Category: Informatics/EHR

Electronic Health Records and Clinical Informatics

Social Distancing reduces more than just COVID-19: Guest Blog (Dr. Eric Glissmeyer)

Dr. Glissmeyer, informaticist, Utah, notes that emergency department visits plummeted in March and are much slower to rebound. Why?

During many winter seasons, pediatric hospitals are bursting at the seams. RSV, Human Metapneumovirus, and other respiratory viruses like non-SARS CoV-2 Coronavirus cause significant disease burden sending pediatric specialists scrambling to find space to admit children with bronchiolitis who need supplemental oxygen and other forms of respiratory support. Patients with the same viruses will “double bunk” in single rooms to receive life-saving care. 

2020 has been very different. COVID-19 was announced to have arrived in Utah March 6, 2020. March 13 2020 Utah schools announced that beginning March 16 online home learning would begin and Saturday March 14 the first case community spread of COVID-19 was confirmed. March 16 the Utah Department of Health issued a public health emergency limiting some services and businesses and Intermountain Healthcare and University of Utah Health announced elective and non-emergent surgeries and many non-urgent ambulatory services would be canceled. March 27 the Governor issued a “Stay Safe, Stay Home” directive. Social distancing during these months, via economic and public gathering restriction, was the only public directive. Mask wearing in Utah did not become widely encouraged until July 2020.

As a result of these social distancing measures, we have witnessed a dramatic decrease in infectious diseases. The following data are from germwatch.org and contain data of common infectious disease prevalence in Utah, as identified by testing performed at and sent to Intermountain Healthcare labs, clinics, and hospitals.

Utah disease prevalence, tests performed at Intermountain Healthcare labs
Group A Strep dropoff quicker in Spring 2020

We have seen a drop in Emergency Department census that is unprecedented. We attribute this change to the decrease in circulating viruses, commonly spread bacterial pathogens and different healthcare consumer choices. In over 15 years, we have not seen ED volumes in the low ranges we are consistently seeing them now. 

Even as many economic restrictions have lifted in recent months, ED census remains lower than previous. At this point, we are uncertain which of the following influencers are playing roles, if all, or others?

  • Health care consumer choices (avoiding health care)
  • Social distancing reducing disease transmission
  • Mask wearing reducing disease transmission as social distancing/economic restriction has begun to lift

Emergency departments are a clinical service entirely dependent upon what is referred or self-referred to them. Yet they are a critical part of the healthcare system for unexpected, emergent care and as a venue for coordinating complex care.

Unprecedented dip in ED visit volumes, Spring 2020

We are seeing an apparent, but slow, increase in ED census over the past 3 months. Much slower than the stock market rebound 😉

July 2020 Daily Census Range: 57-92 July 2019 Daily Census Range: 79-120

Our hospital and others around the country have been bursting at the seams with seasonally variable infectious diseases like RSV and influenza. We now know that social distancing behaviors that decrease disease transmission can have a significantly decrease disease transmission. Data from the Southern hemisphere indicate that influenza season may be better than previous years, perhaps because of societal behavioral changes.

-Eric Glissmeyer, MD
Associate Professor, Department of Pediatrics, University of Utah
Division of Pediatric Emergency Medicine, University of Utah
Medical Director, Care Transformation Information Services, Intermountain Healthcare

EHR v Covid-19. Patient portal trends, 6 months into pandemic

EHR Patient Portal Advocates! I need your brains.

EHR Patient Portal Advocates! I need your brains.

This is the curve of percent of patient appointments each month for the past 3 years, with patient portal accounts. I blogged a version of this back in March. Back then, if you drew a straight line from 2017 through FEB 2020, it looks pretty linear. Then, BOOM, a sharp uptick in March and April. The percentage increases from 71% to 77% in 2 months. Then it has stabilized and flattened in the 76-77% range since then.

On the one hand, one could hope that the increase in patient portal sign up would continue until we got to 80 or 90%. We know that 90% of healthcare ORGANIZATIONS offer a patient portal and that 52% of patients in an ONC survey have a patient portal account (2017 data).

So, in 2017 we were around 56%, right in the ballpark.

I think we understand the bump in portal usage in March and April: our dramatic upscaling of telehealth by 200x from 20 per day to 4000. In order to schedule patients for a telehealth visit, we required the patient to register for and log in to our My Health Connection (Epic’s MyChart) patient portal at UCHealth. Nothing like a pandemic and an available well-oiled telehealth service to bump patient portal stats.

Now, more of our patients can take advantage of: messaging their provider, refilling their prescriptions online, accessing price transparency estimates of anticipated procedures or services, viewing and requesting changes of the: medication list, diagnosis list, view their provider’s progress notes (Open Notes), view their radiology reports AND actual images (UCHealth is one of the first patient portals in the country to offer this).

However, what explains the flattening since then?

Theory #1: It’s those surgeons!

The theory: well, all surgery clinics completely shut down during most of March, April. And, WE ALL KNOW that surgeons are terrible with patient portals (rampant overgeneralization). The answer: Actually, NO. Once we select ONLY primary care practices and exclude surgeons and medical specialists, the same curve occurs. It is not the opening and closing of surgery clinics.

Theory #2: its those Seniors!

The theory: well, since most older patients have been staying home, and a good number of them don’t have access to smartphones or laptops or PC’s to do telehealth visits, it must be ONLY younger patients coming in, who of course have excellent rates of signing up for the patient portal for telehealth, right?

The answer: Again, NO. Turns out, if you filter out all patients over age 65, the same curve occurs.

Huh?

So, what is happening here? Are we bumping up against the natural limit of Coloradoans who own smartphones and/or computers? Have we indeed registered ALL patients who will ever agree to signing up for a patient portal for any reason?

Or, have we gotten lazy and gone back to “hey lets encourage patients to come back to clinic!” and thus relaxed our vigilance at setting up patients for a free portal account?

Or is there another theory, another slice of the data I haven’t thought of?

CMIO’s take? I’m asking for YOUR help! Send me an idea, a theory I can slice on this data and see if it explains the plateau!

 

EHR v Covid-19. Telehealth after 6 months at UCHealth

Six months into pandemic, what is happening to telehealth visits at UCHealth? Inquiring minds want to know!

Here we are, data dilettantes, on our long journey into the unknown.

At the prompting of online colleague John Lynn, we look back at telehealth usage at UCHealth in the past few months. The above graph depicts January 1 to present, the curve of in-person visits at UCHealth (purple) and telehealth visits (cyan). You see that telehealth visits temporarily outpaced in-person visits.

First of all, I feel very sophisticated for writing “cyan” instead of my first (caveman-male) instinct “blue-ish”.

Second of all, notice the curve above compared to our evolving curve from March, 5 months ago (remember, those purple divots are from Thanksgiving and Xmas holidays):

Be careful how you extrapolate, right? Based on this original, one would have thought “Holy Smokes! Telehealth is going to rule the world in a few more weeks!”

And one would have been wrong.

So, now it comes upon us Armchair Data Scientists to hypothesize: why? Why did the curve do what it did? Well, our first external data point is: Colorado Governor’s Safer-At-Home order expired on April 26. On the top graph, this corresponds to the day our 2 lines cross in April, with in-person visits rising again. This also corresponds to our surgery clinics opening up again to see patients.

Averaging the last few weeks of data, we are seeing about 8000 telehealth visits vs 60,000 in-person. Or about 13-15% of appointments being conducted by telehealth. REMEMBER, this is unvalidated data, so, take with some salt.

What have we learned? From anecdotal evidence, I have heard from quite a few patients (most of mine are over 65) that they prefer in-person visits when possible, although telehealth has been “acceptable” when fears of contagion are high. Also, much of internal medicine requires blood testing, vital signs monitoring, examination. Also, I’m finding that non-verbal communication, although “acceptable” via telehealth (tone of voice, body language), it is much richer in-person.

Even when we were conducting 2/3 of clinic sessions exclusively by telehealth, our in-person clinic slots were full, and our telehealth clinics routinely had open time slots. Now that we are scheduling 75% in-person, all our in-person slots are full, and our telehealth slots still sometimes are open.

It will take some intrepid ethnographic researcher to pull interesting trends out of this, as I’m hearing from other parts of the country that telehealth visits are preferred to in-person. Is this: geography and distance needed to travel? Is it the rarity of the specialist’s expertise? Is it access to surgeons? Is it the (gasp) lack of skill of the telehealth provider (please, no)?

We are also still struggling with CMS (Medicare) regulations that, for example, for home vital signs to be “acceptable” for quality reporting, either the MA or the provider MUST view the actual blood pressure from the display of the machine over the video link, or view a printout from the machine, otherwise it “doesn’t count.” Hmm. I get why administrators want good data provenance (proof of authenticity), but isn’t telehealth hard enough? Why make it even harder for patients and docs? Who is going to be so motivated to PAY their co-pay for a telehealth visit, have that visit, and then LIE about their actual blood pressure reading at home, so that they “look good” for the doc, or the doc can “look good” for the regulators, payors? Ridiculous.

Nevertheless, our pandemic / telehealth story evolves. With the fall approaching, schools reopening, flu season coming, watch this space for what happens next.

Things are briefly, perhaps, not as dire as in March and April, in Colorado.

CMIO’s take? Telehealth was gangbusters in March, April, and is now settling down to 13-20% of total volume of clinic visits. We are back to 95% of original clinic volumes (in person plus telehealth together), so there are still some patients who haven’t returned to see us. And, although we have learned a lot, I think we still haven’t optimized “best practice” on when to use telehealth with patients. I think there are still some adjustments and opportunities out there. Let me know in the comments what you’re seeing!

My Failure Resume, redux

Well, it is time to update my resume. It has been a year, I have failed at more things. I’ve read more failure resumes, and I like some of the newer ideas, for example, listing your NON-skills. I’ve added mine.

One idea for brave souls willing to try, is to submit both your Regular CV / resume AND your Failure resume to your next job interview. Here are 1 page versions of mine (REGULAR resume – 1 page / FAILURE resume – 1 page).

And, wouldn’t you know, the most popular post on this blog, after 3 years of weekly writing on aspirational topics in informatics?

My original Failure Resume. Go figure.

I love some of the writing out there on Failure Resumes:

  • Stanford Engineering: “come to terms with the mistakes … made along the way and … extract important lessons”
  • Forbes: Of 10 job applications, received 0 responses to traditional resume, but 8 responses for a traditional resume PLUS a failure resume.
  • Inc.com: why to encourage your employees to make a failure resume.
  • Even Einstein struggled: a scientific paper on how describing Einstein’s struggles to science students increased students’ hopefulness and engagement with science class.
  • ScienceAlert.com: A CV of failures is an entertaining and instructive read

CMIO’s take? I’ll be teaching an Informatics Leadership course soon, and will expect all our participants to write a one-page Failure Resume. Join us!

 

EHR v Covid-19: MDPOA (power of attorney) & Advance Care Plans and the Covid BUMP

Full open-access paper here. https://preprints.jmir.org/preprint/21385/accepted

What I love about working in an academic health center is the luxury of being surrounded by people smarter, and more hardworking than I am. Here are Drs. Portz and Lum analyzing our data on the capture of patient’s Advance Care Plans – ACPs (including the Medical Durable Power of Attorney MDPOA) and other documents online via our patient portal.

We believe we are among the first in the country to offer the ability for patients to complete this online and designate a medical decision-maker in the event of their incapacity. Furthermore, we now accept photos of documents (easy and convenient via our patient portal app integrated with a smartphone camera — hooray modern tools for modern medicine) into the patient chart, and can see signatures, names, contact information, and details of MDPOAs, Living Wills and other ACPs.

And, during the anxieties of the pandemic, we had a significant uptick in patients completing the MDPOA and uploading images.

CMIO’s take? Another publication for our smart colleagues — good. Better patient care — great.

EHR v Covid-19. Taiwan, EHR and effective pandemic response leads to economic growth

https://www.statnews.com/wp-content/uploads/2020/06/GettyImages-1207790641-1600×900.jpg
image from Statnews

https://www.statnews.com/2020/06/30/taiwan-lessons-fighting-covid-19-using-electronic-health-records/

It is fascinating, inspiring (and disappointing) to see effective responses to the Covid pandemic from other countries. Great partnerships and effective connection of governmental leadership, industrial production, and healthcare information can combine to combat the pandemic.

Taiwan has had only 446 cases and 7 deaths, for 24 million residents, since the start of the pandemic, despite their proximity to, and the frequent travel and many flights to and from China.

Dialing in to an Aging Parents Telehealth Visit… Why aren’t more of us Doing it? (Guest Blog: Glenn Sommerfeld)

I forgot about my father’s memory and neurology clinic visit even though I had promised to go down to Denver with both of my parents to help them navigate the complex world of healthcare four months before.  A lot changed in those four months, most notably COVID-19 swept across the world and made its way into the US.  The pandemic placed my aging parents at a greater risk if they contracted the virus while traveling from Fraser, Colorado to Denver and my work schedule was beyond capacity as I added Federal and State COVID-19 reporting coordination to an already full project portfolio.  How could a take a day and a half off work?  How could my parents stay safe?

Telehealth and Rural (Mountain) Living

I decided to move on from my first health care job in neurophysiological monitoring to acute care in 2011.  I also wanted to move to the mountains of Colorado.  My parents already moved from Colorado Springs to Fraser, just outside of Winter Park, Colorado.  Yampa Valley Medical Center brought me on as a quality analyst before they were part of the UCHealth system.  After moving to Steamboat, I realized how remote and isolated Steamboat Springs, Colorado was from Denver and the other “Front Range” cities in Colorado.  Here are some fun facts about driving from Steamboat for medical care:

  • Steamboat Springs to University of Colorado Hospital and the Anschutz Campus
    • 169 miles
    • 3 Hours and 10 minutes if traffic is good
    • One major mountain pass (or two if Eisenhower Tunnel is closed)
  • Steamboat to Poudre Valley Hospital
    • 159 Miles
    • 3 Hours and 21 minutes if traffic is good
    • Two major mountain passes or the choice to leave Colorado, go to Wyoming and drive back into Colorado so you only have to deal with one major mountain pass (adding on 30 more miles)

Many specialists come up to mountain communities on a rotational basis.  However, this may be once a month and possibly less frequent.  Telehealth is the obvious stop-gap for patients in rural and mountain communities that need specialized care.  A barrier to telehealth visits as Dr. Lin has mentioned in his blog has mostly been the providers.  However, with social distancing and with CMS lifting restrictions on reimbursement for telehealth, providers quickly adopted telehealth to keep revenue streams flowing for their practices.

Telehealth and Telemedicine Expansion and Deregulation

Telehealth and telemedicine rules and regulations relaxed at the start of the COVID-19 pandemic.  Now is the time to figure out how else to utilize technology to improve healthcare delivery.  Now is the time for innovation and policy reform.  So, how can telehealth help patient advocates and family members?  Could it be the answer for me and my dad’s visit?  Will it work for others in an urban setting or family members that are geographically separated?

Being a Patient Advocate Remotely

Before the pandemic, I had planned on taking a day off of work to drive down to Denver to accompany my father to an appointment at a neurology clinic.  This appointment transitioned to a telehealth visit following the outbreak.  I considered making the two-hour drive from Steamboat Springs to Fraser to be with him for the appointment.  After all, I would generate a net gain of two and a half hours from not having to drive all the way to Denver.  In a moment of clairvoyance, however, I decided to find out if I could join remotely.  After working with a few key stakeholders at UCHealth, we discovered that if my father gave me access to his My Health Connection account, I could join the same way he would for the remote visit.  This access also allowed me to review my father’s medications as the provider discussed them with my mom and dad and access the summary notes from the visit, so I could discuss treatment options with him and my mother at a later time.

The Visit (that’s me at the bottom, by the menu bar)

It was strange to know that I would be on a video call with my parents, but to be on the phone with them as well, ensuring that they could log on.  My wife and I have discussed the shift in caring for both sets of aging parents, but this was the first time I needed to support them on multiple fronts.  First working with them on technology and second being a health advocate.  The visits felt distant, yet at the same time normal.  The medical assistant greeted us virtually and started the intake process.  Dr. Zachary Macchi jumped onto the call about five minutes in and reviewed history and started the evaluation.  About twenty minutes into the call, Dr. Samantha Holden was able to join as well.  In the span of twenty minutes a total of six people (including my father) were working together.  Had we all gone down to Denver together, this may have been the same outcome.  However, Dr. Macchi joined the call first to help Dr. Holden.  He stated right away that she would be able to join us, but had other commitments.  My guess is that if we were in a traditional setting, we would have waited an extra 20 minutes but telehealth gave the flexibility for coverage.  Telehealth has its limitations.  My father had difficulty following the motor skills test.  We were unsure if it is his motor function or his ability to follow a two dimensional image in the three dimensional world.  For this and other reasons, everyone agreed on an in person visit three months following the virtual visit.

Just the first step… what are the next.

This visit made me realize the opportunity for telehealth in the patient advocacy realm.  While telehealth offers a convenience for the patient, it certainly helps with obstacles that patient advocates face.  I am lucky to live just a few hours drive from my parents.  If I lived outside of Colorado, I doubt I would be as involved in their care.  However, we now have the tools to improve care coordination between family members.  Our first step needs to be promoting the technology to allow for remote patient advocacy.  However, we could take it even further.  What if we could have an MA set up a camera during an in-clinic visit so the advocate (or family member) could join the visit if they lived too far away to join in person?  What are the other ways to utilize telehealth for family members and patient advocates?  Will CMS go back to restricting reimbursement for telehealth?  Time will tell for these questions, but we need the health care community to (dare I say) advocate for telehealth and the access it can bring for patient advocates.

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Guest Blogger Glenn Sommerfeld (thank you!)

EHR v Covid-19. What age groups do well with Video Visits?

Time for more data surfing! UCHealth’s overall visit volume (including in-person and video visits and scheduled phone visits) have recovered about 80-90% of pre-pandemic levels.

Today, we’re looking at visit volumes among different age groups of patients. Keep in mind, UCHealth is primarily an adult hospital. Our partner, Childrens Hospital of Colorado, sees most of the pediatric population regionally. We do have some pediatric practices, and of course our extensive family medicine primary care practices also see pediatric patients. This will explain the low volume of pediatric visits below. On the other end, only 3.9% of UCHealth patients are over age 85.

So, what happened to visit volume with each of these age groups?

Turns out, the curve for EVERY age group is similar! Green is age 40-65 and about 1/3 (our largest fraction) of our patient population. Fuchsia is 65-85 and our second largest, purple is 18-40, orange is under 18, red is over 85. The curves start at different points, but follow the same trajectories. That divot on the right side is Memorial day, clinics closed, so 4/5 of the weekly volume that week.

Here is the Home telehealth Video Visit volume! Some interesting findings here. You notice that fuchsia and purple switched places, meaning that a much higher proportion of 18-40 year old patients chose Video Visits compared to 65-85 year old patients. All the other curves stayed in their relative positions. Furthermore, EVERY age group had a proportional bump up in video visits, even those over 85! Finally, the video visit curve is falling back, about to 50% of the peak (so far). It will be interesting to track this in the coming month or 2 and see where we end up, after in-person visits are fully ramped up again.

CMIO’s take? Who knows? Another example to show that we are going to bed with a cliff-hanger every night. I wonder what happens next. The good news: I’m feeling good about having a better handle, even after a few short months, of what Covid-19 can throw at us. Ain’t data cool?

EHR v Covid-19. Where’s Covid now? And, patient care is already looking different!

Covid-19 RNA positive tests at UCHealth in purple

We are well into our fourth month of this pandemic. Looking at our graph, purple shows influenza B peaking in December, influenza A peaking in February, and leaving aside an artifactual spike in mid March, when we started co-testing for major respiratory viruses at the same time we started testing fro Covid-19 in earnest, all other viruses have dissipated. Then you see this impressive bump in Covid-19 illness, peaking in mid April, in our organization. Keep in mind, this is just POSITIVE tests for Covid-19 RNA in patients seen at UCHealth. Because we care for 1.9 million patients in Colorado, though, it is a reasonably large population sample. Furthermore, Covid-19 tests were SCARCE prior to mid March, and numerous patients were likely developing Covid symptoms in February (see below).

Along left edge, top to bottom lines: In-person visits, online patient messages, phone calls, video visits, scheduled phone visits

So, how has this affected our visits and our telehealth efforts? Purple shows you the dramatic dip with in-person outpatient visits, and the gradual climb back toward baseline. Then there is the green line of home telehealth video visits, going from nearly nothing to about 20,000 weekly in early to mid March, with gradual falling off in the past 8 weeks and it seems we might stabilize near 10,000 visits weekly. This is still about 100x the volume of video visits prior to the pandemic.

Then there are the other trend lines that are interesting: Red is the ongoing volume of Patient messages before and during the pandemic. Leaving aside the bump in mid May (not sure why: perhaps related to a system-broadcast), our baseline of 22,000 messages per week increased to 30,000, about 33% increase in volume, starting to rise on Feb 22. This pre-dated by THREE WEEKS the steep decline of in-person visits and the upswing of telehealth visits on Mar 14, and the Colorado Stay at Home order of Mar 26.

Even more interesting: telephone volume in blue, saw a tiny bump on Mar 14, but then was unchanged during the entire period. By contrast, in fuchsia Scheduled telephone visits (billable as of mid March per CMS rules), appeared in early April.

In one graph, you can see: online patient messaging demand scaling up, phone calls being static, scheduled phone calls appearing when billable, on top of the change for in-person and video visits.

Some hidden factors at work here: UCHealth set up a Covid-19 nurse advice line; those calls are not visible on any line in this graph, and those hard-working nurses took tens of thousands of calls from Coloradoans (not just UCHealth patients).

So, this data dilettante has to ask, could an increase in online patient messaging (regardless of content of message) be another possible leading indicator for future pandemic surges? We can’t be sure if these messages were about general anxiety, Covid symptoms, or perhaps completely unrelated, but it is suspicious that there is a sustained increase in volume of messages by 30%+ since mid-March. On the other hand, why isn’t online message volume falling, like home telehealth visits are falling, now that clinics are opening up in-person appointments? Stay tuned!

The open question now is: what will CMS (Centers for Medicare/Medicaid Services) do with paying for Video visits and scheduled Telephone visits? Will those payments stop or scale back? This will certainly affect all health systems still heavily relying on Fee for Service, until the rise of Value Based Care (insurance plans paying for Quality instead of Volume) takes over.

CMIO’s take? These are unprecedented times, and patient behavior and health system behavior is fascinating. A tiny RNA virus has changed the way (phone, online, in-person) patients and healthcare providers interact. What comes next?