It’s funny; one of the key challenges for healthcare IT leaders during the COVID-19 pandemic is a lack of time. There simply aren’t enough hours in the day. And yet, it’s that time crunch that has forced organizations to shorten the decision-making process and make “informed, but expedited decisions,” said Stephanie Lahr, MD. “We didn’t have time for overthinking.”
As a result, the informatics and technology teams at Monument Health, a five-hospital system based in Rapid City, South Dakota, were able to operationalize extremely quickly in preparation for an influx of patients. According to Lahr, who holds both the CIO and CMIO titles, Monument went from doing almost no telehealth visits to more than 600 per day, and set up a nursing triage center within 24 hours. The keys? Having the support of leadership, and teams that are able to come together to achieve a common goal.
In a recent interview, Lahr talked about the organization’s multifaceted approach to continue to provide quality care during the pandemic, the unique challenges rural organizations face — particularly during a crisis, and how disaster preparation is similar to planning a major implementation.
- Monument Health in “preparation mode”
- 4-phased approach to guide technology & informatics teams
- Standing up a nursing triage center: “Within 24 hours, we were taking 150 to 200 calls per day.”
- The need to “wear different hats” & cross over to help others
- Free tools vs software licenses
- 600-plus telemedicine visits per day
- “It further drives home the need for 5G.”
- Virtual visits with chronic care patients – “They need us now more than ever.”
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The first element was trying to figure out different ways to do our current business so that we can continue to provide the care that patients need, possibly in a new way.
It doesn’t really matter which hat you’re wearing or what lane you’re in; sometimes we have to cross over and help people in other lanes and wear different hats than we might normally wear.
If you’re an independent clinic of three or four doctors trying to figure out how to do telemedicine, FaceTime and Skype are great. But as a health system, we need to have a more programmatic approach, and so we made a selection.
It also allows us to interact with diabetic patients, heart failure patients, patients with high blood pressure, and patients with depression; they all still need ongoing management and care. And to be honest, they may need us more now than ever.
We’re also exploring some of the options to help patients remain connected with their families, and even remain connected in general.
Gamble: I wanted to touch base about what Monument Health is doing in terms of a COVID-19 response, and to get your perspective as a CIO and CMIO. What are your immediate priorities?
Lahr: I’ll start by providing a bit of context about where we are in terms of the trajectory. At this point, we still have a very small number of cases in our area. We don’t have anyone in the hospital who has tested positive. We do have a handful of patients we’re managing throughout the community. We’re at a place right now where we’re preparing for what we think will be the peak of the curve using a variety of different potential timelines, depending on which model you use. Organizationally, we’re working both internally, as well as with the state and with other healthcare systems in our state, to make sure we’re all coordinating and preparing as much as we can, knowing that it could impact different parts of the state at different times, or impact them differently because of our geography, but still trying to focus on consistency.
For us, the first element was trying to figure out different ways to do our current business so that we can continue to provide the care that patients need, possibly in a new way. As the CIO and CMIO, I developed a four-phased approach to help my technology and informatics teams understand the direction of where we were going. Our goals were: 1) keep sick people out, 2) keep well people home, 3) protect our physicians and caregivers, and 4) help our patients and families remain connected.
- Keeping sick patients out
When I say ‘keep sick patients out,’ that’s really our goal. How do we help those potential COVID patients who may not care in a physical setting, but may need guidance, support, or testing, and do that in as safe a way as possible, both for them, as well as for the healthcare providers that are trying to deliver that care? One of the very first initiatives we took on was for them to be able to interact with us without having them come to one of our campuses.
And so, despite being an IT department, one of the first needs we identified was to have a nurse triage call center for our community. This way, people can call and ask questions about symptoms, exposures, or things they may have experienced, and get advice as to whether they needed testing, or whether they needed escalated care outside the scope of what’s covered in a telehealth visit, or even an in-person visit.
On March 16, we went from not having a nurse triage center at all, to having triage 16 hours a day, manned almost exclusively by IT — at least initially. I have nurses and doctors who work for me. And so, we as doctors and nurses in IT, stood up triage, and within 24 hours, we were taking 150 to 200 calls a day.
I think this is a time, at least for me, where it doesn’t really matter which hat you’re wearing or what lane you’re in; sometimes we have to cross over and help people in other lanes and wear different hats than we might normally wear, as long as it’s within the scope of your knowledge and capacity. Even that we might push a little bit, because there’s so much to be done. You can’t say, ‘that’s for nursing to figure out,’ or ‘that’s for the patient call center to figure out.’ We had a need, we saw a way to be able to staff it and manage it, and we said, we’re going to get this off the ground, knowing that we’ll be able to alter it over time and bring in other people. And that’s exactly what happened.
On the same day, we rolled out a tool created by my staff. It’s basically an online symptom checker that allows a person to walk through a chatbot interaction and get some advice by answering some simple questions. It’s mostly targeted at helping people identify whether they should seek care, get tested, talk with a nurse — those types of things. The chatbot will say anything from, ‘You seem to be doing fine, here’s some online resources,’ to ‘we think you should call one of the following numbers so that we can talk to you further about advancing your care.’ That was extremely well received. We’re seeing a lot of activity there. You don’t have to put in any information. You can do it a hundred times a day if you wanted to. There’s no downside.
- Keeping Well People Home
Then we started turning our focus to telemedicine. A month before, we really didn’t do any ambulatory telemedicine, for a couple of reasons. From a payment standpoint, we still have pretty strict rules within the state about who can do what, from where. We didn’t have an opportunity to do direct to consumer in the patient’s home; and then all of a sudden, all of those requirements were suspended. So we opened nurse triage on Monday. On Tuesday morning, I said I wanted to make a decision on a vendor, because our EHR needed that complement to be able to do video.
On Wednesday, it was announced that you didn’t have to have a HIPAA-compliant tool. That took us off track for a moment to say, ‘Are those the tools we should think about?’ We decided to go ahead and proceed with an enterprise tool that we would pay for and license that would we use consistently across the whole health system.
A lot of the free tools are great. If you’re an independent clinic of three or four doctors trying to figure out how to continue to do care and do telemedicine, FaceTime and Skype are great. But as a health system, we need to have a more programmatic approach, and so we made a selection. That Wednesday, I signed the contract. On Thursday afternoon we started piloting, and on Friday, we went live at our first clinic. The following week, we expanded across all of primary care. After that, we expanded to all specialties; we’re now doing 600-plus telemedicine visits every day.
Gamble: That’s amazing.
Lahr: To go from zero to that is incredible. It’s been extremely well-received, both operationally and by patients. For me, it also further drives home the need in rural areas for 5G. We are noticing we have a lot of patients who are not able to take full advantage of video capabilities because they don’t have the bandwidth to be able to accommodate that. They may have a device they can use, but they don’t have the bandwidth. We also have a handful of folks that, for a variety of reasons, including socioeconomic constraints, don’t have a device. Usually we’re able to at least do a telephone visit. Again, those have been really successful and very well received.
All of that helped us achieve the first two goals. We’ve given patients who are sick and potentially contagious a variety of options to be able to connect with us. We do drive-through testing. When a patient calls nurse triage and meets the requirements for testing, we have a drive-through location to minimize that contact.
And we’re keeping well people home through the telemedicine opportunities. Telemedicine allows us to potentially interact with patients at home who have symptoms. But it also allows us to interact with diabetic patients, heart failure patients, patients with high blood pressure, and patients with depression; they all still need ongoing management and care. And to be honest, they may need us more now than ever. They’re looking for guidance, and we can provide that through telemedicine, which enables us to reserve physical appointments for things that need to be done in person.
- Protecting Physicians and Caregivers
Our third priority is keeping caregivers and our physicians safe. We’re now exploring and piloting several different options in the hospital to allow our clinicians who are on the frontline taking care of the sickest patients, to be able to interact with patients using telemedicine and video. That does two things. One, it reduces the amount of personal protective equipment needed, which we know is very scarce and we’re all working really hard to manage that supply chain element. We can limit that by having video interactions with patients rather than having to go in the room each time. There are a variety of other lower tech options to, again, help minimize the amount of interactions that need to happen with a person physically going in the room, thereby reducing both the exposure as well as the need for PPE.
- Help Patients and Families Remain Connected.
This one is quite challenging, more from the perspective of managing hardware than anything else. Right now, we’re limiting the family members that can come in and visit a patient in the hospital. In many cases, we’re not allowing any visitors except in very special circumstances. That’s very difficult for hospitalized patients and their families, who are trying to keep up with how they’re doing and provide support. If they have their own devices, we’re fully supportive of that and provide a network for them to be able to do FaceTime and things like that.
We’re also exploring some of the options to help patients remain connected with their families, and even remain connected in general. For example, through some of the video capabilities we have, instead of it being a formal visit, somebody could read to a patient or play a game with them via video. Because as people start to recover, they might still need to be in the hospital, but that doesn’t mean that they aren’t capable of (and in need of) personal interaction. So what are the ways we can do that?