Improving Telehealth Patient Experience and Access at NYC Health + Hospitals

Introduction

NYC Health + Hospitals (NYC H+H) is the largest public healthcare system in the US, with eleven acute care hospitals, five nursing homes, six diagnostic and treatment centers, and more than seventy community-based primary care sites. The system acts as the safety net hospital system for New York City, servicing over 1.4 million patients a year, including nearly 500,000 uninsured patients. With $6.7 billion in annual revenues, NYC H+H generates significant revenue but needs government funding to support its cost structure servicing underprivileged communities.

Project Objective

The COVID-19 pandemic created an urgent need for remote medical access, and due to the speed of implementation, there are many areas for improvement. Our project goal was to provide recommendations for NYC H+H to improve access to and the overall patient telehealth experience for its patient population. To do this, we utilized Press Ganey telehealth survey results from visits between January 1, 2020, and September 1, 2021. We have formulated the below key points and recommendations for policy decisions to improve patients' telehealth journey.

Data Analysis and Stakeholder Interviews

Our data analysis was focused on patient comments from over 6,000 post-telehealth visit surveys. Using qualitative data analysis software, we coded over 2,500 comments to find themes across patient experiences. We then worked to target our approach to the comments we believed would have the most meaningful information, and each team member coded the fifty longest comments from a top-performing site and a bottom-performing site.

After we analyzed the survey results, we interviewed six stakeholders on the NYC H+H team to review our findings, discuss potential problems, and ultimately detail our recommendations for the healthcare system.

Key Problems Identified

Based on our analysis, we identified two key problem areas, and our recommendations are focused on addressing these two areas:

1. Patients prefer in-person or believe telehealth visits cannot meet their health needs.
2. Significant wait times with telemedicine appointments

Recommendation Matrix

Through our various research and discussions with the NYC H+H team, we came up with eight recommendations that, if implemented, would help NYC H+H accomplish its goal of improving patients' telehealth experience.

To help visualize and prioritize the implementation process of our recommendations, we created the below Impact & Effort matrix with our top right quadrant comprising our top recommendations. Notwithstanding, all recommendations require a significant amount of effort to implement, given the large quantum of stakeholders involved in the NYC H+H system.

Key Recommendations

Scheduler Recommends Appointment Modality

From our interviews with stakeholders, we discovered two ways for patients to schedule appointments: central scheduling and calling the clinic. In the current central scheduling script, unless the concern is urgent, schedulers offer patients the choice of scheduling their appointment in-person or virtually. Hence, there is no current recommendation for the necessary modality of the visit. To address this, we recommend creating departmental lists of pre-approved visit types for digital health and, based on said list, have call center schedulers recommend the visit modality. We believe this will help reassure patients that their health needs can be addressed with a telehealth visit and allow them to consider an option that was not previously recommended to them. This is already being done when appointments are scheduled by clinic staff as they have the clinic-specific knowledge of what appointments can be scheduled as telemedicine visits, but we believe it is important to ensure central scheduling can make the same recommendations.

Require Modality Field

Within Epic, there is a field in provider encounter documentation to denote the recommended modality for follow-up visits. However, this is not currently a required portion of the chart and is utilized inconsistently across NYC H+H locations. Our recommendation is to make this field mandatory. Providers should not be able to sign a visit without denoting which modality they recommend for a patient's next visit. This solution would provide scheduling entities with a recommended modality for scheduling patients and again help reassure patients that their health needs can be addressed with a telehealth visit.

Eliminate Modality Crossover of Double Booking

We discovered in stakeholder interviews that there is a culture of in-person visits having a higher priority than virtual visits. When providers are running late, telemedicine visits are pushed back, sometimes to the end of the day, in order to see the patients in the clinic. This becomes especially problematic when an appointment slot is double-booked with an in-person and virtual visit. As such, we recommend only double booking the same modality appointments together. If double-booked appointments were the same modality, providers would not need to prioritize one over the other. We believe this would make it easier for providers to complete their scheduled telemedicine visits on time and result in less significant delays of telemedicine visits.

Limiting Factors

While we had extensive resources for this project, there were two areas where more resources may have helped influence our identified pain points and areas of recommendation. Firstly, some patients generally have difficulty with technology and accessing telehealth visits. If a patient had difficulty with or was unable to access a telehealth visit, they might not be able to access the virtual survey. As a result, their input is missing from our project findings. Secondly, our team did not have access to financial or operational information. This information might have provided additional insight that would have helped us find and highlight pain points within the NYC H+H system.

Conclusions

Telehealth, on the whole, has many valuable aspects, from convenience and flexibility to safety and versatility. NYC H+H ramped up its telehealth usage out of necessity during the COVID-19 pandemic, and now, we believe it will be strategically beneficial for NYC H+H to continue expanding its telehealth infrastructure. From the analysis done by our group, we identified two main problems that NYC H+H telehealth is facing right now. First, patients prefer in-person visits and believe that their health needs cannot be met via telehealth. Second, there are often significant day-of wait times associated with telehealth visits. Considering the relative effort combined with potential impact, we believe that NYC H+H should implement our three above recommendations to increase patient trust in telehealth and address appointment wait times.

In implementing these changes and addressing unique telehealth issues, it will be important to consider replicating an in-person visit virtually and the purpose of each piece of the appointment. Patient expectations will need to be managed with clear communication to bridge the physical distance and continue to offer the humanistic connection patients have been used to and need for a successful interaction with the healthcare system. Telehealth is an exciting new tool that presents many promising future opportunities along with its own unique challenges.

Contributors: Maya Hamaker, Nick Hyman, Jason Schwartz, Rituraj LNU