Winston Churchill famously said, “Never let a good crisis go to waste.”
In healthcare, that crisis, of course, is the Covid-19 pandemic, which has played a critical role in advancing digital tools — and changing the way care is delivered. “It has been eye-opening,” said Dan Nigrin, MD, who has served as CIO at MaineHealth since January.
The challenge going forward will be to ensure that the industry doesn’t lose momentum, which would certainly be a waste, noted Nigrin, who has more than 25 years’ experience as a pediatrician. Instead, he believes healthcare has an enormous opportunity to leverage the lessons learned during Covid-19 and create “a new standard of care.”
Recently, Nigrin spoke with healthsystemCIO about how his team is working to optimize and streamline processes to improve the experience for both patients and providers, and why physician satisfaction should be top of mind for all leaders. He also talked about transitioning from pediatrics – and city life in Boston – to a large system in Maine, and what his team is learning by participating in the Arch Collaborative.
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- Starting with a new organization as vaccine rollouts began was “trial by fire” for Nigrin. On the plus side, “It forced me to get to know my team very well and collaborate with peers right out of the gate.”
- At one point, MaineHealth had administered one-third of all Covid vaccines in the state, many of which took place at a converted racetrack. “It’s been a very successful enterprise.”
- The fact that MaineHealth had recently become a system with a central decision-making body allowed the organization “to be more nimble and to deploy solutions more efficiently” during the pandemic.
- Because of two key factors – its rural status and the average age of patients – MaineHealth continues to leverage telephone and video visits to engage with, and remotely monitor, patients.
- Leveraging technology to monitor patients remotely has led to significant drops in 30-day readmission rates, particularly in those with hypertension. “It’s been really successful.”
Q&A with Daniel Nigrin, MD, Part 1
Gamble: Can you provide a brief overview of MaineHealth – what you have in terms of hospitals and how the organization is structured?
Nigrin: Sure. MaineHealth is the largest healthcare system in northern New England, serving Maine as well as Northern New Hampshire. We have 12 hospitals, about 22,000 employees, 1700 physicians, and an employed medical group. We do roughly $3 billion per year, and we offer the typical services you’d see in a large system, including home health and behavioral health. We’re headquartered in Portland, which is where our flagship facility — Maine Medical Center — is located. It’s our largest facility, with about 650 beds. And then the remainder of our facilities are scattered throughout Maine and New Hampshire.
It’s an organization that’s very community-centric. In fact, the mission statement for the organization is ‘working together so our communities are the healthiest in America.’ The word ‘together’ is emphasized in a big way; we really do feel as though we’re an essential component of the community and are working collaboratively with the community to achieve that vision.
Lastly, it’s a relatively new system. We only officially unified in the last couple of years. Prior to that, it was a looser affiliation of several facilities. But it’s formally one organization with a single board. To some degree, we’re still we’re still going through some of those initial steps that occur when a system comes together, including within the IT realm. But it’s been a really positive experience so far.
Gamble: And you’ve been there about six months?
Nigrin: Yes. I started just after January 1. I thought I had it figured out perfectly. I thought, ‘things are slowing down with the pandemic, now is a quieter time to make the transition.’ Well, we all know what happened in the fall; right when I got there, we were in a big surge and were rapidly trying to get immunization distribution and administration done. And so it was definitely trial by fire early on — I had to learn fast. But there was a silver lining; it forced me to get to know my team very well. It forced me to collaborate with my peers across the organization right out of the gate. It was helpful in that way. It was a little bit crazy for a while, but with that now behind me, I’m feeling much more settled.
Gamble: What was your strategy when you first arrived? What did you focus on?
Nigrin: As I mentioned, we were very focused when I arrived on vaccine administration. The first phase was our own employees, which is about 22,000 people. And so we needed to set up vaccine administration throughout all of our facilities. Being in Maine, we have a lot of ground to cover; many of the facilities that are part of MaineHealth are in pretty rural parts of the state. And so, from a logistics standpoint, it was a challenge in getting the vaccines there and figuring out storage capacity. Not dissimilar, I’m sure, to what many sites around the country wrestled with. That was priority number one.
Soon after that, we started to focus on immunizing large portions of our population. We did what many other organizations and local governments did, which was to set up mass vaccination sites. We had one that was really interesting. It was at Scarborough Downs, a horse racing facility that closed its doors a couple of years ago, and was sitting there unoccupied. Basically, we helped to outfit that site with network connectivity, the whole bit. Within a matter of weeks, we set that facility up to be one of our largest mass vaccination sites, and delivered tons of vaccine there over the next several months.
One statistic that’s pretty incredible is that at one point, MaineHealth had administered almost a third of the entire state’s vaccination. It shows how large the organization is, but also shows how Maine, as a state, pursued the integration and assistance from its largest healthcare facilities to be part of the vaccination effort — perhaps a bit more so than other communities around the country that did more through government-based efforts.
It certainly has kept us busy, and made us feel like we were doing justice to our mission of being a big part of our community. So it’s been a very successful enterprise. We’ve been one of the states that had the highest vaccination rates since they started measuring it. I think we’re still up in the top three; we definitely exceeded that 70 percent mark several weeks ago.
Gamble: That is impressive. As you’re doing all of this, how much did it factor in that MaineHealth is now a system as opposed to being a loose affiliation of facilities?
Nigrin: It has helped us in many ways to have a central decision-making body and orchestration for things like IT, which I think do benefit from having a unified approach and not scattered approaches in every location. That’s certainly been helpful. I think it was a realization on the part of all of the organizations that comprised the loose affiliation in the past, that there were benefits to be had by integrating formally, especially when it comes to efficiencies of scale. The fact that we had that in place prior to the pandemic was quite fortuitous because it allowed us to be more nimble and to deploy solutions more efficiently when the time came.
The other benefit is in how we deal with telehealth and are able to deploy it rapidly across our system. That would have been much more challenging had we been a more fractionated enterprise. Our ability to have a single video visit platform deployed across the entire system, and have the support in place for both our providers as well as for our patients to be able to get up to speed on this new way of doing things, was definitely an asset for us. And we made good use of it, like many organizations throughout the country.
Gamble: Are the 12 hospitals all on the same system at this point?
Nigrin: All but one. We’re an Epic organization; 11 hospitals are on Epic, and the last one is in the throes of implementation now, with the go-live planned for November. All signs are pointing to that being successful. We’ve gotten quite good at it as we’ve marched through the 12 facilities. That will be an important milestone for us as a system to be completely on a single platform throughout the enterprise. At that point, we’re going to focus around the optimization that inevitably needs to happen after you’ve had a series of individual activations in each of these organizations.
I think one thing that has hindered us a bit is that, because of the loose affiliation in the past, the timetable for how we’ve deployed the EHR across all of these facilities was probably longer than it would have been if we had been unified from the get-go. When there’s a time period of a few years between the original deployments — for example, at Maine Medical Center — versus the current one, it’s challenging. Because of that time period, we have a fair amount of optimization and standardization across all of the sites that we’ll have to take on in the coming years.
Gamble: I can imagine that’s a challenging thing to step into, but you knew going into this role that it was a big part of the organization’s long-term plan.
Nigrin: Absolutely. I knew what I was stepping into for sure. I’m quite thrilled to be part of an organization that already had one of the most highly regarded EHRs in place already for the most part. I’m eager to work on optimizing that and building it out and getting the most use out of it as we all can.
Gamble: What are some of the other really pressing priorities on your plate?
Nigrin: Let me go back to telehealth for a minute. Video visits have been one of the most important aspects of telehealth, as we’ve all experienced over the past year and a half. We’re still doing a fair amount of our ambulatory visit volume through that methodology. At last count, about 14 percent of our ambulatory visits are still being done through a combination of either video asynchronous visits or by phone-based encounters.
We actually have a little bit of a higher phone percentage than other organizations; there are multiple factors behind that. One of the major ones is that, because Maine is quite a rural environment, there are parts of the state that, frankly, just don’t have adequate internet connectivity. We also have an older population. Maine represents the state with the oldest average age of its resonance. I think that too hinders our ability to have as much penetration of technology-based visits as some other parts of the country.
Telehealth and video
Nonetheless, the combination of the two — telephone and video visits — is about 14 percent, which is on par with many other parts of the country. But we’re doing much more than that. We’re doing asynchronous visits, being able to do store and forward-type of consultations for patients in subspecialties like dermatology. Our behavioral health video visits are through the roof, and like many places, have seen remarkable acceptance and enjoyment from the patient’s perspective. I believe those numbers are in the 75 to 80 percentile, which is extremely high.
We’re doing a lot of additional things. We do site-to-site video visits; in areas that are more rural where subspecialists are more difficult to access, we’ll have the patient come into their local site so that they can get monitoring and blood work done. Then they’ll have an encounter with their clinical provider, which is done through a video visit together with another one of our locations. So that’s one of our site-to-site setups we’ve got in place. We’re doing a lot of provider-to-provider consultations asynchronously with providers located in different areas. We’re doing what would have normally been called curbside consultations more formally, using technology.
Remote patient monitoring
The last area is remote patient monitoring. And again, this is one that COVID really fueled and emphasized for us. We’ve got several programs in place now where we’re monitoring patients in the home environment using technology. For cardiac patients who have been hospitalized, as part of their post-discharge monitoring, we send them home with technology that allows us to do routine assessments of their vital signs and other parameters. And those are monitored on a daily basis by clinicians on the system side. When something seems not quite right, we actually reach out to the patient proactively to say, ‘Hey, we noticed your numbers are a bit off today. Can you let us know what’s going on?’ That’s been extremely beneficial for us. Our 30-day readmission rate for these patients has dropped precipitously; it’s really been successful.
We’re monitoring patients with hypertension in their home environments to ensure they’re staying on their meds. We have another one focusing on obesity, where we’re taking measures to help folks lose weight in their home environment using connected scales.
And so, I really do see the pandemic as having helped to stimulate RPM in a big way. I think the notion of hospital at home is going to start to take off over the course of the next several years, largely because we were forced into it to some degree by Covid.