EHR v Covid-19. Pandemic Drives Patient Portal Signup (and helicopters and dinosaurs)?

More CMIO armchair theorizing

Amidst the furor of the health industry struggling to battle a microscopic foe, there are some interesting tidbits. And a data update, thanks to a question by @TheLizArmy on Twitter.

Here’s the TL;DR: Pandemic concerns, relaxation of Federal rules and Stay-at-home orders have resulted in explosive growth in our patient-portal sign ups at UCHealth. We went from 66% to 72% of patients seen between February and April 2020 with an active Patient Portal account. Look at the sharp up-tick. We are now at 700,000 online patients from 650,000 last month! AND, as of yesterday, our Video Visit count exceeded 4000 PER DAY.

All because of a tiny micro-capsid of proteins and a short strand of RNA.

Evil RNA-based life form? Can’t we just get along?

==INSERT SHORT AUTOBIOGRAPHIC ASIDE HERE==

In 1984, I spent a summer studying under Richard Goldstein PhD at the Harvard Medical School Genetics and Microbiology Department, and writing my thesis on the genetic makeup of the P4 bacteriophage, cutting and splicing DNA to figure out how the darn thing worked.

I stayed for the summer with a friend in an apartment on Massachusetts Avenue, and would ride my bike through Cambridge, over the Charles River and into Boston and the Lab. It was a good summer; I even decorated my bike helmet and called it my Bike Capsid:

Actual photo I printed and glued on my bike helmet in 1984

I celebrate my nerdiness.

A capsid is what the virus packages it’s DNA into to travel between bacteria. The tiny feet are what stick-it to a bacterial cell wall, and the tube is what the DNA is injected through, into the innards of the cell, like pirates commandeering a hapless merchant ship.

It so happened, that one late morning, the traffic was backed up for a half mile at the bridge over the Charles; a traffic cop guarded the crossing. I rode up on my commuter bike: “Hey Officer, what’s going on? Why is the bridge closed?”

He looked at me with disgust? boredom? and replied:
“Dinah-soah comin’ up the ri-vah” and walked away.

Dinah … WHAT?!

I turned to a nearby passenger on a public transit bus with an open window: “Did he just say: “Dinosaur coming up the river?” The guy just shrugged.

And sure enough, about 15 minutes later, the sounds of a helicopter, with a museum-quality dinosaur underneath, coming up the river to its new home at the Museum of Science. My summer was never the same after that.

Seriously? (from Arthur Pollack, https://www.boston.com/culture/lifestyle/2015/08/31/this-is-the-story-behind-my-favorite-photo-of-boston)

==END OF AUTOBIOGRAPHIC ASIDE==

Which is all to say: me and viruses, we go way back. And Dino’s are sometimes the hero of the story.

And while I’m meandering, it is fascinating that humans, in their slow, inevitable, dino-like lurch toward progress, sometimes put up such barriers (Federal Medicare prohibition of paying for telehealth, HIPAA Privacy concerns stopping the use of commercial 2-way video, cross-state prohibition on the practice of medicine) that we get in our own way. And then it takes a tiny little single RNA strand and a couple of proteins, to change the globe, and our lives.

The uptick on the curve above proves that humans crave connection. The uptick looks kinda like … the neck of a dinosaur? Anyway, here’s proof that dinosaurs are still ready to battle viruses on behalf of humans, growling in the Command Center at UCHealth.

CMIO’s take? What is your interesting back-story? Lately, we only have one channel in our brains: survive and defeat Covid-19. But we are so much more interesting to each other than that.

EHR v Covid-19. From the front lines: Virtual Visits take off at UCHealth. The Covid-19 burning platform

In-person clinic visits by week (red) and virtual visits (blue) at UCHealth, part of 2019-2020: UNVALIDATED DATA (red blips are likely Thanksgiving and December Holidays)

As recently as 2 months ago, we, the virtual visit leadership team, sat in a conference room bemoaning our fates: HOW will we get our 4000 providers (doctors and advanced practice providers) to start conducting Telehealth or Virtual Visits with patients? In all of 2019, our organization conducted about 2700 visits between providers and patients. This was a disappointing number, having spent a year integrating a 2-way video system (Vidyo) inside our Electronic Health Record (Epic). This was also disappointing because the state of Colorado passed the Parity law requiring insurers to reimburse healthcare providers the same rate for video visits as with in-person visits. What else could one want? Video visits for everybody!

Not so fast.

Turns out, doctors are humans too: you figure out a way to do something well (in-person visits with all your equipment for vital signs, sensors, gee-gaws, tests, fine-tuned teamwork honed over decades of practice), you don’t wanna change.

“If it ain’t broke, don’t fix it.”

CT’s inscrutable high school coach, to an uncomprehending student

We came up with all sorts of leadership plans to increase video visits: more education to front-line physicians (not helpful); sending experts to clinic to tout the benefits (nope); introducing video visits to clinicians already on bundled payments, such as surgeons whose post-op visits were no-fee (slight adoption). Video visit adoption was a local phenomenon: a few docs found it useful and did several hundred visits that way over the course of a year, and most others did not try it. Finally, we did get some traction by dedicating some urgent care docs to Virtual Urgent Care, for either a flat $49 fee or co-pay with participating insurers. For the most part though, bupkis.

In the graph above, the blue line indicates fewer than 100 video visits a week leading up to … March 2020.

And then, we know what happens next: PANDEMIC. Social Distancing. Stay-at-Home order from the governor. Suddenly clinic in-person visits plummet. And all across our 600 clinics: “Hey, wasn’t there someone here last year talking about some kind of video-thingy that we could use to see patients? Anybody have their phone number?”

We are luckier (or perhaps more prepared) than most other healthcare organizations:

  • We already integrated video into our EHR
  • We have a high-functioning IT infrastructure on a single EHR
  • We have a strong informatics group (physicians, APP’s, nurses)
  • Our clinical and administrative leaders collaborate well, and nimbly

And, okay the Feds helped:

  • CMS relaxed the rule prohibiting Medicare from paying for video visits
  • HHS relaxed the rule for HIPAA-regulation on providers of video (allowing for Skype, Zoom, even FaceTime), not that our organization needed this.

As a result, within a week of that first pandemic-related request from our providers, we scaled from 2700 visits in ALL of 2019, about a dozen per day, to 3000+ visits PER DAY. Lets say that again:

Video visits went from a dozen per day to 3000+ per day within a week

That’s just crazy talk. And also proof that John Kotter is STILL right, from his book Leading Change: Your first step is a creating a sense of urgency: a Burning Platform. And boy do we have one now, thanks to a microscopic life form .

And now? Now, I sit here in my home office, with my laptop and my smartphone connected, waiting for my next patient, who is visiting me from their home, arranged by my medical assistant, sitting at her home. Our bricks-and-mortar medical office is 2/3 empty, with a reduced crew seeing in-person visits for those without video visit tools, or needing physical exam or other services.

When we connect, every interaction feels like a victory. Every “return visit” feels like re-connecting with an old friend. In fact, I reflexively raise both arms like our team scored a goal:

“You made it!”

“Yes, I did!”

“It is GREAT to see you!”

“Yes! And how are YOU, doctor? Are you doing okay?”

The empathy of patients toward ME and my colleagues, is touching, and genuine, and so much appreciated. Unbiased opinion: longitudinal primary care internal medicine has the BEST patients in the world. Truth.

CMIO’s take? We are creating a new healthcare world, by necessity. Will we ever go back?

COVID Incident Command: a day-in-the-life

The author, defended by his creature creations.

A recapitulation of a series of tweets about my recent experience at the UCHealth’s command center. I rotate the responsibility for the physician support position with about a half-dozen other docs. The command center has been up for almost 3 weeks now.

1/ A day @uchealth Incident Command Center. Constant stream of calls. Room is full of experts (infectious diseases, pulmonary, disaster) with a dozen other directors. Like being the frontal cortex of a massive organism…

2/ If you’ve never served in a Command Center, it is scary as heck, and also exhilarating. Things happen and decisions are made in minutes and hours, not weeks and months, as is more usual in a large organization… is that

3/ Sample incoming call: ‘ICU wants to know whether to send a second COVID test nasal swab on a patient whose test was negative yesterday but the team has high suspicion they have COVID.’ (Yes, not via nasal swab, but by tracheal aspirate for better sampling)

4/ Sample call: ‘Community organization purchased 10 COVID tests somewhere; would we send a medical assistant to perform swabs on their employees.’ (No, test performs poorly for patients with no symptoms.’ and, how do you choose who to swab? And, what would you do differently if you have a result? negative: stay home. Positive: stay home(!)

5/ Sample call: ‘Hey, if ventilators are scarce, we could build Iron Lungs faster: want some?’ (After internal discussion, no: COVID is associated with ARDS (adult respiratory distress syndrome). ARDS causes stiff lungs, unlike polio, and even then they didn’t work well), AND, how to manage IVs and catheters?

6/ Our converted conference room now is 24/7 staffed with executives, directors, nurses, doctors, staff who connect to every part of our 12-hospital, 600 clinic, 4000 provider system. Kinda like a neocortex…

7/ We sit and take calls from all over the system, clarifying the daily-changing policy, delivering nimble responses to moment-to-moment events in our EDs, our clinics, our hospital wards …

8/ We huddle in purposeful groups through the day: medical officers, informaticists, nurse leadership, respiratory therapists, ICU teams, hospitalists, data analysts, facility managers, tent-building teams(!) …

9/ We ‘run the board’ twice a day to ensure our top issues are addressed, re-prioritized, to keep our eye on the ball: racing ahead of the coming tsunami of COVID-infected patients collapsing on our doorstep…

10/ We marshal our supplies, build negative pressure rooms, re-allocate staff, negotiate new partnerships, create and dissolve projects to solve immediate problems…

11/ Dramatically expand our Virtual Health Center for Virtual Urgent Care, expand our nurse call line to handle COVID concern calls, go from 2700 virtual visits last year to 3000 virtual visits per DAY this week…

12/ Discover new trends: hypoxic COVID patients who are surprisingly not short of breath, patients who oxygenate better laying on their stomachs, how poorly bleach wipes interact with electronics(!) …

13/ We tearfully celebrate improvement: today a cluster of patients successfully extubated from the vent, a few patients de-cannulated from ECMO, a hallway of nurses applauding an ECMO survivor…

14/ And yet we have fun… Jurassic organisms battle for supremacy while modern organisms do the same.

15/ Our loyal administrative intern asked our Incident Commander at the end of her day shift: ‘How do you feel? How do you think we’re doing?’ …

16/ Her reply: ‘For the world, terrible. For our country, very worried. Here, we have prepped well, we have a great team, we forecast constantly, and we are going to meet this challenge.’ So proud of her, and us.

Laocoön, The Aeneid and Captain Picard

https://en.wikipedia.org/wiki/Laoco%C3%B6n_and_His_Sons

My high-school aged son is avidly devouring classic literature, and the echoes of those epic struggles from my own education, float back to me. On our winter break one evening, he had left the Norton Anthology of Western Literature out on the coffee table. Soon I was in the midst of battle at Troy, at Carthage, in Rome.

Aeneas of Troy, in the classic by Virgil, faces a long journey with many trials. Even in 20 BC, storytellers mastered Story. Sometimes the smallest moments are the best parts of a story:

  • Laocoön runs out from the city to warn his fellow citizens of Troy, that the large wooden horse left behind by hastily departed Greeks, was a trick: ‘beware of Greeks, even bearing gifts.’ To punish him, the gods send a pair of serpents to devour his sons and then kill him. The image above of Laocoön dying defending his sons is such a moment. The city elders, seeing him killed by the gods, are then convinced that he is wrong, and bring the Trojan Horse inside the gates. Of course, you know the rest: the city of Troy falls that night as hidden Greek solders pour out, open the gates and ransack the city.
  • Aeneas initially resolves to stay and defend his city to the death. His touching moment with his father and their resolve to stay together and flee is a pivotal moment of change for both of them.
  • Aeneas meets Dido, queen of Carthage, in his storm-tossed journey, and falls madly in love. Soon after, the gods send him a message that he and his lineage are to become the founders of Rome. He leaves immediately. Dido kills herself in despair.
  • With supernatural help, Aeneas journeys to the underworld to see the future: that his descendants establish Rome and create the Roman Empire.

These moments, to which I’ve summarized so prosaically, are told in verse and with rich detail and sensory imagery.

Interestingly, the Norton Anthology also included the ancient translation of Gilgamesh, perhaps the oldest recorded epic story. Being a science fiction geek, perhaps I should not have been surprised that my first exposure to this classic, written in antiquity, circa 1700 BC, first reached my ears via Captain Picard, on the all-time most popular episode of Star Trek, The Next Generation TV show called Darmok (no, not the new, apparently amazing show, that is behind the CBS paywall). Careful, don’t read the links unless you have time; you won’t come out for awhile.

CMIO’s take? Great storytelling captivating, and timeless. Smart people lived thousands of years ago. Sometimes Captain Picard teaches you ancient literature.