At Providence Health, Early Learnings from Ground-Zero Care Delivery in the COVID-19 Crisis
As the outbreak of the COVID-19 novel coronavirus affects more and more individuals and communities across the United States and the world—just Wednesday afternoon, the World Health Organization (WHO) declared it officially a global pandemic—the experience of one health system in the Pacific Northwest is proving to be illuminating for patient care organizations nationwide.
Amy Compton-Phillips, M.D., executive vice president and chief clinical officer at the 51-hospital Providence Health System, based in the Seattle suburb of Renton, Washington, shared her learnings from recent patient care delivery experiences with members of HIMSS (the Chicago-based Healthcare Information & Management Systems Society), in an online webinar on Wednesday. Dr. Compton-Phillips would have shared her presentation at HIMSS20, which had to be cancelled because of the coronavirus outbreak; indeed, today would have been the third full day of the HIMSS Conference in Orlando, had it not been cancelled.
Dr. Compton-Phillips shared Providence Health’s experiences with this public health crisis, noting that the fact that the health system’s service area is on the West Coast, with tremendous connections to East Asia, meant that she and her colleagues realized very early on that they would be tested by it. “It probably wasn’t all that surprising, seeing that we’re on the West Coast, that we ended up with Patient 1. I got a call on January 19” about the first potential case, she recalled, “and a very astute nurse practitioner called the CDC”—the federal Centers for Disease Control and Prevention—after the incoming patient had noted that they had just returned from visiting family in Wuhan, China.
The call alerting Dr. Compton-Phillips came on January 19; on January 20, the CDC confirmed that the patient was positive for COVID-19. The patient was admitted to Providence Everett Hospital, which had stood up a new “BEST Unit”: Biocontainment Evaluation and Specialty Treatment Center. In fact, she recalled, the BEST Unit at Providence Everett had just run a drill a couple of days before the patient was admitted.
The infectious disease specialists agreed that it was a matter not of if, but when, more patients would need care at Providence; so Providence’s clinical and administrative leaders went to work to build on the foundation of a people, process, and technology infrastructure that had already partially been laid.
“Like everybody in the country, we had had fire drills, around Ebola, SARS, MERS, and HN1N, so we had travel alerts set up,” Compton-Phillips noted. “And we had infectious disease specialists with a built network, and a clinical disease network across all our states. So we had this preexisting network built, which was a really good thing to have in the background. We were also monitoring the situation, in terms of what was happening abroad. We had our library scientists and others managing the information from abroad.”
One key element in the organization’s work was what the leaders at Providence Health call “tiered clinical huddles,” which involve a series of different conference calls and meetings among different clinical and other leaders in the health system, with connected communications among participants in the individual huddles. “People would be calling in what they were hearing, and at the same time our infection preventionists and ID docs were conferring. And as this crisis has continued unfolding, we have actually rapidly upped that communication cascade, and now have teams of teams, with cascading huddles,” she explained. As a result, she said, “On a daily basis, we’re hearing what’s going on, we have different workgroups focused on different parts, and then we’re able to distill that information out into our communities, to all of our caregiver teams.”
In addition, Compton-Phillips noted, “Our information services group sprang into action and took the shell of the EMR alert content we already had, and updated that within about eight hours. We have two EMRs, and they were able to stand that up in our Epic-based and MEDITECH-based facilities very quickly.
What’s more, Compton-Phillips noted, Microsoft has helped Providence Health to manage documents, including through the creation of, among other things, “a living, breathing lab document on our repository that is updated centrally and made available to everyone,” for the continuous updating of relevant documents across the organization.
Core strategy: triage, test, treat
Compton-Phillips said that one absolutely foundational element at Providence Health in its response to the coronavirus outbreak has been a focus on triaging, testing, and treating. Given that the COVID-19 outbreak emerged during an already busy cold and flu season, one thing that became apparent early on was the need to leverage technology in order to support Providence’s clinicians. In that regard, the organizations IS professionals created a chatbot that now allows patients to walk through a series of questions around potential symptoms, and then determine whether to seek in-person care. By initiating a chatbot process, a patient can progress through to telephonic or online interaction with nurse practitioners. Providence professionals are further leveraging artificial intelligence to continuously improve chatbot- and web-based capabilities for self-initiated triaging. The system’s telehealth capabilities also allow for the remote monitoring of patients in their homes, through the use of Bluetooth-enabled thermometers and of pulse oximeters, provided to home-based patients.
Keeping the general public informed is important as well, Compton-Phillips noted. “We’ve found that, with the incredible worry that people have around COVID—that we’ve been putting information out there. Rather than waiting for people to contact us, we’ve been working broadly and consistently through web, mailings, and media, to help people in the community have a plan.” What’s more, Providence’s leaders have been working to increase testing capabilities across their region.
“One thing I didn’t expect,” Compton-Phillips said, “was the criticality of having a very active and engaged government relations team. Our advocacy team has been unbelievable in this space. The cacophony of having [divergent] CDC and WHO and NIH [National Institutes of Health] and FDA [Food and Drug Administration] recommendations, is overwhelming. And then your state governor declares a state of emergency saying you have to follow WHO guidelines, but OSHA [the Occupational Safety and Health Administration] says you’ve got to follow CDC guidelines—so we need to know who to follow if the state says one thing, the federal government says another thing, and the evidence says another.” As a result of conflicting recommendations and guidelines, she noted, “We’ve banded together with other care providers in our neighborhood as a consortium. And the big thing for us is, what is the right thing for our caregivers, for nurses, respiratory therapists, everyone touching patients? We care about them as human beings. But they also have to be able to be healthy,” in order successfully care for patients.
The differences between guidelines can be enormous in practice, Compton-Phillips noted, referencing the fact that the CDC, which recommends that patient care organizations follow airborne-spread precautions, while the WHO recommends that they follow droplet-spread precautions. “One patient on airborne precautions requires 9 FTEs of nurses per day to care for them; but only 3 nurse FTEs are required for a patient on droplet precautions. That carries a huge set of implications. So we came together, and, looking at the state regulations and federal guidelines, we felt we could come together with something sensible,” creating a statement of intent that leans towards the droplet precautions standard.
The importance of analytics
A very large number of professionals of all types are very involved in this comprehensive effort right now at Providence Health, Compton-Phillips noted. Among the numerous teams working intensively on the initiative has been a team of clinical informaticists led by Ari Robicsek, M.D., an infectious disease specialist and epidemiologist who is the system’s chief medical analytics officer. Dr. Robicsek and a team of clinical informaticists have created a Coronavirus Epidemic Registry and Emergency Data Platform. That team has been collecting data on how many patients are showing up at each hospital facility and clinic in the system, and is documenting their symptoms and clinical characteristics, and recording them in our registry system. “That too,” she said, “allows us to actually visually see and understand what’s happening. So last week, we saw that what is happening now in Seattle looks like what Portland will look like in a couple of weeks from now, so we’re planning for that.”
All of these elements are coming together right now to help Providence’s leaders to address the COVID-19 crisis on multiple fronts. “So what are our biggest learnings?” Compton-Phillips asked. One, she said, is that “We need to hope for the best but also plan for the worst. And every time we do this, we build on the capacity to build on what we’ve done in the past, so what we’re doing now will stand us in good stead in the future. Also,” she added, it is clear that “we have a very good healthcare system, but it’s also fragile. And we’ve been continuous ratcheting down acute care, and in doing that, we don’t have much redundancy. We’re also trying to take care of a public health crisis with a private industry, and that’s made things actually tenuous. So we’ve needed to figure out how to make the public-private partnership work.”
All of this continues to be a work in progress, Compton-Phillips emphasized. But she added that she and her colleagues at Providence are learning, fast, in real time, what types of efforts and elements work well in terms of really making a difference in comprehensive integrated health system preparedness, as the intensity of need for care delivery accelerates during this disease epidemic.
