Harris Health System in Houston wasn’t ready for telemedicine when the pandemic began. Then it watched virtual doctors’ visits soar from zero to more than 140,000.
That surge is a striking example of the central role telehealth plays in ensuring people get the medical services they need during the Covid-19 crisis. But it also spotlights the logistical and technological challenges that providers have had to overcome to be able to deliver remote care.
“We were building the plane while we were flying it,” Bill Walker, a hospital administrator who leads Harris Health’s telehealth initiative, said. “And we haven’t crashed yet.”
More than buying up computers and iPads to reach out to patients, the shift to telehealth meant doctors had to learn tricks like keeping eye contact to engage with patients remotely. It also meant teaching patients how to help diagnose maladies without a doctor there for a physical examination.
Harris Health, with two hospitals, 18 community health centers, and a variety of smaller clinics, serves around 1 million uninsured and underinsured people in the Houston area.
Despite its size and resources, it had “essentially zero telehealth capacity” at the beginning of the Covid-19 crisis, according to Walker. It lacked the necessary technology platforms, staffing, and training.
Just four months later, nearly 60% of outpatient visits are performed virtually, numbering around 2,300 per day.
That transformation was essential to Harris Health’s operations throughout the crisis—especially as a new wave of Covid-19 hospitalizations threatens to swamp the Houston health-care system, Walker said.
But the changes weren’t easy to make, and it took time and effort to learn how to employ them, said LaResa Ridge, a family-practice physician and interim medical director at Harris Health who has taken charge of the system’s telehealth training.
“This was totally new to me when we started in March, and it was interesting to be exposed to new technology, and doing something you’ve never done before,” she said. “It felt adventurous, like you were on Star Trek, heading to destinations unknown.”
Harris Health began its transition to telehealth early on in the pandemic to preserve hospital capacity and keep doctors and patients from potential exposure, Walker said. It started with a program in early March to remotely monitor patients suspected of having contracted the virus.
Patients received daily phone calls from nurses for reports on their condition. Those whose symptoms progressed were then set up with a video call with a doctor for further evaluation.
As the crisis worsened, doctors across Harris Health pushed to expand its telehealth initiative beyond Covid-19 patients. By late March, Harris Health began offering telehealth to any specialty or clinic that needed it.
“It just exploded after that,” Walker said.
Harris Health now has four different telehealth platforms: video for outpatient visits, email platform for gathering patient information, telephone for audio visits, and an inpatient platform that uses iPads to communicate with those in isolation rooms.
But an initial challenge was finding the staffing to direct and support the system.
“We didn’t have that in place, and we were basically taking other staff and retooling what they’re doing to support telehealth,” Walker said. Most of those involved in the telehealth initiative are still doing their original jobs at the same time, he said.
Another challenge was acquiring new computers, cameras, and tablets. That was particularly difficult in the midst of a work-from-home surge that created competition from relocating workers.
Adjustments had to be made along the way to accommodate Harris Health patients, many of whom are poor and lack access to the latest technology, Walker said.
“Our existing electronic medical record systems requires an app, but a lot of our patients have Walmart phones that don’t work with apps,” he said. “So we’re working with a company that has a system that goes through the browser, it doesn’t task so much memory.”
Making Eye Contact
An essential aspect of creating a telehealth system is teaching providers how to use it, according to Ridge. But first, she had to figure it out herself.
One thing that stood out was the importance of maintaining eye contact with the patient on the video screen, and reassuring the patient that she was “fully engaged.”
“When you’re with the patient in person, the patient can see what you’re doing and you don’t have to explain when you look away to their chart, for example,” she said. “But in a telehealth visit, you need to tell them what you’re doing when you look away, so they know you’re not looking at your phone or messing around.”
With telehealth visits conducted via telephone, doctors also have to learn to “pace their speech” so they aren’t talking over the patients, Ridge said.
Doctors also need to learn to teach their patients how to examine themselves, Ridge said.
“You’re not there with them and you can’t touch them in the way you normally would to figure out where the pain is and what the problem is,” she said. “So you have to get them to do it.”
Ridge told one patient who tested positive for Covid-19 and complained of abdominal pains to imagine placing a tic-tac-toe board against her stomach. Ridge was concerned the patient might have appendicitis.
“I said, ‘if you took one finger, where on that board would you place it as the place where you have the pain the most?’ And thankfully, she put it over on that right upper quadrant, which meant she was just having heartburn,” Ridge said.
Ridge has been teaching what’s she’s learned to clinics and provider groups throughout the Harris Health System.
And now, nearly 50 clinical specialties and 290 departments at more than 30 locations at Harris Health are using telehealth, according to Walker.
Despite the challenges and occasional false starts, patients and providers alike have reported dramatically increased satisfaction.
That’s one reason Walker thinks the transformation to telehealth has only just begun.
“This is here to stay,” he said. “Satisfaction has skyrocketed from patients. There would be an uproar if they tried to roll it back.”