NYU Langone Health
Re-defining Quality of Clinical Care in Telemedicine
Viraj Lakdawala
In March 2020, as the COVID-19 pandemic took hold over the metro NYC area, NYU Langone Health saw a 683 percent increase in Virtual Urgent Care (VUC) video visits. Our clinicians saw an average of 20-30 patients per day virtually before the pandemic began, but that rose to over 1,000 per day at the height of COVID-19. Telemedicine’s growth has been incremental and relatively slow over the previous 5-10 years, but the current pandemic has created a need to quickly adapt to a new normal of social distancing and meet the increase in demand for virtual visits.
NYU Langone was well situated to meet this demand due to our existing infrastructure and strong foundation of digital tools, which we quickly scaled up to accommodate a higher capacity of patients. Our Virtual Urgent Care services began with just 40 physicians and has grown to include 289 providers from multiple specialties to treat patients during the pandemic. As telemedicine demand surged, we noticed an increase in not only the volume of patients, but also the type of patient that sought treatment from our providers. Through these services, our clinicians treat a wide range of patients from standard, low acuity patients to those who are acutely ill with multiple comorbidities.
Measuring clinical quality has been a standard process for in-person care for many years, but yet, has not been a major component of telemedicine-based care
With the significant increase in volumes and higher acuity during the first phase of the COVID pandemic, we noticed that unfortunately, some patients were expiring after VUC visits. Knowing that our patients were suffering untimely deaths, we felt the need to capture data and determine if there were any preventable causes of these deaths. Through a systematic review, we were able to determine risk factors for referrals to the Emergency Departments, as well as identify those patients who may deteriorate to an ICU admission, airway intervention or death.
Measuring clinical quality has been a standard process for in-person care for many years, but yet, has not been a major component of telemedicine-based care. National quality metrics for telemedicine were initially created by the National Quality Forum in 2017 to measure access, financial impact, effectiveness, and patient experience. Unfortunately, these metrics were not built to measure clinical quality of care.
To remedy this, at the beginning of the COVID-19 pandemic, we developed metrics to measure overall quality of care for our Virtual Urgent Care program. The metrics included post-VUC visit ED bounce back rate, death rate within 30 days, and post-VUC ED visit with admission rate, in addition to previously tracked metrics including antibiotic usage rate in upper respiratory infections, and ED referral rates. These metrics were tracked using a dashboard for continuous quality assurance and chart review.
Measuring clinical quality will, of course, need to be specific to the specialty use case, but many metrics can be generalized to multiple specialties. A consensus for clinical quality metrics will need to be developed at a national level in conjunction with the specialty groups. Continuously monitoring quality metrics will help standardize high quality care across the country and allow peers to compare themselves to one other. It will also help drive the conversation towards making reimbursement for telemedicine services a permanent part of healthcare post-pandemic.
