Change doesn’t happen overnight.
We’ve heard it numerous times, and for good reason. In the past year, however, some have learned that the old adage doesn’t always hold up.
For example, at the Hospital for Special Surgery, which is located in the heart of Manhattan, there was a request to implement a color-coding system within Epic to identify whether a patient had tested positive or negative for Covid, or was awaiting test results. “That was on a Sunday; it was in production Monday evening,” said Jamie Nelson. “It literally happened overnight.”
Despite everything that was going on — or perhaps, because of it — her team was able to make quick decisions and implement solutions almost immediately, and as CIO, she couldn’t be more proud. During a recent interview, Nelson reflected on how the entire organization was able to come together and respond to an unprecedented situation, and shared some of the key lessons learned. She also talked about her team’s plans for 2021, much of which focuses on digital health, and the important work they’re doing to promote diversity and inclusion.
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- The first part of HSS’ response to the pandemic was to become “a critical care unit” and take on Covid-19 patients, despite being an elective surgical facility.
- On the IT side, technology was put into place to support clinicians who were providing care, which “required massive order set changes in Epic.”
- Rather than trying to bring IT staff back to the hospital when Covid numbers dipped, Nelson opted to extend the remote work option, both to ensure public safety and help working parents.
- The most important lesson HSS learned during the experience? “Make sure we have a playbook” that includes “the steps to what we did and how we did it.”
Q&A with Jamie Nelson
Gamble: First off, what does the picture look like in New York City in terms of Covid?
Nelson: We are definitely seeing an uptick in the city — nowhere near where we were last March, but still an increase, so that’s a little scary. The governor has been very involved from the beginning and he has had a number of press conferences. He has already stopped elective surgeries in Erie County, which is near Buffalo, because of the hospital capacity. I believe he’s being much more targeted in how he wants to approach slowdowns, shutdowns, and pauses, but it’s frightening for everybody. Last month, he made the announcement asking everyone over the age of 65 to stay home. And so we’re starting to go backwards a little bit to try and keep this thing at a lull.
On the flipside, our main focus now is on how we’re going to administer vaccine, to whom, and in what order, and how we’re going to record it and report it back to the city. So we’re focused not just on how to keep Covid at bay, but how do we now start to administer the vaccine, with frontline workers being first. Who knew nine months ago this is what we would be doing?
Gamble: I’d like to talk about the organization’s initial response to Covid, with elective surgeries being cancelled, etc. I can imagine you had to pivot really quickly. Can you talk a little more about that?
Nelson: Sure. We really did some amazing work back in March. Every hospital in New York — and across the country — did amazing work; it goes without saying. What was unique for us is that we don’t typically take critical care patients. We don’t do critical care. We are an elective orthopedic surgery hospital. And yet, because of the inundation to all hospitals in the city, particularly our friends across the street at NewYork-Presbyterian, we had to stop elective surgeries. We had to retool a number of our operating rooms to turn them into ICUs, and quickly remind our very smart clinicians what’s like to treat critically ill patients. Our intensivists stepped up. Our anesthesiologists stepped up. Our nurses remembered what they learned in different parts of their career. It is amazing how the clinical transformation took place, because we had some very sick ventilated patients here. We really were a critical care unit.
And of course, we have a lot of technology we had to put in place for a few reasons. Number one, there was a huge increase in the number of people working from home, as we needed to ramp up that whole capability. We had to make sure the IT department could work from home effectively because most of our IT staff did transition to remote. We had to put in all the technology to support the clinicians who were providing services to these very sick patients in the hospital — that required massive order set changes in Epic and in the hardware we were using. At one point, we even installed baby monitors so we could communicate outside of the rooms. We did a number of things there.
We also consolidated our outpatient areas; that’s a physical transformation, and in terms of Epic, it’s taking all these different doctor’s offices and merging them into a different instance where patients would come to different doctors, but in the same location. It was very complicated.
Gamble: What about telehealth? What was the strategy there?
Nelson: We did more than 100,000 telehealth visits in 2020; the year before, I think we did 500. There was an operational team really affecting it, but the IT work behind the scenes was just incredible. It was things like making sure we had appropriate platforms for live streams with our administration — our CEO held livestreams every week — with a communication platform that could stand up to the vagaries of having that many people on all at once, which we just weren’t used to. And so it was a lot of very hard work.
Now I think we’re in much better shape from an IT perspective, because things like working from home and the order sets we would need — those things were all there, but we do not think we’ll have to take on COVID patients again. There has been enough work done in New York City in terms of ICUs and capacity planning. Again, the numbers are nowhere near what they were in the spring. I know they’re going to go up, but I do not believe they’re going to be where they were, because we’re so much smarter now as a system. Not just Hospital for Special Surgery, but New York City and New York State. So we’ll see what happens.
Gamble: In terms of remote work, did you start to bring people back once the numbers went down? How did you manage that?
Nelson: The problem is that even though the numbers were going down, we still wanted to keep people safe. One of the reasons the numbers went down is because people were staying at home, and so we’re afraid bringing people back quickly would accelerate that. So we’ve been doing three-month increments, and we’ve extended it through March.
Part of it is safety, and part of it is the fact that there a lot of issues for working parents around school systems. That’s a small set of our IT population, but it’s large enough. We want to help working parents by not having them come in and out of the office every day and try and figure out what’s going on, because it keeps changing. At one point all New York schools were closed, then they were open, and then it only applied to certain grades. As a parent, how do you manage that? For public safety and for helping our working parents, we have decided to extend work from home at least through March and then we’ll see what happens after that.
Some people come in. We recently did an initiative with new barcode scanners, and so a bunch of people came in — they wore masks and worked together while remaining socially distanced. Some people actually like to come to the office. I like to come to the office, so I come in every day. I think as an executive leader it’s important to be in physical proximity. People have different levels of risk tolerance. Some people are here every day. They’re fine; they’re safe. Others haven’t left their living rooms in eight months — they’re happy working from home. That’s where we are right now. People are able to work effectively, and so making a change now just for the sake of it just doesn’t seem to make sense.
Gamble: With everyone that was done to enable telehealth and remote work, I would imagine you had to have a solid infrastructure in place to be able to turn the dial so quickly.
Nelson: The good news is, on the telehealth side, we had already built it out. There were a few nurses and physical therapists looking at it for aftercare, so we had a smattering of interest. And starting from something is different than starting from nothing. We were really lucky to have that.
It’s really interesting because the clinicians and physicians were really not that interested in telehealth — it didn’t seem to make for an acute care or elective orthopedic facility. But once that was the only option, especially for patients who had surgery right before we shut down, it took off. They still needed to come in for post-operative care. They still needed their physical therapy. Being able to manage a lot of that safely through telemedicine was a requirement.
When you have surgery, aftercare is very important to your overall recovery and outcomes. So this is something we absolutely had to do. And to see clinicians say ‘okay, we’re in; we’re going to do this,’ really made it easy. There was no pushback. In fact, I can remember trying to go on a hike on one of those weekends just to get a break, and our head of physical therapy called me and said, ‘Jamie, we have to do this. We have to have physical therapy.’ And so we did it.
Gamble: Let’s talk about the evaluation guidelines that were published — the HSS Rehabilitation Telehealth Evaluation Guidelines for Musculoskeletal Physical Therapy. It seems like there was really a need for that.
Nelson: There were no guidelines; that’s why it was so important for us to publish those. That’s now the de facto standard. And again, because we do such a huge amount of orthopedic physical therapy, we really are the experts. So it was incumbent upon us to codify what we were doing and make sure it was published for the general public to be able to use. We’re very proud of what we do here and I’m extremely proud of how we reacted to the pandemic and are still moving forward.
Gamble: I would imagine that at some point you were able to take a look at the response and see if there was anything that could have been done better. Is that something you consistently addressed or did you sit down at one point and examine it?
Nelson: Actually, our CMIO, Dr. Steve Magid, and I actually wrote a paper about our response in IT and had it published in the HSS journal. We did have a lessons learned section, and I will tell you we are pretty good at looking at what we’ve done and being critical. But I’ll tell you, I think we did a pretty good job given the circumstances. We had tremendous communication within our team, and throughout the entire hospital. We were able to obtain funds to buy laptops for the staff. We quickly had to beef up our firewalls and our internet connection. The hospital, even though money was tight, allowed us to take the technology steps we needed to make some very fast-paced changes.
There are things I’d like to see continue. All of a sudden, a lot of our surgeons were more active in the day-to-day management of the hospital. I think our administration does a very good job of this, but having their perspective was really different and exciting. They’ve continued to be involved in Covid leadership, and it’s been really exciting to see these very smart surgeons use their brains to help us do things a little bit differently.
We had a great organization beforehand, this just enhanced what we’re doing. We ramped up our help desk; we did all sorts of things to improve our processes. I think the real lesson learned was to make sure we have a playbook. There are steps to what we did and how we did it; and so if we run into the situation again, there’s a playbook. Again, we don’t believe we’ll have to take on Covid patients again, but who knows what else will befall us. Now we have a structure in place.
Gamble: I didn’t realize HSS had taken on Covid patients — that’s amazing. It’s such a different type of treatment to provide.
Nelson: We only do things if we can really do them well. There was a lot of clinical input into whether or not we could do this, but we had to. Patients were overwhelming the system. Our anesthesiologists are critical care doctors — they were leaders here. What was really interesting is that the orthopedic surgeons were there to help. Whatever the anesthesiologists, intensivists, and internal medicine doctors needed, those orthopedic surgeons lined up to help. It was amazing. Nobody cared about titles, degrees, specialties, or who does what; it was all about how do we come together to best treat these patients. I can’t say enough about nursing, respiratory therapists, housekeepers, and everyone who lined up to help. Yes, it was a different model, but we can do it and we can do it safely. This is what we’re going to accomplish because for patients who come here, no matter what care they’re getting, it has to be best possible care, and we were able to do that.