Telehealth case study: Virtual-first approach to primary care

After the pandemic propelled telehealth into the mainstream, primary care leaders now are finding ways to bring the technology to the next level during the continued COVID-19 health emergency and beyond.

A primary care practice that offers virtual-first care. Rapid response e-visits where patients are seen within two hours. Device-enabled exams that allow a physician to hear a patient's heartbeat and lungs remotely. These are some of the novel ways primary care physicians are incorporating telehealth.

Those using the technologies discussed how these new methods of providing care have worked at their practices during an AMA webinar, "Clinical Case Study: Telehealth for Primary Care."

Among the challenges, though, are insurance companies creating virtual-only insurance products. Meanwhile, large health plans are investing in stand-alone telehealth companies because they have the potential to create fragmentation in primary care that, in turn, could impede continuity and coordination of care, according to Steven E. Waldren, MD, vice president and chief medical informatics officer at the American Academy of Family Physicians, who presented during the webinar.

The webinar is part of the Telehealth Immersion Program designed to help physicians, practices and health systems implement, optimize, sustain and scale their telehealth efforts. That program is part of the AMA STEPS Forward™ Innovation Academy that lets physicians learn from peers and experts and discover ways to implement time-saving practice innovation strategies.

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Medicine will need to find a balance between making sure there is great access to telehealth and choice for patients while at the same time making sure that patients don't lose the continuity of care and care coordination that primary care can provide, Dr. Waldren said.

"Telehealth today and telehealth in the post-pandemic is not going to be the same as telehealth of the pre-pandemic world, he said. "Telehealth is, and will be, a prominent component of primary care moving forward. The question is: how do we do it well, and how do we integrate it?

It's important, Dr. Waldren said, that telehealth help physician practices accomplish the four C's of primary care:

First contact.
Care coordination.
Continuity of care.
Comprehensive care.

Two physicians shared their experiences of how their practices are answering that question.

Virtual-first visits in California

Sutter Health in California has begun to offer patients Tera Practice, which offers primary care virtually and tries to resolve a patient's issue by phone or video visit before scheduling an in-person appointment when appropriate. It's team-based care that includes a primary care physician, a nurse practitioner, a nurse and a health coach who have daily virtual team huddles.

It was designed in 2018 and first offered in the Palo Alto, California, area and has now expanded into San Francisco.

"We do 90% of our care by messaging, video, audio but I also have a half-day of clinic that I can see my patients in person if needed," said Matthew Sakumoto, MD, a San Francisco "virtualist" and clinical informatics physician champion at Sutter Health.

He noted that communication can include photos, text messages and more. And because the practice is part of Sutter Health, they are able to connect patients with urgent care within the system when necessary, providing continuity of care because patients' records are visible to those health team members as well.

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Virtual exam kits in Detroit

In the Detroit area, patients have 24/7 access to on-demand rapid response e-visits through the Henry Ford Health System (HFHS). It's staffed by an on-demand physician pool and patients are seen virtually within two hours.

Patients in the HFHS who choose a virtual visit with their primary physician can also now bring physician tools into their exam, explained Diane George, DO, chief medical officer for Henry Ford Medical Group Primary Care.

Patients can obtain a device that includes a touch screen, infrared thermometer, camera, intelligent lighting, as well as an otoscope, stethoscope and tongue depressor that attach to the device. Physicians can hear heart, lungs, skin, abdominal sounds and observe a patient's temperature, ears, nose and throat through a live, high-quality video feed.

Also, paramedics can go to a patient's home if a physician makes a referral. The paramedic can connect with the physician and use the device for an exam when appropriate. Under physician direction, paramedics provide treatments such as diuresis, hydration, breathing treatments and intravenously administered antibiotics.

The benefits of expanded telemedicine are clear. Join physicians who are advocating to permanently expand virtual care coverage.

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