“Virtually Perfect” for Some but Perhaps Not for All: Launching Telemedicine in the Bronx during the COVID-19 Pandemic

Abstract

You have accessJournal of UrologyJU Forum1 Nov 2020"Virtually Perfect" for Some but Perhaps Not for All: Launching Telemedicine in the Bronx during the COVID-19 Pandemic Kara L. Watts and Nitya Abraham Kara L. WattsKara L. Watts *Correspondence: 1250 Waters Place, Tower 1; Penthouse, Bronx, New York 10461 telephone: [phone]; E-mail Address: [email protected] Department of Urology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York and Nitya AbrahamNitya Abraham Department of Urology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York View All Author Informationhttps://doi.org/10.1097/JU.0000000000001185AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail Hindsight is 2020— a simple phrase often spoken and heard. In the midst of the COVID-19 pandemic our urology practice in New York City (NYC) was forced to reconfigure how we deliver health care to protect our patients, staff and physicians from transmission of the highly contagious virus. As public awareness of the pandemic increased, patients feared visiting a medical professional or, even more so, going to an emergency room for medical care. Simultaneously, physicians and allied health care professionals struggled with the immediate challenge of being able to deliver health care to their patients without completely freezing their practices and perceivably abandoning their patients for a completely unknown amount of time. As such, our department, like many other local and distant urology groups, launched a telemedicine platform on a dime, encouraged by patient and physician satisfaction alike at other institutions with an established telemedicine program. Now, looking back, several challenges and realities have emerged calling into question this "virtually perfect" solution.1 Our urology department is part of Montefiore Healthcare System, a network of 11 hospitals and approximately 180 clinical sites throughout the Bronx and surrounding neighborhoods. Montefiore Healthcare System is one of the largest hospital networks and the second largest residency training program in the United States. As the number of patients confirmed with the COVID-19 virus rose, NYC earned a reputation as the epicenter of the U.S. pandemic when case numbers exceeded those in China. One week later the epicenter shifted to the Bronx. Why the Bronx? Health care disparities are a pervasive challenge, with the Bronx experiencing the lowest life expectancy and the highest age adjusted death rate of any NYC borough.2 COVID-19 has also had a disparate impact on the people of the Bronx. The death rate from COVID-19 is double in Hispanic (22.8 per 100,000) and Black patients (19.8 per 100,000) compared to white patients (10.2 per 100,000) in NYC. Similar health disparities were soon revealed through our own telemedicine efforts. While most departments using a telemedicine program require months or longer to develop and hone the process and workflow, the circumstances of this pandemic forced us to navigate this essentially overnight and in real time. Our department made an immediate decision on March 13, 2020 to convert all office visits to telehealth phone visits to evaluate, assess, and triage scheduled and newly referred patients. Around this time telemedicine restrictions were lifted by the Centers for Medicare and Medicaid Services (CMS), enabling beneficiaries to participate from any location and lifting restrictions on nonHIPAA (Health Insurance Portability and Accountability Act) compliant platforms (eg FaceTime®, Zoom), facilitating this precipitous transition.3 Within our first week of launching phone televisits, we performed approximately 250 televisits, increasing to approximately 700 in each of the following weeks among our fluctuating staff of 15 full-time surgeons and 4 nurse practitioners. Four weeks after launching the program we deployed our institutional platform to conduct video visits, enabling patients to connect via a virtual platform to one of our providers from a distinct location. Since the start of this transition in-office face-to-face visits were dramatically reduced to fewer than 5% of our total volume, reserved only for those patients requiring urgent in-office evaluation. Our patients have, by and large, graciously welcomed this alternative to face-to-face care, particularly during this pandemic. We have also been able to extend our services to many of our patients (ie medication, bladder training, imaging review), avoiding a face-to-face visit for the next few months or, at times, entirely. This latter point calls into question the hindsight realization that perhaps a considerable portion of what we do in outpatient urology does not actually require an office visit at all. Despite the encouraging visits, several challenges of adopting telemedicine in our particular community have emerged. Video visits require the provider as well as the patient to have access to reliable Internet service or Wi-Fi signal, in addition to an electronic smart device with video capabilities (eg smartphone, tablet, laptop etc). An executive summary by the NYC comptroller reported that up to 48% of households in Bronx neighborhoods do not have broadband Internet.4 Disparities in Internet access worsen when stratifying the population by race (30% no access for Hispanic and Black vs 20% to 22% no access in White and Asian), age (42% no access for seniors older than 65 years vs 23% age 18 to 24 years) and poverty level (44% no access in poverty vs 22% above poverty line). Therefore, video visits are an impossibility for a number of our patients. Furthermore, language barriers are a consideration as the primary language spoken in the Bronx and surrounding communities is not English. During a video visit the auditory quality of a translator dialed in from a third device may be limited, at best. Our patient population, in which 1 out of 5 prefers a language other than English, 40% live in a high poverty neighborhood and 44% rely on Medicaid, is particularly vulnerable to worsening health disparities. Indeed, since launch video visits have been declined by an average of 75% of our patients, opting instead for phone visits. Among those patients opting for a phone visit, 50% attribute this decision to lack of a device and or Wi-Fi/Internet signal. Despite these barriers 95% of our scheduled televisits (video or phone) have been successfully completed. Fortunately, the lift on restrictions for reimbursement from CMS for telemedicine phone visits has facilitated our use of this modality for many of our patients throughout this pandemic. In addition, a recent update from CMS revealed an increase in reimbursement for telephone visits to match that of office visits of a comparable service level.5 These changes have major implications for possible improvements in health care delivery even outside of the pandemic, particularly for rural populations and for those with physical or financial barriers to coming to the office for medical care. The launch of telemedicine during the COVID-19 pandemic has been an invaluable bridge enabling us to continue to provide care to our patients throughout this challenging time. We are continually learning from feedback from our patients, and from each other, with regard to how best to continue to offer these services to our patients in the present and future. As the Institute for Healthcare Improvement advocates, "disparities in health and healthcare are issues of quality and justice." This applies to health care via telemedicine. It is our hope that the challenges we are facing with usability of telemedicine in our community can be addressed with better incorporation and quality of translator services into video visits, continued equivalent reimbursement for televisit phone calls to in-office visits post-pandemic, and increased resources made available to the public to facilitate adoption of this "virtually perfect" solution for all. Through the dust and devastation of this current pandemic, we as physicians have a unique opportunity to reconsider how we have been delivering health care to our patients. Are face-to-face evaluations always necessary? And if so, when? If not, how can we provide care to patients in more geographically or financially limited areas? Now more than ever, hindsight is 2020. Let's not waste it. References 1. : Virtually perfect? Telemedicine for Covid-19.N Engl J Med 2020; 382: 1679. Google Scholar 2. NYC Health: Age adjusted rate of fatal lab confirmed COVID-19 cases per 100,000 by race/ethnicity group. Available at www.nyc.gov. Google Scholar 3. : Implementing telemedicine in response to the COVID-19 pandemic.J Urol 2020; 204: 14. Link, Google Scholar 4. New York City Comptroller: Census and the City: Overcoming NYC's Digital Divide in the 2020 Census. Available at https://comptroller.nyc.gov/reports/census-and-the-city/. Google Scholar 5. Centers for Medicare and Medicaid Services: Trump Administration Issues Second Round of Sweeping Changes to Support U.S. Healthcare System During COVID-19 Pandemic. 2020. Available at https://www.cms.gov/newsroom/press-releases/trump-administration-issues-second-round-sweeping-changes-support-us-healthcare-system-during-covid. Accessed April 30, 2020. Google Scholar © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byBabar M, Zhu D, Loloi J, Laudano M, Ohmann E, Abraham N, Small A and Watts K (2022) Comparison of Patient Satisfaction and Safety Outcomes for Postoperative Telemedicine vs Face-to-Face Visits in Urology: Results of the Randomized Evaluation and Metrics Observing Telemedicine Efficacy (REMOTE) TrialUrology Practice, VOL. 9, NO. 5, (371-378), Online publication date: 1-Sep-2022.Marra G, Gomez F and Cussenot O (2021) "Virtually Perfect" for Some but Perhaps Not for All: Launching Telemedicine in the Bronx during the COVID-19 Pandemic. Letter.Journal of Urology, VOL. 206, NO. 1, (176-177), Online publication date: 1-Jul-2021.Smith J (2020) Intersection of Scientific Publication and SocietyJournal of Urology, VOL. 204, NO. 2, (206-207), Online publication date: 1-Aug-2020. Volume 204Issue 5November 2020Page: 903-904 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.Metrics Author Information Kara L. Watts Department of Urology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York *Correspondence: 1250 Waters Place, Tower 1; Penthouse, Bronx, New York 10461 telephone: [phone]; E-mail Address: [email protected] More articles by this author Nitya Abraham Department of Urology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...