and their patients could interact remotely.

The leaders had also begun using Press Ganey’s Telemedicine for Medical Practice survey to gather feedback from patients regarding their care experiences. Throughout the spring and into the summer, they’ve been using this feedback to determine how well the providers are adapting to telemedicine and how readily their patients are embracing it.

The results thus far indicate that the providers and their patients are adjusting well to telemedicine as the new normal in primary care. From March 1 through June 30, the Clinic’s overall top-box scores rose from 86.2% to 88.6% for the Care Provider domain and from 64.2% to 74.2% for the Telemedicine Technology domain. Scores on questions pertaining to provider empathy, courtesy, and respect also improved. According to Matt Stanton, executive director for digital health, as telemedicine continues to remain popular among patients, the leaders will continue administering the survey to sustain these improvements and identify opportunities that will further optimize the virtual care experience.

Preparing for a Rise in Telemedicine for Primary Care

Cleveland Clinic entered the telehealth space in 2014, when it launched its telehealth consumer program and began offering patients the opportunity to meet with their primary care providers via on-demand and scheduled virtual visits. The organization has since expanded its use of telehealth to also include e-consults, virtual rounding, teleICU services, mobile telestroke services, and remote patient monitoring.

Prior to using the Telemedicine survey, leaders used two in-house methods to gather feedback from patients who received their primary and follow-up care remotely. As soon as their visit ended, patients were asked to rate on a scale of 1 to 5 their experience with their provider and the technology. Then they were emailed a survey developed by the Clinic’s Office of Patient Experience that asked questions regarding the visit as well as whether they’d seek virtual care again and recommend virtual visits to family and friends.

At the beginning of 2020, fewer than 2% of primary care visits with Cleveland Clinic providers were conducted remotely. But a few months into the year, when COVID-19 showed signs of becoming a public health crisis and the need to reduce transmission of the virus and preserve personal protective equipment became paramount, leaders expected that number would rise quickly and sharply.

As an early adopter of telehealth, the organization already had strong legal, financial, and technology infrastructures in place for delivering care remotely. To prepare for the impending influx of primary care patients, they expanded telemedicine privileges for the Clinic’s physicians, nurse practitioners, and physician assistants and expanded their digital platform to work with additional video chat applications.

They also began training the thousands of providers, schedulers, and support staff who would be transitioning to telemedicine. The training included live and on-demand webinars explaining how to schedule patients, navigate the virtual portal, interact with patients through video, and continue a visit if video access is lost. Dr. Steven Shook, interim lead for virtual health, also led a webinar demonstrating a virtual visit from both the provider and patient perspectives. In addition, several instructional videos were made available on YouTube in which Clinic providers share best practices for the delivery of high-quality care via telehealth, conduct and document a virtual respiratory exam on a patient-actor, and explain how to set up, conduct, and document virtual visits in general.

Providers were also educated on how to demonstrate good “webside” manner—the virtual equivalent of bedside manner—through several documents developed by the Office of Patient Experience’s Center for Excellence in Healthcare Communication (CEHC). For instance, a document titled “Empathy in Virtual Visits” explains tactics such as normalizing patients’ discomfort with the virtual platform, outlining the benefits to patients of the virtual modality, and asking patients to show a meaningful object in their home as a way to get to know them better as a person, according to Amy Windover, CEHC director. Other CEHC documents used to educate the providers focus on tactics such as looking at the camera to make direct eye contact with patients, exaggerating and slowing motions such as nods to ensure that patients receive the listening cue, being more deliberate about verbalizing empathy versus relying on nonverbal forms of empathy, and setting patients’ expectations at the beginning of the visit by explaining that they may have to look away from the screen to take notes so that patients don’t think they’re disengaging with them.

The leaders wanted to continue gathering patients’ feedback regarding their virtual visits and turned to the Telemedicine survey for its ability to handle the large volume of feedback they expected they’d be receiving as the demand for remote primary care increased. After a “very quick set-up,” according to Stanton, they began administering the survey with March 1 encounters.

Survey Insights and Added Benefits

The ratings and comments they’ve received since then have provided some important insights. For example, according to Kevin Phipps, program manager in the Office of Patient Experience, consistently high ratings on questions in the Care Provider domain indicate that providers are effectively meeting patients’ needs, particularly in the areas of courtesy and respect, concern, and empathy. Additionally, patients frequently comment on their appreciation for being able to easily and quickly access quality care without having to leave the safety of their homes and risk infection, according to Stanton.

Although scores in the Telemedicine Technology domain have risen since March, indicating increasing proficiency with the digital platforms among patients and providers, leaders acknowledge that there are opportunities for improvement, particularly around educating patients prior to their visit. “We want to help patients better understand the technology—what they’re supposed to click on, why they’re getting a pop-up blocker; we learned through patient comments that these types of things are still primary frustration points for some of them,” Dr. Shook said. “We’re working on ways to give patients a preview of their workflow so that they’re prepared for their visit, which will bring some comfort to them and prevent these problems from occurring during the visit.”

Along those lines, the leaders are also investigating more scalable ways to reach out to patients in advance. “We’re looking into developing more automated ways to determine which patients may need some of this hand-holding ahead of time versus others who are going to be fine,” Stanton said.

The survey is providing further benefits as well. For example, because the survey data are reported within Press Ganey’s Medical Practice database, leaders can compare in-person care experiences with virtual care experiences. “So far, we’ve found that our ratings on the Care Provider questions are closely aligned with what we receive for in-office primary care visits,” Phipps said. They can also incorporate feedback from the Telemedicine survey with feedback gathered organization-wide from their HCAHPS, HHCAHPS, Emergency Department, Hospice CAHPS, and Child CAHPS surveys and include it in physicians’ online public profiles.

In addition, the leaders have been able to share positive patient comments directly with the providers. According to Phipps, this has helped keep the providers and their teams engaged throughout the pandemic and been a source of encouragement during times of extreme stress. “Our providers needed to transition quickly to a new way of providing care. To get near-real-time positive feedback for their effort helped them emotionally during this very challenging time,” he said.

At the height of the first wave of the pandemic, 75% of primary care visits with Clinic providers were being conducted remotely, according to Stanton. Since that time, as in-person operations have adapted to further minimize spread, a rebound to in-office care has occurred. Nevertheless, as of press time that number was holding steady at 15%, indicating that there’s still a lot of interest in telemedicine.

“The pandemic gave life to telemedicine. People are activated now. They’ve had the virtual primary care experience and are excited about it,” Stanton said. “We’ll continue collecting feedback to ensure that we’re delivering the best possible care to patients who request a virtual visit and for whom it makes the most sense.”