Telemedicine: Healthcare's Nerve Center

Leaders at Mercy have developed an inclusive and expansive technology program that focuses on human relationships and partnerships inside and outside the organization.

This article appears in the September 2015 issue of HealthLeaders magazine.

Telemedicine is not merely cables, computers, cameras, displays, software, and sensors. It starts with relationships between people, between the organization providing telemedicine and those providers who benefit from and help direct the evolution of telemedicine efforts, and ultimately the provider-patient relationship itself. Those human relationships also extend to the vendors supplying technology to providers, and, in the case of one health system, Mercy, a brand-new standalone virtual care center to extend its relationships to other healthcare systems looking to partner with it, rather than independently build their own telemedicine nerve centers.

So says the telemedicine team at St. Louis–based Mercy, a 35-hospital system spanning Arkansas, Kansas, Oklahoma, and Missouri that has become a national leader in implementing telemedicine. To Mercy, virtual care represents the opportunity to extend person-centric care delivered by expert teams beyond the traditional institutional setting.

The organization started its telemedicine efforts in 2006 with an eICU program, but with a plan even then to incorporate those efforts throughout Mercy's care system. Today, Mercy Virtual is progressively integrating across the entire system. "We believe virtual care will be integrated into the full spectrum of care and health optimization," says Randall S. Moore, MD, MBA, president of Mercy Virtual.

"Because we partnered with primary care from the very beginning, we knew [that] to live within a construct of population health and risk management, we needed a program that was married very closely with primary care," says Janet Pursley, vice president of care management.

HealthLeaders Media LIVE from Mercy: Telemedicine; Healthcare's Nerve Center

"The technology can be the easy part," says Christopher Veremakis, MD, medical director of Mercy Telehealth Services. "It's all about establishing relationships with people. Much of the work I've done is change management work, getting people to accept [that] the world of medicine is changing, that technology can play a role. Technology is just another tool, and a key part of what we have to do is learn how to use our new tools to build care solutions we could not offer before, while recognizing that relationships are still really important. You can develop different kinds of relationships with patients than you did in the face-to-face world."

A key turning point occurred when one-way video to the bedside was replaced with two-way. "When [we] made that transition and when we went from being the stranger know-it-all from the big city far away to knowing people on a first-name basis, and we were just another provider, like them, who was up all night trying to take care of patients—that's when we went from being the outsider to just one of the team, and the acceptance really developed," Veremakis says.

Even where Mercy first employed telemedicine, in its hospital-oriented tele-ICU and telestroke programs, it was "helping people to retrain themselves on how to deliver better medicine with this new tool and make them understand that some things have to change, but some things can't change and shouldn't change," Veremakis says. "Whenever you're dealing with groups of physicians who you're leading through change, there's politics and relationships, but that's true even of administrators and nurses and other coworkers."

As an example of things that can change, Veremakis cites new technologies that permit physicians to get the same information as they would from a regular physical exam (e.g., heart rate, respiration, and ECG waveforms) without necessarily having to see a patient in person. "Basically," Moore adds, "what we cannot do is touch or smell."

Also, Veremakis says, "everybody thinks that when you start doing telemedicine you are giving up the personal relationship with the patient. We're learning that that's absolutely not true. Number one, with two-way audio-video, you can look at someone face-to-face and have a conversation with them. You often pick up facial nuances and body language more than when in person. That's been surprising."

Mercy psychiatrists, who also use Mercy telemedicine technology, have learned that the distance created by the physical separation actually gives their patients a feeling of safety, Veremakis says. "They're more open and they actually say more, and therapeutic relationships can work better."

"People who need procedures and more intensive care will require face-to-face, but I think an increasing majority of cognitive care can be done via telemedicine," says Wendy Deibert, RN, vice president of telehealth services at Mercy. "So that leaves more time for bedside providers to be face-to-face with their patients."

Mercy Virtual went through a substantial learning curve. New implementations consisted of technology deployment and an introduction to the program and how it would work.

"We learned successful programs required much greater change management than we anticipated," Deibert says. "Based on lessons learned, new implementations now include assessment of current workflows, clinical and operational process reengineering, alignment of incentives, and many more change management activities. Nursing and physician staff turnover leads to reiteration. You've got to constantly be educating, training, updating, educating everybody about what you're doing and why."

When implementing telemedicine in a Mercy practice, "for each individual program or location that we build, we go in and assess the culture and what telemedicine will help them solve," Deibert says. "Once you design around that, the buy-in and the relationships build. You get a long-lasting effect of your program."

Choosing the correct technology partners and vendor relationships is another element of this. "We worked closely with our vendors to develop shared solutions, because part of it is a joint effort," Deibert says.

"Integrating our telemedicine program with our electronic health record platform was critical. Our EHR partner teamed with Mercy Technology Services to make the integration process successful," she says.

"Integrating and transforming a health system is an expensive, complex, and intensive process," adds Moore. "We believe there are many advantages for systems to partner together, learn from each other, and advance virtual-enabled care faster, better, and at less expense for each system."

Integration affects every part of delivery, all the way down to physician quality of life. "By adding physicians to the Mercy telephonic nurse-on-call program, we reduced patient triage to the emergency department from 25% down to 19%," Pursley says. "In addition, Mercy reduced the number of phone calls primary care physicians receive at home by 70%."

Reprint HLR0915-9

HealthLeaders Media LIVE from Mercy: Telemedicine; Healthcare's Nerve Center, will be broadcast on Thursday, October 22, 2015, from 11:00 to 2:00 p.m. ET. Mercy Health System reveals underlying reasons for their successful implementation of telemedicine. How telemedicine has enabled them to improve outcomes, reduce costs, provide their clinicians better quality of life, and made them an increasingly attractive value proposition to payers.