Children’s National Hospital at Forefront of Telemedicine Revolution

Remote medicine. Telehealth. Digital medicine. Virtual visits.

Whatever it might be called, Children’s National Hospital (Children’s National) has been developing and deploying innovative telemedicine protocols, technologies and approaches for nearly two decades. 

So when the pandemic hit the region full force in mid-March 2020, Children’s National was ready. 

As COVID-19 took hold, the way patients engaged with medical professionals shifted nearly overnight. What was once seen as the future of medical treatment had suddenly, and perhaps irrevocably, been transformed into the standard of care for children and adults unable or unwilling to physically visit their healthcare provider because of the pandemic. Children’s National’s deep telemedicine experience empowered its teams across medical disciplines to pivot rapidly and serve what became a wave of patients and families seeking virtual medical care. 

The COVID-19 pandemic didn’t create momentum at Children’s National to build telemedicine programs, it instead created the need that the hospital and its leadership had been anticipating all along. The preparation paid off not only for the hospital but also for thousands of families seeking care during the current health crisis.

The Rare Disease Institute (RDI) conducts a telehealth video visit with a patient family.

A little more than a month before Governor Hogan’s stay-at-home order, the teams at Children’s National started ramping up their existing telemedicine programs to manage the coming spike in telemedicine demand that would be created by COVID-19.

“By the middle of February, it became rather obvious things were about to shift. We prepared by giving our providers the tools they needed to operate remotely and to see our patients. Right about the time the stay-in-place orders came, we closed down our outpatient clinic and in the space of one day converted our entire program to full telemedicine for outpatient visits,” stated Dr. Marshall Summar, Division Chief, Genetics and Metabolism, and Director, Rare Disease Institute at Children’s National.

Prior to the pandemic, the Rare Disease Institute had been running a telemedicine pilot program for its patients in underserved areas for about two years, making it one of the more nascent telemedicine initiatives at the hospital. Pre-COVID-19, the institute’s telemedicine pilot program was able to cover about 80% of visits virtually. Even though the program is young relative to other digital medicine initiatives at the hospital, Dr. Summar’s team was still able to rapidly pivot to a full telemedicine platform in a remarkably short period of time. 

The Rare Disease Institute’s ability to go virtual and scale up its telemedicine capacity is one telemedicine success story of many at Children’s National. 

Dr. Shireen Atabaki, Associate Director, Telemedicine and Medical Director, Informatics at Children’s National, has seen the evolution of telemedicine firsthand in her time at the hospital. She noted that the hospital has been implementing telemedicine programs for almost two decades, starting with consultative services in the region and around the world, including remote radiologic evaluations and echocardiogram programs. In 2015, Atabaki came on board to stand up the system’s ambulatory telemedicine programming with provider-to-provider and direct-to-consumer services, which was cutting edge at the time. 

COVID-19 has been a test of the telemedicine infrastructure; its ability to accommodate an exponential increase in telehealth demand has validated the prescient decision by Children’s National to start building its telehealth ecosystem years ago. 

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“We were able to stand up 22 of our service lines to provide direct-to-consumer and consultative telehealth between 2016 and March 6th of this year. We had 2,000 telehealth visits during this time and we’ve done a lot of advocacy in the district and nationally. We also had some wins over this period —  in 2017, the District of Columbia passed a law that covered direct-to-consumer services and we started to see an expansion of our telemedicine programs,” stated Atabaki.

“In January the coronavirus perked our ears up…and we realized there was going to be a big need for telemedicine. We started to ramp up and prepare to get some grant funding to expand this on a large scale. We quickly engaged legal, PR, marketing, compliance and our clinical and telemedicine teams to ramp up. We had 300 providers that were doing telemedicine before COVID-19; within a week, we ramped up to over 1,000 providers in the program and we now have about 1,200 providers. In February 2020, pre-COVID 19, we had about 80 telemedicine visits per month. In March, we went up to 2,800 total visits and we did over 700 visits per day in April,” she added.

“A lot of this is because of our hospital’s initial commitment to telehealth and direct-to-consumer telehealth, which is aligned to our patient and family-centered care approach,” Atabaki stated. “We’ve gone from 80% in-person visits to 75-80% of our visits being telemedicine on the ambulatory side.” 

Knowing what was about to transpire, Children’s National proactively deployed its existing telemedicine tools like tablets, iPads, high-tech cameras, remote stethoscopes, virtual interpreters, robots and mobile telemedicine carts in anticipation of increased telemedicine need. The hospital also quickly stood up isolation telemedicine-capable tents outside the hospital to test for COVID-19. It expanded its use of ZOOM and other video conferencing tools to enable remote patients to see multiple specialists from anywhere in the world from the comfort of home. And virtual conferencing between physicians and healthcare workers has also increased during the pandemic. 

In addition, Children’s National has a Cardiac Intensive Care Unit (CICU) Command Center, which acts as a sort of air traffic control center for the CICU floor, enabling healthcare providers and doctors to identify patient trends, alert frontline doctors of issues and foment more doctor-to-doctor consultations about patient care. Add to this the increased integration and use of Artificial Intelligence (AI), machine learning and predictive analytics and it is clearly evident that Children’s National is pioneering what will one day be known as “virtual hospitals.” 

“This pandemic has changed the way our generation is thinking about medicine and how we prepare for future pandemics,” stated Dr. Ricardo Munoz, Executive Director, Telemedicine and Division Chief, Cardiac Critical Care Medicine at Children’s National.

“Our vision here is to build a virtual hospital. We are exploring partnerships with important IT companies to see how we can build a virtual hospital that provides more access to patients and families and integrates AI and predictive analytics to enhance care and be more precise with how we deliver it. The combination of human intelligence and artificial intelligence is where we are headed,” commented Dr. Munoz.

Added Clarence Williams, Director of  Telehealth at Children’s National, “The vision is to use telehealth to support community providers, expand access to care, enhance quality outcomes and support service line delivery systems. The COVID environment has catalyzed our efforts and shortened the timelines to implement a virtual hospital.”

Dr. Summar noted that the Children’s National Innovation & Research Campus currently under construction on the former Walter Reed Campus is already incorporating what one might call “virtual hospital” elements into the facility’s design.

Telemedicine / Virtual Care command center Blue lights above screens Currently used in tele-cardiac ICU robot test run

“Our new Innovation & Research facility reflects this coming ‘virtual hospital’ model. We’ll have seven telemedicine rooms per floor that can provide virtual visits. We’re really trying to think about how we can limit who needs to come in, and when they do have to come in, how do we make it as seamless a process as possible?” stated Dr. Summar.       

In a very short period of time, telemedicine has transformed from a borderline “experimental” approach to an absolute necessity during the COVID-19 crisis.  The current environment has brought clarity around the benefits of digital health while also highlighting regulatory challenges that could emerge in a post-pandemic world. 

For the rare disease patients and families under Dr. Summar’s team’s care, telemedicine means that medically fragile patients can stay home and get high-quality care without exposure to a physical healthcare facility that might inadvertently do them harm. Children with autism can be assessed in their home environment, avoiding the behavioral agitation that might occur when taken to the hospital, which enables healthcare providers to more accurately assess autistic children while reducing stress on an autistic child and their parents.

Rare disease patients and families tend to be geographically dispersed, as are the disease experts that can help them, and telemedicine can bring these experts into the homes of patients that might have to otherwise get on a plane or drive for hours to receive the care they need.

Dr. Atabaki notes that the patient benefits of telemedicine are many, including reducing travel expenses and alleviating some of the other burdens faced by patients, guardians, parents and caregivers like missed work days, missed school days or using vacation time to attend an appointment. 

“Being seen in the comfort of their own home really improves the care and it improves what we can see observing a child in a home setting for neuropsychological evaluations. For GI evaluations we can even take a look into a patient’s refridgerator and have a nutritionist, a doctor and a social worker there to advise a diabetes patient on how to prepare meals and what to eat. There’s a lot of value in that,” stated Dr. Atabaki. 

“Our families have been very engaged and happy with the quality of care they’ve received via our telemedicine program and particularly with their ability to see multiple providers at one time. We estimate that our ambulatory telemedicine program has saved over 60,000 miles in travel time. We’ve decreased waiting room wait times from 15-20 minutes on average to about 2 minutes…We’ve also been able to save about 1.5 days of time for families and we’ve even been able to decrease our own carbon footprint,” she added.

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For telemedicine to deliver these benefits to patients, Dr. Munoz, Dr. Summar and Dr. Atabaki all noted the importance of supporting community providers and local hospitals as they work to adopt and integrate telemedicine into their own practices and facilities. Children’s National realizes that in order to maintain high standards of care, the health system needs to lend its expertise to community providers and collaborate with them to augment the entire region’s telemedicine system. The team at Children’s National is working closely with community healthcare providers to ensure the highest quality of telemedicine care possible.

The benefits to patients are manifold, but enabling a telemedicine workplace also mitigates risk for doctors, nurses and other employees, particularly during the COVID-19 crisis. Having to be in physical contact with patients only when absolutely necessary reduces infection risk, limits the use of PPE that is in short supply and alleviates stress that can undermine job performance and affect mental health.  

Despite these strong telemedicine benefits for patients and hospital staff “…the biggest burden, in my opinion, is the programmatic requirement of navigating the changing ecosystem of regulatory requirements. Navigating the local and federal rules in the post-COVID environment will be equally as challenging as it was in the ramp up as different types of emergency declarations were enacted,” stated Williams.

During the COVID-19 crisis, certain states have waived state licensure regulations, which has allowed healthcare providers to render care across state lines. Conversely, some states have not waived these regulations, making for an erratic healthcare regulatory environment that could carry over after the pandemic eases.

What will happen to these waivers after the pandemic subsides is a big unknown for telemedicine and could become a major hurdle for the expansion of digital health services.

“We don’t want the rubber band to snap back all the way. Telemedicine has been quite good for our patients and I think it continues to demonstrate its value. It gets complex quickly, but one thing the pandemic has brought into focus is that we need a better national policy on this,” stated Dr. Summar. 

He noted licensure revenue streams, state rights and a host of other regulatory and legal issues that need to be worked out to provide greater access to quality telemedicine on a national scale. In addition, HIPAA (Health Insurance Portability and Accountability Act) patient privacy laws and data security concerns will also be a factor in the expansion of telemedicine in the U.S.

“Telemedicine, AI and predictive analytics are an important part of the future of medicine. A ‘virtual hospital’ will never completely replace physical visits and procedures but it will help develop more precise, globalized care,” said Dr. Munoz.

“We are not going back to baseline in how we were delivering general medical care prior to COVID-19,” Dr. Munoz said. “Telemedicine will have a more important role after COVID-19, but what happens with all the regulations and waivers after the pandemic? That is a big question. We just don’t know yet.”

Much like the advent of a new remote work age spurred on by the coronavirus pandemic, the widespread integration of telemedicine has an accelerating momentum that makes it seem virtually impossible for a return to the pre-COVID-19 healthcare services environment. 

The regulatory and legal road forward might have its twists and turns, but the benefits of telemedicine, like telework, are real and here to stay. 

And thanks to the pioneering telemedicine work by teams at Children’s National, a more patient-focused, democratized, and efficient future for quality healthcare is dawning.

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