On-Demand,Virtual Health Care During COVID-19: Clinician Redeployment and Telemedicine Utilization in a Children's Health System

Abstract

Background:

The COVID-19 global pandemic inspired an unprecedented surge in virtual health care. Safety precautions limited in-person urgent care options, despite high patient demand. This study describes how one children's health system redeployed clinical health professionals to expand existing pediatric, urgent care, on-demand telemedicine in the early months of the United States' pandemic response. Patient utilization and visit characteristics during the pandemic are contextualized relative to pre-pandemic, business-as-usual (BAU) operations.

Materials and Methods:

This IRB-approved study is a descriptive, retrospective analysis. Key elements of the clinician redeployment process and shift in physician workflow are described. Retrospective data analysis included routine patient and visit characteristics for urgent care, on-demand telemedicine services received January to May 2020. BAU represented telemedicine encounters between January and May 2019.

Results:

Twenty-eight redeployed pediatricians and advanced practice registered nurses were trained and credentialed to assist the on-demand pediatrician team on the existing telemedicine platform. During 2020, providers completed 5,055 telemedicine visits, a 168% increase over the same timeframe in 2019. Pre-pandemic visit wait time was 6.29 ± 5.4 min, which increased to 23.25 ± 34.30 min during 2020. Top chief complaints included skin-related concerns (27.9%) and upper respiratory infections (20.2%) and were consistent across years. Patient satisfaction with provider and platform were high.

Discussion:

By engaging and training redeployed clinicians during the pandemic response, health care access was maintained for thousands of patients.

Conclusion:

Where regulations allow, clinical health professionals can be trained and redeployed rapidly to on-demand telemedicine platforms to successfully meet spontaneous increases in demand for virtual care.

Introduction

During recent natural disasters, on-demand telemedicine enabled physicians around the globe to transition health care operations from “business-as-usual” (BAU) to “disaster-ready.”^1

–9 Today, the coronavirus pandemic and the call for social isolation have placed telemedicine into the front lines, once again, as physicians mobilize to deliver efficient health care to communities in need. The first United States case of COVID-19, the disease caused by the SARS-CoV-2 novel coronavirus, was confirmed in Washington State in January 2020.¹⁰ By March 1, 2020, coronavirus exposures resulted in 80,981 confirmed COVID-19 cases in China and 44,067 cases in 117 other countries.¹¹ Since then, COVID-19 has continued to spread rapidly through human-to-human contact, becoming a global health disaster: the World Health Organization declared it a pandemic on March 11, 2020.¹² By October, United States cases alone mounted to more than 7.5 million, and deaths from the disease had eclipsed 210,000.¹³

The coronavirus pandemic has been a catalyst for telemedicine expansion,¹⁴ where patients' medical needs have been addressed through the technology as they adhere to public health safety guidelines on social distancing. During the pandemic, telemedicine adoption has been facilitated by loosening federal and state restrictions that govern its typical operation. On March 6, 2020, the U.S. Congress enacted the “Coronavirus Preparedness and Response Supplemental Appropriations Act,” which waived Medicare's “originating site” requirement, enabling use of telemedicine directly from a patient's home, regardless of residential location.¹⁵ Likewise, states relaxed legal restrictions on telehealth access and use through Medicaid, the Children's Health Insurance Program (CHIP), and private insurers.¹⁶ Within the current zeitgeist, where continued adherence to technical and privacy requirements is essential amid relaxed access regulations and systemic patient diversion to virtual care, many health care professionals are becoming new adopters of telemedicine.

On-demand telemedicine platforms, where patients are seen for a wide variety of ailments that include many urgent care and primary care complaints, offer considerable flexibility whereby qualifying providers may be redeployed to virtual care. However, provider redeployment necessitates licensing and credentialing, and platform training must be conducted to ensure maintenance of workflow protocols and quality control requirements. This study describes the assembly, licensing, and training of redeployed pediatricians and other health care professionals within a children's health system in a coordinated effort to deliver quality pediatric care through an on-demand telemedicine platform during COVID-19.

The Nemours Children's Health System (NCHS) is a pediatric health system of hospitals and clinics that includes general pediatric, subspecialty, and urgent care facilities in the Delaware Valley and Florida. In 2015, NCHS launched Nemours CareConnect (NCC), a 24/7, urgent care telemedicine initiative. The NCC platform is staffed by Nemours' board-certified pediatricians, who are licensed to provide pediatric health care to children residing in seven states within the continental United States. Families with children between 0 and 18 years of age may access a pediatrician on demand through a smartphone/tablet application, 24 h/day, 7 days/week, while remaining within their medical home. In addition to on-demand services, many Nemours' subspecialists and hospital teams utilize NCC telemedicine to help maximize access to care, increase quality, and offer greater convenience for the children they serve.¹⁷

By mid/late March 2020, in response to the rapid, early, spread of COVID-19 in the northeastern United States, NCHS clinic volume was reduced substantially to limit person-to-person contact and to help control the spread of the virus. Enterprise-mandated limitations on in-person office visits for urgent care and primary care sent the pediatric outpatient overflow to the NCC on-demand telemedicine team. Primary care and urgent care physicians thus were trained and redeployed quickly to aid the on-demand platform to satisfy the growing demand for pediatric telemedicine services. In this descriptive, retrospective analysis, we describe how NCC met the increased demand for virtual care, addressing NCC's urgent care operations and the shift in physician workflow during the early days of the United States' pandemic response. We examined demographic characteristics of patients who utilized NCC during the pandemic, their chief complaints, visit experience, and satisfaction with the on-demand service in a cross-section of users over a 5-month timeframe.

Materials and Methods

This study was approved by the Nemours Institutional Review Board.

Provider Redeployment

Six board-certified pediatricians were staffing the NCC platform when the United States exposure to the crisis began in earnest. Due to the call for social isolation amid the pandemic, primary care and urgent care offices within NCHS began to consolidate services in late March to meet the most immediate care needs. This need was paramount once “stay-at-home” orders were issued in Delaware and in Florida, as pandemic fear and closed doors created a sudden surge of on-demand telemedicine volume. NCHS administration realized the need to leverage pediatricians and other clinicians from the underutilized facilities to assist with the telemedicine platform. Emergency meetings were called with credentialing teams from within the hospital system in the Delaware Valley and Florida to clarify the credentialing process and review emergency state licensing guidelines. An available pool of 28 providers from within the hospital Medicine, Emergency Care, Urgent Care, and Primary Care departments were identified. As appropriate, in-person visits were rescheduled to virtual on-demand visits when possible.

Along with providers, NCHS staff were redeployed to assist in the telemedicine effort. Coming from a variety of departments across locations within NCHS, over 90 staff members called patient families, whose visits originally were scheduled for the office to provide instructions on how to download and use the NCC application in preparation for their child's telemedicine visit. Staff responded to questions from patient families and identified any troubleshooting necessary to help ensure the encounter went as smoothly as possible.

Finally, eight pediatric audiologists with a moratorium on in-person visits were redeployed to help improve the NCC on-demand efficiency and patient experience. Audiologists provided medical record numbers to on-demand providers for previsit chart review and communicated with patients during their wait time, responding to nonclinical questions. The entire process from office closure and telemedicine volume surge to the final aspects of staff redeployment and provider on-boarding took ∼10 days.

Credentialing Considerations

Because providers were located in different states, the credentialing and licensure process differed between those who practiced in Florida versus the Delaware Valley. Providers seeking clinical privileges in telemedicine were mass licensed in the states where NCHS is affiliated. New Jersey was the lone exception, which required an individual application. Consequently, providers in New Jersey submitted their own application for board licensure, whereas in other states (DE, PA, MD), Nemours presented to each state board on behalf of the providers to obtain waivers for licensure. Once providers were licensed, they completed credentialing applications, which were presented to the Nemours' credentialing board for review and approval. Advanced nurse practitioners, not previously practicing on-demand telemedicine in NCHS, required the rapid development of a separate, board-approved, nurse practitioner credentialing process. The final credentialing process changes were put in place for 60 days, at which time they were open to renewal. The newly approved and credentialed providers were added as providers to the NCC 24/7 on-demand platform, followed by training and proctoring of the leveraged pediatricians and nurse practitioners on appropriate use and telemedicine documentation.

Workflow Modification

Telehealth leadership rapidly created a training protocol for educating the 28 redeployed providers on the essential components necessary for delivering care on the telemedicine platform. Providers received instruction on technical requirements, access to the application and provider login and a demonstration of setting availability, receipt of new patient notification, patient intake procedure, video settings, and wrap up. Training continued with remote access to the electronic medical database and patient codes specific to telemedicine, ending with the delivery of the progress note, after-visit summary, and transfer of notes into the NCC database.

NCC provided synchronous, audiovisual telemedicine visits to NCHS patients. Details of the NCC platform's technological compliance and transmission encryption were consistent with standard operation and are provided in prior publications.^1,18 Patient and provider visit procedures mirrored standard operation of NCC¹⁸ with the exception of updated clinical guidelines, consequent to COVID-19, which providers used to assess whether an in-person visit was warranted. As in typical NCC operations, peripheral devices were not used during examinations. Following the encounter, patient (parent) satisfaction ratings were obtained for the provider and the platform using a 5-Star rating system. A rating of 1 reflected a poor patient experience, and a rating of 5 reflected the best.

Patients having symptoms that were suggestive of COVID-19 but who were not severe enough to be referred to the emergency department (ED) were referred by the telemedicine provider to an outpatient Suspected COVID-19 Assessment Team (SCAT) clinic. These clinics initially were erected in the Delaware Valley region to enable off-campus testing for suspected pediatric COVID-19 cases, as New York and the surrounding region became the epicenter of the pandemic. In Central Florida, cases had not yet begun to surge; consequently, COVID-19 testing referrals or clinical in-person evaluations were conducted by Nemours' primary care providers, in urgent care facilities, or the hospital ED. As the pandemic evolved, NCC telemedicine providers ordered COVID-19 tests for Florida patients who met CDC criteria for testing, but did not require an in-person visit. These patients received the mobile COVID-19 test at their nearby Nemours urgent care facility and subsequently were contacted by the NCC provider with the results.

Results

For the present study, data were obtained from Nemours' electronic medical database (chief complaint) and the NCC database (patient age, wait time, engagement time, attempted visit, and 5-Star rating for provider and platform) inclusive of the service dates from January through May 2020. In addition, we compared patient experiences during the pandemic and NCC's standard BAU operation during the same months in 2019, the year prior, to illustrate changes across the variables.

Between January 1, 2020 and May 31, 2020, 25 NCC pediatricians and assisting clinical staff completed 5,055 patient visits. Of the 28 redeployed clinicians who were licensed, credentialed, and trained on the platform, 19 actively saw patients during the patient surge in the early months of the pandemic. Patient visits represented a 168% increase from the same 5-month time frame in 2019 (n = 1,887). The mean patient age in the 2020 sample was 5.01 years (standard deviation [SD] = 4.65, 0–23). The mean patient age in 2019 was consistent with that of patients in the 2020 sample (2019 X = 4.8 years, SD = 4.5, 0–18; p > 0.05). Males represented 50.5% of unique encounters in 2020, and 52.8% of patients in 2019. The patient sample represented seven states (AL, DE, FL, GA, MD, NJ, and PA) in each of the 2 years. From the 2020 pre-pandemic baseline month of January, volume increased from January through April 2020, beginning to taper slightly in May 2020, largely mirroring the telehealth volume transfer due to office closures from March into May. Monthly patient encounters and percent of total patient encounters for the study period by year is presented in Table 1.

Table 1.

On-Demand Telehealth Patient Encounters: January to May, 2019 and 2020

	2019		2020
MONTH	n	PERCENTAGE OF TOTAL ENCOUNTERS	n	PERCENTAGE OF TOTAL ENCOUNTERS
January	313	16.6	533	10.5
February	368	19.5	594	11.8
March	377	20.0	1,266	25.0
April	405	21.5	1,423	28.2
May	424	22.5	1,239	24.5
Total	1,887		5,055

n = number of patient encounters.

Chief Complaints

Chief complaints early in 2020 consisted of skin complaints (27.9%), followed by upper respiratory infections (20.2%). Chief complaints of patients seen during the pandemic were consistent with BAU operations during 2019 and are presented in Table 2.

Table 2.

Number of Encounters by Patient Chief Complaint: 2019, 2020

N, JANUARY TO MAY	2019	2020
N, JANUARY TO MAY	1,886	5,040
CHIEF COMPLAINT	n (%)	n (%)
Upper respiratory symptoms	382 (20.3)	1,016 (20.2)
Skin-related symptoms	452 (24.0)	1,408 (27.9)
Fever as the primary concern	219 (11.6)	602 (11.9)
GI-related symptoms	215 (11.4)	358 (7.1)
Hospital/ER follow-ups	117 (6.2)	144 (2.9)
Eye-related symptoms	201 (10.7)	370 (7.3)
Ear-related symptoms	70 (3.7)	283 (5.6)
Injury	29 (1.5)	167 (3.3)
Asthma and breathing concerns	37 (2.0)	59 (1.2)
Other^a	164 (8.7)	633 (12.6)

Data are missing for 1 child (Year 2019) and 15 children (Year 2020).

Includes all other chief complaints that do not fall into a listed category.

ER, emergency room; GI, gastrointestinal; n, number of patient encounters.

Patient Visit Characteristics

Wait time to see a telemedicine provider during the early pandemic months ranged from fewer than 10 s to 4 h, 25 min (mean 23.25 min, SD = 34.30). These numbers contrasted with the pre-pandemic values of 20 s—43.33 min (mean 6.29 min, SD = 5.4). Despite considerably longer wait times, the pandemic had no measurable impact on engagement time per visit, with patient encounters remaining consistent from 9 min 19 s in 2019 to 9 min 6 s in 2020, on average.

Despite prolonged wait times and newly trained telemedicine providers administering patient care on the platform, patient satisfaction with the service and the provider was high during the early pandemic response. Patient family ratings of the platform during the pandemic were consistent with ratings acquired in 2019: 92% of patient families who responded to the survey offered the top rating of 5 stars in 2020, whereas 93% did so in 2019. Patient ratings of the telehealth provider were similarly strong and consistent across study years: 95.6% of patient families responding to the survey offered 5 stars, as compared with 95.9% in 2019. However, the percentage of patient families who chose to respond to the satisfaction survey was markedly lower in 2020, with 67% of patient families responding to the end-of-visit survey in 2019, relative to 58% of patient families in 2020. Patient satisfaction ratings are presented in Table 3.

Table 3.

Patient Satisfaction by Study Year, January to May

	2019				2020
	n	MEAN	SD	RANGE	n	MEAN	SD	RANGE
Patient system rating	1,266	4.87	0.559	1–5	2,933	4.86	0.579	1–5
Patient provider rating	1,259	4.94	0.349	1–5	2,898	4.93	0.364	1–5

n, number of patient encounters; SD, standard deviation.

Discussion

Whereas increased demand for virtual care occurs during natural disasters and volatile influenza seasons, the complete transition from an in-person to a virtual model of care, as precipitated by the pandemic, led to an unprecedented strain on most standard health care operations. Within our pediatric health system, a pre-pandemic wait time of 6 min increased by up to 4 h for some patients during the pandemic months. As it became apparent that the conventional limitations of telemedicine coupled with diminished access to in-person care were not meeting patient's needs, a systemic operational change was implemented to improve clinical care delivery. Enterprise clinical leadership modified the process by which patients needing in-person visits were referred for consult. In stark contrast to the typical 6–8-month licensing and credentialing process for new telemedicine pediatricians, the expedited process of provider on-boarding was completed within 2 weeks. Labor pool staff assisted with efficiency and patient experience by identifying patients and providing medical record numbers to on-demand providers for previsit chart review, as well as talking with patients on the platform during their extended wait time. Redeployed staff rescheduled appointments from in-person to telemedicine and called patients to inform them of the change in visit modality, likewise talking patient families through the process of downloading and using the NCC application in preparation for their appointment. Although the novel coronavirus pandemic brought an increased reliance on telemedicine, once the deployment strategies were in place, the volume of visits was met and the wait times improved. Patient satisfaction scores remained high, suggesting that their expectations for care quality continued to be met despite increased volume. Likewise, providers report high satisfaction with the platform throughout the pandemic. Permanent credentialing of the trained providers is underway.

In addition to the redeployment efforts that addressed the influx of NCC's on-demand telemedicine utilization, further enterprise-wide efforts were undertaken to minimize potential exposures by increasing telemedicine training and utilization among Nemours' subspecialists and primary care pediatricians during the pandemic. As a consequence of their ability to meet patient care needs during the most challenging times, on-demand, primary care, and specialty care telemedicine services are being incorporated into the enterprise strategy as the new normal, helping to ensure that pediatric telemedicine is here to stay.

Although our study results are largely descriptive, the findings should be interpreted in the context of several considerations. The COVID-19 pandemic affected each state differently. Coronavirus cases did not surge at the same time in each state, and local governing bodies responded to the threat in unique ways. Social distancing guidelines and timing of business closures varied. Consequently, rates of telemedicine volume increases may have differed systematically based on state and local governance. In the earliest stages of the pandemic, a family without access to their child's pediatrician may have had an increased need for an urgent care virtual visit as compared with those families with continued access to their in-person provider.

Additionally, the extent to which families had prior experience with telemedicine was not evaluated. Prior experience may have impacted patient families' comfort level with the virtual visit or reason for accessing the platform during the COVID-19 pandemic. Moreover, prior experience may explain the relatively lower completion rate of the satisfaction survey in 2020. Patient families who were not new to telemedicine may have opted out of the survey if they had completed it in a prior visit. Alternatively, patient families simply may consider the survey to be a lower priority during times of national emergencies. Future research should evaluate the extent to which patients' willingness to complete telemedicine satisfaction surveys is impacted by comfort level with service, wait time, or other factors.

Conclusion

On-demand telemedicine meets health care needs for many patients when access to in-person care is limited by natural disasters, including pandemics. Where regulations allow, clinical health professionals practicing within a children's health system can be trained and redeployed to on-demand telemedicine platforms rapidly, successfully meeting increased patient demand for urgent care elsewhere within the enterprise. Such training and redeployment efforts expand the available corps of telemedicine providers, and offer a “reserve” of telemedicine-trained health professionals whose redeployment may be expedited when another future need arises.

Footnotes

Acknowledgments

The authors acknowledge the contributions of telemedicine providers Andrea Ali-Panzarella, MD, Monica Barajas, MD, Rene Chalom, MD, Mattilie Gednas, ARNP, Wayne Ho, MD, Robert Karch, MD, and Rachel Schare, MD, as well as the staff from the Nemours Children's Health System technology team and the operational support staff who provided assistance and guidance during the coronavirus pandemic. The authors especially want to thank those providers whose unwavering dedication to patient care led them to become new adopters of telemedicine during this extraordinary time of need.

Authors' Contributions

Dr. Murren-Boezem conceptualized the study, collected and interpreted the data, and critically revised the article. Dr. Solo-Josephson conceptualized the study, collected and interpreted the data, and drafted the article. Dr. Zettler-Greeley conceptualized the study, analyzed and interpreted the data, and critically revised the article. All authors agreed to the final version of the article and are accountable for this work.

Disclosure Statement

All three authors are employed by Nemours Children's Health System and have no other competing interests to disclose.

Funding Information

This study was funded by The Nemours Foundation.

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