Deep Dive: Exploring One of the Most Advanced Telemedicine Programs in the US

Morgan L. Waller, RN, says she and her team have been well invested in telemedicine long before COVID-19 – and have not yet interrupted their journey to increase access to highly sought-after medical professionals through virtual care technology.

Waller is director of telemedicine and regional multispecialty clinics at Children’s Mercy Kansas City, where the telehealth program is mature and advanced, staffed with physicians with deep and hard-won expertise.

We spoke with her to learn more about what the program, which is based on Teladoc technology, looks like, what it has accomplished – and even what the program may still be missing. We also discussed why the healthcare industry still talks about telemedicine as if it were something special, rather than a standard of care.

Q. You describe your telemedicine program as mature, if not advanced. What does a mature or advanced telemedicine program look like?

A. A mature or advanced telemedicine program is characterized by a ubiquitous network of modern audiovisual technology that delivers healthcare remotely. It maintains the standard of care and improves efficiency.

An advanced telemedicine program provides an alternative to in-person communication and assessment for almost all traditional patient-provider encounters, including specialty care, chronic disease management, pre- and post-operative assessments, inpatient and outpatient nursing, and allied health care. but also primary, urgent and mental health care.

The essential features of a mature telemedicine program include:

• High-quality AV systems and networks

• Consistency in user experience (e.g. similar graphical user interfaces between services)

• Integration or compatibility with existing electronic health records

• Multiple access points including websites, apps, kiosks, clinics, inpatient rooms, rehabilitation facilities, skilled nursing facilities, home, schools, college campuses

• Compatibility with specialized high-resolution digital examination equipment (e.g. stethoscopes, dermatoscopes, ophthalmoscopes)

A telemedicine program like this should also have a determined, centralized team of forward-thinking professionals with a mix of clinical, technical and creative talents. This team is responsible for regulatory compliance, filing and advising on telemedicine initiatives, education and training, telemedicine technology selection, quality control, monitoring, and user support.

While there are privacy, security, and regulatory expectations (e.g., the Joint Commission, Centers for Medicare and Medicaid Services, private insurance) for telemedicine programs, there is not yet an official group that evaluates or designates maturity levels for these programs.

Telemedicine is seen as an alternative way to provide healthcare, and not as a separate part of medicine or surgery. Some argue that designating tiers for telemedicine programs is unnecessary, while others suggest that not doing so could delay the development of new care delivery models, to the detriment of patients and providers.

Q. What have you accomplished so far with your telemedicine program?

A. In fiscal year 2024, we had 4,689 RN-facilitated, digital device-enabled Level 2-5 encounters hosted at five regional multi-specialty telemedicine clinics; 49,992 direct home appointments with the patient; and 54,681 total telemedicine visits, accounting for approximately 16% of total outpatient visits.

These visits were conducted from the 36 pediatric specialty services including adolescent medicine, cardiology, cognitive behavioral therapy, ear, nose and throat, epilepsy, general surgery, infectious diseases, orthopedic surgery, radiology, rehabilitation medicine, social work, urology, emergency care and weight management .

There are more than 775 specialty healthcare physicians and advanced practice providers and 2,800 registered nurses employed by Children’s Mercy Kansas City. Hundreds more

professionals support pharmacy, nutrition, social work, respiratory, occupational and physiotherapy. 2,704 of these pediatric healthcare professionals are active telemedicine users.

In 2021, a new direct-to-patient home technology was implemented in a phased approach for all users. Within the next twelve months, patient and provider satisfaction rates were 80% or better, and before the two-year anniversary they were consistently 90% or better.

The telemedicine program works together with business development to create asynchronous telemedicine services for regional and accessible healthcare settings throughout Kansas and Missouri. This allows the local facility to provide interpretation of radiological and cardiological diagnostic studies by some of the nation’s top pediatric radiologists and cardiologists. In fiscal year 2024, 2,791 radiology and 4,025 cardiology studies were read by pediatric radiologists and reported to patients’ local facilities.

The regional multi-specialty telemedicine clinics are equipped for laboratory sample collection. A courier service delivers the samples to the main laboratory in Kansas City for processing. This gives patients and families the option of having an experienced pediatric laboratory technician use comfort protocols for their child’s sample collection.

The results of the laboratory tests are entered directly into the patient’s record, which is faster and reduces the chance of transcription errors compared to using an external service.

This fiscal year, the telemedicine team worked with nurses and health informaticists to add telemedicine technology to all medical-surgical hospital rooms at both Missouri and Kansas hospitals. We are one of the first pediatric healthcare systems to go live with what the telemedicine industry calls virtual nursing.

A shortage of nurses and nurses hinders inpatient care and costs organizations millions of dollars in compensation and overtime. Data collection agencies predict serious nursing shortages as they look at the increase in the number of people over 65 and the number of nurses. Too many nurses want to leave the bed and/or are unhappy in their current position.

Although healthcare has undergone tremendous changes in recent decades with the implementation of electronic medical records and ever-evolving patient care equipment, the nurse’s responsibility at the bedside to attend to whatever the patient needs has changed little. We have continued to add regulatory, safety, monitoring, education, documentation, and other requirements to meet patient needs without evaluating or implementing changes to the nursing model.

The virtual nursing care model impacts care and staff – virtual nursing does not replace nursing jobs – by:

• Providing opportunities for the aging nursing workforce

• Follow recommendations for improved efficiency by reallocating responsibilities by type

• Improving the nursing experience by reducing interruptions

• Improving the patient and family experience with faster response times

• Improving patient safety by supporting caregiver focus and retaining experienced nurses

These achievements are astonishing and impactful. What has made all this work more meaningful is that every real-time telemedicine appointment is available with a video translator in more than 65 languages. Our telemedicine program offers on-demand interpreters, reducing wait times and vastly improving communication.

Q. What are you missing from your telemedicine program?

A. Our telemedicine program does not yet provide an audiovisual telemedicine presence in the emergency rooms, in the exam rooms of our outpatient clinics, nor in our intensive care units. Although we are doing asynchronous retinopathy of premature interpretations, I would like to see us do more.

We do not yet have asynchronous telepathology, nor asynchronous dermatology. We have had real-time telesurgical collaboration in the past; we don’t do that at the moment.

Q. Why do you need this?

A. We need these things to improve healthcare, not only for patients and families, but also for our healthcare providers. Telemedicine technology can reduce the stress of travel and workflow interruptions. Our doctors need options. This country loses a doctor to suicide every day. The suicide rate among physicians is double that of the general population.

Q. Why do you think the healthcare industry still talks about telemedicine as if it is something special and not a standard of care?

A. Personally, I underestimated healthcare systems’ investments in telemedicine in the decade leading up to 2020, and I repeated that mistake in 2022. These “curses of knowledge” distorted my expectations and led to a sense of esoteric disappointment.

A collection of problems that have hampered our nation’s health care system for decades are getting worse, not better. What makes it difficult for healthcare systems to implement and maintain telemedicine is:

• The battle between fee-for-service and managed care

• The healthcare offering in the reimbursement labyrinth is growing every day

• Insufficient providers

• CMS and private insurance dictating who provides care, what type of care, when it can be provided, why it is provided, and how it gets to the patient for reimbursement – ​​and frequent changes to all of this care

• Consumer understanding of telemedicine and ability to request/request the services is in the toddler stage

Q. What would be the most important piece of advice you would give to your colleagues at other hospitals and healthcare systems looking to develop a mature or advanced telemedicine program?

A. I recently came across a quote from our 44th President: “A budget is more than just a set of numbers on a page; it is an embodiment of our values.” The intended message aligns with what it takes to create a mature telemedicine program. Without financial investment, you cannot improve access and quality of healthcare through alternative delivery methods.

Moreover, hire a natural leader: someone with experience, not so much as to have become cynical, but someone with energy who believes that anything is possible. Give them access to the resources they need, time, people, a well-funded budget. Remove barriers and tell them that they “won’t be the first, but they will be the best” (borrowing a quote from Steve Jobs), and then let them build the telemedicine program.

As an aside, the world has entered Although we have entered the age of artificial intelligence, healthcare systems still function as they did in the 1990s, bogged down by complex computer systems rather than paper. Telemedicine must quickly become ubiquitous, as the latest healthcare innovations will make even early adopters hesitate.

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