Washington COVID-19 Weekly CMIO Blog: Lessons to Share

This is a weekly update and “lessons learned” on the novel coronavirus COVID-19 and its impacts on our health system in Washington State. As the regional chief medical information officer for Swedish and Providence Washington-Montana in the Providence St. Joseph Health System, I help support 17 hospitals and hundreds of clinics in our region. 

In the past week, Washington has increased from 6585 to 9608 positive COVID cases with 446 deaths. This was the first week in which the flattened curve could really be felt across the state. Our larger hospitals on the western side of the state started to see their COVID positive admits stabilize and even move downward some days. Swedish in Seattle still has just over 100 COVID positive admissions, while the rest of WA-MT has about that number in total as well. The state was able to close a field hospital being constructed at the CenturyLink Events Center, and let those resources be redirected to new areas. Washington also shipped ventilators over to New York. Discussions about surge planning change to discussions about recovery planning. Effective social distancing strategies in our state are working. On my daily rejuvenation walks, I am seeing more families than ever spending focused time with each other and laughing. Hope is rising. 

Though while hope rises, we continue to feel the burden of several challenges:  

• the ongoing financial impacts and realities to our organization with the shutdown on elective procedures and 70-80% reductions in clinical volumes  
• continued changing information around universal masking, clinical guidance and evolving surge projections 
• lab turnaround lags in some of our more rural areas that do not have on-site testing yet, and most ambulatory testing still has a 2-3 day turnaround time 
• rapid integration of telehealth and virtual capabilities into our workflows and care expectations
• schools have been closed for the rest of the spring, putting additional pressures on our healthcare workers and teams.  
• the fear and anxiety of battling this illness in every part of our lives is taking its toll, and our staff and leaders are tired from the added burdens of this disease on our system and our patients. 

Quote of the week: Bill Gates is a passionate philanthropist and a knowledge leader in how to address this pandemic, and his recent interview with CNBC was very insightful. This quote resonated with me about the speed with which we will return to “normal” life: “The behavior of people in terms of wanting to travel or go to events or even go to a restaurant, it’s been utterly changed by the concerns about this disease,” he said. “No one should think the government can wave a wand and all of a sudden the economy is anything like it was before this happened. That awaits either a miracle therapeutic that has an over 95% cure rate, or broad usage of the vaccine.” We are in for a marathon. 

Video of the Week: Want to see why Seattle area has flattened the curve? Watch this moving video. 

Previous blog links: 

March 6      March 13     March 20     March 27   April 3 

Recent Interview with the CMIO Podcast  

Week 6 Themes and Lessons Learned from the CMIO Perspective 

TeleHealth 

Within the past 2 weeks, our clinics have rapidly progressed to the point where they are conducting more telephonic or virtual visits than face-to-face visits. 

• We built a Virtual Crisis visit and rapidly expanded Zoom licenses to over 7,000 providers and have been building out tools in our hospital outpatient departments this week. Lots of security questions around Zoom this week and how to best use mixture of devices at home to deliver care. Our older patients are struggling and many providers are having an MA virtually room the patient to make sure they are ready and able.
• Online training tools and packages built. Using Yammer for FAQ and Sharepoint to house reference materials. We continue to use Teams to house a daily command center for our IS teams to ask questions and escalate tickets.
• We have a web portal that we guide providers and patients to use to secure safety: https://psjhealth.zoom.us/ 
• Asynchronous MyChart visits are a tougher workflow because of rules around 7 day bundles and such. Development continues. 

On the acute side, we continue to refine use cases for various solutions. 

• For clinical evaluation, we recommend InTouch machines that have been in use for TeleICU and TeleStroke programs for several years. Teams working on building over 400 carts to distribute across the organization.
• For communication or discussion with patient for things like palliative care, using an IPad with Teams or Zoom (if already using on clinical side) are reasonable alternatives. Piloting Teams and had to work through the best options for setting to make it easy on providers, patients and nurses. We do not want our nurses running tech support due to too many options or new technology.
• For patients and families, we are supplying IPads if needed and use of Facetime seems to be the most popular in that setting. 

Lab Testing 

• As more of our hospitals bring on-site testing live, we see dramatic reductions in turnaround times which drops the PUI (patient under investigation) numbers down and results in less PPE burn and more appropriate isolation status. 
• Testing guidance still focuses on higher risk patients or those over 65 with symptoms. We are not routinely testing average risk patients under 65 with mild/stable symptoms in the outpatient setting. 
• We are going to test some of our long-term care centers thoroughly to see how much disease is truly in these settings, even in asymptomatic healthcare workers and patients. Anecdotal evidence suggests there is a significant amount of underlying disease we are not catching in this high risk population.
• Everyone wants the serology test to test for antibodies, only being used in small trial right now. If back to work is going to require antibody testing, this will likely be the next frustration if not well-coordinated and supplied.
• New Epic build coming next week for Over/Under Isolation Status based upon test results for COVID and other pathogens. Preliminary data suggests we have a significant portion of patients that are either under or over isolated, so this tool will shine a spotlight on areas we can improve and potentially reduce overuse of PPE. Also going to encourage push notifications in Haiku and Canto as a more focused point of learning for COVID results as part of this build.

Caregiver Health 

• We have been using an MS Forms tool to monitor caregivers who have been exposed to COVID. Caregivers track symptoms twice a day.
• Currently exploring options for a system solution on a daily pre-screening tool/app for caregivers to use when coming to work that will clear someone to work for the day. One of the key questions is if the data needs to be stored in a database and for how long, as this may shape the tool we use (MS Forms versus Power BI versus other). See use for this in the future as well for flu season and such.
• We are finding that our drive-up clinics continue to serve a number of healthcare workers daily and is a primary function of those clinics. Steady volumes, but one of our drive thru testing sites in Monroe is now able to close down due to decreased volumes (good news!).

Care in New Ways 

• Build was completed for Convalescent Plasma administration, and a trial will be launching at Swedish next week if all proceeds smoothly.
• We continue to see growth in our remote patient monitoring through partnership with Xealth and Twistle. We use Xealth to help “prescribe” the Twistle app which checks in with patients a few times a day by text to record temperature and oximetry readings while we remotely monitor them at home. Expansion to more ambulatory settings (not just form ED/Inpatient) on the way. You can see Xealth CEO Mike McSherry's overview here, and here is a link to a recent webcast.
• Hospital-at-Home moved to on hold status. The complexity of such a program is hard to simplify and rollout quickly without all of the full operational pieces in place to do so. We may have this ready for the second wave if it comes later this year. 
• Our COVID Tableau dashboards that are integrated with Epic data are being used universally to track volumes across our regions. 
• Swedish continues to use the The Disaster Response App built with Microsoft 
• We used Microsoft’s Healthcare Bot service running on Azure to create a healthcare chatbot named Grace that could help answer patient’s questions online. Using CDC guidelines and our own clinical protocols, we were able to build a Coronavirus Assessment Tool in just three days. It has been used well over 100,000 times.