Explain how the innovation works and why your organization chose this

Innovation Summary: The New York Presbyterian-Weill Cornell Medicine ED Telehealth Express Care Service uses telemedicine to rapidly evaluate patients who seek care at our Emergency Departments. While traditional in-person Urgent Care and low acuity ED visits may take as long as 2-3 hours to complete, the 3,000 plus ED telehealth Express Care patient visits we have performed have been completed in a median time of 39 minutes. Telehealth Express Care visits are performed collaboratively by an Advanced Practice Provider and a Telehealth Physician. This innovative workflow has led to a dramatic decrease in length of stay in conjunction with a high degree of safety and patient satisfaction. Briefly describe the innovation/process and problem that it addresses. The NYP-Weill Cornell Express Care Service is an innovative ED based telehealth program designed to reduce length of stay (LOS) and improve patient experience for patients with low acuity complaints. High patient volumes lead to correspondingly long wait times, an experience that can be particularly frustrating for patients who seek care for lower acuity problems that could be rapidly attended to, causing these patients to become dissatisfied and even prompting patients to leave without receiving care. Our process for ED Telehealth Express Care patients begins as it would for any of our ED patients: with an in-person triage and assessment. A registered nurse speaks with the patient and categorizes the severity of their medical complaint. Next, an Advanced Practice Provider (Physician Assistant or Nurse Practitioner) evaluates the patient, performs the Medical Screening Exam which is required for all ED visits, and decides whether our Telehealth program would be medically appropriate. Qualification for the Telehealth Express Care Service is based on set criteria. Participation by the patient is voluntary. If the patient declines, a physician will examine them in-person. The telehealth encounter takes place with our Telehealth Physician, a board certified Emergency Medicine faculty member. Evaluation, diagnosis, treatment and education are discussed at-length, with family members present if desired. Discharge instructions are printed directly at the end of the visit by the physician with any prescribed medications sent electronically to a pharmacy of the patient's choice. There is no additional check out process. Background Explain how the innovation works and why your organization chose this

solution over others. When NYP first launched its ED Telehealth Express Care program in early 2016, we were in the midst of working to improve ED core measures. Today, EDs are held accountable for operational metrics (wait times to see providers, walk-out rates, and total length of stay in the ED, along with patient experience scores and feedback). We manage a number of crowded urban EDs that traditionally have had long wait times. Long wait times are frequently cited as one of the biggest sources of frustration for patients, and we have worked very hard to address this. Improving wait time can decrease walk-out rates (i.e., patients leaving the ED prior to being seen by a provider), improves the overall ED environment, and has a particular benefit for patients who arrive with low acuity complaints who can find these delays even more frustrating and have a disproportionately negative patient experience. The ED Telehealth Express Care Service was launched at New York-Presbyterian as the institution began a dedicated effort to establish telemedicine services enterprise-wide under the NYP OnDemand initiative. NYP OnDemand is a global term for our enterprise to bring telehealth services to all segments of the institution. Programs currently established or planned for the near future that involve ED physicians providing telemedicine care include: - NYP Telehealth Express Care Service (patients arriving to the ED electing to have a "virtual visit") - Direct consumer telemedicine (NYP OnDemand Urgent Care) where patients choose to have a visit with the ED doctor from their home or office using a computer or smart phone - Nursing home consultations where ED doctors consult on nursing home patients who may be able to receive their care without needing to come to the ED - Post discharge telemedicine facilitated paramedic home visits for high acuity patients discharged from the hospital - ED follow-up visits for geriatric patients seen and discharged from the emergency department A board certified Emergency Medicine physician is available to provide these ED oriented telehealth services for 16 hours per day, 7 days a week in an audio video equipped office at our academic medical center. Our Telehealth Express Care Service has helped decant low acuity patients from the traditional ED workflow and allows ED staff members to focus on the immediate needs of higher acuity patients. We chose the ED Telehealth Express care service because it was an opportunity to bring innovative care to our patients and improve their ED experience while improving the capacity of our traditional ED to see higher acuity patients, and because it was a program aligned with NYP s commitment to implement telehealth services enterprise wide. Innovation Implementation Implementation required involvement of a variety of multidisciplinary key members. From the clinical team, we required the active involvement and support of our RNs, our Advanced Practice Providers (both Nurse Practitioners and Physician Assistants), our ED physicians and our registration staff. In

addition we required the active involvement of our hospital IT innovations team for work on telecommunications, audiovisual platform support and to assist with the use of EMR and remote printing of patient materials. Prior to the roll out of our innovation, process maps were created and IT was trialed, evaluated and installed. We fully operationalized our approach to providing care to these patients creating a model for low acuity Emergency Medicine care unique to NYP. Our model is similar to a 10 items and under Express Check-out line: separating faster cases, and assigning a staff member to focus solely on them, allowing every lane to move more quickly. For every hour of operation, a board certified NYP/Weill Cornell Emergency Medicine physician is designated for our Express Care service. During their Express Care shift, this physician will virtually evaluate patients presenting to the Emergency Department at NewYork-Presbyterian/Weill Cornell Medical Center, and at the Emergency Department at NewYork-Presbyterian/Lower Manhattan Hospital. In addition, the provider will see patients with minor illnesses and injuries who are using our NYP mobile app or website NYP OnDemand Urgent Care, and will provide consultations for nursing home patients. Timeline Planning for the ED Telehealth Express Care Service began in March 2016. Prior to implementation, NYP IT staff met with Weill Cornell medical providers to understand how the Express Care program could be mapped onto existing workflows. In addition to speaking with the providers, NYP IT staff members also observed the process firsthand. Stakeholder analysis was done early in the process to identify potential sticking points and develop a broad outline of the process. Table top exercises and ED walkthroughs simulating processes were used to test how well the envisioned Express Care processes mapped onto current ED workflow. This careful planning allowed our first iteration of the program to integrate seamlessly with our existing ED workflow. Our providers were quickly engaged due to the simplicity of the process, as well as the opportunity to provide a faster, better experience for our patients. After the initial success of the program at the New York Presbyterian-Weill Cornell site in July 2016, this service was expanded to the New York Presbyterian-Lower Manhattan Hospital Campus in October 2016. For our videoconferencing platform we chose a tool that had already been deployed hospital wide for administrative purposes and had been used in a limited fashion for psychiatric and remote stroke evaluations. Our program required minimal setup and troubleshooting; two weeks to reconfigure and to improve the aesthetic of the examination room for audio/video consultation (the telehealth evaluation room has a feel more similar to a private office than a typical ED room); Physician training on audiovisual equipment and patient flow began as group lectures followed by train-the-trainer sessions took place over 4 weeks. One on one intensive training sessions were performed by the two physician project leads. As stated by our Telehealth physicians, a high level of comfort with the technologic process was usually achieved after 2-4 hours of supervised patient interactions. At both locations, stakeholder analysis involving ED physicians, RN staff, Advanced Practice Providers took approximately 2 months, process mapping and troubleshooting required approximately 6 weeks.

Results Program evaluation is in iterative development and couples qualitative and quantitative components. Our qualitative assessment consists of follow-up nurses reaching out to every patient who completes an express care visit, patients are asked about satisfaction with their visit and asked what we can do to improve the service. Press Ganey results have been uniformly positive. Examples of patient free response comments categorized into content themes are provided in table 1. Quantitative assessment has consisted of evaluating patient door to doctor times, patient length of stay in the ED, patient satisfaction as measured by Press Ganey, rate of unplanned return visits within 72 hours, and rate of change in treatment plan or admission at unplanned return visit within 72 hours. A recent analysis of metrics provided the following results: Express Care patients, compared to those receiving a traditional fast track evaluation, were younger (median age: 38 [IQR, 27-54] vs. 43 [31-58]; P<0.001) and more likely to be male (52% vs. 46%; P<0.001), Express Care patients had less acute illness as measured by triage severity score (ESI 4 or 5: 97% vs. 84%; P<0.001), and more likely being treated for wound check/suture removal and infectious illness. Express care patients were less likely to have x-rays preformed as part of their ED evaluation (24% vs. 42%; P<0.001). Express care patients were treated and released more quickly than fast track patients (median time door to discharge 39 minutes as compared to 120 minute). Express Care patients were less likely to return within 72 hours, and no express care patient returning within 72 hours required admission to the hospital. There was a trend to higher Press Ganey satisfaction among Express care patients as compared to fast track ED patients (median: 100 [87-100] vs. 89 [74-100]; P=0.15). The program was initially launched at the New York Presbyterian-Weill Cornell ED and was then expanded to New York Presbyterian-Lower Manhattan Hospital. The inclusion criterion has also been expanded and now includes x-rays and vaccines. To date, over 3,000 patients have participated in this unique and innovative program. Our median length of stay remains 39 minutes from arrival to discharge and we feel that this rapid evaluation and disposition has been responsible for at least part of our very positive patient satisfaction. We also use this service to help establish primary care appointments. Twenty percent (20%) of the ED Express Care patients receive follow-up appointments via our ED patient navigator program with a primary care physician or sub-specialist prior to discharge. A quantitative comparison between older and younger patients with respect to these same visit metrics dispels the common myth that older patients may not respond positively to novel technology. Our most recent analysis comparing older patients to younger patients in express care we found that although Express Care Patents trended younger than traditional ED pathway patients on average, patients 60 and older comprised 24% of the total express care population, indistinguishable from the percentage of people 60 and older in the conventional treatment fast track area. Among patients 60 years and over seen in Express care, the average age was 72; the oldest patients (2 of them) were 99 years old. Older patients were more likely to be female and were slightly less ill as measured by ESI than younger patients in Express Care. Older patients were more likely to be evaluated for wound check or suture removal and less likely to have a diagnosis of infectious illness or acute traumatic injury. Radiographs were ordered less often for older patients, and older patients had shorter median ED length of stay. There were no significant differences by age group with respect to 72 hour returns to the ED and a low likelihood for a change in treatment plan on return.

In addition to eliciting patient feedback regarding satisfaction with the ED experience, we surveyed participating physicians about their telemedicine background and experience with the program. Most doctors reported having no prior background evaluating patients by telemedicine. More than half of the physicians were "somewhat uncomfortable" seeing patients in a telemedicine environment when the telemedicine program began. After performing evaluations from 80 to 200 hours worked, all respondents felt "completely comfortable" or "comfortable with a few concerns" after having seen patients using telemedicine. All physicians reported feeling positive about their telemedicine patient encounters compared to usual patient encounters and believed that patients reciprocated that positivity about their virtual encounter. The successes of our ED Express Care Service have also been featured in several media outlets (see attached) and we have had over twenty health systems have approached us to learn from our experience. We have also have had three research abstracts accepted regarding the ED Express Care Service accepted at the 2017 ACEP Research Forum and are in the process of submitting several manuscripts to peer review journals. Cost/Benefit Analysis Describe the breakdown of the costs for implementing this innovation and provide a comparison to the costs saving. (NEED TO INCLUDE SOME SPECIFICS HERE SO FEEL FREE TO ADD ANYTHING ELSE) Similar to any new initiative, capital investment in addition to fixed personnel and professional salaries exceed the earnings from this encounter based fee-for-service model. The major equipment costs have included the Avizia telehealth carts at each of the ED sites, three desktop workstations with webcams, and three laptop computers. Workflow incorporated existing nursing and Advanced Practice Provider staffing, so there was no additional staffing cost for these services. As part of the initial pilot of ED Express Care, Emergency Medicine faculty provided coverage for ED Express Care and were paid on an overtime moonlighting basis. The coverage for EM physicians is now fully integrated into their annual clinical hours requirement. Support for physician coverage for ED Express Care has been provided by hospital leadership. Leveraging existing technology such as in-house video conferencing, salaried IT personnel, and expanding medical provider roles contribute to overall cost savings. Value based care, whether in direct reimbursements or indirect penalties may play a major factor in the success of our OnDemand services generally, and the success of these services is directly related to the ongoing viability of our Express Care program. The ability to treat patients with reduced geographic barriers and increased patient convenience, patient acquisition and retention should be factored in favorably towards the true benefit of our telehealth program. We have seen significant improvements in operational metrics which have translated into improved patient experience scores. These improvements in metrics have also led to decreased ED walk out rates (currently less than 1%) and have had a direct positive impact on ED reimbursement. Advice and Lessons Learned A critical element to successfully offering virtual visits in the ED is ensuring that the patient receives the same high level of care regardless of whether that patient receives care virtually via the ED Telehealth Express Care service or the traditional ED in-person

pathway. The technology used to provide these services is not novel or unique it is the people, processes, and systems for patient outcomes that are the hallmark of a good program. In addition, implementation of our ED Express Care Service required comprehensive education of all staff members through several information sessions and regular updates. The commitment and flexibility of our staff has been integral to the success of this program. Our physicians found that they were able to effectively evaluate patients with telemedicine, but they also found that caring for patients in this way allowed them to be more engaged with the patients they were seeing. Although it may seem counterintuitive that a video visit could allow a greater degree of connection than an in person evaluation, the linear nature of the Express Care visit (one doctor sees one patient at a time) allows greater concentration on the individual patient and their needs. Our impression is that patients appreciate the privacy of our telehealth evaluation rooms, and that at least for some patients the act of speaking to the camera is less intimidating than speaking to a physically present physician. Our doctors have described the virtual encounters as more intimate, less distracted, and more connected with the patient and their medical needs. We were also surprised that a program we expected to be unpopular among our older adult patients was actually quite well received. Patients over the age of 60 years have readily accepted this new care delivery model. It is always good to try something new, is something we have heard from several patients who are over 80 years of age Sustainability Our program needs to ensure that every piece of technology involved in the process, from the video cameras to the printers to WiFi connectivity, are active and well-functioning. There is room for growth and improvement in physician workflow, in particular with respect to efficiency in interaction with technology tools and electronic medical record. For future directions, we are evaluating the use of the same tools to facilitate specialty consults within the hospital, to interact with our paramedic service, and to provide post hospital discharge support to patients as an alternative to ED return when appointments with primary providers are not immediately available. While current cost savings analysis may not support the initial capital investment and salary support for the program, utilization of existing technology and infrastructure as well as new reimbursement programs and value based care promotes the financial sustainability of telehealth into future expansion of patient care programs.