It’s not the patient’s portal
It’s your digital front door. 

The patient portal is a reflection of your organization’s strategy on patient engagement.

This shift in thinking tripled my organization’s patient portal use in less than one year.

Patient portals were first used in the late nineties by a few large healthcare organizations but took off with the meaningful use criteria of CMS’s EHR incentive program. The incentives included in the program jump-started the adoption of EHRs by independent practices and hospital systems. The program required thresholds for the use of basic functionality. This included messaging, visit summaries, and access to laboratory results. Providers rushed to meet these goals to receive the incentives, but very few could increase user adoption numbers.

Most organizations treat the list of portal features mandated by MU as a to-do list. If an organization hits each item, they consider the portal “done” and move on to other things.

The common reasons patients were not engaging the patient portal would not shock the average person.

1. Websites were clunky and difficult to navigate; and
2. Portals lacked basic functionality.

Since the nineties, web design has come a long way. Now, most portals are much easier to navigate and include mobile apps. The second reason, lack of functionality, however, should make you rethink how to view your organization’s patient portal.

Most organizations treat the list of portal features mandated by MU as a to-do list. If an organization hits each item, they consider the portal “done” and move on to other things. Despite this “done” mentality, EHR vendors continue to add functionality to their portals that customers can (and should) adopt. For example, the platforms can support scheduling everything from visits to procedures. Patient-generated data from wearables can be entered and viewed by a patient care team. Because the portal is considered finished, however, organizations are slow to or do not adopt these new functionality. If healthcare providers saw their patients more like consumers, a shift would take place in functionality and improve user adoption and satisfaction. 

Friction, in the consumer sense, identifies how hard it is for a customer to get what they want from a digital interface. Why does Amazon have a “1-click to buy” button on their app? It makes it much easier for me to impulse buy toys for my kids. If I had to click through four screens and re-enter my password each time, I might abandon my purchase and invest my money wisely. 

Organizations that remove unnecessary friction will do better. This became clear to our organization over a year’s worth of patient portal steering committee meetings. We had a dedicated patient advocates and IT representatives meeting monthly to discuss our portal because we were stuck at around 12% activation and use. Repeatedly, the group made recommendations to offer canceled appointment slots to a waitlist of patients and online self-scheduling of office visits, but the operational engagement was not there.

The reasons made sense but mainly revolved around changes in our practices’ long-established workflows that were mainly telephone-based. It was only after getting buy-in on the concept of patients-as-consumers did the operational areas come on board. Unsurprisingly our portal numbers are now over 40%.

Patients, like consumers, have come to expect interactions with your system to be on their devices and for those interactions to be easy. These may seem lofty goals, but a few key pieces of functionality will help you get there.

1. Registering for an account: Many organizations require an initial patient visit before a patient may access the patient portal. A registration code and instructions are given to the patient after the initial visit with the organization. Unfortunately, this makes the portal an afterthought. Most portals allow a patient to create an account prior to a visit. Organizations should take advantage of this functionality to do pre-visit planning, paperwork, and communication. Yes, patients may make mistakes when entering demographics or insurance information. They may even create duplicate records if they forgot they have an account, but these mistakes can be fixed on the back end. Getting patients in your digital front door is worth the hassle.

2. Scheduling office visits: Giving patients the freedom to schedule their appointments is almost sacrilegious to the medical community. Physicians and office staff want to retain control over the flow of patients into the office. This is 100% understandable and has merit. Leaving gaps for emergencies or preventing a patient from jamming a 1-hour annual physical into a 15-minute sick visit prevents havoc from being wreaked on the flow of an office.  The reality is that very few of these fears come true with some careful planning and system monitoring.

3. Access to medical records: Viewing test results is a long-standing feature that most organizations adopted due to MU. The federal government pushed this feature to a new level with information blocking rules that went into place this year. It used to be commonplace to block test result release for days or even weeks. Now, delaying test results is considered information blocking. The new rules include office and hospital notes and all of this data needs to be available to patients in almost real-time.
   
   Just because this functionality is on, however, doesn’t mean it is promoted. Trusting patients to see their medical records and understand it feels like a giant leap to most health care organizations. Our organization shares over 35,000 notes a month. Patients viewed roughly 15% of them with no complaints to our patient advocacy department. In fact, we received multiple compliments on how helpful patient data was to patients and families. There is a growing body of medical literature to support this. Check out Opennotes.org to learn more.

4. Make your app a one-stop-shop: App development is an area that most hospital systems do not think that much about. They take their portal as their vendor created it. Think about using it for Wayfinding within your facilities. Give your patients educational material that comes from a trusted source. A health system near us did just this. They created an app and embedded several different apps, including their patient portal. The end result is a seamless experience for the patient and their families.

Patient engagement is shifting towards seeing patients as consumers. Offer them a friction-free portal experience and they will use it to their benefit and yours.

The post The Journey of Patient Portal is Often Incomplete appeared first on HealthTech Magazines.

This happened almost overnight: The federal Centers for Disease Control reported a 154% increase in telehealth visits during the last week of March 2020, compared to the same period in 2019. With hospitals overwhelmed and patients in lockdown, the pandemic flipped the switch to activate a movement that had been building for years.

As innovative tools and technology continue to enhance the virtual experience, healthcare systems face new questions. How can we leverage these advances and growing acceptance by patients? How can we take virtual care to the next level, particularly as the pandemic continues?

Designing the program was a multidisciplinary effort that focused on the dual objectives of Metro Health’s digital health strategy.”COVID-19 has accelerated widespread transformations in healthcare delivery and technology, perhaps nowhere more dramatically than telehealth adoption.

Although the recent expansion of telehealth has emphasized primary-care visits, we also have the opportunity to address the challenges of the pandemic itself by mitigating its burden on our health systems and at the same time, improving patient outcomes.

Home-based monitoring of select COVID-19 patients, paired with telehealth, offers just such an opportunity.

Serving patients where they want to be

On Nov. 30, in the wake of the pandemic’s second U.S. wave, Metro Health – University of Michigan Health launched a 24/7 home-monitoring program for ambulatory COVID-19 patients at our 208-bed hospital in Wyoming, Mich.

By discharging certain patients to recover at home, where they are most comfortable and heal best, we have been able to keep more beds available and limit exposure and workload for staff. In the first month of operation, 33 patients enrolled, saving more than 300 hospital stays.

When an attending physician clears an ambulatory COVID-19 patient for home recovery, we equip the patient with an internet-connected tablet and Bluetooth-synched peripherals: thermometer, blood pressure cuff, pulse oximeter, and scale. We teach them how to use the equipment and we send them home.

Patients take multiple readings a day and answer surveys about their wellbeing, including questions that screen for the depression commonly seen with COVID-19 cases. The readings and responses are automatically entered for remote monitoring by a team of medical professionals. Patients have video visits with providers – which family members can join virtually – and can ask for help via the portal.

Metro Health designed and launched the program in 10 days and we have heard nothing but rave reviews from patients.

No patient wants to be confined to a single room without visitors for any amount of time, let alone the notoriously long length of stay for COVID-19 hospitalization. Studies show patients heal better where they are most comfortable, sleeping in their own bed, eating their own food, and surrounded by the comforts of home.

Technology that enhances the patient-provider experience

Designing the program was a multidisciplinary effort that focused on the dual objectives of Metro Health’s digital health strategy.

“We always want to preserve the intimacy between patient and provider – to enhance, not get in the way of that experience,” said J. Josh Wilda, Chief Information Officer. “We also seek technology that extends when and where we can treat our patients.”

Remote patient monitoring is increasingly recognized for its potential to reduce hospital readmissions, improve outcomes and support data-based care decisions. Metro Health had been exploring expanding its home-monitoring program for cardiology patients, but the pandemic inspired a pivot.

“We are excited for how this and other digital health tools will allow us to shift the patient care model in the appropriate settings, putting more tools in the hands of the patients to be more involved in their care with their providers,” Wilda said.

Metro Health worked with Health Recovery Solutions to design and launch the program. The system integrates with our electronic health record system, Epic, and has the ability to add approved family members to the patient portal for virtual visits.

A robust clinical role

Deploying technology is only part of the equation. At Metro Health, we knew a successful launch would require collaboration across the board, from IT, case management, hospital staff, and importantly, our medical group.

Since we do not have an established monitoring center, we leveraged employed staff across our system to check the patient portal around the clock. This involves physician assistants, nurse practitioners, nurses, medical assistants, and case managers supported by physicians and specialists.

Nurses and medical assistants check the portal at least every two hours during the day and every four hours at night. Providers monitor the portal throughout the day as they conduct virtual visits with patients. Appointments are scheduled for days one, two, four, seven, and 10.

The system also issues alerts if a patient’s readings or responses fall outside established parameters. For example, if a patient’s pulse ox reading is out of range, email and text notifications go out to multiple staff members. Nurses triage the patient, determining whether to escalate the case and bring in the nurse practitioner, physician assistant, or physician.

In addition to being popular with patients, the system has been embraced by Metro Health providers. Gerrit J. Kleyn, a primary care PA at one of our outpatient clinics and part of the team that supported this innovation, put it this way:

“Being able to assist patients while they convalesce from COVID in their own homes has been one of the most rewarding things I have been involved with. We receive daily words of appreciation from our patients and their families for the level of care we were able to provide through the virtual equipment.”

Looking beyond COVID-19

One of the hallmarks of the pandemic era has been the ability of medical organizations to adapt and develop solutions for challenging situations.

Like all good innovations, remote monitoring has potential beyond the pandemic, with opportunities to prevent hospitalizations and support post-hospital recovery. Metro Health is exploring expanding home monitoring for patients with congestive heart failure and COPD to reduce the risk and cost of readmission common with these conditions.

The goal is to provide the expert caring relationship that patients deserve in a setting that makes them happiest – at home.

The post Remote monitoring helps COVID patients at home, where they heal best appeared first on HealthTech Magazines.

Why do so many hospitals have closets full of dusty and unused telehealth equipment? In short, because they fail to consider the broader organizational work needed before technology can be effective. Instead, it’s the cameras, screens, mobile apps, and other telehealth equipment that come to mind when launching a project. I have seen this repeatedly as the Chief Medical Information Officer for two different organizations and have captured the seven key factors to success below. They have been observed over the past ten years and continue to serve me well in my current role at Bayhealth. Applying them will prevent your organization from wasting time, energy, and of course, not filling up another yet another closet.  

Before diving into the organizational work necessary to implement telehealth services, consider that technology to provide patient care existed long before it was widely used to do so. Radiology images were first transmitted over telephone lines in the 1940s, but teleradiology wasn’t widely adopted until the 1990s. Virtual video visits were first used in the 1990s, though it wasn’t until COVID-19 that the use skyrocketed. The reasons why can be found below.

1. Telehealth shouldn’t be thought of as a single thing to bring into your organization. Telehealth should fit a specific niche that is part of your overall organizational and IT strategy. Breaking telehealth up into projects is essential to success. For example, a project adding remote patient monitoring when chronic care management isn’t on your strategic roadmap, will fail. The technology may be great, but the overall project won’t get time, resources, or attention like those that fit the organization’s roadmap will.
   
   
2. Pick a platform to connect – Much of the buzz and advertising focuses on this. You and I receive emails, cold calls, and vendor outreach daily asking to check out a fancy new piece of telehealth technology. Cut through this noise and make sure the platform is easy to use and fits into your organization.
   
   Our organization uses a platform embedded in both our EMR and the patient’s portal for office visits. This makes connecting easy for both the clinician and the patient.
   
   Keep an eye on your overall IT strategy when choosing a platform. You may select one that is best in class for your project, but if it requires proprietary hardware or a ton of interfaces with other technology in your organization, it won’t be integrated or adopted. Imagine a busy emergency department with a different telepsychiatry cart, tele-stroke cart, and pediatrics cart. Maybe your organization can support this, but likely it would lead to confusion, lack of adoption, and patient care issues.
   
   This exact scenario played out at our organization. Now, we insist upon using our video carts rather than a vendor’s, despite losing a small amount of functionality. It was worth the trade-off to keep the workflow simple for our staff. Work with your vendors to understand your IT strategy and find ways to incorporate their platforms and services into your organization’s existing technology. If you need new hardware or software to be successful, think about future uses, so you aren’t boxed in when the next project rolls around.
   
   
3. Ensure operational support – Organizations often try to jam a project into existing workflow and staff responsibilities without much thought. Engage your administrative and office staff in the project. Without their support, the project will fail. One of the reasons virtual visits are declining at this stage of the pandemic is that organizations did not fully embrace the changes need to keep visit volume up. Did you adjust your front desk and scheduling scripts to include virtual visits as an option? Can patients request a virtual visit from your portal? If the answer to these kinds of questions is no, don’t be surprised when adoption is low or fades after launch.
   
   
4. Have a billing plan – The rules for telehealth service reimbursement are complex. They can also vary by state and payor. Having dedicated resources to help your clinicians understand documentation requirements and ensure they get paid is critical. There are whole new sets of CPT codes to learn. Clinician and coder education is a must to be successful. Patients must understand the costs on their end. For example, co-pays can vary between in-person and virtual visits.
   
   
5. Check state, national, and payor regulations – Many of the regulatory reasons for project failure have been removed or suspended due to the COVID pandemic. It is unclear how many will remain. Stay on top of these changes at both the local and national levels. One underestimated restriction is the physical location of both the patient and clinician. It seems counter-intuitive for a virtual visit, but regulation can require licensure based on where they are, not where your organization is located.
   
   
6. Make a training plan – Many organizations forget training altogether or just focus on the clinician. Don’t forget that your patients will need to be trained as well. Both groups received training on our platforms prior to go-live of virtual visits. Materials were made readily available on both our public-facing and internal websites when applicable. Standardizing your equipment and workflows helps tremendously with this. Staff and patients get accustomed to the way things work and adding new services is easier for everyone.
   
   
7. It takes two to tango. Prior to launching any telehealth service, you must clearly identify who will be the provider and who will be the recipient. It seems obvious that you need someone on either end of the technology, but I have seen instances where work begins on a project when one of the two is missing.
   
   An organization that sought to provide teledermatology services due to patient demand failed to identify a dermatologist to see the patients. Another organization with a small rural emergency department installed remote ICU monitoring equipment costing thousands of dollars, so physicians at a tertiary care center could monitor patients and identify those requiring transfer. Unfortunately, this was done without the agreement of the physicians able to provide the care. Unsurprisingly, the equipment was never used.

The seven steps above will help you avoid piles of unused equipment. You will also avoid wasted time and dollars on efforts that ultimately will fail. Telehealth is coming in almost all sectors of health care. Stay ahead of the curve with a sound strategy, good partnerships, and fully fleshed-out projects.

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Healthcare has never been considered an industry easy to disrupt or willing to embrace innovation. It took a global pandemic to change healthcare as we know it today and I am certain that we are only at the beginning of this change process curve, putting one disruption point behind us and a few more to come. We have been working hard over the last few decades, moving past what once was a ‘Sick Care’ and truly focusing on ‘Healthcare’, which promotes our communities’health and well-being. Yet, we failed to prepare adequately to face this pandemic and gave a response that one would consider less than optimal for the most expensive healthcare system in the world. Without a doubt, resilience and dedication to providing quality care have allowed us to get to where we are today despite all adversities we faced.

By virtualizing care and delivering innovations at home, we are building bridges which no health system can build physically.

What needs to change moving forward?

All of us will have many different ideas and perspectives around how to navigate a path forward, but one thing is clear that ‘Status Quo’ is now less desirable than ever. I am not saying that almost all care will need to be virtual & delivered to the patient’s home, but why not aim for it? It is only when we seek dreams we are able to create tomorrow’s success today. We all know that highly complex and advanced care will always require hospitals and medical facilities where patients will have to travel, but can’t we at least work on making HealthCare a little more ‘Caring’ and ‘Healthy’? Self-care equals better patient care and bedside standard of care saves more lives than any other medical interventions. Hospitality in the context of a hospital aims to make the patient’s experience positive. By virtualizing care and delivering innovations at home, we are building bridges which no health system can build physically.

Today, I am able to coordinate a video visit with a daughter in Florida and an elderly parent in my home state Massachusetts where I practice primary care, to go over End-of-Life Planning discussion and help assess medication compliance and home environment which might  prevent next fall &/or ER visit. My care team is able to engage with patients virtually in realtime at the most vulnerable points in their care, such as post-hospital discharge through TCM (Transition Care Management) program, monitoring and preventing the adverse outcome of chronic disease through RPM (Remote Physiological Monitoring) program, & engaging patients, post Emergency Room visit to improve access to care, address gaps in care or prevent further downstream utilization thus reducing total cost of care.

Compass Medical, where I practice as a primary care physician and function as Chief Medical Information Officer, is a physician-owned and led medical organization serving over eighty thousand patients across Southeastern Massachusetts. Just like many other healthcare organizations, we also faced the crisis head-on with a steep decline in office visits, rapid deployment of Telemedicine, and process disruptions around every aspect of care delivery given new safety and infection control measures needed to implement. Patients were avoiding essential in-person care and providers were beyond overwhelmed trying to manage clinical and operational volatility.

Crisis breeds Opportunities and Success breeds Complacency.

A group of our leadership team members and clinicians came together to seek new opportunities amid this crisis and we came out with what we call today ‘Connected Care Services Model’. We doubled down on CCM (Chronic Care Management) we implemented as a centralized service since 2016 and expanded by incorporating TCM (Transition Care Management) program enabled through real-time ADT (Admission Discharge Transfer) feeds. We recruited a pool of clinical staff and providers rapidly to deploy RPM (Remote Patient Monitoring) program and post Emergency Room discharge Telehealth follow-up the program. We increased our TCM utilization by 500% and created a new services model while our peers were either doing 100% virtual care or waiting for this pandemic to be over to go back to “Old Normal”.  

Our patients started embracing these new care delivery models rapidly. They appreciated working outside the box of medical buildings we so get hyperfocused on as our sole means to provide excellent quality care. Now the care was in patients’ hands or reaching out to them in times of their most vulnerable. Remote care is not just limited to providing necessary means to take care of patients in their homes, but also should enable every care team member to provide the highest efficiency of care possible. Remote work from home enabled us to continue many essential clinical and operational processes without major gaps in the workforce due to exposure or other such needed measures. We have a set of providers currently utilizing remote scribing services, including myself which allows for greater flexibility and efficiency by reducing EMR documentation burden.

Remote care or Telemedicine is not the next big thing. I firmly believe that remote care is an opportunity, but at the core, it is just another part of a comprehensive care delivery which we need to continue to enable through data and technology. We cannot wait for the crisis to be over to pave the path forward as our most high risk and vulnerable populations need us in healthcare today more than ever to provide new ways to handle old problems and work together to find solutions to new challenges we all face together.

The post Remote Care: Turning Crisis into Opportunity appeared first on HealthTech Magazines.

I was privileged to get into Health IT right around when the Meaningful Use initiative was the Healthcare industry buzz. The whole point of the initiative was the use of certified EHR technology in a meaningful manner.

I stayed the course, and I have been on this journey every step of the way, waiting to see with bated breath how this will all turn out. Well, I am still in the trenches, and excited to be at the point in which I see that almost every health system in the United States has accumulated an incredible amount of data. Now the question is, what do we do with this data?

In addition to my passion for all things EHR, I have a great interest in the financial outcomes of our health systems.  As a Chief Medical Information Officer, I sit in an enviable position in the whole sausage-making process – in a seat where I see the data collected, processed, and turned around to become meaningful dollars to keep our health system afloat so we can continue to provide care for the millions of patients we see every year. 

Every health system that hopes to survive and keep its doors open to continue to provide care must, of necessity, master the use of technology and the massive treasure trove of data it continues to accumulate.

Although reimbursement of health systems was not one of the five pillars of the Meaningful Use initiative, it has become a crucial byproduct of the whole experiment.

Every health system that hopes to survive and keep its doors open to continue to provide care must, of necessity, master the use of technology and the massive treasure trove of data it continues to accumulate.

Understanding Health System Wealth

I use the term Health System Wealth in my mind. That’s how I see data. I see it as a treasure trove. A chest full of gold and precious stones are hidden away from the average eyes. I personally have a quest to find it, master it and turn it around. 

So, in my mind, “X” marks the spot. The “X” is in our Data Warehouses – tucked away in a basement or somewhere in an EHR vendor’s “Cloud.” We need to mine these.

But let’s take a practical look at the data closest to us and the processes surrounding the collection of those data. Here are a few gold nuggets.

Paying attention to data collection

Data Capture: What, When, and Where

As a physician, I have found over the years that due to the nature of our training, reimbursement of our hospital is often not top of mind when we are seeing a patient. For instance, the Emergency Room (ER) physician. In that highly pressured environment, all she thinks of is the immediate care of the patient’s often life-threatening issues – and rightly so. However, when it comes to reimbursements, all the payer is thinking of is what was documented at the time of the encounter. Did she order the EKG the nurse performed? If she didn’t, that EKG, as crucial as it was when done, will likely go unreimbursed. Did she describe in detail the length and depth of the laceration she sutured, i.e., is this a simple laceration repair or an intermediate layered closure? This simple omission is many times a difference of hundreds of dollars in reimbursement per procedure. And when you think of how many laceration repairs are performed in our ERs, you can start to see how many thousands, even millions of dollars, are lost to our health systems every quarter, every year.

Detailed Provider and Clinician Documentation is Gold

Comorbidities (CC) and Major Comorbidities (MCC).  As we all know, every line documented in your EHR has the potential to turn into (or take away potential) reimbursed dollars. The utmost importance of documenting Comorbidities (CC) and Major Comorbidities (MCC) cannot be overemphasized. This has a direct near-term and long-term impact on at least three things.

• Immediate reimbursement for that particular admission 
  
  
• The Case Mix Index – which translates into immediate dollars for your health system
  
  
• Your quality reporting to CMS has long term implications for reimbursement to your health system

To understand and maximize this, is to realize literarily millions of dollars per year for the health system.  For this reason, many health systems now have not only a Clinical Documentation Improvement (CDI) team they have also hired Physician Advisors to ensure that CCs and MCCs are accurately captured.

The People, Process, Technology Gold

The Admission Process Gold.  

In my world of Clinical Informatics, the mantra is People, Process, and Technology. Most payers require that the hospital checks in with them to ensure that the patient meets the Medical Necessity requirements. To do this, the payers require that they see the documentation that justifies this patient admission within a certain timeline – 24 or 48 hours. This usually is in the form of a History and Physical (H & P) document. As simple as this seems, many hospitals struggle with getting many of their Providers (often heavy admitters) to document H & Ps to meet that timeline. This is so because admission orders can easily be called in verbally or even entered electronically. As we all know, an admission that is not pre-approved many times will go unreimbursed – again, a loss of millions of dollars in reimbursement.

How to Start Gold Mining

So, where do we start?  I suggest starting our gold mining in 3 areas. These areas, I found, are the greatest areas of revenue loss and could, with data capture and process improvements, cause a quick and appreciable rebound in a health system’s bottom line.

1. The Emergency Department. 
   
   
2. The Admission Processes. 
   
   
3. Provider Documentation right through the health system – outpatient and inpatient areas.

My recommendation is to do this through a systematic Process Improvement initiative focused on the health system’s bottom line. For example, targeted Lean events that involve the key players: Revenue Cycle, Quality, HIM, Clinical Informatics, and the leaders of the clinical areas.

The post Mastering the Use of Data, Technology, and Process to Enhance Your Health System’s Bottom Line appeared first on HealthTech Magazines.

On June 30, 2020, IBM Watson Health announced the annual 15 Top Health System awards based on published quality outcomes from the Centers for Medicare and Medicaid Services (CMS). A truly remarkable feat for the 15 systems that were recognized and, more importantly, the patients of these top-in-class systems. The top system in the large system category was the HCA Healthcare Continental Division, with hospitals located across Denver, Colorado, and Wichita, Kansas.

The IBM Watson Award is based on its Top 100 Hospital methodology, which uses data from publicly available sources including MEDPAR, the CMS Hospital Compare data set, Medicare spending, and HCAHPS patient experience survey data. From these data sources, IBM Watson derives ten quality performance metrics. The leading health systems are then segmented into small, medium, and large systems. The HCA Healthcare Continental Division was recognized as #1 in the large system category.

The HCA Healthcare Continental Division uses the Meditech Magic EMR since it is long-implemented, very stable, and has low support expenses. This award shows that health systems can achieve quality excellence without paying a premium for their EMR. From an IT perspective, while the EMR is essential, many other IT factors and technology developments play a substantive role in delivering and monitoring quality.

So how is the HCA Healthcare Continental Division leveraging its less expensive EMR platform and related technologies to achieve these stellar patient outcomes? The focus is primarily on:

• Tight collaboration between the key health system constituents at every phase (planning, delivery, and review)  including the clinicians, support teams, and IT;
• This results in well-defined clinical quality goals and achievable action plans;
• Clinician-centric, intuitive interfaces and order sets that drive high-quality care implicitly and also build into the ordering and documentation processes;
• The power of data, broadly aggregated in HCA Healthcare’s non-EMR data warehouse, analyzable not just retrospectively, but increasingly in real-time;
• The live delivery of actionable information and clinical recommendations, in a concise, meaningful way to the target clinicians– increasingly via HCA Healthcare’s internal non-EMR clinical mobile platforms;
• Constant performance review – which leads to adjustments in all of the above;
• And respect for the adage – People, Process, and then Technology.

In the United States, many health systems began broad EMR implementations in the 1990s, and thus the US is in its 4^th decade of EMR usage. Interestingly, the three most sizeable system EMR vendors in the US today – Cerner, Epic, and Meditech – have their business and technology roots in the 1970s. This length of time and the penetration of EMRs in health systems indicate EMR technology is a mature industry – as is the data organization in the EMR and many of the user assumptions, workflows, and experiences that occur within it.

EMRs are essential to a health system, but often their information presentation methods are dated. They are analogous to a card catalog system in an extensive library assuming the library user has some idea what they’re looking for and where to ‘pull it.’

Modern data/analytics tools and mobile data delivery systems turn this approach on its head.  They enable identifying actionable data and clinical paths, and can ‘push’ such data and recommendations to the right clinical users, often via mobile platforms.

As Professors Lakhani and Iansiti advocate in their recent book “Competing in the Age of AI,” an intuitive user interface is critical, but the real power of software systems is in the data. HCA Healthcare’s Continental Division increasingly benefits from HCA Healthcare’s substantial investments in its enterprise data warehouse, analytics tools, and flexible messaging layers to deliver data, and mobile apps and hardware that put actionable information in the clinician’s hand.

Examples include real-time analytics that trigger text alerts to the clinical team that reduces the central line and other hospital-acquired infections, sepsis risk alerts, and proactive messages to mitigate pressure ulcers. Additionally, HCA Healthcare has developed and deployed machine learning algorithms to screen for and intervene when a patient may be decompensating in an acute care setting based on a variety of clinical data feeds. 

Nearly 50 years ago, Dr. Avedis Donabedian proposed a model to achieve  quality care in health services via “structure, process, and outcome.” HCA Healthcare Continental IT leaders have adopted that, and refer to “People, Process and Technology” every day. Clinicians always consider and acknowledge primarily the people part of this equation and consider the impact of technology on our ‘clinical customers.’ After all, it is the 24/7 bedside clinicians delivering that care where patient outcomes achieve true greatness. And similarly, it cannot be over-emphasized the clinical leaders’ central role such as CMOs, CNOs, VPs of quality and process improvement, and medical directors.

HCA Healthcare’s increasing focus on data, analytics, and actionable clinical information delivery has enabled the HCA Healthcare Continental Division to achieve this IBM Watson recognition, and most importantly, benefit our patients. During this challenging period in the history of humanity, this award further inspires us to continue our clinical collaborations and maximally leverage modern technologies to improve human life.

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A popular saying among emergency medical providers during the height of the COVID-19 was, “where have all the strokes and heart attacks gone?” The answer, of course, was: nowhere. Shelter-in-place orders not only created physical barriers that limited patient access to their providers, but many patients let fear take control and chose to ignore symptoms, both life-threatening and routine. They thought that staying home was better than risking exposure to the virus in a doctor’s office, only to find that these choices led to more risks, complications, or a longer recovery.

Thankfully, telehealth has been an immense force in helping to reverse this trend and reassuring patients. Through virtual medicine, patients can feel safe and get the urgent and routine care they need, both in a crisis and going forward.

While telehealth was not new pre-COVID, adoption was relatively slow. According to a McKinsey survey in April 2020, “Consumer adoption [of telehealth] skyrocketed, from 11 percent of US consumers using telehealth in 2019 to 46 percent of consumers now using telehealth to replace canceled healthcare visits.”

White Plains Hospital had been working on a telehealth solution prior to the pandemic, but it wasn’t until the crisis struck and procedural barriers were lifted that our platform could fully go live. As the pandemic quickly spread within our community, it became clear that in order to provide care to our patients, the Hospital’s ambulatory network of approximately 250 clinicians would need to deliver care virtually for the foreseeable future. In less than ten days, all 250 of these clinicians were trained and delivering virtual consultations and follow-up appointments on our new telehealth platform, “WPH Connect.” As a result, between March and July, more than 25,000 virtual visits had been completed.

Although a crisis thrust technology into the forefront, it also lets us see how technology could support care in other areas of the Hospital. Faced with critical shortages of Personal Protective Equipment (PPE), we began using our platform at the Emergency Department for rapid triage of patients with COVID-related symptoms. This created a safe and effective modality to triage patients while reducing the rapid turnover of PPE between each patient interaction. Between March and July 2020, more than 1,200 telehealth visits were performed from our screening tent outside of the Emergency Department, allowing for safer and more efficient diagnosis and contributing significantly to the preservation of PPE.

Our telehealth platform was also important for patient follow-up, playing a large role in preventing disease spread, and reducing readmissions. For the nearly 1,500 patients who were evaluated and released from the Emergency Department with COVID-related symptoms, we were able to monitor their symptoms and track their progress from home.

As we begin to shift our focus beyond the virus cautiously, there’s an open road ahead to explore technology use to enhance care. To that end, we’ve begun using WPH Connect to deliver virtual physical therapy, virtual breastfeeding support for new moms, virtual discharge readiness, and also to add loved ones to patient visits, like including a family member in an oncologist appointment. We were also able to use the app to create an added layer of service for a hearing-impaired patient. An ASL interpreter was added to the visit and the patient could also use the chat option to type messages.

Innovations are also extending beyond virtual visits. We’re working now to embed geofencing into WPH Connect so that the check-in process can begin once a patient pulls into the parking lot at one of our offices. This will limit unnecessary interaction between the patient and staff, allowing the patient to head directly to an examination room once ready. We are also leveraging software tools in our Emergency Department to immediately alert and assign a clinician to a patient that is in route to our Emergency Department, helping our physicians prepare for the patient’s arrival.

Additionally, the Hospital has recently gone live with a “telestroke” program where clinicians use specially designed carts to remotely consult with fellow providers via the video conferencing screen and conduct examinations using several connected scopes and peripherals. In the future, these carts can also be used for other inter-professional consultations including infectious disease, pulmonary, dermatology, and pediatrics, to name a few.

In less than ten days, all 250 of these clinicians were trained and delivering virtual consultations and follow-up appointments on our new telehealth platform, “WPH Connect.

We are beginning to see first-hand how innovation can augment traditional models of care. However, one of the biggest takeaways is that when harnessed appropriately, virtual health can still feel personal and “hands-on.” During this crisis, clinicians at White Plains Hospital were able to get a glimpse into patients’ lives during telehealth visits and could be there for their patients while many were stuck in their homes wondering how their cancer care or chronic diseases will be managed.

While technology can never replace human interaction, it can enhance patient experience and patient and provider interaction. This pandemic has changed the way we think about a lot of things, including safety and healthcare delivery. While we hope the virus will be manageable soon, the technology innovations and lessons learned are here to stay. 

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I have written before about the role of clinician in healthcare IT – the crucial part that the clinician informaticist plays in translating the end-user (e.g., provider, nursing, patients) needs to IT build, and vice versa. I have even stood on soapboxes to broadcast this message. However, the COVID-19 pandemic laid bare the importance of the clinician in another area: prioritizing IT projects, particularly when it comes to introducing new technologies.

There are two key approaches when it comes to the push-pull of technology – business and operational needs driving IT or IT pulling the organization to find new needs. Where your organization lies on this continuum depends on many factors, but in healthcare, clinical and administrative operations almost always drive the IT agenda rather than the other way around. Although this sometimes means that new technology is introduced more slowly than in other types of organizations, it serves to ensure that the focus remains on the clinical and administrative priorities. In the past six months, the need for a fast-paced pandemic response turned that on its head. There was no time for IT to wait for broad-based consensus and identification of needed services – we had to use the clinical knowledge available to us directly to anticipate those needs – even as they were evolving. This phenomenon wasn’t isolated to catapulting into virtual care delivery as so many organizations experienced but crossed the entirety of the hospital’s operations.

I was part of the core team of our hospital incident command through the Massachusetts COVID-19 surge in Spring 2020. As the largest safety-net institution in New England, Boston Medical Center experienced the surge earlier and more intensively than other area hospitals. The coordination of the IT response to COVID-19 has been as complex, broad-reaching, and lasting as the clinical response.

The hospital incident command structure allows for a small group to orchestrate the larger organizational response to a rapidly evolving situation. The vantage point from within incident command allowed me to influence and communicate these rapidly evolving priorities of the institution such that the IT response could be both proactive and reactive. Although we had only a cursory understanding of pandemics, we did understand that our hospital would need to care for its patients while taking public health measures to flatten the curve for the population overall. Having a clinician leading the IT response meant that we could integrate intimate knowledge of care delivery for individuals and populations into this process. We were able to provide for a workforce numbering in the thousands to quickly move to “work from home” (WFH) and engaging patients virtually. We redesigned our clinical spaces to support a surge of inpatients, provided clinical tools to care for a new disease, and produced data analysis to support our clinical and operational work. The combination of knowledge of care delivery and how IT systems are built to support that delivery meant that we could anticipate and respond to emerging needs. Having a team that focuses on the next clinical (and administrative) needs is crucial for the organization to pivot the IT response to meet those needs – and an important function of the clinical informaticist.

The clinician informaticist’s place is not unique to our current pandemic:

1. Anticipate care delivery systems and applied informatics (health IT) needs to support evolving clinical, operational, and business needs (in a pandemic: a surge of infected patients, distancing mandates that sent almost all non-urgent care virtual, new treatment protocols, disease surveillance, and contact tracing)
   
   
2. Ensure the end-user remains a key part of the design and implementation process. No matter how rapidly the process moves from conception to implementation – workflow must always come before IT design.
   
   
3. Broker agreement between competing priorities and institutional functions to arise at solutions that address the challenges at hand.
   
   
4. Guide the analytics and contextualize the data (in a pandemic: to track prevalence, testing, contact tracing, and clinical outcomes; to understand and ensure supply chains of PPE, medications, and testing supplies)
   
   
5.  [in academic centers] Support (and sometimes pursue) research opportunities in clinical trials and health services research through health IT changes and data analytics.

In addition to serving as operational and IT experts, clinical informaticists must take responsibility for going beyond responding to identified needs and anticipate what will be needed next. We must be comfortable both pushing and being pulled into new health IT frontiers.

The landscape continues to evolve as the pandemic progresses and our clinical understanding of COVID-19 sharpens. From video conferencing vendors offering special services to educational institutions, to ride-sharing apps repurposing their software to direct people to care, to clothing companies and plastic manufacturers producing face masks and shields, the outpouring of support and singular focus in combating a common scourge is palpable. This is the time for healthcare leaders to use that momentum for change to lead their organizations in new directions. Clinical informaticists must be seen as integral to healthcare leadership and do the same.

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During a time of crisis, such as the COVID-19 pandemic, healthcare organizations must rely on an “All Hands on Deck” approach. However, what has this meant for those that support their healthcare organization via the organization’s information technology? It likely meant the Information Systems (IS) department was even busier developing new processes, implementing new technologies, and supporting more users as the pandemic approached. Team members needed to remain strong to meet the needs of our patients and our communities. However, it also meant that we all had to keep our team members safe and fully informed.

At Baptist Health, we were in the early stages of our telemedicine journey prior to the COVID-19 pandemic. We understood that we would need to incorporate telemedicine models into our strategic plan for growth and sustainability. I sometimes joke that we implemented five years of strategic plans for telemedicine in five weeks. We deployed telemedicine via Zoom for all of our ambulatory clinics, including specialties such as psychiatry and cardiology, in just two weeks. We quickly deployed telemedicine for pediatric and adult rehabilitation services, including physical, occupational, and speech therapy. One of the challenges we faced was determining how we could utilize telemedicine for our inpatients. After many hours of pilots and process evaluation, we were able to deploy telemedicine for the inpatient providers using Zoom and an iPad on a cart for tele-ICU rapid assessment, wound care consults, and dietary requests. We developed a strategy where each COVID-19 patient had an iPad in the room so hospitalists could meet with the patients virtually to minimize exposure and save Personal Protective Equipment (PPE). Finally, we enhanced the patient experience by promoting Zoom virtual visits with loved ones while the inpatient units had visitor restrictions to keep our patients and our staff safe.

As an IS leader, my lesson learned was the primary emphasis is on the importance of our people, rather than technology.

Baptist Health was in early discussions about beginning a work-from-home program prior to the pandemic. Several analysts worked remotely, enabling us to recruit top talent. However, we were also evaluating how work-from-home could be applied to other areas in order to have increased employee satisfaction. An announcement was made that work that was not essential to be on-site should be remote. We had to evaluate what could be done remotely and to further assess how to stand up the necessary infrastructure required for a remote workforce for an entire organization of over 12,000 team members. We supported the transition of our employees to a remote workforce by increasing the number of VPN licenses, purchasing laptops, and enabling Webex and Zoom technologies.

To support the deployment of these technologies, IS team members, from executive assistants to project managers, went to our temporary storage location to open up boxes and set up iPads on carts, Work Station on Wheels (WOWs), and laptops with Nuance microphones. We wanted to ensure the bedside caregivers were not limited by the technology, but rather have an expanded reach because of the technology.

Our Clinical Informaticists (CI) and analysts were essential to the support of the organization. They designed new rules to minimize the clinician risk of exposure, developed lab orders, created order sets specific to caring for COVID-19 patients, and streamlined documentation templates. They also designed, built, and validated COVID-19-specific reporting tools to track and monitor our patients.

Additionally, we evaluated whether the nurse informaticists could serve in a patient-care capacity, and if any additional training would be necessary. It was ultimately decided that the nurse informaticists could serve patients by manning the drive-thru testing site, where they swabbed potential COVID-19 patients in a tent equipped with appropriate PPE.

As an IS leader, my lesson learned was the primary emphasis is on the importance of our people, rather than technology. “All hands on deck” was asking myself what I could give to my team members during this time of crisis. During this time of working extended hours to support the organization, our employees were and will continue to be at risk of feeling fatigued and isolated. I tried to think of new, virtual ways to make my team feel appreciated and engaged. I hosted a virtual “Town Hall” at the end of every week. To do this, the first requirement was to ensure video capabilities were turned on for all team members. The second creative challenge was to come up with a theme everyone could participate in. The themes included superheroes, with appearances by Superwoman, Spiderman, and, of course, many nurses (the real superheroes!). My favorite theme was the “Tiger King.” It was a fun way for me to communicate important updates about COVID-19 with all of my team members while allowing for a little levity and togetherness in a time of social isolation.

It is important to tell your team members, although they may not be the ones performing the telemedicine visits with patients, they have impacted the care of those individuals by developing and testing the process. The team members who deployed the WOWs, iPads on carts, and laptops are very much a part of the care team. We made an impact every day, keeping the workforce safe by supporting the capability to work from home and facilitating virtual provisioning care. It is also important to remind your team to take time to care for themselves. We sent daily system-wide communication with simple self-care steps, including tips for eating healthy and reminders to spend time outside. In fact, several rest-and-revive tents were set up throughout the organization for team members to recover in a relaxing setting surrounded by soothing music and support of our Baptist Behavioral Health and Spiritual Care team.

Now, we must look to the future. We need to think about how to restart the physical organization, but also how to adjust to the changing paradigm of health care in which telemedicine is a new reality. Baptist Health successfully maximized the care of our COVID-19 patients by developing a home-monitoring program utilizing home health nurses via telemedicine visits with our primary care physicians. We will need to expand these innovations into the future by developing a “Hospital at Home” program utilizing digital monitoring devices. We should all be evaluating how we can develop a telemedicine workforce dedicated to monitoring patients for disease states beyond COVID-19, using digital devices and telemedicine visits.

The impact each of us has had on our organizations will last long after COVID-19. I was just lucky to be a part of it, at Baptist Health, and as a teammate of health professionals throughout America. 

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The healthcare industry is going through an incredibly massive digital transformation, and this change comes with new responsibilities for the clinical leaders of healthcare organizations. Traditionally, is the Chief Medical Information Officer (CMIO) that is tasked with the role of Information Technology (IT) physician executive. Depending from organization structure and dimension, that role may be taken, or shared, by the Chief Medical Officer (CMO), or by the VP of Quality, or by others. Regardless, physician leadership in health care information technology acquisition and management is a crucial requirement for the success of healthcare digital transformation.

IT physician executives need to act as “transformational leaders” in strategizing a health care system’s successful transition to digital Population Health Management.

The changing environment

There is a sea change occurring in American healthcare. Aging population and a steady rise in the incidence of chronic diseases have created unsustainable cost pressures on health systems. The development of outcome- and value-based health care delivery models and the associated reimbursement constructs, including ACOs, value-based purchasing, clinically integrated networks, and bundled payments, have generated an environment in which hospitals and physicians are scrambling for a diminishing piece of the reimbursement pie. At the same time, especially in Population Health Management (PHM), the focus is turning to the individual. Access to unprecedented amounts of data creates an opportunity for deeper insight, earlier intervention, and a new level of engagement. The rising voice of the consumer is empowering individuals to expect higher quality at lower cost.

This shift toward value and consumerization is accompanied by the availability of innovative technologies as never seen in the past. New technologies are driving exponential change and opportunity into an industry traditionally slow to adapt and alarmingly vulnerable to attacks and disruption, and, in turn, new players are entering and reshaping the industry.

The CMIO agenda for the Population Health Management Digital Ecosystem

Healthcare organizations are focusing on what technology can do across the continuum and outside their walls, in order to positively affect population health. In the progressively more common clinically integrated organizations, the IT physician executive must be able to interact with other executive leaders, as well as possibly multiple regional CMIOs, and strategically direct the integration of ambulatory care, in-patient care, and post-acute care, both inside and across organizations.

In this environment, physician executives must expect from technology partners greater value, improved quality, and better outcomes – at a more affordable cost. A slew of new technologies is disrupting the PHM ecosystem, and each has the potential to dramatically improve the translation of disparate data and analytic models to value for the patient.

As the amount and types of healthcare data grow, it is becoming increasingly complex to manage and, ironically, more complex to use for insight generation. The hybrid cloud is a cloud computing environment that uses a mix of on-premises, private, clouds and third-party public cloud services. This “multicloud” capability is a key characteristic to emphasize because it enables the ecosystem to move beyond the constraints of legacy and provides the flexibility to expand across partner organizations and payer-provider networks. The hybrid cloud enables the storage and management of multiple healthcare data types on a robust IT platform with native security and privacy features, high availability, low operational overhead, and global connectivity. Healthcare organization of all sizes can take advantage of the latest technologies, such as integrated analytics and machine learning, to obtain advanced data insights, without the need for individual organizations to build them by themselves.

APIs and Microservices enable trusted connections with advanced cloud capabilities. They are essential for the development, rapid prototyping, and deployment of convenient, easy-to-use applications. APIs bridge the gap between care system and advanced capabilities built on the Cloud.

Finally, Artificial Intelligence (AI) and advanced analytics bring the most potential to redefine the use of data to fundamentally impact PHM outcomes. Increasing analytics maturity is going to raise the bar for data-driven insights, from descriptive to predictive to prescriptive. And while advanced analytics respond to specific coded requests to make determinations, AI systems will interact with humans naturally to interpret data, will learn from every interaction, and will propose new possibilities through probabilistic reasoning.

Choosing your technology partners

IT Physician executives need to embrace the newest technologies to advance the PHM mission and drive value. In doing so, they need to demand from their technology partners an unapologetic focus on experience with a continuous drive to improve, reinvent and impact behavior. More than any other executive in the healthcare organization, the CMIO must clearly articulate to potential partners the contributions you seek to the outcomes that matter.

Proposed technological solution must protect your data and create “evidence platforms” to fuel clinical decision support and real-time analytics. Any PHM solution needs to place the whole person into the heart of the digital healthcare ecosystem, and extend empowerment using mobile and the Internet of Things.

PHM AI solutions need to accelerate pattern identification across populations and fine-tune delivery of care up to personalized patient engagement; in other words, move from reactive to proactive PHM.

Each new technology solution must also be flexible enough to share data, partner and platform for scale, and access multicloud solutions. Any solution must be available to build ecosystems with new or unlikely partners, to advance real interoperability across the continuum of care and payer-provider networks.

Finally, it is the physician executive that must identify and understand the technology partner basis of differentiation for quality and efficiency and expect them to invest in your success. The most trustworthy and confident partners will support your digital transformation by sharing risks and rewards.

In conclusion, IT physician executives need to act as “transformational leaders” in strategizing a health care system’s successful transition to digital Population Health Management and demand from their technology partners innovative and effective solutions that support digital transformation while sharing risks and rewards. Regardless of title or role, physician leadership in health care technology will only continue to grow in importance, including increased responsibility for operational management of a digitally advanced population health ecosystem.

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