At UCSD Health, Clinician Leaders Leverage the EHR for COVID-19 Preparedness

On March 24, a team of clinicians and clinician informaticists at UCSD Health in San Diego published online in the Journal of the American Medical Informatics Association (JAMIA) an important paper on their organization’s response to the COVID-19 crisis, entitled “Rapid Response to COVID-19: Health Informatics Support for Outbreak Management in an Academic Health System.”

The article’s authors, all associated with various departments of UCSD, are J. Jeffery Reeves, M.D., Hannah M. Hollandsworth, M.D., Francesca J. Torriani, M.D., Randy Taplits, M.D., Shira Abeles, M.D., Ming Tai-Seale, Ph.D., M.P.H., Marlene Millen, M.D, Brian Clay, M.D., amd Christopher A. Longhurst, M.D.

As the authors note in the article, “The EHR [electronic health record] is a useful tool to enable rapid deployment of standardized processes. UC San Diego Health built multiple COVID-19-specific tools to support outbreak management, including scripted triaging, electronic check-in, standard ordering and documentation, secure messaging, real-time data analytics, and telemedicine capabilities. Challenges included the need to frequently adjust build to meet rapidly evolving requirements, communication and adoption, and coordinating the needs of multiple stakeholders while maintaining high-quality, pre-pandemic medical care.”

As they note, “The University of California, San Diego Health (UCSDH) is a large regional academic health system encompassing two acute care hospitals, outpatient primary and specialty medical and surgical care, and emergency patient care. UCSDH is also one of five academic medical centers within a broader 10-campus University of California system. UCSDH utilizes a commercially available, electronic health record (EHR), Epic (Verona, WI), and also hosts over 300 affiliate physicians across 10 medical groups on this EHR. San Diego County served as a quarantine site for both Chinese ex-patriots and cruise ship passengers, and also experienced community spread of COVID earlier than much of the US. An Incident Command Center was established at UCSDH on February 5, 2020 for 24-hour monitoring and adaptation to rapidly evolving conditions and recommendations on a local, state, federal, and global scale. An assessment of the institutional current state revealed the need to develop a rapid screening process, hospital-based and ambulatory testing, new orders with clinical decision support, reporting/analytics tools, and the enhancement/expansion of current patient-facing technology.”

And, the result, they write, is that, “With the guidance of the Incident Command Center, our clinical informatics team prioritized projects related to COVID-19 to enable expedited build and implementation. In response to the pandemic, we configured our EHR with the technology-based tools listed in Table 1. [Among the many elements listed in Table 1 in the article are the following: triage of patient phone calls; triage of nurse-directed patient phone calls; managing patient concerns for providers; home isolation instructions; screening or treating a patient in an ambulatory care setting; screening or treating a patient in an urgent care setting; decision support for who needs testing; embedded modifiable required isolation orders; detailed personal protective equipment needs for providers; detailed instructions for proper specific collection; the health system’s COVID-19 operational dashboard; tracking of COVID-related infection in EHR-embedded database; tracking of persons under investigation (PUI) in EHR-embedded database; reports regarding prior PUI, existing and pending tests; EHR-integrated secure messaging; video visits for outpatient clinic encounters; and other elements.] Awareness and training of novel resources for clinicians and staff were distributed via a variety of communication channels in concurrence with important epidemiologic, policy, and health safety information by the Incident Command Center and health system leadership.”

As the authors note, “One of the first needs for the health system was the development of a rapid and effective multimodal COVID-19 screening process, including telephone calls, direct email, and EHR messaging, all before in-person encounters. A protocolized triage system was developed and embedded into multiple EHR templates, which could be rapidly updated as screening guidance evolved (Table 2). These instructions can be easily accessed by call centers and triage nurses, allowing them to provide guidance to patients regarding requirements for home isolation, appropriate locations to obtain COVID-19 testing, and when to visit the emergency department. In order to limit exposures and relieve the burden on physical healthcare locations, automated email notifications were sent to patients prior to their clinic appointments indicating that persons with fever and/or new cough call the health system for proper triage before presenting to the health care facility.” The article goes on to detail the initiative’s numerous dimensions, and the roles that the members of the team played in bringing it about.

As the article’s authors note in their Conclusion, “The EHR is an essential tool in supporting the clinical needs of a health system managing the COVID-19 pandemic.”

Upon the release of the article, J. Jeffery Reeves, M.D., the physician lead for perioperative improvement and informatics at UCSD Health and the lead author of the article, spoke exclusively with Healthcare Innovation Editor-in-Chief Mark Hagland regarding its content and the organization’s initiative more broadly. Below are excerpts from their interview.

Can you share with me the origins of this broad initiative?

It all started because we realized the important role that technology and the EHR can have, in managing this COVID-19 pandemic. And we wanted to highlight for the world the various tools that can be used to manage the pandemic. So the project started by identifying operationally what we as a health system, UC San Diego Health, to manage this, and what we need from IS to support that. We’re trying to automate as much as possible, trying to make everything visual, just trying to make the day-to-day lives of our clinicians easier.

Probably the most important piece has been the use of telemedicine and patient-facing technology. As you know, the pandemic has shifted everyone to stay home as much as possible. But as healthcare providers, it’s incredibly important to remember that we still have a tremendous number of patients who have needs outside COVID-19. And with hospitals becoming overwhelmed, and with the fear of going to hospitals for care, telemedicine has become more important than ever. And now, a little over half of our ambulatory encounters are video visits. Fewer than 2 percent had been video visits before that. In the first three days, we did more video visits than in the previous two years. We had built video visits out to reach rural patients; we had the technology, but most weren’t using it. So we rapidly trained more than 2,000 clinicians in the first few days, and now, more than half are video-based. And it’s important to remember that there will always be encounters where you need a face-to-face visit with the patient, of course.

Also, you can include three to four different providers in the same video visit. So a diabetic educator along with your endocrinologist; so you can bring in more than one doctor or nurse at the same time.

What’s more, a lot of our patients in our newer hospital have iPads at the bedside. So for COVID-19-positive patients who are PUI, persons under investigation, people who might be positive, and the test is pending, this allows them to communicate with others.

And the second most important part of this is the COVID-19 operational dashboard. That was operationally vital for us, I would say. This dashboard allows visual, analytic reporting, to support data-driven, evidence-based decision-making, particularly at a time when emotions can be present. So over 2,000 providers have this, and you can see the number of COVID-19-positive patients in house, the number of patients we’ve tested; you can also see the number of ventilated patients who are COVID-19 and non-COVID-19. You can see the number of ventilators and ICU beds we have available in the organization. This is vitally important for driving decisions, and for bed management; and can help curb the ever-increasing anxiety among clinicians.

So that’s important both practically and psychologically, correct?

Absolutely; the psychological aspect cannot be overstated. On a day-to-day basis, we get calls from frightened clinicians. So this dashboard is important to give an accurate, up-to-date, real-time snapshot, for what’s happening. And so what you see on CNN is not necessarily what’s happening at UCSD. So, these are the patients we have, this is the availability of resources; and it really helps our providers see what’s available, and it gives them some peace as well.

To me, this type of dashboard is usually only available to institutional leaders making decisions, but we made the decision early on that we would share this with everyone, so that everyone could see the data driving the policies, so that everyone knows that policies are fact-based and evidence-driven.

Tell me how that plays into the decision-making process among the organization’s clinicians, individually and collectively?

We have daily readiness huddles, going from tier 1, frontline providers, to tier 5, executive leadership, and it goes from tier 1 to tier 5 in half-hour increments. And every single tier of the institution is looking at the same, easily available data, to make decisions based on projections. And this graph shows not only the positive test results today, but from the past month. So pretty much all of our huddles start with a glance at this dashboard.

Right now, where are you in terms of your experience as an organization, of COVID-19?

We have not yet been hit as hard as New York, here in San Diego County, even though we had positive patients in early February, so we were hit earlier. But so far, we have around 20 patients in house, and plenty of ICU and ventilator availability. The epidemiologists are estimating that our peak will come in mid-April. So right now, we’re still good in terms of resources.

In other words, implementing these forms of clinical decision support and resource decision support, will help you and your colleagues prepare for when the surge does come to San Diego County?

Absolutely, we’re in total preparation mode.

Have there been any particular challenges so far?

Oh yes, there were dozens of challenges in getting to where we are right now. Any IT technological build normally has a build, testing, roll-out phase. You sort of scope out an idea, test it, spend weeks or months testing it, educating providers; but with COVID-19, we were not able to do any of that. I think everyone in the U.S. woke up at the same time, in early March, recognizing that this was an urgent situation. So those normal processes went out the window, so our IS team worked tirelessly and nonstop to get this built quickly.

We have around 300 IS people in the institution. On this project, everyone pitched in, but we had CMIOs—inpatient and ambulatory; an analytics team, clinical informaticists—me, Dr. Longhurst (CIO), three infectious disease physicians, working with about 15 dedicated IS folks to complete the rapid build.

Was there any other fundamental challenge apart from the need for speed?

Yes, another one was decision-making. In any project you put out there, you normally have governing boards, or some sort of operational owner. But as recommendations changed on a daily basis from the CDC and others, those decisions were tough to come by; so having everybody in the room, the so-called incident command center, helped. But those operational decisions happened, and then they changed, and changed again, so that was also a challenge to overcome.

I’d like to note a few other important challenges. In telehealth, we went from 180 annual televisits to 1,000 in one day, and so the bandwidth need was enormous in terms of the demands on the technical team. That rapid onboarding in a matter of weeks as everyone wanted to switch from in-person to video visits, was a huge lift. So for a week, that involved 24/7 nonstop work in that area.

And another challenge often overlooked in the current medical environment is the need to balance the focus on COVID-19 while also remembering that there are so many patients with heart failure, diabetes, foot infections, and all the other problems that won’t go away; those patients are still important, and in a country with existing access problems, we had to continually remind ourselves of the need to manage those other diseases as well. Remembering the rest of the patients is incredibly important.

What have been the biggest lessons learned so far, in this work?

First, that, as COVID-19 has shown the rest of the world, we live in an age of technology, and meetings that you used to have in person, you now have in Zoom; so it’s important to recognize what technological tools you have, to help you manage a crisis like this. The second is probably information distribution: as our providers were being thrown information from mainstream news media, other outlets, e-mail chains, trying to apply that to your organization’s specific situation and needs is very important, keeping everyone in alignment and aware.

The second is probably information distribution: as our providers were being thrown information from mainstream news media, other outlets, e-mail chains, trying to apply that to your organization’s specific situation and needs is very important, keeping everyone in alignment and aware. And so with that, another tool that I think was incredibly important in the EHR has been templated phrases—you can type .UCSDCOVIDtriage, and get recommendations. Do you first test for flu, then COVID? And what about patients coming from this country or another? So when you build out templated phrases modifiable in real time, you can update it on the back end, so that front-line providers know the latest recommendations. That eliminates the requirement to go onto websites or search through overflowing email boxes, it’s there inside the EHR, as a templated phrase.

A patient asks, what do I do in home isolation? You type, .UCSDhomeisolation. If you’re in the urgent care section, you can type .UCSDCOVID19, and you can see all the different recommendations, and you get links. It takes only 15 minutes to update something like that, so that it’s automatically disseminated across the organization.

So you’ve built into the system a quick ability to update; that’s fabulous.

Yes, and specifically regarding COVID-19, that piece was very important to us. In the first week of this pandemic in the U.S., no one knew what to do, and recommendations were constantly changing, and you’d get one email from a federal group and another from a state group, and knowing what to do was constantly changing. So the ability to quickly and continually modify something to the most updated recommendations, is vital right now.

What do you expect to have happen in the next few weeks?

To be honest, no one really knows; you can look at places like New York and northern Italy, to see what might come. We’re continuing to try to prepare as much as we possibly can. We’re using our dashboards to help us on a daily basis; we’ve enabled video visits for as broad a possible use; we’re constantly working with each other on this. We’ve built out these technological tools to prepare for if and when our peak hits.

And one of the mitigation strategies is establishing that incident command center early. Making sure it’s multidisciplinary, and that you have the infectious disease physicians, the administrative executives, the clinical informaticists, and the pure IT people, in the room. Otherwise, you end up with endless strings of emails. In order to get that real-time feedback and be quick in making changes, that command center is key.