Technology leaders at U.S. health systems have learned a lot this past year-plus. They've gotten better with adaptability and rapid implementation of new workflows. Some have learned that 24- to 72-hour downtime processes are inadequate to prepare for a 23-day outage. And they've discovered that teams that don't usually spend time together can co-create innovative fixes for urgent challenges.

Among some other lessons learned by IT execs during the past year and a half: the importance of IT teams partnering with clinical, financial and operational teams at a moment's notice, and the difficulty of hiring key staff during a crisis that needed all hands on deck.

In this 11th installment in Healthcare IT News' Health IT Lessons Learned in the COVID-19 Era feature series, we speak with three health IT leaders from points across the map, including:

• Dr. Andrew W. Burchett, chief medical information officer at Avera Health, based in Sioux Falls, South Dakota.
• John Gaede, director of information services at Sky Lakes Medical Center in Klamath Falls, Oregon.
• Beth Lindsay-Wood, CIO at Moffitt Cancer Center in Tampa, Florida.

(Click here to access the portal to see all the features in this series of articles.)

Working with new workflows

Burchett of Avera Health said one of the lessons he learned during the pandemic concerned the adaptability and rapid implementation of new workflows.

"Typically, we move at glacial pace as we look to begin using new technologies and solutions," he observed. "With the pandemic, we were able to rapidly virtualize our care environments, continue to provide excellent care to our patients and keep our staff working.

"Virtual care has continued to be part of our new normal," he continued. "We are performing about 400 virtual visits per day, where at peak last year we were seeing about 1,500 per day. Both patients and providers prefer virtual for certain types of visits. Interim follow-ups, medication management, quick visits to name a few."

"We are performing about 400 virtual visits per day, where at peak last year we were seeing about 1,500 per day."

Dr. Andrew W. Burchett, Avera Health

The convenience of attending these visits from home, work or even in a parking lot has been satisfying, he noted.

"In our rural environment, this also saves patients a tremendous amount of time on the road and keeps them in the workforce," he added. "The behavioral health service line continues to utilize virtual care in high numbers. They have seen better patient engagement, lower no-show rates and higher provider and patient satisfaction."

Hospital at home

Another lesson Burchett learned was big: Hospital-level care can indeed be provided in the home.

"We were able to serve more than 5,000 patients in our hospital-at-home service," he reported. "Daily census was nearly 500 at peak with more than 100 of those on oxygen. We were able to use remote patient monitoring software with peripherals to care for patients in a more robust way in their homes, protecting our emergency departments, hospitals, urgent cares and clinics.

"This also helped preserve personal protective equipment and preserve precious capacity in our already full hospitals," he continued. "For those patients who had increasing care needs, a controlled admission to the hospital was achieved through our transfer center and EMS, avoiding the emergency department visit and exposure."

Avera Health has closed down the COVID-19 hospital-at-home program in the last month because of exceedingly low numbers in the region.

"With this experience, we can confidently transition these efforts and participate in the new CMS Acute Hospital Care at Home Program," he said. "Another area of growth is our remote gestational diabetes management program, or e-GDM. Remote monitoring allows more continuous engagement rather than episodic care.

"With significantly improved glycemic control, these patients have better perinatal outcomes, with lower preterm birth rates, lower Cesarean section rate, lower rate of large for gestational age babies and fewer as well as shorter neonatal intensive care unit stays," he added.

Staff members are able to centralize the care in the tertiary care center and one regional facility. As they have seen with other virtual services, these patients are saving thousands of miles in travel and hundreds of hours of time, thereby keeping them in the workforce and lowering child care costs. Ultimately, the organization has healthier moms and babies, he said.

Dealing with a ransomware attack

One health IT lesson learned at Sky Lakes Medical Center in the past year – one that surpassed the unusual setting that COVID-19 brought to the organization – was the realization at the height of the pandemic that the organization's 24- to 72-hour downtime processes were inadequate to prepare for a 23-day outage.

"Our vice president for patient care and chief nursing officer said, 'We have worked downtime out of our processes.' This statement captures a stunning learning: IT is so often seen as an unrecoverable expense to the bottom line."

John Gaede, Sky Lakes Medical Center

"In October of 2020, the Sky Lakes organization, which includes the medical center, a cancer treatment facility, and primary care and specialty clinics, experienced a tip-of-a-spear Ryuk ransomware attack that hit the healthcare industry with blunt force trauma," said Gaede of Sky Lakes Medical Center. 

"Our vice president for patient care and chief nursing officer said, 'We have worked downtime out of our processes.' This statement captures a stunning learning: IT is so often seen as an unrecoverable expense to the bottom line.

"What we learned is that the investments done over time in IT do in fact yield organizationally dependent efficiencies that we quickly forget about," he continued. "When Ryuk took all systems offline, all the many employees required to process orders and results, prescribe medications, and transport everything related to these items were 'worked...out of our process' and instead replaced by various technologies."

The organization no longer had runners in the emergency department to transport specimens to lab services. It no longer had unit secretaries on the various medical, surgical and intensive care units to process orders and results. It no longer had runners in pharmacy to transport medications.

"All these employees were 'worked … out of our processes,'" he said. "We no longer had these resources for the day-after-arduous-day of operations held hostage by a 100% paper downtime after decades of electronic medical record use. IT does make us more efficient and that is why we make these investments."

The way the organization plans on applying this lesson today and beyond is by capturing, documenting and implementing the salient learnings from each clinical, financial and other operations workflow.

"After six months of recovery from the 23-day outage, each department solidified the deficiencies and the inadequacies of our 24- to 72-hour policies and procedures," Gaede said. "We lacked the real-world understanding of a longtime outage of IT. When every system in your healthcare system is offline, your organization must be able to operate differently.

"We have just officially recovered from the ransomware attack and we are now meeting with each department's leadership and frontline staff to capture, document and then categorize the information in a playbook, should something like this ever happen again," he explained. 

"This will allow us to put into play these key learnings at the front-end of an IT downtime disaster, rather than learning about our inefficiencies and deficiencies, and building our solutions, on the fly."

Exhilarating agility

A big lesson for Lindsay-Wood of Moffitt Cancer Center centered on agility.

"There is nothing like a good disaster to bring people together in a different way," she said. "It was exhilarating to see teams that don't usually spend time together creating solutions to address an urgent need. One specific area for us was virtual visits, which we had in place prior to the stay at home order.

"We recognized immediately that to scale dramatically to ensure we can keep treating our patients we had to do something dramatically different as our current telemedicine platform could not scale rapidly for a number of reasons," she continued. 

"The great ideas come from amazing places in the organization and sometimes leadership needs to get out of the way."

Beth Lindsay-Wood, Moffitt Cancer Center

"We increased visits by 5,000% in two weeks. In order to do that, we used a well-known communications platform as a base. It was easy to use for patients and providers with minimal training, had robust architecture, and is secure and already used in our organization."

In addition to preparing the platform and users, staff rapidly developed software to integrate both their EHR and patient portal for scheduling, notifications and other key requirements.

"A multidisciplinary team worked on all aspects of rolling all this out extremely fast. It was amazing to watch," she said. "Great ideas were fostered, everyone engaged to see what they could do to help. All areas of IT were in the mix, platform support and new development leveraging an agile framework for rolling out changes, running virtual command centers, provider and patient training, at the elbow support, some of it virtual as well.

"We knew it was critical to get this online within the first few weeks to ensure our cancer patients had no delays in care," she continued. "We used a huddle format twice a day in IT that included all areas to foster ideas, garner support and maintain focus. There were many examples of this during COVID, but this stands out as an early example of how much we can accomplish in a short period of time if everyone is working together with focus."

Lindsay-Wood and her team are leveraging a model called radical interdependence (RI) to ensure they engage and empower teams to work together.

"The great ideas come from amazing places in the organization, and sometimes leadership needs to get out of the way. And the best thing we can do is let teams work together 'without walls' or differing priorities, and allow failure of ideas," she said. "My vision of without walls is having a big open space with mobile desks that allow people to join teams to solve specific problems.

"But not just new and innovative initiatives, all work," she added. "This is a mantra for our new Center for Digital Health, a new organization that includes IT, health data services and digital innovation. The idea is that radical interdependence doesn't have any heroes. It is all of us that bring their specific skills to the table to evaluate ideas and solve problems, and get egos out of it."

She sees the matrix structure as more important than the formalized reporting structures, ensuring they do not duplicate skills across organizations, reducing siloes and relying heavily on one another in different ways to achieve the most important work staff can do to prevent and cure cancer.

"It really is about the mission and transforming the organization," she said.

Speedy teamwork

Another health IT lesson Sky Lakes learned in the past year, spurred by the unusual setting and requirements of 2020, has to do with never-used-before technologies that were brought online through "the resiliency, creativity, thoughtfulness, compassion and ingenuity of our IT teams partnering in close coordination with clinical, financial and operational teams in a moment's notice," said Gaede of Sky Lakes Medical Center.

"A prime example, experienced by many in our industry in the past year, was acknowledging that our telehealth capabilities were not robust enough," he recalled. 

"In response, we built out full-scale telemedicine technologies and workflows literally over a weekend. Our teams discussed rolling out telehealth on a Thursday morning, looked at various technologies that Thursday afternoon, discussed the technologies with clinical, financial and operational leaders late Thursday afternoon, engaged a vendor the next day, and went live on Monday morning.

"This kind of innovation is typically a nine-month project, coordinating all the people, processes and technologies," he added. "Not so in 2020, when it was a weekend process."

Gaede and his team will be applying this lesson by starting with an understanding that crises can breed ingenuity.

"The idea here is to no longer wait for the crises to think outside the box, but rather to dream it, create it and implement it now," he said. "We had to have our infrastructure in place and be able to scale rapidly. Setting up overnight drive-through clinics, overnight call centers and the like all demanded a robust investment in IT and technologies that allow scale."

Fortunately, he added, Sky Lakes Medical Center supported investments in key technologies in the years prior that allowed this scale.

"You never know the curve ball life will throw, and having the right technologies and vendor partnerships in place are literal lifesavers," he said.

Hiring under difficult circumstances

On another front, Lindsay-Wood of Moffitt Cancer Center was the interim CIO when COVID-19 arrived. In January 2020, she had just received approval for funding to dramatically increase staffing in IT in order to rapidly mature the IT group and address gaps in services and tools.

"I mean adding 50% of our current workforce into the organization," she stressed. "Moffitt was growing very rapidly, and we needed to grow and mature rapidly to support our strategic plan along with a very complex environment with a strong research mission and our highly specialized patient care environment due to our specialized oncology services.

"It was very difficult to hire during COVID and required a tremendous amount of perseverance by our leaders in IT and our HR team to move that along," she continued. "We have onboarded well over 100 people during the year of COVID-19, most of which was all virtual from recruitment through orientation."

Much of IT was virtual until early April of this year, which was the first time leaders saw many of their team members.

"It was great meeting people in person, working in our new expanded building space, creating our new culture – all driven by our maturity efforts," Lindsay-Wood said. "We keep to huddles and rounds to ensure constant communication on our efforts to improve our core processes, implement our new IT tools, increase team member education and development, and learn to run IT as a business.

"All of that work was happening while we addressed COVID-related projects, several strategic and operational initiatives (opening a new ambulatory center, building a new hospital, etc.) very successfully," she continued. "It has been a challenge and a delight to see the progress we are making on a number of fronts, forging partnerships within the organization, and constantly improving our core metrics – keeping our eye on the ball."

While the staff was working hard on the maturity efforts, the organization just kept moving and the staff stayed engaged, which was so important to advancing the mission, she added.

Getting things done

"The lesson is that you don't let something like a pandemic become the focus and make that a reason not to get important things done," she said. "It could have happened easily – putting our fortification efforts on hold, halting recruitment efforts, slowing down strategic initiatives, cancelling important projects.

"We really didn't do that for the most part," she continued. "The organization was really smart, and implemented cost savings initiatives extremely early, which put us in a more favorable position. I think we all hoped that the pandemic would be short and merciful, but our leaders planned for a long haul and took early steps to manage it."

No one came out unscathed in this. Everyone had a tremendous challenge to keep moving forward, she said.

"Our research had to continue. Our clinical trials are critical to our patient outcomes, and our patient complexity required us to operate as close to normal as possible," she concluded. "There was no playbook for much of this, but we – all of healthcare – have one now."

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