Can telemedicine improve triage and patient satisfaction in urgent care settings?
Can telemedicine improve triage and patient satisfactionin urgent care settings?
Lesia A. Aungst, MSN, CRNP, FNP-C
Journal of the American Association of Nurse Practitioners
Urgent care centers (UCCs) frequently experience long wait times, overcrowding, and patient dissatisfaction. According to recent studies in the emergency care setting, utilization of telemedicine during patient triage has demonstrated reduction in patient wait time and improvement in patient satisfaction. Implementation of telemedicine in urgent care settings may make triage faster and more efficient and lead to similar improvements in wait time and patient satisfaction. Finally, there is potential for telemedicine to improve working conditions for providers and staff of UCCs.
Urgent care centers (UCCs) are designed to provide walk-in care, extended hours, weekend availability, and prompt treatment of urgent but not life-threatening conditions. They have filled a niche between expensive hospital emergency departments (EDs) and primary care practices (PCP). Over the past two decades, the demand for valuable and necessary UCC services is steadily growing. There are more than 7,500 urgent care facilities in the United States, and their number is increasing each year (Urgent Care Association, 2018).
The goal of any UCC is providing patient care with efficiency and speed. The flow and complexity of the patients who walk in at any given time are unpredictable because of the absence of advanced scheduling. Therefore, fast and efficient triage is paramount.
The purpose of this article is to explore whether the use of telemedicine in UCC triage can reduce wait time and improve patient satisfaction and turnaround while keeping the cost of urgent care visits low.
Overview of patient management in urgent care centers
When patients walk into a UCC, they are usually greeted by the front office assistants (FOAs), and the check-in process starts almost immediately. It usually takes about 10–15 minutes, on average, to complete the necessary insurance paperwork and consents. After that, patients are taken to the triage room by a medical assistant (MA), registered nurse (RN), or licensed practical nurse (LPN), where the purpose of the visit is recorded, as well as vital signs, medical, surgical histories, and allergies are reviewed. Once triage is completed, patients are escorted to an examination room to wait to be seen by an available provider on duty.
If the flow is steady and the complexity of the patients is manageable, the time from check-in to check-out is usually not more than 30 minutes. However, if many patients walk in simultaneously with time-consuming needs, such as laceration repair, abscess drainage, or injuries requiring X-rays, the wait time drastically increases. This causes the UCCs to become overcrowded, and some patients may leave because of the lack of time or willingness to wait. In turn, this leads to patient dissatisfaction and the loss of revenue for UCCs.
Another problem that UCCs encounter very often is illnesses that are beyond the scope of urgent care practice. It is not uncommon for patients to have to go through the wait time, process of check-in, and triage just to be told by a provider that they need to be referred to the ED because their illness is beyond the urgent care scope of practice.
Some patients tend to use UCCs to manage their chronic illnesses, such as hypertension, diabetes, and depression, despite the posted list of services that UCCs can provide. Again, the last thing they want to hear from a provider after a long wait is that they need to follow-up with their PCP for their chronic conditions. In both cases, patients get very frustrated and may feel like they have wasted their time and money. Many times, they blame providers for that and give very negative feedback afterward.
Urgent care center policies state that because of the scope of practice and skill set, FOAs, MAs, RNs, or LPNs are not qualified to turn patients away. Only a physician, nurse practitioner (NP), or physician assistant (PA) can evaluate the patient and make a decision about whether the patient can be treated at the UCC. At the same time, it is considered to be a poor clinical practice, which may create medico-legal risks, for providers to come to the front desk or triage room and give patients medical advice without performing a proper full evaluation.
These issues negatively affect wait time and lead to overcrowding of UCCs and patient dissatisfaction. This article outlines how telemedicine implemented in triage in urgent care settings can offer a solution to the above problem.
Potential uses of telemedicine in the urgent care center environment
Telemedicine is defined as the remote delivery of health care services using telecommunications technology. It includes a broad spectrum of clinical services using the internet, wireless, satellite, and telephone media (AmericanTelemedicine Association, 2018). By bringing telemedicine to UCCs, every patient who walks into a UCC can be seen by a remote telehealth provider right away and triaged very quickly. The patients, who have straightforward conditions and do not require hands-on care, can be treated by a telehealth provider immediately without a long wait. The patients whose health conditions are beyond the scope of urgent care practice can be referred to an ED or their PCP right away. If they are not stable enough to be transported by a private vehicle, they can be attended by the providers on duty immediately and transported to the ED by ambulance. Patients who have more complex conditions or need any hands-on procedures and are not appropriate for telemedicine triage could be triaged in a regular fashion and brought to the examination rooms to be seen by an available provider. In addition to the above, the expanded use of telemedicine would enable patients to seek medical attention from home for simple conditions or to consult a knowledgeable clinician if they have any doubts about the complexity of their illness and which level of care to use. They could discuss concerns with a remote telehealth provider using a smartphone application without leaving their home.
Implementation of telemedicine in urgent care settings is a relatively new topic in the literature. However, there are some recent pilot projects and research studies available that focus on the utilization of telemedicine in EDs, urgent care, and walk-in clinics.
Telemedicine in emergency departments
Wisconsin (Milwaukee) Aurora Health Care deployed telemedicine with the aim of improving patient flow in its emergency departments with the overall goal of enhancing patient care and providing a better patient experience (Landi, 2016). The tele-triage technology solution allows patients who seek care at EDs of the Aurora Health Care to be seen and treated by a physician via video. The remote physician can provide care to multiple Aurora EDs at the same time. Consequently, check-in and check-out times were reduced by 75%, and patient and provider satisfaction scores were significantly improved (Landi, 2016).
New York Presbyterian and Weill Cornell Medicine jointly launched their cutting-edge Emergency Department Telehealth Express Care Service (ECS) with the goal of utilization of telemedicine to treat minor conditions, such as rashes, sprains and contusions, upper respiratory infections, wound checks, and suture removals (Khalek, 2017). After an initial RN triage and medical screening examination by a PA or NP, qualifying ED patients are offered a real-time video visit with one of the board-certified Emergency Medicine faculty physicians. Because ECS was launched in July 2016, more than 3,000 patients were seen with a typical length of stay of 35–40 minutes as compared to an average of 2–2.5 hours of stay in the ED for patients seen in person via the traditional ED pathway. Patient satisfaction scores for ECS have been outstanding, ranking in the 99th percentile (Khalek, 2017). Similar projects were implemented in Duke University Hospital's ED in South Carolina and Prince Edward Island's island-wide health system in Canada with the same outstanding results (Craig, 2017).
Unfortunately, a telehealth pilot program at the University of San Diego Health System's Hillcrest Hospital ED was unsuccessful soon after launching in 2013. The reason for its failure was insurance reimbursement difficulties. The model required two physicians' participation, and not all insurers were willing to provide compensation for that type of telemedicine visit. However, patients were very satisfied with the program, and the program showed enough potential to be restarted in the future (Guss et al., 2016).
Marconi, Chang, Pham, Grajower, & Nager, 2014 decided to explore if there is any difference between traditional nurse triage(TNT) in a pediatric emergency department (PED) and physician telepresence (PTP). This crossover study was based on PED at a large children’s hospital with a random assignment using a sample of walk-in patients. The study concluded that triage scores of PTP were 95% correct compared with TNT 71% correct. Patients and their parents gave very positive feedback with respect to PTP, stating that they would like to have PTP visits again in the future. There was no statistical difference between PTP diagnostic ordering and the actual PED physician ordering (Marconi et al., 2014).
Telemedicine in urgent care and walk-in clinics
According to Bazzoli (2016), the chain of Doctors Care UCCs in South Carolina and Tennessee first began examining telemedicine in 2013, studying it to balance loads between its facilities. Wait times at some of its urgent care sites could be three hours or more, whereas other locations had no wait times. By equipping facilities with telemedicine, patients were offered an opportunity to be seen immediately and remotely. In its load-balancing approach, there is a high-definition connection for the sites, and an all-in-one camera supports otoscope and dermatology examinations of the eye, ear, nose, throat, or skin. Bluetooth-enabled stethoscopes are used at both presentation and provider sites, and patients can have laboratory and X-ray procedures at the presentation site; physicians examining patients remotely can switch to another patient until these tests are run. Utilization of telemedicine helped Doctors Choice achieve two of its key goals of reducing patient wait times and increasing patient satisfaction (Bazzoli, 2016).
Polinski et al., (2016) conducted a cross-sectional patient satisfaction survey at CVS walk-in Minute Clinics with the goal to examine patient satisfaction with telehealth visits. At the end of the study, satisfaction scores were ranging from 94% to 99%. Patients reported being very satisfied with all of the aspects of the telehealth visits. Ninety-five percent of the patients were very satisfied with the quality of care they received during the telehealth visit. Ninety-four percent of the patients were very pleased with the treatment plan and educational materials provided for them. Ratings for the technology, ability to see and hear an NP, along with diagnostic images on the monitor were 95%. Identical scores were given for the convenience of the service. All patients reported that they would use telemedicinein the future and would recommend it to someone else (Polinski et al., 2016).
In summary, the literature showed that telemedicine has been well received by patients and providers. It has succeeded in reducing patient wait times and increasing patient satisfaction. Telemedicine has been successfully used in urgent care settings but is not widely used despite its benefits in this environment.
Potential challenges of telemedicine implementation
Some essential barriers must be overcome to implement telemedicine successfully. One of them is telemedicineservice reimbursement. Telehealth reimbursement is a complex challenge because of a lack of consistency in patterns of compensation for different applications of telehealth. Medicare reimbursement differs in each state and therefore remains difficult. Some states begin to expand their telehealth reimbursement, whereas others put restrictions on telehealth services. Forty-eight states and Washington DC compensate for some form of live video consultation. This number has remained the same for the past couple of years (The National Telehealth Policy Resource Center, 2017). The American Telemedicine Association put a lot of effort into lobbying at the legislative level to increase the number of approved billing codes for Medicare. Compensation for telemedicine services by Medicare and Medicaid is generally limited to rural areas with a lack of providers. However, the meaning of “rural” has become broader recently, as well as who can provide services and from where (Weinstein et al., 2014). A correct Current Procedure Terminology (CPT) code along with a specific modifier must be submitted to specify that medical visit took place via audio and video telecommunications system (Sikka, Paradise, & Shu, 2014). Most of the states include NPs in the acceptable provider type for telemedicine. A few states limit the types of providers who can provide telemedicine. For example, Florida does not recognize NPs as telehealth providers (Melerba, Richman, & Kozicz, 2017).
Private insurers are reluctant to provide compensation for telemedicine visits, which impede telehealth development and expansion. Thirty-five states have requested that private insurance companies offer reimbursement for teleconsultation similar to an in-person consultation. (Sikka et al., 2014).
Another hurdle that stands in the way of telemedicine is licensing and credentialing for providers. According to current state laws, all providers who want to deliver telemedicine services in different states must be licensed in those states. However, recently 18 states have developed individual telemedicine licenses (compact) for providers to make it easier to deliver telehealth visits to different states (Weinstein et al., 2014). Medicare and Medicaid have recently made credentialing requirements less complicated by allowing hospitals to accept the credentialing decisions of those hospitals where the telemedicine provider practices (Weinstein et al., 2014).
Telehealth may pose some risks to the security and privacy of patient health information. This has the potential to negatively affect the level of trust between a patient and a clinician. Risks of confidentiality can be a lack of control over the collection, utilization, and sharing of information. For example, some patients may feel a violation of privacy if other people are present in the room during teleconsultation. Patient demographics may play a significant role in security concerns. According to recent research, younger patients may be less concerned about confidentiality than older patients (Sikka et al., 2014).
The cost of telehealth systems is challenging for administrators evaluating these systems. Costs can be categorized into two groups: starting costs and maintenance expenses. Typical starting equipment includes a telemonitor, the cost of the network used, devices for patient monitoring, and a room for providing telehealth consultation with adequate lighting, sound, and security. Ongoing expenses include the cost of telehealth consultants, personnel, informational technology support, equipment licenses, monthly internet fees, and management of medical records from remote sites. The Southern Arizona Telemedicine and Telepresence Association noted that startup telehealth costs, approximately, $70,000, and ongoing expenses equal to $1,000 per month (Sikka et al., 2014). However, there is some less expensive equipment available for telehealth video consultations as well. A simple setup could consist of a laptop, high-definition web camera, electronic otoscope, and stethoscope. A one-year subscription for this equipment currently costs around $6,000. An advanced package would contain a zoom camera, portable electrocardiogram, and an ultrasound would cost approximately $18,000 (Sikka et al., 2014).
Integrating with medical record systems has been considered as desirable but often very difficult to implement because of the issue of different medical record systems and communication between them. There is a possibility to capture telehealth session video and store it into the electronic record system for late asynchronous access (Li & Wilson, 2013).
A significant barrier to telehealth development can be social disapproval. Some clinicians think that telehealth visits will negatively affect patient–provider relationships and cause patient opposition. However, studies have shown high satisfaction and acceptance with telehealth consultations even among older patients. Recommendations to avoid potential disapproval include starting with a pilot project and moving forward gradually (Sikka et al., 2014).
Implications for nurse practitioners
The use of telemedicine in urgent care settings presents new opportunities to increase patient access to care and decrease costs while improving patient care outcomes. Technology allows NPs to connect with patients in a variety of distant settings, expanding the reach of health care providers (Rutledge et al., 2017). Telehealth enables access to care for those who need care or who have difficulties with travel. It improves outcomes through increased frequency and quality of communications and patient engagement. It reduces the cost of health care by avoiding unnecessary ED visits.
It is essential for NPs to have advanced knowledge and skills in the use of telehealth technologies to address health care needs of the future. Because most NP programs still do not include formal training related to telehealth within their curricula, many providers are expected to obtain the necessary training for telemedicine on the job (Rutledge et al., 2017).
The Telehealth Resource Center (TRC), a national clearinghouse for telehealth information, provides essential information about use, policy, program development, and helps prepare providers for telehealth. Most training programs consist of asynchronous modules with hands-on testing at the conclusion of the program (TRC, 2018a). The American Telemedicine Association (ATA) is another good resource for health care providers. Information available on the ATA website is related to telemedicine program startup, types of technology and equipment, policy, laws, and regulations affecting telehealth usage (ATA, 2018).
Nurse practitioner entrepreneurs who would like to implement telemedicine in their practice must educate themselves about licensing and prescribing requirements of telemedicine pertinent to their state, in addition to the Nurse Practice Act standards in each state where patients will be located. Nurse practitioners must confirm that they have the required credentials and privileges to provide telehealth services in all appropriate states. It is essential to check with malpractice insurance provider to see whether there are any restrictions or requirements to be aware of and whether their malpractice liability extends coverage to multiple states (TRC, 2018b). Finally, the more NPs educate themselves about telehealth as a provider, the easier it will be for them to decide whether telemedicine is right for them, their practice, and their patients.
As with any new project, the precise impact of telemedicine in urgent care settings cannot be known until implemented and studied, but current pilot projects and research studies suggest positive effects of telemedicine on improving UCCs flow, wait time reduction, and patient satisfaction. There is a strong possibility that utilization of telemedicine in urgent care settings would make triage faster and more efficient. Consequently, the wait time would be decreased and patient satisfaction would be improved. The number of patients who would like to use urgent care services would therefore increase, and the cost of the visits could be kept low. Finally, working conditions of providers and staff would be potentially improved. Inevitably, there will be challenges in the implementation of telemedicine that will need to be overcome to make it successful.
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