Telemedicine & The Hospital Org Chart

Telemedicine & The Hospital Org Chart

Morgan L. Waller, Director of Telemedicine Business & Operations, Children’s Mercy Kansas City

Morgan L. Waller, Director of Telemedicine Business & Operations, Children’s Mercy Kansas City

If you haven’t had your own healthcare appointments via a computer or phone in the last six months, telemedicine (TM) or telehealth is the delivery method of choice for healthcare when patient and provider are not physically together. At minimum provider and patient need text or audio/voice. However, what amazing complex care can be achieved using high definition video with a Blue Yeti® microphone or similar, Bose®700 headphones or similar and digital ancillary exam devices that can capture images not able to be seen by the human eye! The technology exists and has for years. So, why did it take a pandemic to introduce the concept of FaceTime<sup>®</sup> healthcare to patients/consumers?

Prior to COVID, use of TM was like that of electronic health records in the first decade of the 21st century, only without a government mandate to make it happen. On the contrary, government TM regulations have been, bar none, the greatest barrier to contemporary healthcare access because of their limitations on:

• types of providers eligible for reimbursement

• qualifying delivery and access location types

• geography

• proprietary state medical licenses versus highly mobile patients

• arbitrary metropolitan area exclusions

• county health professional shortage designations

• county medically underserved designations

• types of care/current procedural terminology codes.

"The adoption curve for TM has gone from linear to exponential and everyone now knows what TM is and what benefits it offers"

In addition to the aforementioned barriers, healthcare is in an uncomfortable and challenging place between the reality of reimbursement, which is still largely dependent on fee-for-service care, and the presentation of new value-based care opportunities that involve virtual/remote technologies but don’t have the same return on investment or short-term pay-offs. Organizations now face difficult decisions regarding their investments in TM. Hospital systems tend to place TM program responsibilities under an already maxed-out VP or member of a C-suite or they designate a percent of an interested physician’s time to leading the TM effort. Unlike most other programs or departments in medicine, TM doesn’t come with an instruction manual. There are recommendations and examples of what to do and what not to do in published editorials and white papers; however, even if you have experience in information systems & technology, strategy, medical leadership or operations, that doesn’t automatically mean that you know how to launch and sustain a TM program. Closely related, implementation of a telemed program has been like international business, one cubical with a “we should do this” (but don’t know how) mantra.

As with most things, there are exceptions. A few healthcare systems have created impressive TM programs despite all the challenges. Although, they too have struggled and may still be struggling with where TM belongs in their organizational chart. Since COVID-19, the importance of this decision has changed considerably. The adoption curve for TM has gone from linear to exponential and everyone now knows what TM is and what benefits it offers.

Many hospitals and health systems have put TM under the auspices of their CIO, in Information Systems (IS) because it has technical and electronic security needs. I read or heard someone say once, that “IS is where TM goes to die.” In defense of our IS/IT friends, they are mission critical to TM; however, I agree with the sentiment that IS is not where TM should live if that placement excludes clinical or bilingual (clinical and IS/IT) professionals. Others have drawn the line to their COO, due to the many different operational and cross specialty uses of TM. Won’t a mature TM program touch every department including: inpatient, ambulatory, pathology, lab, radiology and surgery? Does it not affect office space, parking, planning and staffing? TM reporting to the CSO might find a way to turn the financially challenged program into a money maker or patient centered differentiator. Since TM is relatively new and, depending on how it is used, it also can be innovative, direction by the VP of Innovation is an option. Another place for administration of TM is the Medical Executive chain of command. While not its own specialty, it does provide a tool or method for all providers to use for their patients’ benefit.

Perhaps TM belongs with the executive in charge of capitated care? Many applications of TM are cost avoidance tactics rather than ones used to generate revenue.

I wouldn’t recommend TM’s placement in the org chart being decided by finding out what other hospitals have done. TM is still in the early growth and development phases; giving organizations the opportunity to think for themselves.

The challenge is that TM doesn’t fit nicely and neatly under just one executive branch. The amount of dependence on clinical, technical, legal, risk, billing, finance, coding, government, payer, informatics et al expertise, gives a piece of TM to everyone. It is a gestalt, requiring support from all executives.

TM must have leaders that are pro-physician/ pro-provider. COVID-19 may have forced institutions to use virtual care for a time, but if the processes, solutions and ongoing design do not incorporate the providers’ values, needs and knowledge, it won’t be sustained. Do not separate the technical decisions from the clinical users and program leadership. The pre-COVID-19 exceptional programs were developed by somewhat unconventional leaders with strong beliefs in TM; no doubts ever that it would be anything but one day mainstream. Persistent, convincing, creative and refusing to accept “no” kinds of people have led the way. Professionals with emotional intelligence quotients so high they can feel what patients and their families want and need, sometimes before they know themselves, are what you want leading your TM program.

TM won’t solve all our healthcare problems; however, it is pretty stinking powerful! When the different pieces come together and make more efficient ways to access needed healthcare, it is beautiful and rewarding. The potential is limitless.

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