Being an early adopter — or, at least, an organization on the cutting edge — requires a great deal of investment, but not just from a financial perspective. In fact, upfront costs are only part of the picture, said Anna Schoenbaum, VP of Applications and Digital Health at Penn Medicine.
“You want to make sure [solution installations] are well-resourced with the right stakeholders. Additionally, it also important to understand the support model, the sustainability of the solution and the optimization process,” she said during a recent interview with Kate Gamble, Managing Editor at healthsystemCIO. Any solution needs to meet the needs of patients and providers, and incorporate into the workflow, or else it doesn’t stand much of a chance.
During the discussion, Schoenbaum talked about how Penn Medicine is working toward its vision to “be part of a changing world” through initiatives focused on patient care and clinical efficiency and wellness.
Schoenbaum, who received the HIMSS-ANI Nursing Informatics Changemaker Award in 2023, also shared insights on the critical role of feedback loops in driving adoption; why strong governance and engagement must be part of an organization’s DNA; her team’s goals when it comes to leveraging ChatGPT; and her passion for informatics.
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Bold Statements
If a virtual nurse can come in and provide discharge instructions and training, that can help alleviate some of the workload on the bedside nurse. It can also provide a one-on-one concentration to the patient and make sure they really understand instructions … when patients are educated regarding their care, it can lead to better outcomes.
We always want to understand the purpose statement of the problem we’re trying to solve and where we want to go, and then we go through our governance group. That’s part of our DNA. We have really strong governance and strong engagement.
You need to listen and develop relationships where people can knock on your door, and you need to do some observation.
We’re all learning; we’re learning from our colleagues as well as our experts within the organization on how to shape that. We’re at the very beginning of the journey.
We’re excited to be on this journey to help our clinicians and to help our patients. And we do it in a very thoughtful and meaningful way so that we’re able to find the right solutions for the problems we’re trying to solve.
Q&A with Anna Schoenbaum, VP of Applications & Digital Health, Penn Medicine, University of Pennsylvania Health System
Gamble: Hi Anna, thank you so much for joining us. Let’s start with a high-level overview of Penn Medicine, and then we’ll get into your role.
Schoenbaum: Wonderful. Thanks so much for having me. Just a little bit about us; Penn Medicine is a six-hospital system providing care throughout Pennsylvania and New Jersey. We have 49,000 employees. We have 3,600 inpatient beds on the acute care side, and we have around 6.9 million ambulatory visits per year. Our home health program is also very large. We have an average daily census of 4,000 which equates to 716,700 annual visits.
We’re an organization of many firsts. We have the nation’s first hospital, which was founded in 1751, and we have the first medical school in the United States, which dates back to 1765.
In addition to that, we recently had two physicians named winners of the 2023 Nobel Prize in Physiology/Medicine: Katalin Kariko, PhD, and Drew Weissman, MD, PhD, for their remarkable achievements.
Changing Delivery Models
Gamble: That’s fantastic. Congratulations to the whole team. So, in terms of your role as VP of Applications and Digital Health, what do you consider to be your most pressing objectives?
Anna: We have many initiatives at Penn Medicine focused on patient care and clinician wellness. In this changing environment, our mission is to improve the health and well-being of people in our neighborhoods, in the region, and around the world. Our department, Information Services, provides support to patients in all settings. When I say, ‘patient care,’ I’m referring to the ambulatory space, emergency department, acute care, rehabilitation, and home care.
If I were to dig deeper, it’s about improving access to care, as well as patient experience. On the front end, we’re looking at how to find providers, how to schedule appointments more easily, and how to do self-service; for instance, online scheduling or mobile arrivals so that we know when a patient has arrived at the practice.
We’re also changing some of our delivery models on the acute care side. We’re looking at how virtual nursing can assist nurses at the bedside. In terms of home care, we’re also looking at innovative tools that can make nurses more efficient while also delivering better care and better communication.
In addition, we’re involved in a lot of value-based programs. We’re implementing tools so that our patients can be seen across the continuum in more of a holistic care model and we’re providing those tool sets to our providers. That’s on the patient care side.
Virtual care possibilities
Gamble: You mentioned virtual nursing — can you talk more about what you’re doing in that space, and what’s driving that?
Anna: Sure. As we go through the post-pandemic recovery period, we’re dealing with workforce challenges, as well as keeping our clinicians well and helping them to be more efficient. As a result, we’re looking at different models of care. We have great virtual programs in different spaces. We have a world-renowned program for critical care in our ICU, where a centralized program provides adjunct care virtually at the bedside.
We’re also looking at virtual nursing models. At this point, we’re still working on assessing the right workflow to have virtual nurses overseeing patients in, for example, med-surg or labor and delivery, when patients are ready to go home or move onto to other spectrums of care.
Right now, we’re looking at whether virtual nurses can be valuable in triage, maybe by gathering data on social determinants of health, as well as discharge. If a virtual nurse can come in and provide discharge instructions and training, that can help alleviate some of the workload on the bedside nurse. It can also provide a one-on-one concentration to the patient and make sure they really understand instructions and are able to demonstrate that before they go home. When patients are educated regarding their care, it can lead to better outcomes. Those are all under evaluation at this point, and so, we’re going to be deciding how to move forward and how we may deploy that from an enterprise standpoint.
Gamble: Really interesting. I imagine the approach needs to be fluid when you’re talking about something like virtual nursing because it’s changing quickly. But it seems like it can be a huge win in terms of improving patient care while also taking some of the burden away from nurses.
Anna: Absolutely. We need to understand what the patient needs and how the technology can be used in the patient room to help nurses. We’re considering a model using a WOW or an in-room camera and a TV type of solution that allows for that two-way interaction. A WOW may be more costly effective, but it may have disadvantages because you’re rolling in those carts, and it may not be suitable for the situation at hand. And so, right now, we’re going through the technology evaluation to figure out the best model for our organization.
Strong governance and engagement
Gamble: In terms of your approach with this project, is that a reflection of the culture at Penn Medicine and how you tend to approach initiatives?
Anna: It is. We always want to understand the purpose statement of the problem we’re trying to solve and where we want to go, and then we go through our governance group. That’s part of our DNA. We have really strong governance and strong engagement. To make sure we understand the scope, we need to understand the requirements from a patient perspective and nursing, clinical, and administrative perspective, as to how that would work, and then we go through an evaluation system selection process. That’s typical with an implementation.
You want to make sure the solution installations are well-resourced with the right stakeholders. Additional it is important to understand the support model, the sustainability of the solution, and the optimization process. It’s working closely in partnership with operations as well as clinicians, whether it’s at the frontline or at the executive level. It’s making sure we are moving forward together, arm in arm.
Focus on clinical wellness
Gamble: What are some of the other clinically focused initiatives you’re working on?
Anna: We’re also focused on clinician wellness. Our clinicians have been through a lot, and so, we want to help reduce the workload, improve efficiency, eliminate redundancy, and improve the care of our patients. We’re looking at using artificial intelligence and ChatGPT for intelligent electronic health record in-basket management. We’re also looking at other ways to streamline documentation and improve workflow. Those are some of the innovation projects we’re looking at.
We’re also about to start ambient listening technology where software can provide draft responses to a summary visit of a provider speaking in a patient’s room during an examination. That solution can be used for an admission note, H&P (history and physical), or some type of summary. We have this project underway right now at one of our hospitals.
Feedback loops
Gamble: In terms of ambient listening, has that been received well? I know it has critics, but is it something where the pros outweigh the cons?
Anna: I think with any new technology it takes time to understand what it requires to be an early adopter. It’s really important to make sure you understand how it works and how it fits into the workflow. If it’s too cumbersome, it’s not going to be used as intended. That feedback loop with providers is extremely critical for early adopters, whether it’s the in-basket auto response or ambient listening technology.
That feedback loop is also important during the early development with vendors — that’s what they’re looking to us for. As long as the communication is open, it will be well received, and we can continue to grow that product.
We’re testing ambient listening. When it works right and is incorporated into the workflow, we’ve been getting very positive results from our providers. We won’t be able to deploy it fully until we get on to a certain platform in our her vendor and improve our device integration. It’s still ways away, but we’re doing a pilot test run prior to the general release available with that integration. We’re really looking forward to it. We have a lot of providers raising their hands for this opportunity, and so we’ll see how it goes.
Prompt engineering to help “overwhelmed” providers
Gamble: With something like intelligent EHR in-basket, I’m sure getting feedback is really important. How are you approaching that?
Anna: In terms of in-basket messages, we have selected five practices, but we know it can’t just be providers because there’s also nursing that’s also part of their team. It’s a team. We have five practices with multiple providers that are helping us test this product. But I want to put something into context. At Penn Medicine, with our 6 hospitals and 6.9 million ambulatory visits, we have 5 million in-basket messages from patients. Our providers are overwhelmed in answering the messages in between patients. .
As we look to see whether ChatGPT can help with prompt engineering, that’s still to be determined. We have to provide responses that reflect how certain providers communicate. And that requires continuous updating of our prompts to make sure it works. We need to make sure it sounds authentic in that context. We need to make sure it’s accurate and that our messages are clear so that patients receive the right communication.
Measuring ROI
Return on investment will be measured by accuracy of response and efficiency of data, as well as provider satisfaction. We have providers who were selected for the pilot because they provide us with feedback; we meet with them on a regular basis. Additionally, our EHR vendor has open office hours during which we can provide feedback, not just with Penn Medicine but other colleagues that are implementing it. It’s a community of feedback.
It’s really exciting to be early adopters with this technology and trying to shape the direction it goes. We also plan to look at ChatGPT for clinical summaries; hopefully it’ll get started in the next few months.
Prioritization challenges
Gamble: Being an early adopter isn’t something Penn Medicine has backed down from, and although there are benefits to that, I’m sure there are challenges too.
Anna: There are. Right now, with the multiple priorities we have, as well as the workforce challenges everyone is dealing with, it’s difficult to prioritize. But our leadership has been very supportive in making sure we’re focused on improving patient care while also reducing the burden of our clinicians, nurses, physicians, administration, and case managers. And so, we have to make priorities of these bigger innovative solutions. We’ve weaved them in and made them part of the list of projects we want to implement throughout the year.
Gamble: There’s a lot of emphasis on making sure any objective fits into the workflow. Is that your experience coming through?
Anna: Absolutely. To me, if you work in healthcare IT, it has been proven that we need to keep providers within their workflows. Whether you have one EHR or a seamless connection, the goal is to reduce redundancy and have information at the right time and the right place. I started out in pediatric critical care, and so, my background is all about providing holistic care from one setting to another. That certainly plays into understanding what a provider may need.
Informatics – “the best of 3 worlds”
Gamble: Interesting. How did you come into the IT space?
Anna: I kind of stepped into it. When I was going for my master’s many years ago, I went to an informatics open house. Unbeknownst to me, that university has one of the top nursing informatics programs in the country. I wanted to solve problems to make things better for patients as well as clinicians, and it has been the best of all 3 worlds: information science, clinical science, whether it’s nursing or academic science, and the leadership component. I’d love to have all three of those pieces, and to be part of communities that drive forward better patient outcomes.
Gamble: It seems like that nursing experience stays with you in a lot of ways, especially in leadership roles.
Anna: Yes, absolutely. It does. It is part of me; it’s who I am. Once you become a nurse, you’re always a nurse.
An “open door” for innovation
Gamble: Absolutely. One of the last topics I wanted to cover is innovation and what it takes to foster it. There’s no blueprint, but what have you found to be a good way to keep ideas flowing?
Anna: I think it’s having an open door. You need to build relationships with your executives, your frontline clinicians or physicians, respiratory therapists, case workers, etc., and ask how things are going. But you also have to be present. I like to do rounding on the units and do some observation, both before and after an implementation.
Right after the virtual nursing pilot started, I held an observation day because I wanted to see the great work everyone had done. I noticed one nurse was always interacting with the patient, which is great, but she was writing on paper. And so, we asked if a dual monitor would help so that she see the patient on one screen and also work directly in the EHR. Those little things are big wins when you can streamline workflow.
You need to listen and develop relationships where people can knock on your door, and you need to do some observation. Also, I give Penn Medicine credit for having a really robust governance process and a process where you can review projects while also keeping work groups going during the implementation.
The explainability factor
Going back to AI, it’s different from a system implementation. Whenever you implement any predictive model, you have to go through a little bit more robustness in the evaluation process. And it’s not just the implementation; it’s also on the support side. Before you implement, you check for data security and privacy and make sure you know how information travels from one system to another if you use a third party. You also need to understand how things are calculated or scored, which is called explainability.
You have to look at the resources needed for implementation, but also for sustainability, because you need to continue to monitor these predictive models. They may change as your population changes or as you expand your program. Those are things that probably are different than a normal system implementation. We’re all learning; we’re learning from our colleagues as well as our experts within the organization on how to shape that. We’re at the very beginning of the journey. It’s going to be very exciting in the next couple of years here.
“Part of a changing world”
Gamble: For sure. Well, I’d definitely like to catch up with you again down the road to see how things are moving. There’s a lot of curiosity when it comes to things like ChatGPT, and I know others will appreciate your story. I give your organization a lot of credit for being an early adopter.
Anna: It’s exciting. And it’s great to have that partnership with our clinicians and our executives helping us push it along. The vision here at Penn Medicine is to be part of a changing world. That was the tagline from our new strategic plan, and it really resonates with me. We have a lot of support from our leadership, and we’re excited to be on this journey to help our clinicians and to help our patients. And we do it in a very thoughtful and meaningful way so that we’re able to find the right solutions for the problems we’re trying to solve for our patients and our clinicians.
Gamble: With so much innovation happening in the industry and so much interest in tools like ChatGPT, do you have any advice for other leaders on how to proceed and do it in a way that’s going to be sustainable?
Anna: I think there’s a lot of consideration regarding the resources that are required for engagement and adoption, but I really want to bring it back to the core of this: the patient. The patient has to be in the loop to make sure our results are accurate. It’s a good idea to have a patient advisory board to get ideas on how patients respond and how communications should be formulated. And it’s also about understanding what clinicians need and what we intend to do. We need to keep everyone in the loop and not let technology outweigh the human element.
Gamble: That’s great advice. I like what you said about building trust; that’s going to be such a huge part of this going forward.
Anna: Absolutely.
Gamble: All right. Well, thank you so much. I really appreciate your time and look forward to catching up with you down the road.
Anna: Thanks so much, Kate.
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