To kick off McLean’s Fall 2020 Nursing Conference, titled “The Digital Revolution in Behavioral Health During a Pandemic,” Michael Hasselberg, PhD, RN, presented a talk, “Telehealth and Informatics.” A wide-ranging look at the past, present, and future of telehealth and other technologies, the presentation drew on Hasselberg’s experience as senior director of Digital Health for University of Rochester Medicine and co-director of the school’s UR Medicine Health Lab. Hasselberg discussed the growing use of technology in health care delivery, specifically behavioral health, advances in data collection, and how the COVID-19 pandemic has accelerated change.
The Rise of Telehealth
Telehealth, or the use of telecommunications technology to deliver health care, “is not a new thing,” Hasselberg asserted. He explained that the practice began in the 1950s when the University of Nebraska used early video conferencing technology to transmit their grand rounds to other institutions. By the early 1960s, the practice had expanded to facilitate group psychotherapy and communication between state psychiatric facilities.
In recent years, telehealth and other health-related technologies have been growing as Google, Amazon, Microsoft, Apple, and Facebook have “all entered the health care space,” Hasselberg said. These tech giants are bringing their expertise to a variety of projects. For example, he reported that Apple “built their own electronic health record, which is used by several hospital systems,” and Amazon “has been shipping medical products to systems across the country for years.” Also, he said, Facebook has engaged in efforts to use their data to identify individuals at risk for certain disorders, and Google has created a “cloud-based server that many health systems now use for their IT infrastructure.”
Learning From Tech Companies
This growth has been fueled in large part by consumer demand. “Health care consumers have been adapting to technology for quite some time now,” Hasselberg said. “If we look over the last five years, we’ve seen a rapid increase in patients going online to seek out the sites like WebMD for their health care information, and consumers are going online to look up their doctors and nurse practitioners and their providers” looking for ratings and reviews. Moreover, he stated, more and more patients are wearing “Fitbits and Apple watches and other remote patient-monitoring technologies.”
As tech companies have been making inroads into health care, health care has been adopting lessons learned from tech. For example, Hasselberg discussed how Amazon has “disrupted” the consumer experience, and consumers now demand and expect choice and convenience when they purchase goods and services—including health care.
At his lab, Hasselberg and his colleagues are “trying to replicate that same type of experience” that Amazon offers “across the spectrum in the entire health system.” The lab is engaged in initiatives to use smartphones to collect data on its patient population and streamline patient interactions, including scheduling and billing. The lab also worked on the creation of a model for delivering telepsychiatry visits, and it developed a CBT mobile app for managing anxiety and stress.
“If we don’t develop the same consumer experiences, people are going to not go to us, and they’re going to go to Amazon to get their health care.” And, he stated, “I don’t want to get my health care from Amazon.”
The Impact of COVID-19 on Health Technology
Consumer demand has pushed forward telehealth and other technologies, but the COVID-19 pandemic has truly accelerated the adoption of health care technologies. “Pre-pandemic, about 30% of our population had used telemedicine,” Hasselberg said. “Then came March and the COVID pandemic, which ignited digital health across our country.” He explained that with more and more people working from home, “we’ve been forced to use video conferencing platforms to interact with our colleagues, so it’s really pushed folks to become more reliant on video conferencing technology.”
While social distancing mandates are fueling the adoption of online platforms, Hasselberg believes that financial pressures caused by the pandemic will force patients and health systems to further adopt digital health solutions. “In my opinion, where the pandemic is going to shake up digital health is the recession that our country is heading to,” he asserted. Rising unemployment, he explained, will lead to millions losing health insurance, causing more people to be more careful about how and where they spend their health dollars. “This will have a major impact on whether or not someone is going to go to the hospital for care or go to see their primary care doc or their psych nurse practitioner or their psychiatrist in person—or are they going to seek out potentially lower-cost services?” he said.
An increase in mental illness diagnoses caused by the pandemic may also push forward the adoption of telemedicine. “In June of this year, after the pandemic started, the CDC did a national survey looking at behavioral health symptoms across the country, and it was estimated at that time that about 40% of Americans in June were having symptoms congruent with a behavioral health disorder,” reported Hasselberg.
“That is just going to get worse the longer that we’re in the pandemic and folks become more socially isolated—and more folks lose their jobs or have financial strain due to the recession.”
The Challenges, Successes, and Future of Telehealth at McLean
Telehealth is here to stay.
That was the message of the “Telehealth During COVID-19” panel discussion, held over the Zoom platform during the Fall Nursing Conference.
Moderated by Deborah S. Mindnich, MS, RN/PCNS, nurse director of the Clinical Evaluation Center, the panel was made up of four McLean nurses from across the hospital: Christopher A. Hicks, MSN, APRN, PMHNP-BC, Electroconvulsive Therapy (ECT) Service; Victoria Maxwell, RN, Short Term Unit; Jonathan Foley, RN, Schizophrenia and Bipolar Disorder Inpatient Program; and Elizabeth Murray, RN, McLean SouthEast. Kara Backman, McLean’s chief information officer, also lent her perspective.
Each panelist talked about how their departments ramped up the use of telehealth during the early months of the pandemic. They also discussed the challenges they faced, the lessons they have learned, and how they will continue to adapt and improve care using this technology.
Describing the early weeks of the pandemic as a “whirlwind,” Backman explained how the hospital and the entire Mass General Brigham system got up to speed with telehealth. “We really started getting engaged in conversations around March 11,” she said. “Prior to that, we actually didn’t have a lot of telehealth at McLean, and we did not have a telehealth team.” Backman detailed the process of assembling that team, creating workflows, and training staff on using the Zoom platform for delivering care.
“It was amazing to see how quickly the staff took to it and patients took to it and were able to work through the best workflows,” Backman stated. She explained how her team communicated with inpatient and residential staff to explain the benefits of telehealth, describing “how we could use it in an inpatient or residential setting to really promote social distancing between patients and providers, as well as minimizing additional staff having to come into the program or floating between the programs.”
As this was happening, nurses throughout the McLean community were adapting to the new technology to their specific environments and patient populations. “It was a big change for us,” said Foley. He described how his team quickly shifted from having patients, nurses, psychiatrists, and social workers all in the same room to “being a member of the team that ‘Zooms’ in.” He said that much time was spent finding a quiet place for virtual meetings, ensuring access to Epic (the electronic health record system), dealing with technical issues, and maintaining “transparency and team feeling” in a way that “allows you to continue to care for the patient in a similar way as you would normally.”
Foley’s colleagues relayed similar experiences. “There was a lot of trial and error at first—just trying to figure out the coordination,” said Murray. “We had no idea how it would affect our practice, and there was a lot of fear.”
But it worked out.
“We were able to roll this thing out and do it,” she said. “I can’t believe how quickly you learn things!”
Murray said the experience produced many positive outcomes. She cited the increased use of cell phones to keep case managers in touch with doctors and more efficient time management as improvements caused by the shift to telehealth. “I think we were able to work a little bit more collaboratively between the disciplines,” she said.
At the ECT Service, Hicks reported that the pandemic posed a unique set of challenges. “Telehealth and neurotherapeutics don’t exactly go hand in hand with our treatment modalities, which require direct in-person care,” he explained. “When the pandemic started, our focus was more towards adapting our treatment protocol to make sure that it was as safe as possible.”
Hicks said that the ECT Service made significant changes to ensure safety. “We shifted all outpatient consoles to be performed via virtual platforms with real-time audiovisual feeds via Zoom,” he reported. Hicks also stated that “we had to change our workflow procedures for scheduling and educating patients, as well as billing and documenting practices.” Moreover, all departmental and organizational meetings were shifted to Zoom. He said “being flexible” was key to keeping the ECT Service running.
Flexibility and adaptability were cited by all panelists as important factors in ensuring ongoing service and patient safety through the adoption of telehealth. Each said that accessing necessary equipment, learning new technologies, and troubleshooting technical difficulties made telehealth a challenge at first, but working through those issues may help improve care in the long run.
“I’m glad we have navigated the challenges,” Maxwell stated. “I think the nurses and the staff and everybody who’s been helping out have really risen to the occasion.”
Looking ahead, Backman said that McLean and the Mass General Brigham system are learning lessons from the early adoption of telehealth and making improvements. She reported that work is underway to improve training for patients and staff. Efforts are also being made to acquire adequate supplies of equipment, including laptops, iPads, cameras, and microphones.
Overall, the panel felt that telehealth had the potential to help patients and staff even when “things get back to normal.”
“This is a great tool for us to have,” Maxwell said. “I didn’t know how well it was going to work, but it did.”
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