The moniker is in flux, but patients, clinicians and organizations are embracing the connectedness of virtual hospitals.
What do we mean when we talk about “virtual hospitals”? Telemedicine, mostly. But beyond that, it can get a bit squishy.
“I don’t know if there’s a working definition,” says Joseph Kvedar, MD, vice president of connected health at Partners HealthCare in Massachusetts. He’s been involved with connected health technologies for nearly 25 years.
Precisely what is meant by “virtual hospital” varies by organization, but the most fully realized application is probably the e-ICU. “It’s a very clear vision for what a virtual hospital could be,” Kvedar explains. “You have a group of intensive care physicians in a call center environment—instrumented with lots and lots of screens and technology—and they’re guiding other providers, usually ICU nurses, in an ICU that’s remote from them.”
Another view of the concept is a central freestanding facility staffed with healthcare professionals. Perhaps the best-known example is Mercy Virtual Care Center, which opened in 2015 and bills itself as the first virtual hospital. The four-story, 125,000-square-foot building located in Chesterfield, Mo., provides the hub for Mercy’s virtual care program and has garnered considerable mainstream media coverage. But Mercy is far from alone.
“I do think that there is a group of us across the country that are opening virtual care centers or virtual hospitals … using a centralized approach,” says Krista Stadler, RN, senior director of telehealth services at Idaho-based St. Luke’s Health System, which opened its 35,000-square-foot virtual care center in August of 2018. It has three service areas: ambulatory, acute and postacute.
Not everything has to be under one roof. In early 2019, Intermountain’s Connect Care Pro will open a 20,000-square-foot facility that will house 150 clinicians. Connect Care Pro represents consolidation of its 35 telehealth programs and 500-plus caregivers in one connected platform, explains Jim Sheets, MHA/MBA, Intermountain Healthcare vice president of outreach services.
Sheets points out that clinicians can be located anywhere in the world. And he doesn’t call it a virtual hospital. “‘Virtual’ sounds like it’s not real, but the care we’re providing is very real,” he emphasizes.
“And it’s not really a ‘hospital,’” he adds. A hospital, he notes, is where sick people go. “And that’s not what it is either.”
Overall, roughly 65 percent of U.S. hospitals connect patients and consulting practitioners remotely via video and other technology, according to the American Hospital Association. How they connect varies, and few would dub themselves a virtual hospital.
Triage & discernment
Part of advancing the virtual hospital concept involves breaking old habits and rethinking traditional ways of delivering care. For example, says Kvedar, “You don’t always need the patient in front of you.”
A frequent speaker at conferences, he often invites audiences to ask themselves, “Does this patient need to be in the same room with me today for me to be able to help them?”
Often, the answer is no. “I think we do a lot of office-based care because we can, because that’s how we get paid,” Kvedar says. “And [because] we’ve always done it that way.”
But, he emphasizes, sometimes you do need to see the patient in the flesh.
Deciding draws on the art and science of triage. “There are times when the doctor is going to be collecting information about that patient on the spot that involves using all five senses,” Kvedar says.
Simply asking the question is the first step. “We have to put on our best triage hat so we can make sure that, when we’re doing virtual, it’s advantageous to both the patient and the clinician,” he explains. “And when we have someone in front of us in the office, it’s because they absolutely need to be there.”
One day, an app may wear that triage hat. Mobile apps as part of the healthcare delivery systems are still relatively new, says Kvedar. Partners offers virtual, on-demand urgent care consults with clinicians via the Teladoc platform. Eventually, an app or website could determine what level of care patients need and direct them accordingly. That’s still a few years off, he predicts. “The digital concierge concept is a dream, but that’s where we want to head.”
Access & efficiency
The value proposition for virtual health “really boils down to access or efficiency,” Kvedar says. Access issues led Medicare to start paying for telehealth, he acknowledges. “But I’m making the case that in certain environments, it’s more about the efficiency of the labor force.”
He again points to the e-ICU as an example of sourcing labor in a centralized location for multiple geographical endpoints. “When you start to think of it that way, it might be a rural or underserved play. It might be an urban play, but it might be a delivery system where it’s just more efficient to put one group of ICU docs in the center and use them that way.”
Given the anticipated shortage of intensivists, the e-ICU makes sense. But it’s not limited to physicians. He points to home-health nurses. Making in-person visits, they may see five patients in a day. “But if you put them in a call center and monitor those patients in the home, they can cover 80 to 100 people.”
Clearly, this approach won’t yet work for the patient presenting with chest pain or requiring a triple bypass. But virtual care does have a role in cardiology.
Chronic care management & social determinants
At St. Luke’s in Idaho, postacute remote patient management focuses on patients with one or more of the following: chronic obstructive pulmonary disease, congestive heart failure, diabetes, hypertension or coronary artery disease.
“These are patients who are struggling to manage their illness,” says Stadler.
Patients receive a mini-iPad and the appropriate Bluetooth peripherals for their condition—for example, a blood pressure cuff, pulse oximeter or scale—and they have regular video visits with their clinician.
For some patients, this gives them more freedom. “We have a patient who had a low heart rate and arrhythmias,” recalls Stadler. “The doctor told him he could go hunting if he took his tablet. So, he did.”
It also provides a way to address social determinants that might otherwise go unaddressed. For instance, a clinician or social worker can get a look at the patient’s living conditions and even the contents of the refrigerator or pantry.
“There’s an opportunity to really connect with patients in a meaningful way,” says Stadler. For example, the technology allows them to check in more frequently to ensure the patient’s not depressed or even suicidal after a major health event, such as a heart attack.
Stadler reports that a 12-month pilot resulted in a 38 percent reduction in emergency department visits, 54 percent fewer hospital visits and a 64 percent cut in hospital stays.
“Patients with chronic disease will be admitted to the hospital sometimes,” she acknowledges. “We’re trying to avoid that as much as possible, but when they do need to, we’re getting them there quicker, so they can get home sooner.”
Profit & reimbursement
Coding is gradually catching up with the technology. “Within the next two years we’ll have all the codes necessary to bill our insurers for virtual care,” Kvedar predicts, adding that it will take longer for commercial insurers to follow Medicare’s lead and pay for it. “There’s lots of good traction on reimbursement, which will be a stimulant to adoption.”
Still, some commercial payers are on board. “We’ve been pleasantly surprised that many of our commercial payers have adopted the CMS policies around reimbursement and so we are able—especially in our rural clinics—to do some billing and reimbursement in the traditional fee-for-service environment,” Stadler says.
Still, in a fee-for-service world, it’s hard to make a profit providing virtual care. “Risk-based models make it possible today,” Kvedar says. Partners HealthCare is at risk for about 600,0000 lives. “It’s helping us be more efficient in the context of these risk-based contracts.”
Intermountain hasn’t yet turned a profit on its virtual efforts, says Sheets. “That’s hard to do in telemedicine, and that’s one of the reasons why many organizations haven’t approached it.” But the savings are real, from the congestive heart failure patient who doesn’t have to drive hundreds of miles every week, to avoiding hospital visits, readmissions and emergency department visits. And as value-based reimbursement slowly crawls into the mainstream, those savings will matter.
“Why are we doing this?” Sheets asks. “It’s the right thing to do. It’s challenging, it’s expensive, but it’s the right thing to do,” It’s also the future of healthcare, he believes. “There’s that old Wayne Gretzky quote: ‘This is where the puck is going to be.’”