Hospitals across the country have been slammed with challenges over the course of the past 12 months as the COVID-19 pandemic has ravaged the U.S., creating all kinds of chaos for CIOs and other health IT leaders to contend with.

While juggling all of these challenges during this most unusual period, executives have learned many valuable lessons. That's the theme of this ongoing feature story series, where Healthcare IT News talks with IT leaders to focus on new lessons learned and how the executives will be applying those lessons today and into the future. 

You can read past installments at this special theme portal.

This latest feature story has a special focus: children's hospitals. Healthcare IT News interviewed three CIOs and a telehealth director at four of the most prominent pediatric care institutions in the country. These executives include:

• Lisa Grisim, RN, vice president and associate CIO, Stanford Children's Health, Palo Alto, California. (@LisaGrisim)
• Matt MacVey, vice president and CIO, Children's National Hospital, Washington, D.C. (@MattMacVey)
• Keith Perry, CIO, St. Jude Children's Research Hospital, Memphis, Tennessee. (@dkeithperry)
• Morgan Waller, RN, director of telemedicine, Children's Mercy Kansas City, Kansas City, Missouri. (@MorganMwaller)

Adaptive and agile teamwork

The pandemic has brought incredible new perspectives and insights to the role of data and technology, said MacVey of Children's National Hospital.

"We are unquestionably leveraging technology in new and different ways," he said. "As I talk to peer CIOs, the Children's National Hospital experience parallels so many other organizations, including the rapid transition to remote workforce for a large number of our staff, overnight acceleration of telehealth care delivery, and rapid efforts to create a digital consumer experience."

The biggest health IT lesson MacVey's team has learned from these efforts is that the emergence of the pandemic also has placed big demands on the team to be adaptive and agile.

"It's been a bit of a shock to the system," he said. "Like many healthcare IT organizations, we have a legacy of delivering longer-run projects, many implemented over the course of months or years. Over the last year, we've implemented a great deal in days or weeks. The circumstances required an agility that really changed how our organization delivers technology and system enhancements."

MacVey tells his teams that he wants to bottle agile change management and rapid cycle innovation. He's been very pleased.

"The circumstances required an agility that really changed how our organization delivers technology and system enhancements."

Matt MacVey, Children's National Hospital

"We are applying agile approaches to our digital transformation efforts," he said of applying lessons learned. "An ideal convergence is happening with flexible digital platforms, consumer expectations and provider perspectives. We are studying the nature of our consumer interactions and identifying how we can make them more seamless and friendly. Key to our strategy is an ability to serve up personalized experiences based on deeper insights on the children and families we serve."

The Children's National IT team also is applying agile concepts to its cybersecurity efforts. Over the last few years, the healthcare industry has seen a significant increase in cybersecurity attacks. Bad actors are very agile in their attacks. MacVey and his team have had to rapidly adapt their approach to protections, policies and user vigilance.

Rallying together for innovation

Perry of St. Jude points to innovation as being an emphasis during the past 12 months, saying innovation is and continues to be a core competency of a technology team.

"By innovation, I mean being able to think about something differently in order to introduce something new – a new way to work, act, think, etc.," he observed. "Because we didn't have the luxury of time, we were forced to look around the room, roll up our sleeves and start to work. This innovation was one of the only exciting parts of the pandemic in that you watched a team come together and rally around the challenge."

There are several examples. Among them was suddenly switching from an on-campus workforce to a predominantly remote one, he said.

"We had to think of new ways to work together as a team, remain productive, and stay connected in the absence of what we were accustomed to – working alongside each other on campus," Perry said. 

"Important aspects of this were being able to accelerate delivery of our infrastructure upgrades to support the remote workforce and ensuring everyone had the tools necessary to work remotely. With more than 80% of St. Jude employees working remotely during the initial pandemic response, we also had to look at effective leadership through a different lens."

Virtual meetings and check-ins

Staying connected as team members, as a department and as an institution is an important aspect of St. Jude/s culture, he noted. Use of virtual meeting platforms and daily team check-ins has been vital to the organization's successful communication efforts, he said.

"A great example of where we came together and rolled up our sleeves to address the challenge of connecting with patients in the midst of the pandemic was when we expedited our telehealth offerings," he recalled.

"We expedited our telehealth offerings. This extraordinary effort included building carts in-house in three days. In the first 22 days, 97 patients were seen, St. Jude interpreter services were incorporated into our telehealth services and more than 150 providers were trained."

Keith Perry, St. Jude Children's Research Hospital

"This extraordinary effort included building carts in-house in three days. In the first 22 days, 97 patients were seen, St. Jude interpreter services were incorporated into our telehealth services and more than 150 providers were trained."

The organization continued to expand services to increase convenience and safety of patients and caregivers by reducing or eliminating travel and decreasing stress, he added.

"More than 2,000 virtual patient visits were performed in the first six months of the COVID-19 pandemic," he said. "These played a critical role in allowing patients to continue to receive care. Nursing continues to explore ways to use telehealth for inpatient care to reduce the use of personal protective equipment and the number of times in and out of patient rooms."

Screening and testing

In addition to supporting the remote workforce and expediting telehealth services, St. Jude needed to find an effective screening and testing solution that allowed employees who needed to be on campus back on campus.

"Our screening process began with a manually intensive protocol that required collaboration across the institution," Perry said. "Knowing screening and testing would remain ... important [aspects] of campus life due to the COVID-19 pandemic, we developed the mobile application St. Jude PASS to manage campus access."

This application prompts employees to enter information for daily survey screenings and notifies users when they have been selected for asymptomatic testing. Currently, St. Jude PASS provides a quick and convenient way to decentralize the previous screening process. More than 90% of daily campus visitors use St. Jude PASS for entry.

"We learned many lessons over the past year, and we will continue to challenge ourselves and build upon our momentum of innovation, including having a strong sense of urgency around our effort," he said. "An innovative area that is especially important is the speed and agility at which we deliver products and programs."

Some of these programs are mammoth, so staff learned to break them into smaller components, challenge the true "must-have" capabilities, define a minimal viable product (MVP) and deliver them in pieces of consumable functionality at a set cadence over time, he explained.

"We build checkpoints into the process to ensure we have the right resources working on the right things, and the right plan at the right time," he noted. "We work in hybrid teams to have the benefit of a wider range of resources. By working together in this way, we also can apply best practices to projects and avoid reinventing the wheel. If something is working in one area, we can try adapting it to another."

Wasting no time

As soon as employees were sent home to work, the information services team came together to identify and deliver the technology needed for the workforce to work from their homes.

"We established a central site for remote workers to connect to St. Jude services and documents, enhanced our library of applications, deployed a virtual desktop interface (VDI) solution, and provided virtual training to help employees understand and use VPN connections and digital-workspace platforms," he said.

St. Jude purchased hundreds of additional laptops in order to extend its loaner laptop program, allowing employees without laptops to work offsite. In addition, the organization launched an electronic signature process using ServiceNow and DocuSign.

"Similarly, we shored up our virtual collaboration capabilities, which remain vital to staying connected during the pandemic," he said. "We extended our existing cloud-based online meeting solutions – Cisco WebEx and Microsoft Teams – to allow individuals to meet virtually using computers or mobile devices. These platforms enabled faculty and staff to conduct standard web conferences, hold training sessions and breakout sessions, and take advantage of live chat and remote desktop control support."

Use of WebEx jumped from 2,500 meetings in March 2020 to more than 12,000 in April 2020, and monthly meeting counts have averaged more than 11,500 through October 2020. More than 97% of WebEx meetings since March 2020 have included content sharing, and more than 40% have included video conferencing.

"Also, we expanded our virtual conferencing capabilities to accommodate the need for physical distancing and the suspension of large in-person gatherings," he noted. "When in-person gatherings are once again permitted, we foresee there being a virtual component to symposiums and conferences, as it allows for a wider audience to be able to participate."

Managing remote teams

For Grisim of Stanford Children's Health, one of the key things she and her team learned over the past year is how to effectively manage remote teams.

"Apart from our desktop and biomed teams, the bulk of our IS department went from being onsite most of the time to working from home 100% of the time," she said. "This drastic change in the way we do our work forced us to focus on strategies to manage our teams successfully in this new remote-working world."

Areas of primary concern for Stanford were maintaining the team collaborative culture; managing, enhancing and monitoring productivity; and staying connected to staff – all while keeping wellness and work-life balance as priorities.

"There is a mechanism that I instituted to get a better understanding of how my direct reports are doing from a mental-emotional perspective on a day-to-day basis."

Lisa Grisim, RN, Stanford Children's Health

"Prior to the pandemic, we were a highly productive and social group, bringing many new IT solutions live each month, while engaging in a variety of team-building activities throughout the year," she recalled.

"We had extremely high employee engagement scores, and, as a leadership team, placed great emphasis on having a team-based culture, where new hires felt welcomed; those struggling with an issue were supported by others jumping in to assist them; and providing excellent service to our customers was embraced by all."

New strategies to maintain culture and performance

Suddenly becoming physically distanced, the team quickly learned that they needed new strategies to manage remote teams to maintain the culture and previous level of performance.

"Shortly after going 100% remote, we instituted a regular bi-weekly Zoom Q&A session with all staff in IS," Grisim reported. "Prior to each meeting, we solicit questions from staff. In addition to reviewing the Q&A at each meeting, we also do staff and project recognition, along with sharing any key communications and updates with the staff."

Grisim and her team also spent some time and energy building out an IS Staff Corner on the company intranet site. Included on the site are numerous resources and tips for remote workers. Ergonomic best practices, staff recognitions, a staff spotlight updated monthly, a listing of wellness activities being offered across the organization, some virtual games staff can participate in to enhance social interactions, as well as a posting of the Q&A sessions FAQs – all are housed there.

Another tool the team implemented to increase the ease at which teams could collaborate remotely was the implementation of Microsoft Teams. Not only do staff use it for work-related chat and collaborations, but they also are using social channels where people can post pictures from their personal life with short descriptions or captions.

Team members' mental health

"Lastly, there is a mechanism that I instituted to get a better understanding of how my direct reports are doing from a mental-emotional perspective on a day-to-day basis," she explained.

"I was finding that I no longer had a good handle on how they were really doing, since I was not seeing them in person each day. The quick 'how are you doing' at the start of my daily huddle with them was producing the typical 'fine' or 'things are good' answers."

Therefore, she wanted more information individually from each of them regarding their overall state of mind and wellbeing on any given day.

"Things like: Are they overwhelmed? Are they stressed out about things at work or at home, etc.?" she said. "So, each morning when we meet via Zoom to do a quick 15-minute check-in huddle, I ask them to rate how they are doing on a scale of 1 to 5. I told them that their rating is not limited to just things that are going on at work. Their rating is about their overall wellbeing on that particular day, regardless of whether it is because of a work or a personal situation."

A 5 means "I'm doing great," 4 means "I am good," 3 means "neutral – not good, not bad," 2 means "I'm not great," and 1 means "I am not doing good at all."

"I told them they did not have to give a reason for their rating, unless they wanted to, but if they rated themselves as a 1 or a 2, I would be reaching out to them after huddle to see if there is anything I could do to support them or assist them in any way," she said.

"The fabulous part about this practice is, when someone gives a low rating on a specific day, others from the team reach out to them as well to see how they can help," she continued. "It really has been a remarkable way for me to know how my directors are doing daily and provides me and others with the opportunity to assist them without them having to ask me directly."

Making an impact with telemedicine

Another lesson Grisim learned during the past 12 months was what she calls "the power of the burning platform for adoption of IT technology solutions."

"Over several years before COVID-19, we had been on a journey to gain telehealth adoption in our organization," she recalled. "Those of us in IS, along with our operational sponsors and a strong physician champion, have always believed that virtual visits via telehealth were a key component of comprehensive, customer-focused healthcare delivery into the future.

"Since the World Health Organization officially declared the coronavirus outbreak a global pandemic, Stanford Children's Health has ramped up its telehealth services and digital health programs to help care for patients safely amid the COVID-19 epidemic," she continued. "By late April 2020, Stanford Children's Health care teams were seeing up to 800 virtual medical visits daily. Before COVID-19 hit California, it was 35."

Virtual visits allow patients and/or their guardians to interact and consult with their healthcare provider, who can review the patient's medical information for the purposes of diagnosis and treatment, go over test results, fulfill prescription, and provide patient education.

"Patients and parents overwhelmingly loved it, found it to be so much more convenient, and many even reported it being a better experience then the traditional in-person visit," Grisim said. 

"Providers, too, saw first-hand the benefits it provided for not only their patients and parents, but for them as well. By monitoring the patient's data, learning to identify the issues and reaching out to the patient proactively to make care changes from a distance, we can better promote continuous, proactive, connected healthcare, and happier, healthier children and families."

Digital transformation roadmap

When looking to apply this lesson now, as well as into the future, Grisim thinks she and fellow staff members will be more thoughtful and spend more time finding and communicating the burning platform for initiatives on their digital transformation road map.

"In order to continue to propel us forward, and knowing that the narrative we build around our technology-enabled programs will be central to their adoption success, we will need to invest the same amount of time in creating the burning platform that we would in creating a solid IT project plan," she said.

After witnessing what transpired related to telehealth adoption during COVID-19, it is clear patients and families expect and want more convenient digital options for receiving healthcare, she said.

"We know we must focus more on creating and communicating the compelling vision for why digital transformation is not an option to remain competitive in the healthcare space going forward," she stated. "We are fortunate to be located in the Bay Area, where innovations happen more rapidly and encourage a healthy, competitive environment. Focus on building alignment with key influencers in the organization will be another essential strategy for us."

Influential clinicians who have experienced the benefits of this technical, logical wave and who can take up the charge to champion the burning platform for change can drive adoption among their colleagues in a way that an IT professional cannot, she added.

"We've all had experience with some resisters to change and to critical IT advancement, knowingly or not," she said. "This is where it will be particularly critical for us to call on our clinician influencers to assist with bringing their colleagues along to enable the type of widespread, rapid technology adoption we saw this past year."

Preparing ahead for telehealth

Waller of Children's Mercy Kansas City points to a quote from the late technology kingpin Steve Jobs: "Some people say, 'Give the customers what they want.' But that's not my approach. Our job is to figure out what they're going to want before they do."

"Our organization, as with all health systems, had enormous challenges to overcome last spring," Waller observed. "Yet, having what many of my colleagues have looked at with envy over the years – a well-educated and self-educated team of varied telemedicine professionals – allowed us to convert our traditional in-person clinics to virtual care in the home for 55 specialties including allied health in just over three weeks."

Children's Mercy went from 1.5% of ambulatory specialty care being provided via telemedicine in 2019 to a high of 63% of that care via telemedicine in 2020.

"My telemed team has been pondering solutions, critically thinking about 'what-ifs' with me for years. Pandemic was never on the 'Think Tank,' but our mobile telemed and disaster recovery unit created for 'what-ifs' was."

Morgan Waller, RN, Children's Mercy Kansas City

"My telemed team has been pondering solutions, critically thinking about 'what-ifs' with me for years," she said. "Pandemic was never on the 'Think Tank,' but our mobile telemed and disaster recovery unit, or MTU, created for 'what-ifs' was. And it was designed with pertussis and other contagions in mind. Almost immediately after receiving state-of-emergency instructions, the MTU served as the center of our drive-through testing, providing the nurses with a warm, dry, technology-packed space to keep supplies, complete documentation, print labels, etc."

It was immediately deployable. Waller said she cannot count the number of times she had been asked, "What are you going to use that mobile telemedicine unit for?"

"Can you imagine a couple of years ago, if I had replied, 'We are going to use it to conduct drive-through nasal-pharyngeal swabbing to test hundreds of people for a deadly, highly contagious virus in a global pandemic," she asked.

EHR evolution – not fast enough

Waller of Children's Mercy Kansas City remarked that it's no surprise that the legislative, regulatory, billing and reimbursement changes necessary for the incorporation of telemedicine into healthcare have not occurred near the pace of the supporting audio-visual technology.

"At least temporarily, a worldwide pandemic did force legislators to demonstrate the ability to take swift action," she noted. "What is surprising is that our electronic health record scheduling, documentation, coding and billing solutions haven't done any better to prepare for the inevitable spread of telemedicine, which has left many, many organizations in a total sitch."

There were clues that this lack of forethought by the electronic health record giants would be a problem: inability to process a code/bill, with each patient having a unique location like their home, inability to schedule and code/bill a multidisciplinary encounter when some patients and providers are in person and some are remote, she said.

"When healthcare laws don't line-up with the electronic solutions healthcare has evolved to rely on, facilities cannot operate in compliance," she said. "In a state of emergency, ideally recovery plans should be supported by companies and their solutions that can produce changes as fast as healthcare responders can mobilize to care 24-7 for our fellow humans.

Telehealth start-ups

"Applause for the start-ups and entrepreneurs that tirelessly went to work to peddle additional virtual care options. However, the new, the small, do not have the power to engage the behemoth five EHR market share leaders to integrate into their legacy solutions for registration, scheduling, documentation, discharge, coding and billing," she said.

This sluggish interest in allowing interoperability is causing disjointed patient records, causing disruptions in the continuum of care, creating additional points of failure and error, and financially paralyzing systems of care that cannot correctly process billing, she said.

"I can't begin to express, in less than a novella, the Amazon-like jungle that is our coding, billing and insurance systems," she observed. "Add, please, the complexities of electronic solutions that were designed, built and implemented over decades to support that jungle. What we have done to ourselves is not easily undone or altered when a big change in routine, like telemedicine, presents itself. Is a behemoth ever nimble? I'm thinking of an elephant on a circus ball."

Waller offers a caveat for her self-admitted "sweeping generalizations."

"Looking at the EHR market leaders, some have done a better job preparing for the inevitable than others," she said. "I have yet to hear, however, any health system that has an EHR that performs well, from the first patient point of contact through the life of the relationship with that health system, regardless of patient and provider location."

Reexamining where resources are going

The innovative products and programs St. Jude's IT team delivers – and how it delivers them – remain particularly important, Perry said.

"Prior to the pandemic, our team had several projects in progress and many in the queue," he recalled. "The pandemic challenged us to take stock of and reexamine where our resources were being spent."

First, the team learned that not everything it was doing in March 2020 was something it should pick up again in March 2021.

"Basically, everything came to a halt in March 2020 to focus on the institutional response to the pandemic," he said. "This resulted in some great IS efforts. The process of slowing, stopping and re-prioritizing based on the current needs of the organization has been important and allowed us to reset. This also allowed us to deliver faster, as we were not shackled with the burden of trying to deliver 100 things when only 10 were truly needed.

"The dependency we have on our suppliers and their pipelines also came to light," he continued. "Like everyone else during the pandemic, we were faced with delays while waiting for supplies to be delivered. Ensuring adequate access to resources will be paramount in supporting our strategy to deliver solutions quicker."

EHR and ERP

A year ago, St. Jude was in the middle of evaluating its future EHR and enterprise resource planning direction. It took the March 2020 "pause everything" lesson to determine the best path to implement these core systems.

"We have partnered with Epic on our electronic health record platform to enhance the quality of care we provide, improve coordination of care, support clinical research efforts, and ensure better physician and clinician experiences," Perry reported.

"This will be a two-year project, and we will apply lessons learned during the pandemic to our approach.

"Another major shift for us is switching to the Workday cloud-based solution, which will provide a single source for core business processes, reporting and analytics," he added. "Workday will help us reduce system and data redundancy across multiple departments as it replaces and minimizes many integrations and interfaces by supporting applications."

Perry is convinced St. Jude's pandemic response to question everything will be an extremely useful skill as they move forward with all strategic information technology efforts.

"With this mindset," he concluded, "we are living one of the St. Jude values to always recognize that advancing treatment for children with catastrophic diseases is at the center of everything we do."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.