key: cord-029582-kap3tdiy authors: Srinivasan, Malathi; Phadke, Anuradha Jayant; Zulman, Donna; Israni, Sonoo Thadaney; Madill, Evan Samuel; Savage, Thomas Robert; Downing, Norman Lance; Nelligan, Ian; Artandi, Maja; Sharp, Christopher title: Enhancing patient engagement during virtual care: A conceptual model and rapid implementation at an academic medical center date: 2020-07-10 journal: NEJM Catal Innov Care Deliv DOI: 10.1056/cat.20.0262 sha: doc_id: 29582 cord_uid: kap3tdiy Stanford Healthcare shares the lessons learned during its rapid deployment of virtual visits during the Covid-19 pandemic. Stanford Primary Care and Population Health clinics comprise thirteen clinical groups including general primary care, senior care, urgent care, employer-based clinics, concierge medicine, and coordinated care. During the first two months of Virtual Health roll-out, our Stanford primary care providers conducted over 15,000 video and 3,500 telephone visits. Virtual Health encompassed virtual visits and all of the clinical activities surrounding the clinical care which were no longer conducted in person. Within four weeks after initiating the Virtual Health program, we conducted more than 80 interviews with staff and providers (physicians, advanced practice providers, medical assistants [MAs] ) in Stanford Primary Care to understand their experiences around Virtual Health. Despite high provider and patient satisfaction, technical limitations and system readiness challenges hindered visit quality, and from the provider viewpoint, left some patients unprepared for virtual visits. Providers observed that patients with cognitive impairment, language barriers, or technology access concerns experienced disproportionate challenges. Providers struggled with platform connectivity, the provider-directed patient self-exam, and establishing an emotional connection with patients. Some medical assistants (MAs) felt unfulfilled, with less direct patient contact. Providers observed that patients with cognitive impairment, language barriers, or technology access concerns experienced disproportionate challenges. Providers struggled with platform connectivity, the provider-directed patient self-exam, and establishing an emotional connection with patients." The next six weeks saw a period of creativity, led by clinic MAs who spontaneously formed improvement teams to address identified challenges. These were later brought together centrally to coordinate clinic improvement efforts. At ten weeks, we surveyed all primary care providers system-wide to identify general issues relating to provider burnout. We re-conceptualized our engagement strategy and identified new areas for growth. The Virtual Health program delivered extremely variable quality of care,3 for several reasons. In Virtual Health, more responsibility is placed on patients to prepare for the visit, to examine themselves and to generate their own health data, while providers are expected to make sound decisions with a very different set of data. Given the circumstances of the transition, many patients became highly activated, whereas others were left behind. Our prior systems were optimized for in-person care, and were not as suitable for Virtual Health care delivery. Several factors were difficult or in some cases impossible to adapt to Virtual Health. In-person visits relied on our medical staff to obtain in-person patient updates, vital signs, and " perform detailed follow-up. Patients had time to prepare for their visits while in the waiting area, center, and develop their visit agenda. Provider exams, routine imaging and procedures occurred immediately on-site. Rapid, direct communication around patient encounters by providers and medical assistants enhanced care follow-up and continuity, while informal face-to-face communication with colleagues and specialists supported clinical decision-making. We developed a Virtual Health Patient Engagement model that incorporated principles of the NAM Quintuple Aim,4 which evolved from the NAM Triple Aim (quality of care, cost, patient experience) to include patient equity and inclusion, and prevention of provider burnout.5 Drawing from the WellMD model, 6 we considered factors to support patient engagement in Virtual Health, including system/technology support, support by clinical teams, and customized support for self-care ( Figure 1 ). A foundational step to building the infrastructure for Virtual Health was to convert key elements of the in-person visit to the virtual experience. This included developing processes for Virtual Rooming, Virtual Waiting Room, Virtual Visit, Virtual Check-Out, and Continuous Virtual Care & Support ( Figure 2 ). Providers and MAs quickly recognized that many patients were unprepared for their video visit. At several primary care sites, care teams met to develop and pilot independent solutions for pre-visit preparation. MAs experimented with virtual rooming strategies, depending on their resources, ranging from low touch (secure patient portal message with written rooming questions/screenings) to medium touch (5-10 minutes phone calls with chief complaint and health maintenance review) to high touch (15-minute phone or video visits for comprehensive agenda setting, health maintenance review, behavioral health screening, and medication review). After three weeks of experimentation, MAs and clinic leadership had division-wide meetings to share and adopt best practices and develop new workflows around health maintenance (HEDIS and MIPS measures). Two weeks later, about 75% of patients had a Virtual Rooming visit with a MA. Providers reported that patients undergoing Virtual Rooming were generally more prepared for and more engaged in their video visit. Patients were asked to log on to the patient video portal 5-10 minutes in advance of their provider visit, to ensure that they didn't have videovisit access problems, to verify medications, and to help the clinic keep running on schedule. When patients logged on, they could complete questionnaires, prepare for their visit, or watch videos related to their health (CHF only, at this writing, with expansion plans). Based on provider/patient feedback, we have begun plans for an interactive virtual clinic platform to maximize the utility of this waiting time. Teams were concerned that critical issues in scheduling/follow-up would fall through the cracks with Virtual Health implementation. Employer-based clinics and Coordinated Care recognized that many patients did not want to discuss health maintenance when they had acute issues. To address this gap, MAs called patients after video visits to help with scheduling procedures and labs, and also conducted appropriate health maintenance screening for depression, tobacco cessation, and more. Positives screens in the after-visit setting triggered actions such as behavioral health follow-up. MAs called patients after video visits to help with scheduling procedures and labs, and also conducted appropriate health maintenance screening for depression, tobacco cessation, and more." During program evaluation, providers reported wide variation with establishing patient rapport and conducting the virtual physical examination. Two education teams began working on engagement and physical examination best practices. To help providers achieve meaningful connection with Virtual Health patients, the Stanford Presence group developed and distributed five best practices for telepresence communication4: • Prepare with intention (pause, refresh, focus, prepare) " • Listen intently and completely (remain visible on screen, lean in, maintain eye contact, communicate through facial expressions, avoid interruptions) • Agree on what matters most (establish a virtual visit agenda, incorporate patient priorities/ goals) • Connect with the patient's story (engage virtually with the patient's home environment and social support) • Explore emotional cues (look for/validate emotional cues in facial expressions, body language, changes in verbal tone/volume). The provider-directed patient self-exam recast the patient's role from examinee to both examiner and examinee. "Exam coach" was added to the provider's role. Based on provider feedback, we developed "practical tips" videos for the 10 most useful outpatient problem-focused examination sets, including: • common concerns: upper respiratory tract infection, shoulder pain, back pain, knee pain, • critical conditions: screening stroke exam, congestive heart failure/cardiovascular exam, pulmonary exam • sensitive examinations: male and female genitourinary exams. An initial video to teach providers how to coach self-exams on upper respiratory tract, low back pain and shoulder pain was viewed 1,800 times on YouTube within a few weeks. Research has begun on validating these measures, and developing additional exam videos for both providers and patients. To address the need for targeted support for patient self-care, including education and integrated home monitoring, we developed and have begun to build out the following resources. Over two months, we strengthened the Virtual Support programs that provided longitudinal health monitoring and support for goals of care. We launched a Digital Lending Library to send Internet of Things (IoT) devices to appropriate patients, allowing for home-monitoring of parameters such as blood pressure, weight, and pulse, with these data streamed to our electronic health record system (EHR). We have several hundred devices available, funded by grants. Technology/AI-enabled care Within a month of launching Virtual Health, several care teams converted their in-person programs to virtual programs, adding new offerings to support self-care. Chronic disease management and group education Teams converted existing diabetes, weight management, intensive behavioral health, and depression programs to virtual programs, adding both group classes and one-on-one support. Psychologists at one site offered new Virtual Support groups for stress management. To address Covid-19 health concerns, we provided advanced care planning large (>300 person) and small (20 person) group classes. In the two months since near universal Virtual Health program implementation at Stanford, we developed new models and processes to drive patient engagement in the virtual setting. Central to our implementation was a combination of individual program innovation, robust rapid program evaluation, centralized program development, and a willingness to foster creativity at every level. This transformation took thousands of hours to develop and hundreds of people to deploy, and, we hope, has positively impacted our larger community. While we believe that elements of Virtual Health are here to stay, Virtual Health has not yet been proven to achieve the Quintuple Aim, including improving equity in care, promoting joy in practice, and bending the cost curve." We are still building out our Virtual Health programs. The future of post-pandemic Virtual Health is unclear. While we believe that elements of Virtual Health are here to stay, Virtual Health has not yet been proven to achieve the Quintuple Aim, including improving equity in care, promoting joy in practice, and bending the cost curve. During this rapid program growth, we learned valuable lessons which will inform our future work in Virtual Health. • Equity and justice as core Virtual Health principles:While Virtual Health may increase health care access for many patients, it may exacerbate equity-related issues for those with limited access to advanced technologies or limited technology literacy. 5 We should carefully evaluate the technology gap in our patient populations and augment with alternatives where needed. For example, some patients may not have smartphones, but may still be able to interact with care teams via SMS. • Rapid evaluation, rapid change: Rapid qualitative assessment was critical to making mid-course corrections, to gain a deeper understanding of participant experiences. To do so, we used highefficiency qualitative evaluation rather than traditional longer form qualitative evaluation.6 • Change-makers as interviewers: Unlike traditional third-party qualitative interviews, many interviewers were qualitative research trained faculty who were involved in program development and implementation. For instance, Population Health leads heard firsthand about MAs' concerns regarding their lack of patient contact. In response, they expanded the Virtual Rooming project to increase high quality interactions between patients and MAs. • Empowering creativity: Improving patient engagement was not a "top down" process: all individuals within the health system were encouraged to innovate, in a coordinated manner. For instance, each clinic experimented with ways to address patient needs for visit preparation, layering on additional components as new needs emerged. • Highest level of the license: The foundation of many health systems, including ours, is medical assistants.7 , 8 These well-trained, compassionate personnel are often overlooked as sources of innovation. Yet, their deep connection to patients, and understanding as a bridge between patients and providers gives them a unique vantage point as innovators. For instance, the technology access program START began as one bilingual MA reached out to help her Spanish language patients navigate the Virtual Health app and ensure their comfort with the technology. • Patient as Partner: Patient engagement is critical to the success of health care endeavors to improve quality of care.9 -11 With the initial press of Virtual Health implementation behind us, we can now partner more deeply with patients and our existing patient advisory groups to develop and test future engagement strategies. While devastating, the Covid-19 pandemic has created an opportunity to re-think the very core of care delivery. The future of health care will likely involve a balance of in-person and virtual care, with the integration and strategic use of different technologies playing a vital role.12 , 13 As the health care community collectively innovates, we are asking fundamental questions regarding the way in which we practice medicine. We are considering what patients really need from our health care system, the role of the clinical encounter, and the unique advantages/issues of providing care in the digital sphere. While these questions may not be fully answerable now, if Virtual Health is to be a significant part of post-pandemic health care, we need to begin to address these issues from the patient's perspective. Rapid System Transformation to More Than 75% Primary Care Video Visits within Three Weeks at Stanford: Response to Public Safety Crisis during a Pandemic Virtually Perfect? Telemedicine for Covid-19 Engaging patients to improve quality of care: a systematic review Tele-Presence 5: A Ritual of Connection for Virtual Visits -Stanford Center for Continuing Medical Education -Continuing Education (CE) Addressing Equity in Telemedicine for Chronic Disease Management During the Covid-19 Pandemic Comparison of rapid vs in-depth qualitative analytic methods from a process evaluation of academic detailing in the Veterans Health Administration The Expanding Role of the Medical Assistant. Pop Health Mat New roles for medical assistants in innovative primary care practices A Multilevel Analysis of Patient Engagement and Patient-Reported Outcomes in Primary Care Practices of Accountable Care Organizations The association between patient engagement HIT functionalities and quality of care: Does more mean better? What the evidence shows about patient activation: better health outcomes and care experiences; fewer data on costs Rapidly Converting to "Virtual Practices": Outpatient Care in the Era of Covid-19