Virtua Health is a nonprofit community health system with five hospitals, seven urgent care centers and 280-plus locations across South New Jersey and Philadelphia. It employs 14,000 people, including more than 2,850 doctors, physician assistants and nurse practitioners, and has more than one million patient encounters per year.

Virtua Health had an early start to digital technology that included the implementation of an integrated electronic health record across its inpatient and ambulatory campuses.

"Fast forward to 2020, the health system experienced what can only be described as a convergence of factors driving deployment of fully remote virtual digital health practices ─ achieved within days of the onset of the COVID-19 global pandemic," said Dr. Tarun Kapoor, the health system's chief digital transformation officer.

THE PROBLEM

In the summer of 2020, the Virtua Board of Trustees presented a strategic challenge to organize the rapid transformative learnings over the prior months into a structure that was sustainable and scalable.

"As our health system was on the front lines of transformation during the first wave of the coronavirus, our decentralized digital health initiatives were rapidly evolving to the point of a strategic function," Kapoor explained. 

"Organization-wide, we decided to establish the Digital Transformation Office to consolidate our digital initiatives into a central office and build upon our existing enterprise digital infrastructure.

"Thankfully, Virtua's leaders did not perceive the adoption of digital technologies as an opt-in mechanism, but rightly the springboard for an entirely integrated, digitally enabled approach to healthcare delivery," he continued. 

"It was generally understood that deploying digital health tools would propel foundational changes for the caring of our patients wherever they may be in their personal health journey."

"The virtual tool also gives our staff the opportunity to immediately reach out to that patient if we notice they are struggling during initial engagement."

Dr. Angela Skrzynski, Virtua Health

The staff also learned then what the virtual care model would look like, whether an in-person visit, a virtual visit or a combination of both.

"Internally, we referred to the DTO as a catalyst to unite our virtual care vision ─ and while a catalyst can accelerate change, it can't do it in a vacuum. It works with foundational units within Virtua, such as our medical group, IT, etc.," Kapoor said.

"Additionally, Virtua Health's three strategic priorities in 2020 were to transform and improve our delivery system, evolve and align our caring culture, and to orient it to the consumer, which arguably reflected the ubiquitous role of digital transformation in the three working together in harmony."

Many organizations define the meaning of digital transformation differently. While the hot tech buzzword is open to interpretation across the healthcare industry, the term represents an entirely different meaning to the patient, said Danielle Wilson, assistant vice president of digital transformation at Virtua Health.

"Stating that you're 'going digital' does not mean completely avoiding the human," she said. "To humans, digital transformation might mean the channel in which you're engaging your provider is different than picking up a smartphone and dialing 1-800.

"Whether they are aware or not, consumers already are accustomed to digital engagement in other aspects of their lives," she continued. "They may not necessarily know that part of their clinical care is normalizing to AI-assisted support."

Two years ago Virtua Health encountered the following three concerns, which prompted the launching of its Digital Transformation Office and fully remote virtual digital health practice.

Rising expectations and demands of patients to use digital services

• Health system leadership directed the implementation of the on-demand digital experience for consumers during the height of the pandemic to present immediate value to the community.
• Username/password issues were impacting call centers, and patient requests for human agents resulted in higher than normal wait times.
• Like many health institutions nationwide, COVID-19 prompted Virtua to launch consumer-facing patient engagement solutions to manage the outbreak more proactively. At the same time, Virtua Health's leaders realized patients increasingly wanted and expected their healthcare to be delivered with the same convenient, consumer-friendly digital capabilities they've become accustomed to in other aspects of their lives. Patients also wanted to engage with their providers online quickly and conveniently.

Reduce patients' risk of exposure to COVID-19 and other diseases

• Virtua Health's leaders aimed to reduce a patient's in-person exposure to at-risk infectious environments. The health system's hospitals experienced an influx of patients of all ages with diverse medical conditions and inoculation statuses combating the virus. For example, patients with cancer during the pandemic needed continued care management.

Legacy technology alone is inadequate

• Legacy technology did not support the increasing labor shortage and overwhelmed clinicians and staff suffering burnout related to COVID-related workforce issues.
• Virtua Health needed new clinical digital technologies to augment the in-person experience in managing the rising volumes of patients in inpatient and ED settings.
• The previous telehealth technology was app-based and cumbersome to download and use for both clinicians and patients. Patients were deterred by an app download and multiple clicks.
• Clinical and IT teams advocated for a supplemental platform after deeming Virtua's EHR was not always optimized to deploy in certain rapidly evolving clinical scenarios.

PROPOSAL

Virtua Health's DTO formed an advisory committee, comprising medical professionals, legal, IT and other healthcare department representatives to select the right digital technologies and to safeguard sharing of health information.

"Realizing the importance of having the consumer's perspective represented, we invited an employee from the marketing department to join the team," Wilson recalled. "The employee played the role of a non-tech-savvy consumer who delved deep in their mindset to ensure the engagement was beneficial for both the patient and Virtua Health and that the user experience was smooth and quick to digest.

"The employee was given full voting governance and made part of the technology decision-making process," she continued. "Our IT folks, along with our doctors, were thrilled to have a team member representing the patient community."

"Whether they are aware or not, consumers already are accustomed to digital engagement in other aspects of their lives," she continued. "They may not necessarily know that part of their clinical care is normalizing to AI-assisted support."

Danielle Wilson, Virtua Health

The advisory committee quickly embraced the idea of "Get human, and get there quickly," a concept describing expanding access to consumer-friendly care through immediate bidirectional interaction between patients and their care teams.

"Our solution to support this concept was to extend our initial secure messaging contract with vendor QliqSOFT to build a new web-based collaboration platform," Kapoor explained. "The AI-powered platform engages patients, staff and clinicians through a chatbot designed with 100% remote care capabilities.

"Leveraging patient feedback to posting the request for proposal to the solution selection process, Virtua went from build to complete to initial implementation within six weeks," he added. "Multidisciplinary project teams advanced digital patient access via SMS-delivered conversational chatbots and video-based telehealth."

New programs for remote patient monitoring were implemented and helped escalate patients online to appropriate clinicians when needed.

"Engagement with a chatbot begins with a staff-originated secure link delivered via SMS text message or email," he said. "The chatbot initiates by connecting patients or their caregivers with a predetermined conversation promoted by workflows that intuitively guides them through different clinical use case interactions.

"This conversation can take the form of a scripted routine encounter that can be escalated quickly to a live text-based or video interaction with a healthcare professional to reach the appropriate outcome."

Staff also applied Agile development methodology practices to the chatbot solution to improve the effectiveness of responding proactively to the changing demands of patients and clinicians.

"By addressing the needs of patients and multidisciplinary clinicians situated in different departments and care settings, Agile helps Virtua Health achieve substantial change by helping our patients and employees embrace these iterative changes and engage with the new digital solutions quickly," Kapoor said.

A significant feature at Virtua Health is that the virtual care tools are built upon a purely browser-based platform and not within an app-based platform, which usually has multiple and sometimes complex touchpoints. This web-based platform has been transformational in expanding the health system's patient engagement capabilities, including ease of use and accessibility.

"The web-based platform's benefits are continually validated by patients and also through positive, real-time feedback, such as a short internal 2021 survey of patient users," said Dr. Angela Skrzynski, clinical lead for the urgent care telehealth, COVID remote patient monitoring and care after COVID programs at Virtua Health. "We learned that meeting patients when, where and how they want to receive care is the foundation of quality virtual care, especially the use of chatbots."

The chatbots are short, sweet and to the point, Wilson added.

"The virtual tool also gives our staff the opportunity to immediately reach out to that patient if we notice they are struggling during initial engagement," she explained. "The chatbot is designed like a hybrid model where patients don't feel deserted on an island because they are in a feedback loop.

"Though patients participate in AI conversations, we are literally a fingertip away," she continued. "We can quickly assist, whether they're filling out paperwork and have questions, or if they need help along the way accessing the right clinicians, information and resources relevant to their medical condition."

An example of the necessity of digital care tools is happening right now in the Omicron wave of the pandemic, Kapoor noted.

"Typically, we'd received up to 60 on-demand patient encounters during a non-surge," he said. "At the turn of the 2022 new year, 600 people per day were attempting to reach us through our digital health platform's virtual care programs: Urgent Care Telehealth, Care After COVID, COVID Emergency Department Remote Patient Monitoring and COVID Inpatient Discharge Remote Patient Monitoring.

"While we weren't clinically able to see all 600 people concurrently per day, we are able to connect, engage with and touch them digitally – including long-haulers – to some extent," he stressed. "That would have never happened with a telephone, right? Patients' requests for care would automatically go to voicemail."

Also, touching the patient digitally likely wouldn't have happened with text messaging, either, Wilson said.

"A text message would require some sort of overlay technology to circle back with a response," she said, "where with a chatbot, we can customize what you want to say to the individual based off their message and information found in Q&A responses brought into the chatbot."

Since switching over to the web-based platform model from a fully on-demand app model, the wait times are much more palatable to patients.

"They communicate anecdotally their satisfaction within the virtual care tools," Skrzynski said. "Moreover, a large contributor to their satisfaction is the fact that patients can wait in the comfort of their homes for a call or text when the clinician is ready to see them. We also realized the change in their demeanor in our real-time survey's polled feedback and in our NRC scores, which is our feedback platform as well."

Nobody wants to download an additional on-demand app, Wilson contended.

"They either want to access our virtual services within text messaging from us or through a web browser featuring the look and feel of an app," she said. "Our host of virtual tools provides that easy tech touch, not only for the patient, but also for front-desk administrators and clinicians.

"Over the last two years, we've realized this web platform can be used for multiple other use cases, such as a scheduling platform, instead of an on-demand platform during COVID-19 surges."

[Click here for Part 2.]

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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