Telehospitalists And The Resilient Hospital
Written by Andrew McWilliams
COVID-19 placed an unprecedented strain on hospitals, testing their resilience in the face of a dangerous and poorly understood disease, inadequate bed capacity, staff shortages, supply chain problems, and financial stresses. Many of these challenges existed before COVID and will not go away with the end of the pandemic, indeed they are part of the “new normal” for most hospitals.
Resilience is commonly understood as the ability to adapt to or recover from a difficult situation. However, resilience is proactive as well as reactive: it is the capacity to foresee and plan proactively for future events that could adversely impact a hospital’s care or business model.
Hospitals have always been concerned about resiliency and preparedness for when disaster strikes. However, the pandemic has given them an opportunity to rethink what resiliency means in a hospital context, and how it can be enhanced going forward.
The resilient hospital
The resilient hospital is one that continues to meet the community’s health care needs, regardless of sudden events or long-term changes in the care environment. Sudden events range from outbreaks of disease to natural or man-caused disasters. Potential long-term changes include local population growth and demographic trends, climate change or obsolescence, to name just a few.
The pandemic highlighted several fault-lines in the US hospital system that weaken its resilience, among them:
- Insufficient numbers of hospital beds and staff
- Substandard care for lower-income, rural, elderly, disabled, minority and other underserved groups
- Difficulty protecting hospital personnel and patients from highly infectious agents
- The financial vulnerability of many hospitals to sudden cost increases and revenue disruptions
During the pandemic, governments and hospitals took extraordinary measures to fill these gaps, including changes in financing, facilities, supply chains, policies and protocols, and personnel. This article focuses on one of the personnel-related measures, specifically the increased use of telehospitalists and how they contributed to increasing hospitals’ resiliency.
How can telehospitalists contribute to hospital resiliency?
The increased use of telehospitalists can help, directly or indirectly, to address each of the weaknesses highlighted above.
Shortages of hospital beds and staff
Over 70% of US hospital beds were full during much of the pandemic, peaking at around 80% in late 2022 as severe flu and SARS cases were added to the COVID patient load. The situation was even more severe at the individual hospital level. Many overwhelmed hospitals, with no beds available, were reportedly forced to put critically ill COVID-19 patients on planes, helicopters and ambulances and send them hundreds of miles to other states for treatment.
The number of available beds in US hospitals has been shrinking steadily, falling from 941,995 in 2010 to 920,531 by 2022 (a decline of minus 2.3%). Over the same period, the US population increased by 8.7%. The ratio of population to beds thus grew from 330 people/bed in 2010 to 367 in 2022.
There are a number of reasons for the decline in the number of available US. hospital beds, one of which is shrinkage in the number of hospitals. Apart from rural hospitals, 143 of which closed between 2010 and 2022, it is hard to get consistent data on the total number of hospital closures and consolidations, but closures and consolidations have certainly been a major factor behind declining bed availability.
The wave of closures and consolidations in turn has been driven by the deterioration of many hospitals’ financial position. The overall deterioration in hospital finances, and the role telehospitalists can play in ameliorating the situation, are discussed below.
In addition to hospital bed availability, the pandemic strained hospitalist availability, as a growing number of hospitalists contracted COVID. In addition to hospitalists who contracted COVID, an unknown but probably relatively large number of hospitalists experienced burnout due to pandemic. Some burned-out hospitalists quit their jobs or took leave, while many of those who remained on the job performed at below- normal levels.
One of the most compelling arguments in favor of telehospitalist medicine is its potential impact in reducing hospitalist burnout, by affording hospitalists some relief from their crushing workload and providing them with greater opportunity to rest and recharge away from the job.
Shortcomings in care for medically underserved groups
Medically underserved groups such as the poor, rural, elderly, disabled, and minorities populations have been hit especially hard by the COVID-19 pandemic. Rural hospitals are not the only ones that have been closing; a number of inner-city urban safety net hospitals (USH) have suffered a similar fate.
USH care disproportionately for people with low incomes and communities of color, the very groups hardest hit by the pandemic. Those hospitals typically treat a larger share of Medicaid and uninsured patients than other hospitals and thus often operate on thinner financial margins, making them especially vulnerable to the financial and other stresses caused by the pandemic.
So far, USH closures have remained infrequent compared with the cascading disappearance of their rural counterparts. However, the closing of a few could portend problems at others.
It is widely accepted that paying insufficient attention to differences in cultural backgrounds can cause harm to a patient’s overall health. Conversely, patients tend to be healthier when their care givers take their ethnicity and race into account.
Hospitalists face added difficulties with cultural issues compared with primary care providers, because they are typically thrust into a situation of acute illness, while a primary care provider has some opportunity to establish a relationship with the patient. The use of a remote telehospitalist makes it easier to match patients, if need be, with a hospitalist who is familiar with the patient’s language and culture. Doing so can result in better care and outcomes.
Risks to medical personnel and patients from highly infectious agents
Hospitalists placed themselves at great personal risk caring for COVID patients. According to a Massachusetts General Hospital study, frontline healthcare workers—including hospitalists—had a nearly 12-times higher risk of testing positive for COVID-19 than individuals in the general community. The limited availability of adequate personal protective equipment (PPE) such as masks, gowns and gloves, especially in the early stages of the pandemic, magnified the risk to hospitalists and other front-line care givers. Where medically appropriate, seeing patients remotely obviously protects hospitalists from contagion.
It is widely accepted that paying insufficient attention to differences in cultural backgrounds can cause harm to a patient’s overall health. Conversely, patients tend to be healthier when their care givers take their ethnicity and race into account.
Hospitalists face added difficulties with cultural issues compared with primary care providers, because they are typically thrust into a situation of acute illness, while a primary care provider has some opportunity to establish a relationship with the patient. The use of a remote telehospitalist makes it easier to match patients, if need be, with a hospitalist who is familiar with the patient’s language and culture. Doing so can result in better care and outcomes.
Risks to medical personnel and patients from highly infectious agents
Hospitalists placed themselves at great personal risk caring for COVID patients. According to a Massachusetts General Hospital study, frontline healthcare workers—including hospitalists—had a nearly 12-times higher risk of testing positive for COVID-19 than individuals in the general community. The limited availability of adequate personal protective equipment (PPE) such as masks, gowns and gloves, especially in the early stages of the pandemic, magnified the risk to hospitalists and other front-line care givers. Where medically appropriate, seeing patients remotely obviously protects hospitalists from contagion.
The use of telehospitalists can also reduce the risk of contagion among hospital patients by facilitating the “hospital without walls” model in which hospitals concentrate on treating extremely sick, highly contagious patients while treating other patients outside the hospital via digital links. After an initial assessment, the telehospitalist remotely monitors, plans and oversees the care of patients in their private homes or other decentralized venues from a digital monitoring and control center.
Weakened hospital finances
The pandemic showed, as never before, the financial vulnerability of many hospitals to sudden cost increases and revenue disruptions as a result of the pandemic. Between 2017 and 2019, median hospital operating margins in the US were between -1% and -2%. In 2020, the median operating margin dropped to -5.4%. In 2021, the median margin “improved” to -1.5%, but the 2021 average margin remained at a dismal -11.7%.
Even in normal times, average hospital expenses increase by about 5% per year, while revenues only increase 3%. The pandemic accentuated the hospital revenue/expense imbalance, e.g., by reducing hospitals’ revenues from elective treatments, while driving up costs.
One of the reasons for hospitals’ worsening margins is rising labor costs. To help mitigate critical staffing challenges, hospitals have been forced to make more extensive use of expensive contract labor in a variety of positions to ensure patient care and overall hospital operations are not compromised.
As hospitals seek ways to get their costs under control, the use of telehospitalists in place of bedside hospitalists is worth considering: telehospitalists are paid an average of 30% less than bedside hospitalists, and their use can yield other operating efficiencies and revenue opportunities. Together with other cost savings and efficiencies, telehospitalists can help to tip the balance between some hospitals remaining open or closing.
The long-term outlook
As the pandemic winds down and hospitals move toward a new post-pandemic “normal”, they have the opportunity to put the emergency measures taken during the pandemic into permanent daily practice, adapting them as necessary to provide a more evolved healthcare delivery model and a more resilient hospital system. The successful deployment of telehospitalists during the pandemic provides a powerful illustration of the impact that they can have in increasing hospitals’ long-term resilience.