Overview

Cleveland Clinic engaged in a multiyear collaboration with a third-party telemedicine provider to bolster the capacity and quality of its telemedicine services and improve visit-type appropriateness, documentation completion, and antibiotic stewardship.

Organization Name

Cleveland Clinic

National/Policy Context

  • Professional organizations (e.g., American Medical Association, American Academy of Pediatrics) believe that a lack of care standards and nationally-recognized clinical guidelines has impeded telemedicine quality control.

Local/Organizational Context

  • Cleveland Clinic launched its telemedicine practice in September 2014 in order to increase patient access to care, support its transition to value-based care, improve system efficiency, and attract new patients to its clinical practice.
  • However, Cleveland Clinic realized it lacked the necessary infrastructure to support robust telemedicine services, so they partnered with Online Care Group, an outside network of telemedicine physicians that delivers services through the American Well online platform. In June 2015, Cleveland Clinic launched Express Care Online, an on-demand, 24/7/365 urgent care telemedicine service.

Patient Population Served and Payor Information

  • In 2018, Cleveland Clinic Health System’s patient service revenue was 47% Medicare, 37% managed care or commercial insurance, and 14% Medicaid.

Leadership

  • Medical and Quality Directors of both the Cleveland Clinic and Online Care Group
  • President of Online Care Group

Research + Planning

  • Early into the collaboration, both Cleveland Clinic and Online Care Group recognized the importance of bidirectional communication. With this in mind, Cleveland Clinic and Online Care Group hosted monthly quality review meetings to establish quality metrics and audit the data from the previous month’s telemedicine clinic visits. Attendance was mandatory for the Medical and Quality directors of both Cleveland Clinic and Online Care Group, and the entire clinical team was always invited and encouraged to attend.
  • Based on evaluation of quality metrics and outcomes, the collaborative constructed the initial quality improvement plan around four main objectives: Organizational Alignment, Clinical Guidelines, Collaborative Partnerships, and Quality Assurance and Improvement (see figure below).

Tools or Products Developed

  • EHR Smart templates: Online Care Group enhanced the electronic medical record with smart templates which include distinct data elements to prompt the physician on visit standards to improve documentation and ensure consistency across its clinical services.  
  • Virtual team meetings/newsletters/guidelines: Online Care Group created standing virtual team meetings, a weekly email-based newsletter, and guidelines on when to trigger one-on-one remediation conversations to bolster its digital communications infrastructure.   
  • Private discussion board: Both Cleveland Clinic and Online Care Group created a private, online physician discussion board to allow for cross-communication amongst the physicians.

Training

  • Over the course of the first year of the partnership, Cleveland Clinic and Online Care Group trained their respective physicians on visit type appropriateness.
    • Transparency was a key pillar to the training such that early on, physicians were made aware of the results of the audits and the goals of the partnership.
    • At first, Online Care Group relied on email campaigns and online training, but when outcomes didn’t change over the first six months, the organizations developed alternative training and communication avenues. See Tools or Products Developed for Project for details.

Team Members Involved
  • Physicians
Workflow Steps

  • Cleveland Clinic and Online Care Group determined three quality measures upon which they sought to intervene: visit-type appropriateness, documentation consistency, and antibiotic stewardship. From 2016-2018, both organizations worked on each issue one at a time.
    • Visit type appropriateness: At each meeting the Quality Directors audited approximately 30% of the total number of adult patient visits and 100% of the pediatric visits from the preceding month.
      • They established that an “inappropriate visit,” was “a completed visit leading to a treatment plan in the absence of one or more physical examination components considered to be necessary to arrive at the diagnosis or clinical decision.” An example of an inappropriate visit would be diagnosing acute otitis media without visualization of the tympanic membrane.
    • Documentation inconsistency: At the meetings, the two groups agreed on the minimum elements for an online telehealth visit: patient identifiers, allergies, medical and surgical history, medications, the history of the current problem, physical examination findings, and decision-making and treatment plan with patient instructions for follow-up.Templates were established and distributed within Online Care Group.
    • Antibiotic stewardship: At meetings, the groups coordinated their guidelines regarding antibiotic appropriateness and first-line medications. They determined that physicians needed to document a specific reason for deviating from the first-line antimicrobial, e.g., a patient allergy to the medication.

Budget Details

  • Cost of time to establish learning and training materials for physicians
  • Cost of working with EHR to establish documentation templates
  • Cost of time spent collecting, synthesizing, and auditing clinical data

Where We Are

  • The project began in 2015 and is currently ongoing.

Outcomes

  • Inappropriate pediatric visit rate: This rate decreased from 76% to 1% within 14 months of implementation of the intervention.
  • Rate of full documentation: This rate increased from 45% to 85% within 6 months of intervention implementation and currently hovers around 95% to 97%.
  • Rate of appropriate antibiotic prescriptions: This rate increased from 69% to 97% within 6 months of intervention implementation.

Benefits

  • Health systems can enhance their processes to offer consistent, quality patient care through collaboration with third-party providers of telemedicine services.  
  • EHR technology can be successfully deployed to ensure compliance with appointment standards and protocols.
  • Offering multiple communication channels is a strategic and effective way to disseminate changes to guidelines and clinical standards internally.

Unique Challenges

  • For Cleveland Clinic, partnering with a third-party physician network, Online Care Group, challenged their ability to ensure that Express Care Online upheld the same organizational standards maintained across all Cleveland Clinic institutions.
  • As a national physician network, Online Care Group faced its own organizational challenges to ensure consistency across its telemedicine services. They employ physicians who work in different time zones, maintain in-person clinics, and are contracted with other health system telemedicine services.

Sources

Innovators
  • Kari Gali, DNP, PNP-BC, CPHQ
  • Sylvia Romm, MD, MPH, FAAP
  • Matthew Faiman, MD, MBA, FACP
Editors
  • Emily Fink, BA
Location

Cleveland, Ohio

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