When the University of Alabama at Birmingham health system created a telehealth program, the main problem it was trying to solve was how to improve access to care across the state.

THE PROBLEM

Alabama has some of the worst healthcare outcomes in the country. Telehealth technologies were adopted to eliminate the geographic excuse for these outcomes and start to address the issues, said Dr. Eric Wallace, professor of medicine, medical director of telehealth and UAB eMedicine medical director.

"The access to care issues were both ambulatory and inpatient," he explained. "Videoconferencing has allowed us to redistribute care across our state. UAB partnered with our Alabama Department of Public Health to obtain funding and purchase videoconferencing equipment for each of our county health departments. We used these county health departments as a way to deliver subspecialty care across our state.

"Further, we started inpatient telehealth at rural Whitfield Regional Hospital. We implemented a tele-stroke program and general neurology to start. Then we expanded to telenephrology, tele-critical care and telecardiology."

The COVID-19 pandemic allowed videoconferencing to expand into the home. UAB went from 1,000 video visits in 2019 to 280,000 video visits in 2020. Today, about 15% of total ambulatory volume remains telehealth.

Also, during the pandemic, UAB implemented a remote patient monitoring program to better address the needs of its diabetic and hypertensive patients.

PROPOSAL

Telehealth was meant to alleviate the problem of access to care in Alabama.

"We have many hospital beds in our state, but, despite that, 70% of our rural hospitals are operating in the red," Wallace noted. "This largely is because patients start to bypass the rural hospital when the hospital does not have the services needed to care for a patient's illness. Urban area hospitals have subspecialists with capacity, but hospital beds are always full.

"Telehealth allowed us to redistribute this care," he continued. "This was all too clear during COVID. We had times where rural hospitals without telehealth subspecialty support of critical care and nephrology life-flighted patients to other rural hospitals that had these subspecialties.

"Once a healthcare professional witnesses how telehealth can completely change care delivery if organized appropriately, they understand how virtual care not only is necessary but mandatory if the industry is going to reform the healthcare system in a meaningful way."

Financially, UAB's inpatient telehealth services have transformed hospitals.

"One of our hospitals went from an average inpatient census of 20 to an average inpatient census of 50," Wallace noted. "Their case mix index increased from 1 to 1.5 as did the case mix index of their transfers to UAB.

"We haven't just seen improvements in care in rural areas," he added. "Even internal to UAB, we have implemented full tele-ICU capabilities in more than 250 beds and have seen a significant and sustained reduction in observed rate to expected rate ratios and mortality."

On the ambulatory side, UAB has seen telehealth enable access to rare disease specialists, not just in rural areas, but across the region, and even internationally. It has seen improved access to all of its subspecialty services.

"More important, we have seen a tool by which we can continue to transform care delivery," he stated.

RESULTS

Through its telemedicine programs, UAB has racked up many solid successes, including:

• Increased census and case mix index of rural hospitals.
• Increased case mix index of patients transferred to UAB hospitals.
• Achievement of more than 650,000 ambulatory telehealth visits.
• Remote patients monitoring average systolic blood pressure drop of 9 mmhg in 45 days.

ADVICE FOR OTHERS

"To create a telehealth program, you must learn lessons from the software industry," Wallace advised his peers. "Healthcare needs to plan for the minimum viable product. Once that is in place, you need to start with a goal to see one patient. Then two, then three.

"With technology implementation, there is no time for a randomized controlled trial, and by the time the trial is complete and analyzed, the technology has changed," he continued.

Find the problem, then decide if technology is a viable means to eradicate the problem, he added.

"If so, plan just enough to get one patient seen and scale from there," he concluded. "Too often we plan so much that nothing happens. Finally, having a clinical lead paired with an outstanding executive lead has worked well for UAB."