Telehospitalists: Enhancing Overnight Care at Academic Hospitals

The use of telehospitalists has generated a lot of buzz since the COVID pandemic because of their utility to rural hospitals, but a Houston Methodist program suggests they can have great value at big academic health care systems as well.

The Houston Methodist program, initiated last year to balance the load caused by high volumes at the emergency department, deploys virtual hospitalists to deliver care to patients admitted overnight, when there are fewer hospitalists on site.

"It made perfect sense because of the lag time from when late-evening patients get to the ED and when a primary-care doctor is typically available to explain their condition and plan of care," says Dr. Henry Ellison, a Houston Methodist internist and the medical director of the virtual hospitalist program. "Telehospitalists enable faster communication between the doctor and patient."

The overnight program has enabled faster communication for more than 1,000 patients since its inception Oct. 1 at Houston Methodist's flagship hospital in the Texas Medical Center, and Dr. Ellison says the reaction from patients and families has been overwhelmingly positive.

Telehospitalists are a byproduct of the hospitalist movement that began in the 1990s and telemedicine's COVID-spurred growth in the early 2020s. The most common use involves small, isolated or critical-access hospitals that often don't have the resources to deploy primary care doctors to acutely ill patients and employ distant telehospitalists because interactions with patients only require wheeling a computer into the patient's hospital room.

Virtual hospitalist programs are little used at well resourced, high-throughput academic centers, even though its staff are also often taxed. But it was a natural application at Houston Methodist, where state-of-the-art technology includes room TVs and wall-mounted cameras with 360-degree rotation, zoom, scan, and pan capabilities.

While rural hospitals rely on outside contractors, Houston Methodist built its program in-house, initially relying on moonlighting hospitalists, now having hired two full-time telehospitalists. Hiring is a challenge — short-term plans call for two more — since no one today is really trained in the new role and there aren't even online courses available.

"So we've made sure to really strongly recruit effective communicators, doctors who first and foremost can compellingly and charmingly get a point across and connect with people and their families through the virtual format," says Dr. Ellison.

Dr. Ellison said some boots-on-the-ground tech training has helped, particularly to troubleshoot glitches involving computers on mobile carts. But he says the program has been generally easy to pick up for both telehospitalists and the bedside nurses who connect the patient and doctor and coordinate the virtual appointment.

The program has, on occasion, been deployed for scheduled big surgeries, typically procedures that were delayed or went much longer than anticipated. But the vast majority of the telehospital consultations have involved patients admitted directly from the ED.

Dr. Ellison's biggest concern was whether hospital patients might see the telehospitalist appointment as "somehow less than" than in-person ones. He even did some scripting: "The telehospitalist is a fully board-certified internal medicine doctor employed directly by Methodist, not an outside contractor. I can refer you to an in-person option but on average that'll mean a wait of a few hours before they're able to get to you."

In fact, resistance never materialized. To date, no patient has rejected the telehospitalist option.

It's too soon since the program's launch to have any data, but Dr. Ellison says the program has significantly reduced the time between when overnight patients get to the ED and when the "quarterback of the team" at the hospital becomes involved in their plan of care.

Dr. Ellison says he's interested in determining whether the program is able to help move the needle on measures like length of stay, readmission rates, patient satisfaction scores but acknowledges that's a challenge given those are institution-wide goals and telehospitalists only have the patients for, at most, the first 12 hours of their stay.

Plans call for the program to be expanded to all of Houston Methodist's hospitals, says Dr. Ellison, perhaps as soon as the end of the year.

Dr. Ellison says other big academic health centers should follow Houston Methodist's example.

"The program seems to be a model of how telehospitalists can benefit large academic hospitals, not just small, rural hospitals," says Dr. Ellison. "It's a way to get the ball rolling and make processes more efficient and communicate sooner with patients who are going through one of the scariest times in their lives."