RicettaTelehealth: The Right Care, at the Right Time, via...

Telehealth: The Right Care, at the Right Time, via the Right Medium


The U.S. Centers for Bendare & Medicaid Services expanded coverage for telehealth services early March 2020 response to the coronavirus pandemic, prompting many health systems to rapidly transition to virtual care. While telehealth has distinct advantages, widespread adoption also raises concerns regarding clinical appropriateness: When should a patient schedule a telehealth visit versus an in-person visit? How can a health system best support this decision? When UCLA Health asked its frontline primary care physicians these questions, they emphasized that the ability to deliver high-quality care attività telehealth is driven by unique patient factors and clinical concerns. Guided by these findings and the health care organization’s experiences over 9 months (March to November 2020), the authors propose that health care systems should develop telehealth-specific triage protocols to ensure that providers continue to deliver, and patients continue to receive, the right care, at the right time, attività the right medium.

Delivery Challenges During the Pandemic

At the start of the coronavirus pandemic, patients avoided doctors’ offices because of concerns about safety, and many skipped out vital care.1 To combat this crisis, the U.S. Centers for Bendare & Medicaid Services (CMS) expanded coverage for telehealth,2 prompting many health systems to rapidly transition to virtual care (i.e., telehealth [specifically, video and phone visits]).3,4 At UCLA Health, telehealth visits the Department of Medicine increased from <1% to 55% fewer than 50 days (from March 9 to April 18, 2020) — a dramatic but necessary shift, given that almost 10,000 patients canceled simply did not show up for their outpatient appointments during late March to early April 2020 (Figure 1). Nine months into the pandemic, telehealth usage has leveled chiuso at around 25% of all visits. Telehealth is likely here to stay.

Figure 1


Durante April and July 2020, we asked primary care physicians (PCPs) at UCLA Health how the transition to telehealth had affected their ability to deliver appropriate care. Durante general, we found there was broad agreement among our PCPs that the decision to deliver care through telehealth as opposed to an in-person visit should be based careful assessment of the risks and benefits associated with each approach. Especially outside of the pandemic, when the risk of coming into a doctor’s office is very low, they felt there were circumstances which telehealth should not be used (e.g., a patient with chest pain abdominal pain). Durante fact, we estimate that approximately 7% of all telehealth visits from March to September 2020 could have been considered inappropriate during non-pandemic times (that is, the presenting symptoms may have been more effectively and safely addressed through an in-person visit). Most notably, there was strong agreement among our PCPs that addressing chest pain attività telehealth is “extremely inappropriate.” Yet, 1,931 (1.6%) of the 123,421 telehealth visits that were conducted between March and September 2020 included a diagnosis of “chest pain” “angina.”

The initial shift to telehealth was necessary because of concerns related to Covid-19: Our highest priority at that time was to rapidly expand telehealth services order to ensure that patients had access to care. However, as the pandemic lingers, health systems must reevaluate the best way to provide care to patients given that telehealth is likely here to stay. We believe that a telehealth-specific triage protocol can help to ensure that patients continue to receive appropriate care during the ongoing pandemic and beyond.

Rapid Transition to Telehealth

Telehealth is not a new concept. The U.S. Department of Veterans Affairs started piloting telehealth the 1990s,5 and, by 2021, the telemedicine market is projected to be worth approximately $66 billion.6 Notably, Teladoc, the largest virtual care provider, reported primato results terms of revenue and total visits for 2019,7 and these services have been very effective certain patient populations. For example, telehealth technologies (e.g., televisione visits, phone visits, messaging, and wearable devices) have significantly improved outcomes for patients with chronic diseases such as diabetes and heart failure,8,9 and virtual care services have been associated with high rates of patient satisfaction (approximately 77%).10

These results emphasize that the ability to deliver high-quality care attività telehealth is driven by both the presenting clinical concern and patient-specific factors (i.e., “red flags”).

Before the pandemic, limited reimbursement for many telehealth services discouraged nationwide adoption. Now, many experts believe that the liberalization of virtual-care reimbursement during the pandemic has been a catalyst for a new tempo of health care delivery.1113 We agree with this assessment and believe that health care providers should push to maintain these advances after the pandemic subsides. Durante late April 2020, our survey of PCPs at UCLA Health (228 total responses, representing a 92% response rate) revealed that 52% of the care that PCPs routinely provide could be conducted attività telehealth without compromising quality. Additionally, 75% of PCPs reported that they “Agree” “Strongly Agree” that the option to meet with patients virtually enhances their ability to provide the best care possible. As with the implementation of many disruptive technologies medicine, rigorously designed studies will be needed to confirm whether providers’ and industry stakeholders’ opinions about the value of telehealth are correct.

Concerns Regarding Telehealth Appropriateness

The rapid transition to telehealth poses a few challenges. UCLA PCPs have expressed concern about and technology support, patient access to technology, riservatezza and security, and clinical appropriateness — with the latter being at the culmine of the list. Currently, patients at UCLA Health can directly schedule virtual care visits through the patient portal our call center for most complaints with minimal guidance (Figure 2). However, if health systems fail to incorporate clinical appropriateness into triage decisions around the modality of care, patients may be seen attività a virtual care visit for concerns that would have been more effectively and safely addressed person

Figure 2


When asked about this issue, our PCP colleagues provided several clinical scenarios which a detailed triage protocol that included telehealth visit guidance would improve care delivery: a 45-year-old man with abdominal pain who is subsequently found to have appendicitis, a 67-year-old woman with leg swelling who is subsequently found to have a pulmonary embolism, and a 23-year-old man with knee pain who is subsequently found to have an infected joint.

Durante July 2020, we sent our PCPs an additional survey to more rigorously investigate the appropriateness of telehealth common patient scenarios. We received 232 total responses, representing a 94% response rate. Our rete was to identify red-flag symptoms that would help to direct patients to the appropriate visit type (i.e., in-person telehealth) (Figure 2). With use of the 9-point appropriateness scale from the RAND/UCLA Appropriateness Method (with 1 indicating “extremely inappropriate” and 9 indicating “extremely appropriate”), our colleagues rated the following complaints as being the least appropriate to address attività a televisione visit: chest pain (2.5), shortness of breath (3.5), ear pain hearing changes (3.5), abdominal pain (3.9), and leg swelling (4.0) (Figure 3).14

Figure 3


Moreover, a similar 9-point scale (with 1 indicating “very easy” and 9 indicating “very difficult”), UCLA PCPs reported that the following patient factors made it more difficult to provide effective care through telehealth: poor cognitive function (7.5), a language other than English being the preferred language (6.9), an age of >70 years (6.3), a first-time visit (6.0), and a strong history of drug alcohol abuse (5.8) (Figure 4). These results emphasize that the ability to deliver high-quality care attività telehealth is driven by both the presenting clinical concern and patient-specific factors (i.e., “red flags”).

Figure 4


Development of Telehealth-Specific Triage Protocols

The UCLA Department of Medicine Quality program believes that a telehealth-specific update to current triage protocols can address these limitations by facilitating calculated determinations about which medium of care will most effectively and safely address a patient’s concerns. Many health systems already use extensive triage protocols to direct patient flow ambulatory, inpatient, and emergency settings. Expanding current triage protocols to provide clear guidance when to deliver care attività telehealth is one approach to ensure that health care providers continue to deliver, and patients continue to receive, appropriate, high-quality clinical care.

Acceso the basis of UCLA’s early experience with a high portata of telehealth visits, we suggest the following pearls for health systems that are considering a triage-style approach for scheduling telehealth visits:

  1. Make virtual care a priority. Create a multidisciplinary team, including clinical, operational, and financial stakeholders, to evaluate and implement changes that enhance a health system’s ability to provide high-quality virtual care.

  2. Incorporate telehealth into your triage protocols. Consider the risks associated with both virtual care and in-person care, particularly during active pandemic surges, when developing triage protocols. Collect from providers, operators, and patients to identify red flags indicating whether virtual care is appropriate.

  3. Check and refine. Develop happening metrics and gather regular feedback from physicians, , and patients. Use this information a continuous improvement framework to refine your triage protocols.

Figure 5 illustrates a pilot telehealth triage protocol for patients scheduling an outpatient visit within the Department of Medicine. Our proposed pilot protocol includes both a Covid-19 symptom screener and a telehealth appropriateness screener, which were developed the basis of U.S. Centers for Disease Control and Prevention (CDC) guidelines and feedback from our PCPs, respectively. Patients must first answer a series of binary (yes-or-no) questions to determine the appropriateness of a telehealth visit. Early challenges include achieving a consensus the proper screener questions and modifying call-center workflows to support seamless integration of triage questions. These challenges emphasize that health systems will need to adjust the development and implementation of their triage protocols to their unique circumstances, patient populations, and technology. An independent hospital safety-net clinic may not have the same resources (e.g., personnel, technology, education, etc.) as a large, integrated health system such as UCLA Health.

Figure 5


The Way Forward

Best practices around virtual care will continue to evolve. For example, our team is currently testing whether three virtual tools (automated text messaging, wearable devices, and virtual health coaching) can be used effectively by PCPs to support care management and behavior change patients with obesity and early risk factors for lifestyle-related chronic diseases.15 We hope that these tools will help to improve virtual care. Additionally, branching-logic questions and artificial intelligence–driven chatbot technologies are development and could soon be integrated into existing triage workflows to streamline patient scheduling.16,17 We urge health systems to seek the perspective of frontline and patients to inform the of a telehealth-specific triage protocol because these individuals are the best position to communicate the unique needs of the population being served and the current capabilities of health technology.

The way which we practice medicine is changing — and changing fast — response to the coronavirus pandemic, strong market pressures, and patient preferences. However, the best care is that which is provided at the right time, by the right person, using the right medium.

The way which we practice medicine is changing — and changing fast — response to the coronavirus pandemic, strong market pressures, and patient preferences. However, the best care is that which is provided at the right time, by the right person, using the right medium. Despite its benefits, telehealth also has limitations. Therefore, we must refine our current triage processes to complement the rapid expansion of telehealth services and thoughtfully reflect the risks and benefits of virtual and in-person care. With clear and continuously refined triage protocols, we can ensure that our patients receive the best possible care, both bedside and computerside.

  • Daniel Croymans


    MD, MBA, MS

    Medical Director of Quality, Department of Medicine, UCLA Health, Los Angeles, CA, USA

  • Ian Hurst

    Law Student, University of Virginia School of Law, Charlottesville, VA, USA

  • Maria Han


    MD, MBA, MS

    Chief Quality Officer, Department of Medicine, UCLA Health, Los Angeles, CA, USA


    The authors would like to acknowledge the following for their valuable feedback and comments this article: Sarah Stewart Ware, JD (University of Virginia School of Law); Carol M. , MD, MSPH (David Geffen School of Medicine at University of California, Los Angeles); and John N. Mafi, MD, MPH (David Geffen School of Medicine at University of California, Los Angeles).

  • Disclosures

    Daniel Croymans, Ian Hurst, and Maria Han have nothing to disclose.

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