Expanding Telehealth for Specialty Care with Emily Warr, MSN, RN

MUSC Health is known for innovation and telehealth with a strong history of using telehealth to improve access to quality health care for medically underserved areas in South Carolina. Now, new and existing rheumatology and endocrinology patients have access to MUSC Virtual Care. Emily Warr, MSN, RN, is the administrator of the MUSC Center for Telehealth and talks about this innovative new offering for patients that reduces wait times and gets people the care they need sooner.

“Our mission is to the state of South Carolina and to make South Carolinians' lives better. And we think virtual care is a great way to do that. For convenience, for access, and really just to serve citizens of South Carolina no matter where they live or what their zip code is."
Emily Warr, RN

Topics Covered in this Show

• Access to telehealth has improved with most people owning a device that allows them to connect to a telehealth visit. The South Carolina State legislature has supported telehealth efforts for the past decade, which has led to the formation of the South Carolina Telehealth Alliance. This alliance is a collaboration among previously competing hospital systems to provide telehealth services, including virtual visits from home to hospital settings, to residents of South Carolina.
• Telehealth can fill gaps in access to specialized and primary health care, particularly in rural areas, by providing services in patients' homes or local libraries.
• Telehealth benefits patients by allowing appointments to be scheduled more easily, without the need to factor in travel time, while also allowing providers to expand their schedules beyond the limitations of physical clinic space and availability.
• Virtual care was previously limited by a "what can't be done" mindset, but the COVID-19 pandemic revealed that many aspects of care, such as physical assessment, can be conducted virtually using devices patients have in their homes, with some exceptions like surgical procedures that require in-person assessment.
• Telehealth is patient-centric and flexible, with patients having the option to see physicians in person if they choose, while virtual visits can help patients recognize the benefits of telehealth and facilitate their treatment plan.
• A team consisting of a physician, nurse, scheduler, and other healthcare professionals work together to ensure efficient and effective care, with the specific mode of interaction with the nurse varying depending on the patient's needs and case.
• To support the work of virtual specialists, a comprehensive team and post-visit support system have been built, with a network of local ancillary services to provide follow-up care, labs, imaging, and infusion centers as close to the patient's community as possible.
• Patients are responding positively to the virtual care services, which offer faster access to treatment and medications and the opportunity to build relationships with physicians beyond the initial visit,leading to the expansion of the service to other specialties.
• The specialties of endocrinology and rheumatology can help patients manage chronic diseases such as diabetes, thyroid disorders, and inflammatory diseases like arthritis. Long wait times for appointments prompted the offering of these specialized virtual services.
• The wait times for patients seeking a first appointment with an endocrinologist or a rheumatologist can be as long as four to six months, which can slow progress and healing. This is especially discouraging for patients who are in pain or have impaired activities of daily living. To address this issue, a self-scheduling opportunity was opened up for patients seeking endocrinology and rheumatology care, with wait times reduced to 24 to 48 hours.
• The virtual specialty care for endocrinology and rheumatology is accessible to anyone with specific symptoms, and they can easily identify their needs through a series of questions on the website without requiring a referral.
• The biggest barrier to specialty care is the wait time, which they aim to mitigate through virtual care, especially for patients who have difficulty traveling or with activities of daily living.
• The virtual specialty care service currently serves South Carolina and intends to solve the access issues for endocrinology and rheumatology specialties in the state first before expanding beyond. The service currently focuses on adults 18 years and older but may expand into pediatrics in the future.
• The virtual specialty care service offers appointments from 8:00 a.m. to 6:00 p.m. on weekdays for patients in South Carolina. Patients can check availability and schedule appointments directly on the website. The service generally offers same-day or next-day appointments. Visits are typically 15-30 minutes, similar to an in-person visit.
• MUSC Health has metrics in place to track wait times and patient access, but they are primarily focused on patient engagement and experience. They want to hear patient feedback to understand what they can do better and how virtual care has affected their lives.
• The pandemic accelerated the use of telehealth for patient care and there is now a focus on sustaining and measuring the success of telehealth services in the post-pandemic world. MUSC has been designated as an HRSA Center of Excellence, allowing for the evaluation of their own services and sharing of best practices with other centers across the country. Telehealth is used variably across different regions of the country, and it is a useful tool for both rural and urban areas, addressing different access barriers such as convenience, space, and distance.
• Before the pandemic, MUSC had successful virtual service offerings for hospital-to-hospital and school-based programs, but less than 1% of ambulatory activity was virtual. During the pandemic, they saw 65 to 70% of activity being virtual and now settle at around 10 to 15%, with some specialties being better suited for virtual care than others. Some health systems in the country are seeing as high as 20 to 30% of their ambulatory activity occurring virtually.
• Warr believes that in the next 10 to 20 years, there will be more care occurring where people live and work, and less commuting to receive care. There are already solutions in the market to send labs directly into a patient's home, and Warr believes it is not out of the realm of possibility for larger lab samples to be collected from home in the next few years.
• To access MUSC Virtual Care, one can search "MUSC Virtual Care" on Google and choose from the virtual urgent care program or the specialty service offering. Additionally, a primary care provider can refer a patient directly to the virtual specialty offering by physician name or by indicating the patient is open to virtual care within the referral.
• Growth is part of the strategic goals for MUSC Health with virtual care being a strong tool. However, the main goal is to serve and make South Carolinians better regardless of their location or zip code through the convenience and access provided by virtual care.

Read the Show Transcript

[00:00:00] Erin Spain, M.S.: Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. MUSC Health is known for innovation and telehealth with a strong history of using telehealth to improve access to quality healthcare for medically underserved areas. South Carolina now, our virtual care services are growing to offer specialty care to new and existing rheumatology and endocrinology patients. Emily Warr is the administrator of the MUSC Center for Telehealth and joins me to talk about this innovative new offering for patients. Welcome to the show, Emily.

[00:00:49] Emily Warr, MSN, RN: Thank you.

[00:00:50] Erin Spain, M.S.: So, for those who have yet to experience it, explain telehealth. What exactly is it? How does it work when we're talking about virtual appointments? What do patients need to receive telehealth care?

[00:01:01] Emily Warr, MSN, RN: Well, telehealth has come a long way in that most people have in their possession either a phone or a laptop computer or a tablet that they would be able to use to interact with their provider for a telehealth visit.

[00:01:14] Erin Spain, M.S.: Tell me about the history of MUSC Health and the Center for Telehealth. It's really made a mark in the world of telehealth. It's fairly rare across the country.

[00:01:24] Emily Warr, MSN, RN: Yeah, indeed it is. We have been very fortunate to have had the support of the South Carolina State legislature for some years. About 10 years now, they have funded telehealth efforts to be extended across the whole state. And as part of that work, we formed what's called the South Carolina Telehealth Alliance, which is really a collaboration amongst historically competitive hospital systems, frankly, to serve South Carolinians through telehealth and digital health. Really virtual visits into the home all the way up to those that are offered to hospital settings.

[00:01:54] Erin Spain, M.S.: South Carolina has a lot of rural areas in the state; what need, or gap does virtual care fill?

[00:02:02] Emily Warr, MSN, RN: Well, it can fill a lot of gaps. One of the biggest ones and sort of our primary focus is access. So, the access to highly specialized care and even primary care in pediatrics is highly variable across the state. In the urban areas, there's certainly much more access, within driving distance to highly specialized care, but in rural areas many people may not have access to mental health services or care. And through telehealth we can come right into your living room or to the library, to a local place that would have equipment that you could connect with your provider. So, open up the ability to bring specialty access directly to the patient where they are.

[00:02:40] Erin Spain, M.S.: What is it about virtual care that makes it easier or quicker for the health care system to respond to patients?

[00:02:46] Emily Warr, MSN, RN: One is on the patient side. The ability to meet the patient where they are, whether it's in their office, during their lunch break in or in their home, is that they don't have to factor in the travel. They may be able to fit a visit into their busy schedule more readily. And then on the provider side again, we schedule months out for brick-and-mortar locations. Some of that is related to space: the ability to actually get into a brick-and-mortar clinic and have the space to be seen by the provider and the care team. But also, there's just a finite number of specialists that have schedules available in those brick-and-mortar clinics.

[00:03:18] Erin Spain, M.S.: What can and cannot be done during a virtual visit?

[00:03:22] Emily Warr, MSN, RN: That's a great question. I think historically we've approached virtual care from a what can't be done mindset. But what we learned during the pandemic, when everything had to be virtual, was that actually most things can be done. Now, certainly surgical procedures can't be done.

There are elements of the continuum of care that absolutely require in-person assessment, physical assessment and even procedures, of course. But there are many elements of physical assessment, visually, but also with the help of devices that people have in their homes we can get a very clear picture of what's going on with a patient via a virtual visit using video, audio, and then also devices that many patients have in their own homes.

[00:04:03] Erin Spain, M.S.: So, if you're starting out with virtual care, can you still see a doctor in person if you want to?

[00:04:09] Emily Warr, MSN, RN: Absolutely. So, we really want this to be patient-centric and focused on patient needs and also patient choice. So absolutely, if the patient wants to see as part of a follow up and, continuation of their care a physician in person, we will absolutely advocate to help them make that happen and work with scheduling to get them in, either here in Charleston or anywhere in the state that's appropriate for their next level of care. What we've found is that patients, once they've tried virtual visit or telehealth, recognize there actually is a lot that can be accomplished through a virtual visit. And indeed, their care plan starts, and their treatment starts and then those next steps in their plan fall into place.

[00:04:46] Erin Spain, M.S.: And will you be interacting with anybody else during one of these virtual care visits, such as a nurse or a medical student, perhaps?

[00:04:54] Emily Warr, MSN, RN: Certainly, a nurse is going to be involved in the care. Now, whether or not you interact with that nurse via the phone or on video or after your visit as part of your follow up planning, that may vary depending on your needs and your specific case. But in general, there is a whole team wrapped around the physician to make sure that the care is done efficiently and effectively. So, you could interact with a scheduler for follow up reasons, a nurse, a physician, or a nurse practitioner, or physician assistant during your care continuum.

[00:05:22] Erin Spain, M.S.: And if somebody needs something like lab work done, they can go in their local community and have it sent back to their specialist?

[00:05:28] Emily Warr, MSN, RN: That's right. That was a really important part of building out this virtual specialty service that there would be follow-up needs. We would need labs, imaging, infusion centers to support the work of these virtual specialists. So, what we've done is we've built a really extensive wraparound team and post-visit support mechanism to make sure that we are finding the patients that next step of care, the follow up, the labs and imaging as local as possible, within their communities. So, we're building out a network of ancillary services that we partner with so that, perhaps, we see a patient up in the Myrtle Beach area and we're in Charleston. We would then work through local resources to make sure that we're connecting the patient to a location where they can get their labs done, their imaging infusion, whatever's required.

[00:06:12] Erin Spain, M.S.: So, what has reaction been so far from folks who have taken part and they've had a few appointments?

[00:06:18] Emily Warr, MSN, RN: The response that we're hearing has been very positive, which is encouraging. You can imagine that if you tried a general traditional mechanism and were told that you would have to wait four to six months, and then had the opportunity to be seen within 24 to 48 hours, begin treatment, get medications prescribed, and have a relationship with a physician that can be. Continued beyond that initial visit. It's really been a positive experience for a lot of our patients. That's why we're looking to add other specialties because we think we've found an opportunity to really reach the people where they are and help them, in a timely.

[00:06:51] Erin Spain, M.S.: And the news today is that there's now going to be this virtual care for rheumatology and endocrinology patients, and this is really important because there are a lot of diseases and conditions that fall. Into these divisions. Can you tell me about that? What sort of conditions may people have that they need to see an endocrinologist or rheumatologist?

[00:07:12] Emily Warr, MSN, RN: The most common endocrinology disease or chronic disease that people are very familiar with is diabetes. So, whether it's type one diabetes or type two diabetes, specialized endocrinology can really help. Patients manage their disease, but also, have better outcomes. There are also thyroid disorders, really any, uh, human disorder associated with hormones, frankly. And an endocrinologist can really accentuate and improve the care and outcomes of patients with those sorts of disorders. Similarly, rheumatology is intended for patients who have inflammatory disease processes. So that's arthritis, rheumatoid arthritis, some autoimmune, some more related to something called osteoarthritis, which is in your bones and joints. but can be very painful, frankly. and the reason that we offer endocrinology and rheumatology as our first two specialties to offer this way was because we have real challenges with access. In fact, we have long wait times for patients who are seeking a first appointment with an endocrinologist or a rheumatologist.

[00:08:10] Erin Spain, M.S.: Tell me about those wait times. What can they be like if you want to see someone in person?

[00:08:14] Emily Warr, MSN, RN: It ranges, but generally four to six months is what we were looking at which is incredibly long. Particularly if you're in pain, or you're impaired in any way. Activities of daily living, particularly with rheumatologic disorders, can be impaired. People have trouble walking. Swollen joints can be very painful. So, as you can imagine, if you're trying to get in to be seen and begin your care plan, waiting four to six months to see a specialist is really discouraging and can slow your progress and healing. So, we decided to open up a really easy-to-access self-scheduling opportunity for patients seeking endocrinology and rheumatology care. And are able to actually achieve wait times that are more like 24 to 48 hours.

[00:08:56] Erin Spain, M.S.: Now tell me about who's a good candidate for virtual specialty care?

[00:09:01] Emily Warr, MSN, RN: Anyone I think is a good candidate for virtual specialty care that has the specific symptoms associated with endocrinology and rheumatology disorders. The way we help identify whether or not a patient is appropriate is through.

The website that we bring patients into, the virtual specialty website, we ask a series of questions to identify what the true need is and if it's something that we can help you with these two specialties with, or if we need to try to capture you and bring you into a different specialty, perhaps in person or via a separate mechanism.

And so, as patients come through that list of questions and identify their needs, then we have a nursing team will contact them and ask if they have any other questions and then can really help connect them to the appropriate, level of care. whether it be within our service or outside of our service. We do not require a referral. However, we welcome referrals. And so, I think that is a differentiator here. Certainly, specialties that have access issues many times, a referral is absolutely required to even get put in the queue to get a visit.

In this case, we recognize that there are patients who may not have a referral, but know they have a need. And so, we take on the responsibility of figuring out what the appropriate next step is for their care by breaking down any barrier to access and bringing them in with or without a referral.

I think the biggest barrier to beginning treatment is just that wait time, there's also, of course drive times and the requirement to travel and difficulty with traveling. Certainly, when you work and have a family and other Requirements of general life outside of driving multiple hours to see a provider and, we're able to mitigate that challenge with virtual care.

[00:10:32] Erin Spain, M.S.: And there are certain requirements such as this is only in South Carolina and right now for adults.

[00:10:38] Emily Warr, MSN, RN: That's right. The goal certainly if we continue to see successes to ultimately grow the service offering, but we are serving South Carolina and intend to really solve for the access issues for these two specialties in South Carolina first before we move beyond South Carolina. So yes, patients that live in South Carolina and are 18 years of age or older are the ones that we're focusing on now. I get a question a lot about pediatrics, and certainly we would love to serve pediatrics, but we're beginning with adults and we'll likely move into pediatrics down the road.

[00:11:07] Erin Spain, M.S.: You mentioned that sometimes a patient may be seen within 24 to 48 hours. What time of day is this available and what are some of the, the logistics around it?

[00:11:16] Emily Warr, MSN, RN: Right now, we're focused on Monday through Friday, but we do offer as early as eight o'clock in the morning for a visit, and then all the way to around 6:00 PM depending on the day. And the nice thing is the patient can go directly to the website and see what's available.

[00:11:30] Emily Warr, MSN, RN: But generally speaking, our availability is either same day or next day. But generally, very quick turnaround times for patients

[00:11:37] Erin Spain, M.S.: And how long did these interactions last?

[00:11:40] Emily Warr, MSN, RN: Almost exactly the same as an in-person interaction. So, if you see your provider in person and it typically takes 15 to 30 minutes; that's about what you can expect with a virtual visit as well.

[00:11:50] Erin Spain, M.S.: So, you mentioned we could be seeing more specialties coming online here and years to come. How are you going to be evaluating the success of this program?

[00:11:58] Emily Warr, MSN, RN: Well, we have some tried and true metrics around wait times for patients access related metrics. And we're already tracking those. But I think the, one of the biggest metrics that we're looking to hone in on over the course of the next couple of months is around sort of the patient engagement and experience those stories from the patients that tell us what we could do better what's going well and what it meant for their own personal lives. To be able to see a specialist quickly and via this virtual mechanism. So, patient and family feedback is really important too.

[00:12:26] Erin Spain, M.S.: You mentioned that the COVID 19 pandemic did allow telehealth services to go to that next level and really prove that it can be used for a lot of different reasons. Tell me about how telehealth around the country has really exploded and how MUSC Health is being a leader in an example for other institutions.

[00:12:46] Emily Warr, MSN, RN: It was a game changer for the pandemic for sure. This idea that we could take very good care of patients virtually and, via video, was really, an innovative idea that a lot of people were dabbling in prior to the pandemic, but of course the pandemic accelerated that activity.

In the post pandemic world, I think we're focusing on more mature ways to sustain programs and to measure our success and really articulate the value of telehealth as part of the service delivery continuum. MUSC, as I mentioned, has had a great relationship with the South Carolina State legislature. That's given us the opportunity to build out extensive service offerings and also led to our center at MUSC being designated as HRSA Center of Excellence.

So, what that's given us is the opportunity to rigorously evaluate our own services here, and also identify best practices to disseminate across the country. So, we have a great opportunity to work with other telehealth centers and academic medical centers across the country to share best practices that we have learned and also, learn from them. I'd say, you know, it's highly variable, by region in the country, how much telehealth is being used. Interestingly, it's a great tool for rural estates like ours, like we discussed, but also in the urban areas, there's a significant amount of telehealth occurring there. Different barriers, not having to drive far perhaps not access issues, but also, you know, convenience and space. In big cities there are issues with clinic space and so being able to take part of your practice and deliver directly to the patient's home changes those sort of access barriers that historically were challenging.

[00:14:20] Erin Spain, M.S.: Post pandemic, have you seen an uptick in people using the virtual health and telehealth services at MUSC Health?

[00:14:27] Emily Warr, MSN, RN: Yes, definitely. Prior to the pandemic We had some service offerings that were very successful, hospital to hospital. We had a school-based program that was very successful. But the ambulatory activity was less than 1% virtual.

During the pandemic we went to approximately 65 or 70% virtual. And then coming out of the pandemic, we've settled out at a similar percentage to our colleagues around the country, 10 to 15% of ambulatory activity occurring virtually.

But it really ranges by specialties. Some specialties are super well poised, frankly, for virtual care. Mental health is a great example, endocrine and room, or great examples as we've discussed today. But there are others that are really well poised for virtual care. There are some academic medical centers and other health systems across the country who are seeing as high as 20, 25, 30% of their ambulatory activity occurring virtually.

[00:15:18] Erin Spain, M.S.: Now you mentioned there are some things that cannot be done over telehealth, such as lab work or surgery, but maybe that could change someday. Tell me about the future of virtual and telehealth and what we might see in the next 10 to 20 years.

[00:15:33] Emily Warr, MSN, RN: Oh, I definitely think so. I mean, it's all evolving. In the next 10 to 20 years, we'll see more and more care occurring where people live and work, and less commuting or traveling to a different city or even to a different part of town to have the vast majority of your needs delivered.

With regard to labs there's already solutions out on the market to send labs directly into a patient's home. There's really easy ways to get small blood samples. Now, certainly, you know, phlebotomy where you need larger vials of samples will take a little longer to solve for. But I don't think it's out of the realm of possibility within the next few years to be able to really accomplish a lot.

[00:16:07] Erin Spain, M.S.: Well, as we wrap up here, can you tell folks listening what are the next steps? Let's say they do have a. They want to see someone in rheumatology or endocrinology. They want to see a physician through virtual telehealth care. What should they do?

[00:16:21] Emily Warr, MSN, RN: There are a couple of pathways. The first is to just Google MUSC Virtual Care. And the page that comes up will give you a couple of options. We have a virtual urgent care program that people use often for urgent care needs. Then we also have this specialty service offering that they'll be able to come right through to that self-scheduling page and answer some triage questions. Go ahead and get scheduled and seen. your primary care provider can offer you a referral directly into this virtual specialty offering. So, if you know, primary care physician knows that you need to see a specialist and they can refer directly into this virtual specialty offering,

[00:16:57] Erin Spain, M.S.: It's important to say that for MUSC Health Virtual care is an important part of the mission. Tell me about that.

[00:17:04] Emily Warr, MSN, RN: Absolutely. We have, strategic goals around growth and innovation, and certainly with access, growth is part of virtual care's ability to be a strong tool in our tool belt. But our mission is to the state of South Carolina and make South Carolinians' lives better. And we think virtual care is a great way to do that. For convenience, for access and really just to serve citizens of South Carolina no matter where they live or what their zip code is.

[00:17:30] Erin Spain, M.S.: Thank you so much, Emily Warr, for coming on the show and talking about these new specialties, which I'm sure many folks are going to be interested in pursuing. So, thank you for your time today. For more information on this podcast, check out advance.muschealth.org.