For health systems serving rural populations, there are many common themes, one of which is the need to do more with less. And while it may seem like a disadvantage, sometimes it’s quite the opposite. A perfect example is Guthrie Clinic, which earned the 2023 ECRI Health Technology Excellence Award for leveraging an AI-enhanced platform to address staffing shortages and improve patient care. “We’re not a large system with a ton of resources. We have to find ways to be nimble and do great things,” said Terri Couts, Chief Digital Officer, during a recent conversation with Kate Gamble, Managing Editor at healthsystemCIO.
They did. Like many organizations (especially in rural settings), buying an eICU solution wasn’t an option. And so, Couts’ team added some cameras and “a little bit of innovation,” and cobbled together “something very similar that can have a big impact.” And telesitting is just one facet of the digital health strategy that she believes will position the organization for success as care models evolve.
During the interview, Couts talked about how the virtual command center — called the Guthrie Pulse Center — aims to centralize functions, create synergies, and improve access to care; why her team is changing its focus from feeding people data to ‘fetch the data’; the key obstacles in implementing virtual nursing; and how she has benefited from her experience as a nurse.
LISTEN HERE USING THE PLAYER BELOW OR SUBSCRIBE THROUGH YOUR FAVORITE PODCASTING SERVICE.
- On Guthrie Pulse Center: In addition to virtual nursing, centralized telemetry and telesitting, and transfer centers, Guthrie’s virtual command center will also house transport and staffing “so that as we manage patient flow, it can be centralized to support the whole system.”
- On virtual nursing’s benefits: Another use care for virtual nursing? The second-sign process for high-risk medications can shrink from 36 minutes to as little as 33 seconds by leveraging technology. “There have been so many quick wins.”
- On data and decision-making: As part of its analytics revamp, Guthrie is bringing data feeds into a data lake “so we can build out the governance around it with definition, ownership, and contributors,” said Couts, and ultimate enable users to “pull the data and aggregate it in a way that they can use it for whatever decision they’re trying to make.”
- On her role as CDO: “I’m able to help level set and make that connection to not just my end-users that ‘I hear you and we’re going to try to address this,’ but also to my staff, who needs to respond to that and respond in a way that’s compassionate and has empathy.”
- On healthcare’s future: “Care models have to change. We can’t continue to do what we’ve done in the past and expect to survive. And so how do we look at it a little differently — how do we rethink the process and then apply the technology that helps enable that?”
Q&A with Terri Couts, Chief Digital Officer, Guthrie Clinic
Gamble: Hi Terri, thank you for carving out some time. We spoke at some point last year, but things change so quickly in this industry. I want to talk about what you guys are doing, especially around digital transformation.
Couts: We’re launching our command center [Guthrie Pulse Center], which is housing virtual care models and an operations component to manage aspects from a system perspective. It’s not located on any of our hospital sites; it’s attached to a medical office building. It currently houses our virtual RN, the eICU, centralized telemetry, centralized telesitting, and our transfer centers. In the near future, it’s going to grow to house things like EBS (evidence-based surveillance), transport, and nurse staffing, so that as we manage patient flow, it can be centralized in a way that supports the whole system, rather than a siloed approach.
We cover about 9,000 square miles in both New York and Pennsylvania on the northern and southern tiers. Capacity can be a challenge when everybody’s trying to get into our highest level of care — Robert Packer Hospital — when some of these patients can be managed in other locations, particularly with some intensivist support, which wasn’t in place prior to our eICU program.
We have a partnership with Equum, a virtual intensivist group that provides 24/7 coverage for hospitals that have a hospitalist but not an intensivist. It allows them to keep those patients closer to home unless there’s a reason; for example, if there’s a procedure that they don’t do at that location, then they’ll be transferred.
That’s been our largest focus. We’re also moving to the cloud and revamping our analytics to transform how we use data, because historically, we’ve been reactive to data instead of using data to drive decisions.
Covering more patients with telesitting
Gamble: You mentioned that the command center is doing eICU and telesitting, among other things. Can you talk more about telesitting and how that’s being used?
Couts: With telesitting, patients that have a fall risk or low ideation of suicide can be watched remotely through a camera. Prior to telesitting, we would have to have someone sitting in that room, one-to-one. With telesitting, they can monitor up to 20 patients, if not more. It gives us the ability to provide more coverage. And it’s not restricted by location; it’s across our system.
We’re using an AI platform from Artisight to help with that. This way, they have a visualization of the patient, but they also have AI that, based on movements of the patient, will alert us to an increased risk of fall. It will show red, yellow, or green depending on the movement of the patient in that room.
Working with Artisight to free up nurses
Gamble: Is Guthrie a co-development partner with Artisight? How is that partnership structured?
Couts: They are a platform that exists today. However, we have partnered with them on some additional use cases for co-development. For example, we are co-developing some automated documentation. We have cameras in every patient room. If a patient has an incentive spirometry order, that’s typically done every hour or two hours; and so, a nurse typically would have to come in, remind the patient, observe the patient, and go back and document it — hopefully. What we’re doing is, based on the integration with the EMR, they know the patient requires the incentive spirometry every hour, and so it will issue a reminder. If the camera observes the device being used, it won’t remind them. It will also translate that into the EMR to document it. By doing this, we’re removing that workload from the nurses and freeing them up to do other things.
We’ve instituted a program called iCare to improve patient interactions. Part of that is the introduction — knocking on the door when you enter a room — and observing that knock so we can re-educate departments that aren’t doing it well.
Additionally, it already has a pressure ulcer algorithm built into it. And so, based on the turn of a patient, the camera can observe if that’s been done or not. If it hasn’t been done during the allocated timeframe, it can then alert a nurse that the patient requires turning to reduce pressure ulcers.
The final thing we’re implementing this year deals with workplace violence. We’ve seen a lot of increased aggression in the hospital setting with patient assaulting their caregivers. And so, we’re using the Artisight cameras to alert security that there’s a need. But we’re using code words, like, ‘hey Artisight, test speakers,’ and so the patient isn’t necessarily aware of what’s happening, but it will alert that additional help is needed before it escalates further. We’re trying to figure out all types of use cases that require a little bit of development.
Virtual nursing challenges – “we need a lot of communication”
Gamble: I want to talk more about virtual nursing. It’s pretty clear why organizations want to do it, but what would you say are some of the challenges you’ve encountered?
Couts: One of the challenges with virtual nursing in particular has been getting the staff to understand that this is an additive support, and not necessarily replacing the bedside nurse. There’s a lot of fear there; ‘are they going to increase my ratios?’ ‘Are they monitoring me?’ There’s a big brother concern because the camera is in the ceiling. When you turn it on, it has a doorbell that rings so you know that someone’s entering the room, but there’s still that perception. And so, we need to do a lot of communication around that.
Phone-a-friend for nurses
In terms of our strategy, we went live the ICU first. We have two virtual nurse components. One is ICU critical care and the other is med-surg. They’re staffed a little bit differently, and what they’re doing is a little bit different too. The ICU was first, because we had a ton of new nurses who were going straight into the ICU and didn’t have the experience or the intuition that you get as you become more familiar with patients and how they look and respond to things. And they felt like they didn’t have any reach.
And so, part of the goal was retention. We wanted this to be a call for help or a secondhand phone-a-friend type of thing. There have been a ton of quick wins that have helped some nursing units attach pretty quickly, while others have been a little more resistant — we’ve had to drag them to the water. They’re slowly drinking, but they’re not necessarily thirsty yet. I wouldn’t say it’s been 100 percent easy.
From 36 minutes to 33 seconds
The one hospital that we’re having a little bit of challenge with is also a union, and so, there’s a cultural shift there too. But there’s been so many quick wins around showing someone how to give medications through a PEG tube when they’ve never done that before. Or, they may have done it once in nursing school and never done it elsewhere.
Another use case is with second sign of high-risk meds like heparin. We did a time study and found that it took 36 minutes to find another nurse to leave what they were doing, come in and do that second sign, and go back. With a virtual nurse, it’s something like 33 seconds to assist with codes, because once a code starts, they can come in and help with documentation.
They can even help with a simple thing like observation. Because nurses are given a scan of the room, they might notice the person giving chest compressions is getting tired and suggest that you might want to switch out because it looks like it’s not as impactful. And they’re able to make that suggestion in a way that was more like a team approach. It’s a lot of little things like that.
But I think the biggest value is having all of these components in one room or one command center. It leads to synergies among the team. I’ll give you an example. We had a call come into our transfer center from one of our critical access hospitals. The patient was being intubated, was in critical need, and needed to get to Robert Packer pretty quickly, and so, they called the transfer center. As they were arranging the transport, they turned around to the virtual nurse and said, ‘you have a really critical patient at Troy. You might want to help.’ They were able to ping into the room and start assisting the nursing staff, and at the same time, they were starting to communicate with the receiving nurse to clear a bed. The synergies in that process allowed a transfer to happen almost seamlessly that otherwise probably would have taken lots of different steps. Somebody who was in cardiogenic shock was able to go home in two days; it was pretty amazing.
Gamble: That is amazing. What I found compelling is that you have the metrics to show this is working and you also have anecdotal stories.
Couts: Right. Of course, we’ve accepted transfers and are able to take more patients at the right location, which helps with keeping some of the lower acuity ICU patients in those other two hospital locations and saving our higher acuity trauma facility for those who need it.
We also measure weaning time off of a ventilator because with Equum being part of that care team 24/7, then patient may be ready to wean at 11 o’clock at night, but we don’t have an intensivist rounding, so we would have to wait until the next day. Now, they can start the weaning protocol. We’re also looking at sepsis reduction, length of stay, and excess days. These are all metrics that we’re tracking.
Gamble: How is the command center staffed? Were certain people pulled from different departments?
Couts: We started telesitting about a year ago, before we were in the central location. It was our first use case with Artisight. It was a pretty easy ROI because of the number of staff you could reduce on the one-to-one sit. They were already staffed; we just moved the location. However, it was still a challenge because they were sitting in a Pennsylvania location, and we were moving them to a New York location. It doesn’t seem like a big deal, but it was. The same is true for our transfer center staff, which was at Robert Packer Hospital — they only focused on transfers in and out of that particular facility. And we moved with the idea that they would focus on the system and not just Robert Packer.
For our central telemetry, we pooled from a couple of different locations. The only location we couldn’t pool from was Corning because they’re union, and so there were some challenges around that. Some people opted out and chose another role, but most people have taken it on. And the virtual nurses were all net new hires.
Gamble: Another area you mentioned before was revamping analytics. What are you guys looking to do there, and what needs to be done to enable that?
Couts: We’ve been an Epic customer since 2003. Our analytics department was really built around that — getting data out of Epic for the things that we need. But as you know, healthcare has become more agile in how we course correct. A lot of things are not in the EMR that need to be aggregated to get you the full picture, including our cost accounting system, ERP, human capital, and even some outside sources like Press Ganey, along with some other benchmarking datasets.
We’re looking to bring all of those data feeds into a data lake in Azure so that we can build out the governance around it with definition, ownership, and contributors. It’s creating a catalog of information on where the data source is coming from and allowing our users to be able to ask insightful questions; to pull the data and aggregate it in a way that they can use it for whatever decision they’re trying to make.
From ‘feed you data’ to ‘fetch the data’
We were transitioning from a ‘feed you the data’ mode to more of a ‘fetch the data’ scenario. We had something like 1,100 reports being emailed out in a batch, and we don’t even know if they’re using the reports, or if the data is a value-add. We’re flipping that on its head and having our users be the owners of the data, and we’re feeding it through a platform that’s little more agile.
Gamble: That makes a lot of sense. Switching gears a bit, I saw that Guthrie won the ECRI Health Technology Excellence Award [for leveraging AI-enhanced video to address staffing shortages]. What does something like that mean to the organization? I’m sure getting that recognition was really impactful.
Couts: It is. We’re not a large system with a ton of resources. We serve rural communities. We’re struggling with reimbursement for the work that we do because we’re primarily Medicare and Medicaid. We have to find ways to be nimble and to do great things. Being recognized with ECRI was amazing.
We were competing with organizations like Johns Hopkins; and so, knowing that we could have such an impact using mostly the technology we already had and just being creative and innovative of how we augment what Epic couldn’t do — to pull that together was so gratifying. For us, implementing an eICU through a platform like Philips is just not attainable. It’s not something that we can afford. Buy by adding some cameras and a little bit of innovation, we were able to pull tougher something very similar that has a ton of impact. And being recognized for the quality aspect of that in the technology world was really exciting. Particularly because I’m a nurse.
Gamble: I’m sure it’s been advantageous for you having that background. It gives you credibility, but also helps you understand a little bit more about workflows and how they affect people who are using them.
Couts: Yes, and then tying it back to the patient. So sometimes in the IT world, they get a ticket, and they don’t really understand the level of impact or the level of nuisance associated with it. Obviously, we can’t do anything without technology. But it can also be such a barrier; making it so that it’s seamless takes a ton of work on the translation.
With my role in particular, I’m able to help level set and make that connection to not just my end-users that ‘I hear you and we’re going to try to address this,’ but also to my staff, who needs to respond to that and respond in a way that’s compassionate and has empathy — all the things that come to the table with healthcare.
From nurse to CIO to CDO
Gamble: And speaking of your role, you recently went from CIO to chief digital officer. Is that a reflection on where the organization is headed in terms of its focus?
Couts: Absolutely. I still have all the traditional CIO responsibilities; the digital aspect is really the sponsorship of the organization on the use of technology to enable care. It’s not, ‘we have to do this,’ but really, ‘how can we drive care differently?’ Because care models have to change. We can’t continue to do what we’ve done in the past and expect to survive. And so how do we look at it a little differently — how do we rethink the process and then apply the technology that helps enable that?
Telesitting is a perfect example of that; we can monitor multiple patients in different settings and still have a ton of value. Some of that is direct replacement of staff, but some of it is a support structure for staff. Because bedside care is different. It’s more complex. Our patients are sicker, and because of regulatory and other components, there are things that have to happen in order for us to get reimbursed, but that shouldn’t be their focus. Their focus should be on the patient.
Gamble: It’s an interesting dichotomy because your organization is doing all this cutting-edge work, but you still have the challenges of being a rural healthcare organization.
Couts: Right. And everybody struggles with workforce issues — even other industries — and in healthcare, we’re dealing with the higher skillsets of nursing and other licensed individuals. We can’t produce them fast enough.
It’s a paradigm. We had the pandemic, which influenced a mass exodus from healthcare, and we have people who don’t want to go into healthcare — for a long time they were viewed as heroes, but not so much anymore. And then there’s the fact that we have a bunch of baby boomers who are going into retirement, and we can’t produce healthcare workers fast enough. We have to change. We don’t have an option. If we don’t do it now, more places are going to close because they haven’t made the investment and are figuring out the process around it.
Gamble: This is where things like virtual nursing make so much sense. But it’s a matter of making the investment, getting the infrastructure in place, and taking the leap.
Couts: I envision that in the next year, we won’t have a traditional discharge process. Discharge will be all digital. You’ll have somebody come into your room to help you with your education and make sure you have your transportation arranged. They call the transporter. They call the EBS staff. The nurse won’t have to intervene in any of that — it’ll all be cued up, and you can go home. Because it’s time for you to go home instead of waiting and dealing with throughput issues because we can’t get people out the door.
There are a lot of initiatives in health systems around getting people out by noon so you can put somebody else in that bed. It’s just thinking about it differently. I think this kind of interaction is going to be normal for people; it’s going to be the same way you get your information before going home, as well as registration or even some consultations. Anesthesia might not come to your room; they may actually ping you and check on you that way. It’s a different way of working.
Gamble: Right. There are a lot of opportunities for virtual and digital technology to really make things easier.
Couts: Yes. And you have to move. I hear a lot of people talk about failing fast, but I think you have to learn fast. Let’s learn and work and keep going because you can be stalled forever in pilots trying to get it right. And healthcare is so risk-averse; it’s never going to be perfect, but let’s figure out what works and continue to improve upon that. Otherwise, it’ll take forever to stand up programs and adoption will be less than optimal.
Gamble: I like that because it emphasizes the learning part.
Couts: And failure has such a bad feel to it. There’s lots of things that don’t work, but you learn from it, and you make changes. You hear about patient safety being all about culture; you report, you learn, and you get feedback loops. This is similar. You learn from it, reiterate, and keep changing the process until it does work well; until it’s baked into whatever you’re doing.