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Innovation Summary:

The New York Presbyterian-Weill Cornell Medicine ED Telehealth Express Care Service uses telemedicine to rapidly evaluate patients who seek care at our Emergency Departments. While traditional in-person Urgent Care and low acuity ED visits may take as long as 2-3 hours to complete, the 3,000 plus ED telehealth Express Care patient visits we have performed have been completed in a median time of 39 minutes. Telehealth Express Care visits are performed collaboratively by an Advanced Practice Provider and a Telehealth Physician. This innovative workflow has led to a dramatic decrease in length of stay in conjunction with a high degree of safety and patient satisfaction.

Briefly describe the innovation/process and problem that it addresses. The NYP-Weill Cornell Express Care Service is an innovative ED based telehealth program designed to reduce length of stay (LOS) and improve patient experience for patients with low acuity complaints. High patient volumes lead to correspondingly long wait times, an experience that can be particularly frustrating for patients who seek care for lower acuity problems that could be rapidly attended to, causing these patients to become dissatisfied and even prompting patients to leave without receiving care. Our process for ED Telehealth Express Care patients begins as it would for any of our ED patients: with an in-person triage and assessment. A registered nurse speaks with the patient and categorizes the severity of their medical complaint. Next, an Advanced Practice Provider (Physician Assistant or Nurse Practitioner) evaluates the patient, performs the Medical Screening Exam which is required for all ED visits, and decides whether our Telehealth program would be medically appropriate. Qualification for the Telehealth Express Care Service is based on set criteria. Participation by the patient is voluntary. If the patient declines, a physician will examine them in-person. The telehealth encounter takes place with our Telehealth Physician, a board certified Emergency Medicine faculty member. Evaluation, diagnosis, treatment and education are discussed at-length, with family members present if desired. Discharge instructions are printed directly at the end of the visit by the physician with any prescribed medications sent electronically to a pharmacy of the patient's choice. There is no additional check out process.

Background

Explain how the innovation works and why your organization chose this

solution over others.

When NYP first launched its ED Telehealth Express Care program in early 2016, we were in the midst of working to improve ED core measures. Today, EDs are held accountable for operational metrics (wait times to see providers, walk-out rates, and total length of stay in the ED, along with patient experience scores and feedback). We manage a number of crowded urban EDs that traditionally have had long wait times. Long wait times are frequently cited as one of the biggest sources of frustration for patients, and we have worked very hard to address this. Improving wait time can decrease walk-out rates (i.e., patients leaving the ED prior to being seen by a provider), improves the overall ED environment, and has a particular benefit for patients who arrive with low acuity complaints who can find these delays even more frustrating and have a disproportionately negative patient experience.

The ED Telehealth Express Care Service was launched at New York-Presbyterian as the institution began a dedicated effort to establish telemedicine services enterprise-wide under the NYP OnDemand initiative. NYP OnDemand is a global term for our enterprise to bring telehealth services to all segments of the institution. Programs currently established or planned for the near future that involve ED physicians providing telemedicine care include:

- NYP Telehealth Express Care Service (patients arriving to the ED electing to have a "virtual visit")

- Direct consumer telemedicine (NYP OnDemand Urgent Care) where patients choose to have a visit with the ED doctor from their home or office using a computer or smart phone

- Nursing home consultations where ED doctors consult on nursing home patients who may be able to receive their care without needing to come to the ED

- Post discharge telemedicine facilitated paramedic home visits for high acuity patients discharged from the hospital

- ED follow-up visits for geriatric patients seen and discharged from the emergency department

A board certified Emergency Medicine physician is available to provide these ED oriented telehealth services for 16 hours per day, 7 days a week in an audio video equipped office at our academic medical center. Our Telehealth Express Care Service has helped decant low acuity patients from the traditional ED workflow and allows ED staff members to focus on the immediate needs of higher acuity patients. We chose the ED Telehealth Express care service because it was an opportunity to bring innovative care to our patients and improve their ED experience while improving the capacity of our traditional ED to see higher acuity patients, and because it was a program aligned with NYP's commitment to implement telehealth services enterprise wide.

Innovation Implementation

Implementation required involvement of a variety of multidisciplinary key members. From the clinical team, we required the active involvement and support of our RNs, our Advanced Practice Providers (both Nurse Practitioners and Physician Assistants), our ED physicians and our registration staff. In

addition we required the active involvement of our hospital IT innovations team for work on telecommunications, audiovisual platform support and to assist with the use of EMR and remote printing of patient materials.

Prior to the roll out of our innovation, process maps were created and IT was trialed, evaluated and installed. We fully operationalized our approach to providing care to these patients creating a model for low acuity Emergency Medicine care unique to NYP. Our model is similar to a "10 items and under" Express Check-out line: separating faster cases, and assigning a staff member to focus solely on them, allowing every lane to move more quickly. For every hour of operation, a board certified NYP/Weill Cornell Emergency Medicine physician is designated for our Express Care service.

During their Express Care shift, this physician will virtually evaluate patients presenting to the Emergency Department at NewYork-Presbyterian/Weill Cornell Medical Center, and at the Emergency Department at NewYork-Presbyterian/Lower Manhattan Hospital. In addition, the provider will see patients with minor illnesses and injuries who are using our NYP mobile app or website NYP OnDemand Urgent Care, and will provide consultations for nursing home patients.

Timeline

Planning for the ED Telehealth Express Care Service began in March 2016. Prior to implementation, NYP IT staff met with Weill Cornell medical providers to understand how the Express Care program could be mapped onto existing workflows. In addition to speaking with the providers, NYP IT staff members also observed the process firsthand. Stakeholder analysis was done early in the process to identify potential sticking points and develop a broad outline of the process. Table top exercises and ED walkthroughs simulating processes were used to test how well the envisioned Express Care processes mapped onto current ED workflow. This careful planning allowed our first iteration of the program to integrate seamlessly with our existing ED workflow. Our providers were quickly engaged due to the simplicity of the process, as well as the opportunity to provide a faster, better experience for our patients. After the initial success of the program at the New York Presbyterian-Weill Cornell site in July 2016, this service was expanded to the New York Presbyterian-Lower Manhattan Hospital Campus in October 2016.

For our videoconferencing platform we chose a tool that had already been deployed hospital wide for administrative purposes and had been used in a limited fashion for psychiatric and remote stroke evaluations. Our program required minimal setup and troubleshooting; two weeks to reconfigure and to improve the aesthetic of the examination room for audio/video consultation (the telehealth evaluation room has a feel more similar to a private office than a typical ED room); Physician training on audiovisual equipment and patient flow began as group lectures followed by train-the-trainer sessions took place over 4 weeks. One on one intensive training sessions were performed by the two physician project leads. As stated by our Telehealth physicians, a high level of comfort with the technologic process was usually achieved after 2-4 hours of supervised patient interactions.

At both locations, stakeholder analysis involving ED physicians, RN staff, Advanced Practice Providers took approximately 2 months, process mapping and troubleshooting required approximately 6 weeks.

Results

Program evaluation is in iterative development and couples qualitative and quantitative components. Our qualitative assessment consists of follow-up nurses reaching out to every patient who completes an express care visit, patients are asked about satisfaction with their visit and asked what we can do to improve the service. Press Ganey results have been uniformly positive. Examples of patient free response comments categorized into content themes are provided in table 1.

Quantitative assessment has consisted of evaluating patient door to doctor times, patient length of stay in the ED, patient satisfaction as measured by Press Ganey, rate of unplanned return visits within 72 hours, and rate of change in treatment plan or admission at unplanned return visit within 72 hours. A recent analysis of metrics provided the following results: Express Care patients, compared to those receiving a traditional fast track evaluation, were younger (median age: 38 [IQR, 27-54] vs. 43 [31-58]; P ................
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