Lord knows that through the bedlam of the past year-plus there have been countless lessons to be learned in healthcare and health IT. Executives have been facing challenges they've never had to contend with before. But they've also been dreaming up creative solutions.

In this newest installment in Healthcare IT News' feature story series, Health IT Lessons Learned in the COVID-19 Era – read others in the series here – we talk with four health IT executives with very different vantage points: a CIO, a telemedicine director, a chief nursing informatics officer and an IT director. They are:

• Andrew Buscemi, director of information technology at Holyoke Health Center in Holyoke, Massachusetts. (@HolyokeHealth)
• Rebecca Canino, administrative director for the office of telemedicine at Johns Hopkins Health Systems, based in Baltimore. (@HopkinsMedicine)
• Paul Coyne, RN, assistant vice president of clinical practice and chief nursing informatics officer at the Hospital for Special Surgery in New York. (@hspecialsurgery)
• Dr. Kevin Dawson, CIO at Howard University Hospital in Washington. (@HowardU)

Reimagining everything for remote care

The entire foundation of healthcare is built on in-person care. The building blocks assume that patients and providers are on-site together at the same time. Everything needs to be reimagined for remote care, said Canino at Johns Hopkins Health Systems.

"This includes the entire patient experience – scheduling, registration, ambulatory visits for primary and specialty care, inpatient services, discharge, follow-up, care in step-down facilities, home care, education, and wellness," she explained. "Everything needs to be questioned and potentially redesigned – from clinical staffing models to technical support staffing and help desks. Nothing is off limits."

Healthcare should be researching how it can best reach underserved populations, examining payer contracts for cost savings, leveraging regional partnerships for shortages of specialty care, and lobbying for change at the state and federal level, she added.

"First, listen to patients. They were impacted directly by either the success or failure of the virtual visit. Gathering their feedback and implementing change based on their feedback will give you the biggest bang for your buck."

Rebecca Canino, Johns Hopkins Health Systems

Canino is applying this lesson learned in six different ways.

"First, listen to patients," she said. "They were impacted directly by either the success or failure of the virtual visit. Gathering their feedback and implementing change based on their feedback will give you the biggest bang for your buck.

What do the providers say?

"Next, listen to providers," she continued. "They are in the trenches of virtual care. When virtual care works, they love it. They promote it. They are engaged to partner with IT to improve it. When it doesn't work, they disengage quickly and find alternate pathways and platforms. They will use whatever works to get to their patients. Find out how they are doing it and what they are using and build your platforms accordingly."

Then, examine what worked.

"Who leveraged telehealth the most?" Canino asked. "What modality proved most successful for them and their patient population? Why? Once you have some of these answers, you can begin to apply those best practices to like areas. You can determine which service lines make the greatest impact and prioritize them for optimization."

Next, let go of assumptions.

"Just because you have a waiting room in the bricks-and-mortar clinic doesn't mean you need a waiting room for a virtual visit," she observed. "Expand on newly adopted technology. Use voice-to-text functionality to not only write your note, but to communicate with your hard-of-hearing patients.

"Then, use what you have and integrate your services," she said. "Leverage your in-house translation services to provide on-demand video and audio-only translation. Integrate your third-party translators into scheduled video visits. Convert some of your support staff into a virtual SWAT team."

And finally, use the data.

"We have collectively done millions upon millions of virtual visits now," she noted. "It's time to dig into the data and shine a light on both the good and the bad. Who was unable to access care? For those who accessed it, what was their preferred mode of care? Did virtual care lessen downstream costs? Is virtual care cheaper than in-person care, and to whom?

"We quite clearly see the benefits to the patient," she said. "They were able to access care where and when they needed it. We now need to show the benefit to the provider, the payer, and to the local, regional and national system."

Repurposing technology in a crisis

Throughout the COVID-19 pandemic, clinical teams have struggled to take care of the surging census and care intensity of the patients in the beds while seeking to minimize total time spent in room to avoid viral transmission, said Coyne of the Hospital for Special Surgery.

"The coupling of these two realities led to a potential patient safety issue," he noted. "A greater number of patients needing high care intensity with less caregiver interaction is clearly not a recipe for success. And so, countless technologies were repurposed, almost overnight, to ensure patients were kept as safe as possible."

Hospitals and skilled nursing facilities implemented baby monitors, video cameras, Amazon Alexa and Google Nest, all to monitor and communicate with the patient, expediting the implementation of remote patient monitoring solutions in the inpatient setting.

"It is not enough to just implement technology that simply takes the old care paradigm and makes it remote. That is comfortable innovation, and we cannot be comfortable."

Paul Coyne, RN, Hospital for Special Surgery

"In the outpatient setting, organizations repurposed video chat capability to usher in the dawn of the telehealth era," Coyne said. "And while remote monitoring and telehealth are potentially useful tools if deployed correctly, the majority of solutions still do not automate any aspect of the care process. Without a human being, the clinician, sitting on the other end of the computer, these tools have minimal impact."

They do not alleviate the burden of charting. They do not aid the clinician in making decisions. They do not free up any of the clinician's time. They do not alert the clinical team if something is wrong. And so now, despite all of this innovation, clinicians are left with the same problems they had before the pandemic, except remotely, he observed.

Say no to comfortable innovation

"It is not enough to just implement technology that simply takes the old care paradigm and makes it remote," he said. "That is comfortable innovation, and we cannot be comfortable, for there is no greater feeling of vulnerability than to be lying alone in a hospital bed. When something is this important, we cannot simply repurpose existing technology for the use-case of patient care."

Healthcare must deliberately conceptualize and create technological innovation specifically to alleviate the vulnerability of the patient in the bed, he added.

"We will be seeking to implement tools that aid an increasingly overwhelmed clinical workforce in their tireless quest to keep the patient safe," he said. "There is truly no cause more noble. Advancements in computer vision, radar, AI and machine learning are growing nearer on the horizon, where computer systems can alert clinical teams of potential events, such as a patient fall."

Automated charting solutions are coming that analyze conversations between caregiver and patient so the provider can spend more time answering a patient's questions without needing to leave to write down what they said, he noted.

"Clinicians and patients must demand [that] hardware and solutions give them what they need, and not be forced to give the computer what it needs," Coyne said. "As we expedite the potentially wonderful tools of remote monitoring, telehealth and other digital solutions, we must not allow ourselves to be pulled toward the computer. We must use the computer to pull us back to each other."

Quadrupling Internet bandwidth

Regarding his experiences during the past year or so, Buscemi of Holyoke Health Center says that remote VPN connections are now the lifeblood of his organization. Before COVID-19, the organization had a small VPN system in place that maybe a dozen employees used sporadically. But seemingly overnight, the demand for 7X24 remote access exploded.

"As a result, our local ISP, Holyoke Gas & Electric, immediately quadrupled our Internet bandwidth, and we implemented a new Barracuda VPN system that supports an almost unlimited number of users," he recalled. 

"I should point out, too, that it only took one phone call to our ISP to have the bandwidth increased – and for free. Just an amazing level of customer service, and it is incredibly helpful to have local technology partners that know and support the mission of our health center."

Like many organizations pre-pandemic, Holyoke had discussed the possibility of having employees work from home, but it was always deemed too costly or too technical to implement.

"The old model of making a phone call and scheduling an appointment to see your provider has quickly been transformed into a hybrid mix of phone, text and video access."

Andrew Buscemi, Holyoke Health Center

"At this point, though, I have colleagues working almost exclusively from home, and some who literally have not physically come into the office in more than a year," Buscemi said. 

"We settled on Zoom as our meeting standard early on, and it has allowed us to communicate in ways that we never thought were possible. We routinely have update meetings now from our CEO, with hundreds of employees attending remotely."

At this point, Holyoke also is questioning the need for conference rooms going forward – wondering if that physical space would be better used for patients and clinicians.

New ways for patients to access the organization

Remote connectivity now is allowing Holyoke to reach patient populations it never has been able to reach in the past.

"The old model of making a phone call and scheduling an appointment to see your provider has quickly been transformed into a hybrid mix of phone, text and video access," Buscemi said. "At one point last year, we were telling the vast majority of our patients to not enter our buildings, and yet patient care was still being provided to most, but just being delivered in a different manner."

Holyoke now has the ability to provide patient care at just about every location within its community, he added.

"Over the past few months, we've set up clinics at schools, senior centers and parks," he noted. "In the past few weeks, we've even utilized a customized bus to help with vaccination efforts. Yesterday, for example, the bus rolled up at 7 a.m. at a local Boys and Girls Club in Chicopee, and an hour later we had eight laptops, four digital scanners and two HP printers installed and remotely connected to our NextGen medical system."

There, Holyoke vaccinated more than 150 patients in a day, and it is planning similar events through the end of June.

"We also are looking at doing in-chair dental services at elementary schools and deploying medical vans to various remote locations," he said. "All of this remote technology is truly allowing us to meet our goal of being a world-class, federally qualified community health center."

Human resources IT

Human resource information systems (HRIS) are not typically what come to mind when those within the healthcare industry discuss what IT solutions are paramount to ensure optimal patient care, said Coyne of the Hospital for Special Surgery.

"While technological advancements in areas with direct impact to patient care such as remote monitoring, telehealth, and AI and machine learning get much of the attention, this pandemic has shown in so many ways, that without those on the front line, caring for patients is not possible," he said.

"Therefore, a system that knows who those staff members are is a basic requirement, though it is often overlooked."

Every health system knows who works at its facilities – it is a requirement for employees to get paid. But that HRIS system that is kept accurate for payroll does not always interface with other essential systems where employee data is stored – causing a vast amount of resources required on the back-end to attempt to reconcile the disparate datasets, he said.

"A great example of the need for bidirectional interface between HRIS payroll system and every other system that has employee data is vaccination status reporting," he noted. "The requirement from every state department of health is to report which employees are vaccinated.

"To do this accurately on a daily basis, the payroll system, containing active employee status, and the employee EHR, containing vaccination status, must have a bidirectional interface," he added.

If this interface does not exist, this is a manual effort each day to run reports from both systems and then attempt to cross-reference any new employees who are hired or who leave the organization.

Multiple systems that need to know 'who'

"This similar need exists when tracking compliance for completing daily health checks on a mobile application, attempting to aggregate what percent of employees became COVID-positive, and any metric that requires knowing who is working at the organization," Coyne added.

The lesson here is that it is not enough to just know who works at a hospital in one system, he stated.

"We must know who works at our organization, their department, and who they report to, in every system," he said. "We do that, very simply, by ensuring interfaces, much like those that exist for our patient care software such as the EHR and a medication scanning device, are in place for every system that has employee information."

It is not technically difficult, he insisted.

"It simply requires a basic data join on employee ID," he explained. "However, it requires a renewed focus. Organizations must ensure their interface infrastructure is in place for their HRIS systems and then create operational processes to ensure that the evaluation system, the employee recognition system, the organizational learning system, EHR, payroll systems and active directories are not only tied to one source of truth, but that all update simultaneously in real time when there is a change to that one source of truth."

Not doing so has always had financial and cybersecurity implications, he observed.

"However, this pandemic has shown that not doing so has implications to an organization's ability to keep its employees safe," he said. "Our organization has a large project underway with stakeholders from every area to ensure we are able to do this even better."

Putting the patient at the center

Canino at Johns Hopkins Health Systems learned another lesson this past year – the true power of putting patients' needs at the center of the healthcare delivery system.

"Suddenly, not just as a health system, but as a nation, we were all willing to do anything we could to reach and care for our patients," she said. "We proved that health systems can be nimble and change quickly in the face of adversity. In a manner of days, external barriers that were previously insurmountable were eliminated. Congress was moving quickly, states were waiving licensure restrictions, and payers were releasing waivers daily."

In the face of significant challenges, groups came together to design, stand up and operate new virtual care models, she recalled.

"Health system leaders were immediately available and allocated the necessary resources for rapid change," she said. "Virtual care, by necessity, became part of the conversation in almost every major strategic decision. Existing review committees added telemedicine representation. Teams formed around specific care delivery models and IT products were scaled or developed quickly.

"Purchasing was leveraged heavily and proved key in sourcing goods and services," she continued. "The RFI and RFP cycles were dramatically shortened. What we couldn't source, we developed internally. Existing development pathways were utilized and new ones formed."

Also, best practices rose to the surface, she added.

"Health systems across the nation shared information and experiences freely," she said. "Virtual care solutions and optimizations were built into EHRs, interactively improved and disseminated broadly."

Simplicity, scalability and patient-centeredness

Moving forward, Johns Hopkins Health Systems will continue to apply the principles of simplicity, iterative improvement, scalability and patient-centeredness in its telemedicine efforts, Canino stated.

"At the onset of the pandemic, the notion of pilots went out the window," she said. "We scaled existing platforms instantly. We launched new services in days. The new norm was to get consensus and move forward rapidly. If it's not working, reassess and reset, and if it still isn't right, re-evaluate and go in another direction. We now have experienced that we must be willing to act quickly, and be willing to fail in some endeavors to keep up with the rapid pace of change in this field."

These principles applied meant mass training and retraining of providers, staff, support systems and patients, she added.

"We were all fortunate to implement change in a grateful climate," she said. "Both the provider and the patient were desperate to connect and thus were tolerant of the steep learning curve and the technical hurdles they encountered as both sides learned simultaneously. We had to make sure we could communicate easily, both internally and externally via text, while maintaining privacy. We had to expand open source education portals like YouTube for tutorials and tip sheets."

Everything needed to be immediately accessible, easily absorbed and translated into multiple languages, she said. Staff learned to assume nothing, use pictures whenever possible and keep it short and sweet. If one could not explain it easily, then it probably was the wrong platform, she said.

"We will continue to work toward simple, efficient and easy access for patients with streamlined communication channels," she said. "Building systems that can provide multiple care options – audio-only, video and in-person care – all based on patient resources, patient preference and clinical appropriateness – ensures that all patients can access and receive care.

"During this crisis, we have earned the goodwill of patients and providers, we cannot squander it as we work through the optimization phases," she continued. "Federal and state legislators play a vital role in providing certainty about the post-pandemic future, so we don't fall off the telehealth cliff."

Comprehensive IT transformation

Howard University Hospital is an academic medical center in Washington, and currently is implementing a comprehensive IT transformation program.

In the past, investment in IT had been highly variable. Some of the enterprise applications were deployed with just the bare minimum features implemented and necessary for operations and compliance. One of the minimally configured applications is its current ERP system, Infor. The procurement and finance departments' workflows were particularly limited by the inadequacy of scanned document processing.

"While the hospital is planning for a major upgrade or replacement of our ERP system in the next couple of years, we established the business case for an interim solution gapping over the period until the new ERP goes live," said Dawson at Howard University Hospital. 

"Investment in interim and add-on solutions are typically not the preferred way of improving an application portfolio. However, if a business case clearly justifies it, investing in temporary, add-on products may be needed."

Dr. Kevin Dawson, Howard University Hospital

"We decided to implement new workflow enhancements last year with the help of MHC Software. The hospital had good prior experience with this vendor, which provides tools to augment ERPs, including Infor."

MHC's ImageExpress products provided the capabilities Howard University Hospital was missing. Recently the hospital completed deployment. Users are pleased with the outcome, to the extent that two additional ImageExpress components were also ordered serving the accounts payable and HR departments.

"Investment in interim and add-on solutions are typically not the preferred way of improving an application portfolio," Dawson said. "A best-of-breed application portfolio and too much complexity may lead to higher integration and maintenance costs, and more frequent malfunctions. However, if a business case clearly justifies it, investing in temporary, add-on products may be needed. Our ERP enhancement with MHC's ImageExpress was one of these solutions."

Next up, the EHR

The hospital's current EHR is Cerner Soarian. It is an end-of-life product, and the hospital is planning to replace it in the next four years.

"Similar to the ERP example, improvement of some functions that are typically provided by an EHR cannot wait until the full deployment of the new EHR," Dawson explained. "One of these functions serves the perioperative department. The reason for replacement was that our prior perioperative software vendor discontinued support for their product."

As a replacement product, the hospital selected Surgical Information Systems as the next perioperative system.

"We went live last year in 10 operating rooms," he said. "This year, we are adding four more procedure rooms in our labor and delivery department, upgrading SIS Analytics, and implementing many other improvements that we combined into phase three of the SIS deployment project. While the hospital may migrate to the perioperative package provided by our new EHR vendor in four years, we were unable to wait, due to a need to decommission our legacy perioperative system."

Health IT is an art similar to having to reconfigure an airplane in flight, Dawson described.

"We need to build future-proof, modular solutions that can be easily reconfigured in response to changes in health policy, mergers and acquisitions, healthcare markets, and major events impacting healthcare such as the COVID-19 pandemic," he said.

"While vendor consolidation and primary reliance on enterprise applications remains the preferred long-term strategy," he concluded, "interim, add-on products often are needed in order to remain adaptive, flexible and responsive to these changes as demonstrated with these two examples."

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