The COVID-19 pandemic radically changed healthcare delivery over a short period of time. Even before the first confirmed case of COVID-19 in Ohio on March 9, Cleveland Clinic leadership activated a rapid transition plan toward predominantly remote care. In part due to social distancing requirements, the rapid pivot and expansion of telehealth became necessary to ensure uninterrupted access to meet patient needs, minimize healthcare worker exposure, and contribute to the overall effort of “flattening the curve” by keeping patients home.
Cleveland Clinic continues to explore new, innovative ways to meet our patient’s needs through telehealth capabilities, and believe these solutions will continue to deliver value to our patients in a post-COVID-19 environment.
Click here to access Cleveland Clinic’s Digital Health Playbook.
Rapid transition plan
Despite early adoption of digital care by Cleveland Clinic, telehealth represented less than 2% of the total care provided throughout the organization in early 2020 – an experience not unlike that of other large healthcare organizations. However, Cleveland Clinic leadership quickly realized the importance of remote care in the context of COVID-19 and activated a rapid transition plan. Elements of this plan included:
- Expansion of telehealth privileges. In step with state and federal guidance, Cleveland Clinic’s legal department provided guidance early in the pandemic to allow Cleveland Clinic providers (physicians, nurse practitioners and physician assistants) to: (1) provide COVID-19 related virtual care to any established patient in any state or US territory; (2) provide care using several modalities (including telephone); and (3) prescribe controlled substances to established in-state patients at virtual visits.
- Expansion of digital platforms. With the rapid and massive transition of 19 clinical institutes (representing close to 4,000 physicians) to digital care, Cleveland Clinic’s Information Technology leadership quickly ramped up additional platforms by which providers and patients can interact remotely. These included workflows that surround the use of video chat applications such as Apple© FaceTime, Google© Duo and Doximity© Dialer. Additionally we are rapidly developing an EMR integrated virtual visit solution, which will be maintained post pandemic.
- Training and reorganization of the workforce. In order to provide patient continuity in a digital world and meet the increased demand for care for those exposed to or infected by COVID-19, primary care and subspecialty teams were quickly trained, as well as asked to flex site of care delivery outside of their usual clinical niche.
- Development of a standard playbook. Creation of a unified dynamic playbook that lived on a central COVID-19 internal website greatly improved use and efficiency in a platform on which providers did not previously engage.
- Communication. Leadership at various levels huddled daily, across workgroups and translated key points to the frontlines regularly. This transparency at a regular cadence allowed for innovation, quick iteration and early success.
Making telehealth a reality
In the span of 6 weeks (from March 7 to April 11), total Cleveland Clinic outpatient visits went from 2% remote (virtual or phone) to 75% remote. In that time, hundreds of providers were newly trained or retrained in the available virtual platforms. To organize the effort, several steps were taken almost simultaneously, including: synchronous and asynchronous video training of providers; creation of new documentation templates; and creation of new workflows.
- On-demand care. By March 12, various government and Cleveland Clinic media were encouraging the public to seek medical care via remote access for their COVID-19 related symptoms and concerns. The public on demand platform (Express Care Online©) saw a 10-fold increase in volume, quickly overwhelming the workforce dedicated to this service. Workflows to address on-demand patient care include both synchronous and asynchronous modalities, such as Express Care Online© (ECO), Telephone Triage, eVisits and COVID-19 Results Management. To date, over 200 providers augment the Express Care Online© platform to provide 24/7 virtual access without the need for a scheduled appointment. The majority of providers are primary care physicians, nurse practitioners and physician assistants. These providers split their time between staffing the on-demand platform, and providing in-person or virtual primary care in their home sites or physical Express Care© sites. The platform currently sees an average of 600 visits per day, from a high of 1,000 visits per day in early March.
- Scheduled virtual care. At the same time that on-demand care was ramping up, CCF patients and providers became interested in receiving and providing care that minimized the need to see each other in person, when possible. Using a similar framework to train providers to go online, develop specialty-specific documentation templates and iterate workflows, Cleveland Clinic achieved a remarkable shift toward predominantly virtual outpatient care in a short period of time. Additional operational elements include: proactive patient outreach; proactive schedule management; and organization-wide efforts to increase the ease of scheduling.
- Remote monitoring. As the number of identified COVID-19 positive cases increased, an organization-wide, standard, comprehensive approach was needed. A multidisciplinary working group came together in mid-March to design the intervention, which identifies all CCF-tested COVID-19 positive patients, monitors their symptoms daily and escalates any concern quickly in order to intervene prior to decompensation. The clinical monitoring is aided by a self-reporting app within the patient portal, along with pulse oximetry and temperature monitoring. To date, more than 1,000 patients have been enrolled in the program.
Please note: These materials are provided as an example of how to implement virtual care and reflect a snapshot of Cleveland Clinic’s approach as of April 2020. As circumstances (including clinical and regulatory) evolve, Cleveland Clinic’s operational approach likely will change; however, these materials will not be updated to reflect any changes.
