Staying Power

Advocate Aurora Health began laying the groundwork for virtual care more than seven years ago, introducing a new clinic model designed to integrate in-person visits and telemedicine (telemedicine defined as doctor-provided care via telecommunication technology). “Telemedicine was a better way to directly reach our patients in a more convenient way, for the right applications,” says Scott Nelson, systems vice president for planning, design, and construction for Advocate Aurora Health (Downers Grove, Ill.).

Starting in 2014, nearly 40 clinics were designed and built using the new concept, which features a core module of 12 exam rooms with two rooms set up for telemedicine. By early 2020, Advocate Aurora Health set a target of 35,000 telemedicine visits for the year. Shortly thereafter, the COVID-19 pandemic hit, sending the healthcare industry into emergency mode as providers suspended outpatient operations and temporarily closed ambulatory locations. Facing that reality, Advocate Aurora Health saw an opportunity to ramp up its telemedicine program even more, providing video visits with patients at home while clinicians were working from an outpatient facility or remotely. The formula worked, with the provider delivering nearly 800,000 telemedicine visits last year, Nelson says.

Advocate Aurora Health wasn’t alone in scaling up telemedicine offerings to fill the gap between patient need and limited appointments available for in-person care. According to the “COVID-19 Consumer Survey,” released in May 2020 by McKinsey & Company, a U.S.-based worldwide management consulting firm, health systems, independent practices, and others reported seeing 50-175 times the number of patients via telehealth than they did before (telehealth is generally defined as a broader term for the technologies and services used to support remote healthcare and services). Consumer adoption also jumped, from 11 percent of U.S. consumers using telehealth in 2019 to 46 percent using it to replace canceled healthcare visits, according to the report. Houston Methodist, which includes a network of eight hospitals serving the Greater Houston area and 180 clinic locations, saw telemedicine visits grow from 115 to 15,500 a month from February to March 2020, with volume doubling again by April 2020, says Dr. Sarah Pletcher, vice president and executive medical director of virtual care at Houston Methodist.

(For more on Houston Methodist’s telehealth initiative, visit https://healthcaredesignmagazine.com/?p=48638&preview=true).

Now, as the country eagerly awaits a return to “normal” in many aspects, design professionals and healthcare organizations say they don’t anticipate telemedicine practices will return to pre-pandemic levels. “Telehealth is going to continue to grow—probably not as much as it did last year, but it certainly is an accepted platform now by patients,” Nelson says. “It’s a new world.”

Providing a lifeline

In the beginning of the pandemic, telemedicine was primarily used to screen patients to ensure those coming to the hospital absolutely needed to be there. This not only helped hospitals from being overwhelmed but supported efforts to keep staff and patients safe and maintain robust supply levels, especially for personal protective equipment (PPE).

The U.S. Coronavirus Aid, Relief, and Economic Security (CARES) Act, which included emergency polices that improved provider payments for telehealth and allowed for providers to deliver care across state lines, helped fuel greater adoption. “There’s been interest in telemedicine for some time but what was holding a lot of clients back was the payment structure, because they weren’t getting paid as highly for telemedicine visits as they were for in-person visits,” says Amy Douma, design principal and architect with HGA (Minneapolis). When restrictions were relaxed last spring, telemedicine became a more financially viable option, she says. “During the lockdowns, particularly, there was a huge spike in telemedicine use. It’s been tapering downward since then as things have become a bit more normalized, but its use is still considerably higher than it was pre-COVID-19,” she says.

As the year progressed, and many patients were still reluctant to visit a health facility for fear of contracting the virus, many healthcare providers expanded telemedicine services to include primary and specialty care platforms, such as mental health or physical therapy, improving care access to patient populations that may have never considered a virtual visit.

The new types of uses and deployment not only resulted in expanding access but also broadening acceptance of the model among patients. In HGA’s new “Impact of Telemedicine on Outpatient Care, Insights from HGA’s 2020 Exploratory Study,” the firm cited an April 2020 online survey by The Harris Poll that shows 82 percent of U.S. consumers who’ve utilized telehealth services reported having positive feelings about using it or the idea of using telemedicine services, while 80 percent said they were likely to seek the services post-COVID-19.

All these factors—from changing regulations to broader consumer acceptance—are making it easier for design professionals to have conversations with clients about telemedicine going forward. “The conversation is no longer ‘should we?’ or ‘will we?’” says Lindsay Radford, regional leader of healthcare consulting at HOK (New York). “It’s more of, ‘OK, we know we need to have this, now how big does it need to be and how do we best deploy it?’”

Planning for a new world

As healthcare organizations begin to consider the best way to accommodate or scale up their telemedicine programs within the built environment, a few pieces to that puzzle remain unclear, especially regarding regulations. For example, Douma says it’s uncertain if providers will be able to continue delivering care across state lines after the pandemic or where reimbursement rates will land. “Most groups don’t expect reimbursement to go backwards, because people see the value of remote care,” she says. “It’s a much more positive financial environment than it was pre-COVID-19.”

Still, she says more clients are interested in finding space for telemedicine to occur. “In more cases than not, that is outside the exam room because you can conduct telemedicine visits in a much smaller space,” she says. Furthermore, clients are also scrutinizing the impact of telemedicine on existing and future exam rooms and waiting spaces, as fewer patients come into their buildings. “It’s a discussion point on what is the role of telemedicine and is that going to change the physical footprint or design of the building going forward,” Douma says, adding that the jury’s still out on the degree to which it will be affected.

Kara Friehoefer, director of research at HGA (Milwaukee), says most providers in the firm’s study noted they preferred an integrative approach, with telemedicine visits conducted between in-person visits in the clinic to still allow some in-person engagement and connection with patients. To accommodate this, she says designers need to think about adjacencies and the right type of technology in exam rooms as well as the use of teleconference rooms versus actual exam rooms or offices. “There’s a lot that goes into understanding what type of workflow they’re trying to achieve and then accommodating for that,” she says.

Understanding an organization’s infrastructure and whether it uses a decentralized model, where telemedicine is deployed by service line or department, or a centralized platform, where services and providers are organized in one location that serves as a command center, is also important, Radford says. In some cases, she adds, clients will start with decentralized deployment with the goal to move to a centralized model in the future. “Then the conversation is about how to scale it and how do we pull it out of that clinical setting to a nonclinical, cheaper real estate space, where it can be that command hub for the entire enterprise,” Radford says.

When it comes to the best environment for providers to conduct video appointments, industry views differ. Some clinical environments include specific quiet rooms or offices for telemedicine while others design exam rooms that feature additional components such as technology and video screens to support either in-person or remote visits.

HGA’s report notes that one of the most popular adjustments to outpatient facilities has been the addition of micro-offices or small booths that enable auditory privacy on telemedicine calls. Other ideas focused on supporting connectivity in exam rooms, including integrating technology into the planning and infrastructure so exam rooms can be equipped for telemedicine at a future date, or using mobile devices and carts so that technology can be brought to a patient or provider anywhere in a facility.

Based on expectations that 30-40 percent of patient visits will be virtual in the future, Advocate Aurora Health is rethinking its clinic model, reducing the size of standardized rooms for telemedicine and then backfilling space with services that support a wellness program or other components, such as a retail pharmacy, gym, and community kitchen. The new hybrid model, which could reduce the clinical footprint by 30 percent, is expected to open in several locations in 2022. “Over 30 clinics have been a standardized kit of parts, built on efficiency and throughput and designed primarily around a physical visit,” says Mike Doiel, senior vice president at HDR Architecture (Chicago), which has partnered with Advocate Aurora Health on its clinic program. “This hybrid or virtual-visit model kind of turned things upside down and with that could present more flexibility in operations and space allocation.”

Houston Methodist is also rethinking its clinical spaces, including evaluating the number of exam rooms assigned to each provider based upon the amount of in-person visit activity. “Additionally, we’ve started to add huddle rooms to our primary care group locations, which have a video conferencing capability that enables the provider to perform virtual visits from this room, if they don’t want to do it from their work area or an exam room,” says Jeff Carr, vice president, finance, administration, and managed care at Houston Methodist/TMH Physician Organization.

Growth year

The last 12 months have pushed the industry to deliver a rapid-fire environment for implementing and growing telemedicine. Nelson says he anticipates another year of lessons learned; but in the end, he expects the acceptance level of telemedicine is here to stay. “One of the silver linings of COVID-19 is that a lot of patients learned that you don’t need to physically visit a [facility] to get good or better healthcare,” he says.

Friehoefer at HGA says she expects clients will continue to explore what’s best served by telemedicine. “It’s adaptable to certain service lines more so than others,” she says. For example, she says a majority of mental health visits could be done within a telemedicine setting, while other processes, such as screening or check-ups, also might benefit.

HOK’s Radford says she’ll be spending the next year focused on preventing clients from regressing. “If you know you can do 40 percent of your visits via telemedicine, why go backwards?” she says. “Let’s grow it.”

Anne DiNardo is executive editor of Healthcare Design. She can be reached at anne.dinardo@emerald.com.

 

 

 

 

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