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In Tacoma, CHI Franciscan Leverages IT to Transform Care Delivery

April 7, 2017
by Heather Landi
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The virtual urgent care service has achieved a 95-percent patient satisfaction rate and saved over $1.5 million in health care costs and 10,511 hours of wait and travel time

Many hospitals and health systems are piloting mobile and digital technology projects, such as telehealth projects, to improve patient outcomes, enhance the patient experience and also with the aim of reducing health care costs. In many cases, these projects impact one service line, such as telehealth visits offered in the emergency room. At Tacoma, Wash.-based CHI Franciscan Health, clinical and executive leaders are going much broader and deeper to leverage health information technology to transform care delivery.

CHI Franciscan’s Care Transformation team launched in 2009 with a team of four people focusing on one small project, virtual urgent care, according to Lana Adzhigirey, R.N., program manager, Care Transformation, Virtual Health Services at CHI Franciscan. Today, that team has grown into a multi-disciplinary and multi-dimensional service line with more than 150 clinicians and IT professionals. What’s more, the initiatives that the Care Transformation team has implemented are resulting in significant positive impacts on patient outcomes, avoided healthcare costs and unprecedented system efficiencies.

As such, the project was awarded semifinalist status in this year’s Healthcare Informatics Innovator Awards Program.

The CHI Franciscan Health system, which consists of eight hospitals and a large network of physician clinics, has a mandate to redesign its healthcare delivery towards a value-based system serving the Pacific Northwest. The health system’s Care Transformation initiative is a massive project that is patient-focused in scope and has the dual benefit of added value to business and clinical outcomes. The Care Transformation team consists of a number of providers, nurses, information technology specialists, analysts and others roles and responsibilities, all of which focus around providing care to patients where they are, and eliminating any geographic, time commitment and language barriers in accessing that care, Adzhigirey says.

To date, the Care Transformation team has implemented a number of successful programs, most utilizing digital and mobile health technologies—virtual urgent care, post-discharge outreach, a virtual intensive care unit (ICU), virtual consultations with nurses and specialists, virtual diabetes education, regional telemetry monitoring program and a virtual inpatient companion program.

St. Anthony Hospital, Gig Harbor

Going back to 2009, the program had humble beginnings with its four-person team focused on the virtual urgent care project. “We started out with a telehealth initiative, and then we quickly realized that if we just work with technology and just implement technology, it doesn’t get us far. So, we redesigned our concept to include any and all programs across the care continuum for the patient so that we are working with people first, and technology second,” Adzhigirey says. “That has really blossomed into a large team that went outside of telehealth and we decided to call it Care Transformation.”

The team then focused on a virtual diabetes program to enable patients to use an app on their smartphones to interact with their diabetes educators for better diabetes management. The Care Transformation has since broadened the initiatives to both the acute care side and the outpatient side.

“We’re very focused on a multidisciplinary approach” Adzhigirey says. “In healthcare, it’s very easy to get siloed into either a service line or a specialty and even the acuity of the patient, so I think we are unique in the way that we want to make sure that we approach it as a multidisciplinary team. So, we have providers, we have nurses, we have some IT folks, we have program managers, so a variety of people.”

St. Elizabeth Hospial, Enumclaw

However, Adzhigirey notes that one challenge early on was building credibility around the program among clinicians, physicians and executive leaders “Telemedicine was brand new back then. So, we implemented it with our employees first, and our employees actually helped use that service and then talk about it so that word-of-mouth really helped to solidify that program and then spread it out to the community,” she says. Jessica Kennedy-Schlicher, M.D., now runs the virtual urgent care program as the medical director of the virtual and transformational health services line at CHI Franciscan Health.

The results of the Care Transformation team’s work, to date, have been very impressive:

  • Virtual Urgent Care: As one of the first hospital systems in the U.S. to provide wide-scale virtual urgent care services, the health system has extended its full-spectrum primary care services to the public any time of day. Since its implementation, the virtual urgent care service has achieved a 95-percent patient satisfaction rate and saved over $1.5 million in health care costs and 10,511 hours of wait and travel time.
  • Virtual Intensive Care Unit: This program is one of the few in the country that developed the software algorithms and hardware solutions in partnership with clinicians, according to Matt Levi, director in healthcare administration and innovation at Franciscan Health System and previously director of the clinical operations for the Care Transformation team and virtual health services. Within one year of operation, the nursing team handled more than 8,000 inquiries from the bedside clinicians with the volumes nearly doubling in the last two months (as of November 2016). In addition, the ventilator bundle compliance has improved by 17 percent points and is consistently staying at goal.
  • Virtual Diabetes Education: Since its inception in 2012, 35 patients with diabetes have received high touch interaction and education from diabetes educators and have demonstrated sustained decreases in their Hgb A1C, have lost weight, stopped smoking and improved their activity levels.
  • Regional Telemetry Monitoring: Franciscan Health was the first U.S. health system to utilize regional telemetry monitoring. In 2014, the team spearheaded patient heart monitoring across five hospitals, in order to observe heart arrhythmia and heart saturation levels so that nurses could immediately be tapped to check on patients who may be at risk for further cardiac monitoring. The regional telemetry monitoring has enabled CHI Franciscan Health to proactively monitor patients’ heart rhythms and rates for over 2 million hours and engage 24 patients in the first six months from the launch before cardiac issues occur. Due to its success, the health system expanded monitoring to two additional hospitals. Adzhigirey says the initiative has enabled an efficient, standardized way to communicate warning signs to the bedside clinicians and provided for expertise sharing of the monitor technicians who are monitoring from the same location.
  • Virtual Companion program: Utilizing Microsoft Lync, the health system developed “virtual companions” to provide the same service as in-room patient “sitters,” or certified nursing assistants who sit with inpatients at the bedside to reduce falls. In the nine months since implementation, the companions have cared for 994 patients and nearly 50,000 hours of sitting. Preliminary results have shown a downward trend in patient falls in the units who participate in the Virtual Companion program compared to those who have opted out. For example, the last measured month, there were 4,270 hours of virtual sitting, participating units had a fall rate of 4.4 (falls per 1,000) versus 9.0 (falls per 1,000) in non-participating units at the same hospital.
  • Virtual Pharmacy program: When a newly added clinic lacked the resources to employ a pharmacist, the Care Transformation team offered a virtual video solution which leverages the existing pharmacist across four clinics. The newest program, yet within the first week of implementation, the service improved medication compliance by including the patient in decision making.

What has been key to the Care Transformation team’s success with these IT initiatives? First, the programs were developed at the grassroots level, and built around the patients’ needs, Kennedy-Schlicher says.

“We center all our work around the patient. And, we always come from the point of view from a patient—if you are sick, if you are in the hospital, or outside of the hospital, even before you get sick, how do you access the system What are some challenges to go through the health care system? We all know how complex is, our goal is to take it to the next level. We are serving the patient, so the patient is at the center instead of the health care at the center, as if health care is at the center, then patients are left with trying to find their way through the system to get what they need,” Adzhigirey says.

And while IT is foundational to most of these initiatives, in many ways, the projects improved patient outcomes because the technology enhances a patient’s engagement with their own care and enables physicians to provide a high level of care. With the virtual diabetes program, the diabetes educators were able to form a relationship with patients and communicate frequently. If the diabetes educator received an alert about a patient’s high blood sugar level, then the educator contacted the patient right away. “This just-in-time learning led to behavior changes as the constant communication kept the patients motivated,” Adzhigirey says.

St. Joseph Medical Center, Tacoma

Along with clinical outcomes, the initiatives have had an impact on business outcomes as well by increasing efficiency and streamlining processes. Previously, all eight hospitals in the system had their own telemetry monitoring programs and those were combined into the regional telemetry monitoring program. “We found in that process that a lot of the telemetry units had varying standards and safety checks and processes around notifying the nurses and physicians, so we streamlined those processes and, ultimately, made care safer for patients,” she says.

Health systems looking to replicate the Care Transformation team’s work should first build a passionate team, Adzhigirey says. “Have your champions with the same goal in mind,” she says, and adds that health system leaders should look at leveraging IT, especially in the area of care coordination and analytics, to help monitor and manage large patient populations. “With CMS [the Centers for Medicare & Medicaid Services] metrics tying more reimbursement to the control of A1C and blood pressure, it has to be done in a way that clinical resources are deployed effectively and that requires technology to be better around the patient.”

Kennedy-Schlicher adds that physicians want to provide excellent care, “it’s their number one driver,” so they have an interest in technology that enables that. Technology such as virtual consultations enables a multidisciplinary team of clinicians and physicians to work together to care for a patient, which mirrors what happens at the bedside. “We use telemedicine in the Key Free Clinic (Key Peninsula, Wash.) where I work and it’s an asset. There is nursing expertise that physicians need, and to have access to that to improve the quality of care dramatically, that’s a unique asset and any physician would love to have a consultant that they could ask, such as about medication administration,” Kennedy-Schlicher says.

As the health system continues its care transformation journey, the work is not without its challenges. The cost of a technology is a hurdle, as is reimbursement for telemedicine, although many payers are catching up, the team members say.

“As our health environment goes from the traditional fee-for-service environment to a more value-based environment, there’s no way you can do population health and scale it without telemedicine, and so I think every health system has that movement to make a transition,” Kennedy-Schlicher says. “We are constantly thinking about keeping the patient at the center, as any industry would do, having your customer at the center is going to be the key. And, we’re figuring out how to do that.”

“We got lucky that one executive that had a passion around [the program.] However, even eight years later, we’re still fighting that fight,” Adzhigirey says. “There’s still varying opinions about telehealth and this program on its own as some people understand it and some people need to be educated about it, almost on a daily basis. We’re continuing to champion this program because we know how important it is.”




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Research: Trends Point to Positive Increase in Telehealth Acceptance, Access

December 17, 2018
by Rajiv Leventhal, Managing Editor
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Current events and issues, such as the opioid epidemic, are increasing the need to provide telehealth services

Stakeholders’ recognition of telehealth benefits has continually increased, as doors are now opening for various subsets of medicine, including tele-mental health, according to new research from law firm Epstein Becker Green (EBG).

The 2018 Tele-mental Health Laws survey provides an update to state telehealth laws, regulations, and policies for mental and behavioral health practitioners and stakeholders across all 50 states and the District of Columbia. The survey’s researchers said that in the last few years, “the public’s and the healthcare industry’s recognition of the benefits of telehealth has continually increased. While the shortage of behavioral health providers has long been acknowledged, the use of telehealth technologies, including practice management systems and online patient portals, to provide greater access to behavioral health professionals has increasingly gained traction and continues to gain validation as an alternative model of care delivery.”

What’s more, EBG also found that current events and issues, such as the opioid epidemic, have put more pressure than ever before on federal and state legislators to pass laws that promote access to, and provide guidance for, providers seeking to utilize telehealth services.

The survey revealed various reasons for the increase of access to tele-mental health services, and telehealth services overall, including:

Bipartisan support: The Bipartisan Budget Act of 2018 signed into law in February expanded Medicare coverage for certain telehealth services to beneficiaries who are being treated by practitioners participating in accountable care organizations (ACOs).

Greater advocacy from Medicare & Medicaid: In June 2018, the Centers for Medicare & Medicaid Services (CMS) publicly encouraged states to utilize telemedicine and telepsychiatry to facilitate coordinated care for Medicaid recipients. As of August 2018, 49 states and the District of Columbia provide reimbursement for live video telehealth services through Medicaid fee-for-service programs.  Massachusetts is the only state not yet participating.

The opioid epidemic: Several states, including Indiana, Michigan, and Missouri, have introduced and/or passed legislation that expands remote prescribing of controlled substances for treatment of substance use disorders (SUDs). In October 2018, President Trump signed into law H.R. 6, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (“SUPPORT”) for Patients and Communities Act.

This year’s survey also looked at positive trends in telehealth adoption and usage models, including: school sites and pediatric care; the Department of Veterans Affairs’ expanded telehealth programs (since its rollout, the VA’s telehealth program has onboarded approximately 20,000 new patients and hosts more than 6,000 virtual visits each week); and the promotion of care models for growing aging-in-place populations.

Despite the continued telehealth momentum, several barriers and policy variances do remain, the researchers stated. Some of these include: limited federal guidance on coverage and reimbursement and the lack of meaningful coverage by third-party payors, the report said. To this end, A recent MedPAC survey noted that coverage of telehealth services continues to vary widely across commercial health plans, with most covering only one or two types of telehealth-based services.

“While telehealth parity laws are currently in effect in 39 states and the District of Columbia and are intended to ensure the same coverage of (and in some cases, reimbursement for) telehealth services, there is more work ahead to achieve comprehensive coverage and access. States must continue to enact new parity laws or expand existing ones,” the researchers stated.

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KLAS: EHR Integration, Enterprise Scalability Key Challenges Facing Telehealth Vendors

December 11, 2018
by Heather Landi, Associate Editor
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Healthcare organizations report high satisfaction with their telehealth virtual care platforms (VCPs), however there are significant differences in how broad the various platforms are and in the quality of the vendors’ service. What’s more, integration with electronic health record (EHR) systems is a key challenge facing every telehealth vendor, according to a KLAS report.

In its report, “Telehealth Virtual Care Platforms 2019: Which Telehealth Vendors Have the Scalability Customers Need?,” KLAS evaluates some of the top telehealth companies including American Well, MDLive and Epic, and analyzes what capabilities will set vendors apart as more healthcare organizations adopt virtual health technology solutions.

Most virtual care platform vendors receive positive performance ratings, but the depth and breadth of their capabilities vary, and this can impact scalability for organizations looking to grow, according to KLAS. No two vendors are alike in their capabilities, offering different combinations of functionality and experience.

Of the companies KLAS evaluated, the most common type of visit varied—most of American Well’s visits were on-demand urgent care, while the majority of Epic’s visits were associated with virtual clinic visits.

A key factor of scalability is the ability to support multiple visit types, KLAS researchers note. While multiple vendors offer support for all three visit types (on-demand or urgent care, virtual clinic visits and telespecialty consultations) no single vendor has a large proportion of customers using all three (only 12 respondents across all vendors said they were doing so).

American Well, a market share and mindshare leader, and MDLIVE, two of the vendors used most frequently for multiple visit types, receive generally positive—but lower than average—performance scores. Vendors more specialized in specific visit types or component layers (e.g., Vidyo and Zipnosis) have high scores but narrower expectations from customers.

No one vendor meets all needs equally well, but several are reaching for “all-purpose” status with internal development and/or recent acquisitions (American Well acquired Avizia; InTouch acquired TruClinic), according to the report.

KLAS’ analysis also uncovered a general trend of poor integration. In most cases, the addition of a virtual care platform also means the introduction of a second EHR into the clinician workflow.

“Although integration between EMRs is generally understood to be important for care quality, patient safety, efficiency, and productivity, few interviewed VCP customers have full bidirectional transfer in place. Most say that they are too early in their virtual care programs to pursue integration or that it simply costs too much,” KLAS researchers wrote.

Only American Well, Epic, and MDLIVE have more than half of interviewed customers currently on an integrated path, KLAS found. Epic has placed virtual care capabilities directly into their top-rated MyChart patient portal, which many patients already use. Epic integration means clinicians are able to stay within their existing workflow environment as well.

Many provider organizations are in the early phases of their virtual care programs where showing an ROI is an important milestone and one that organizations want to achieve as soon as possible, KLAS notes. “A key promise from vendors is that their technology and accumulated expertise will result in a fast start and continuous acceleration. When this comes at significant cost or progress is slower than expected, provider organizations can experience disappointment,” the KLAS researchers wrote.

When it comes to getting their money’s worth and achieving desired outcomes, Epic and InTouch are rated highest among fully rated vendors, and swyMed and Vidyo perform well among their smaller groups of respondents, KLAS researchers note.

“For each vendor, the current value proposition is somewhat narrow but well understood: Epic’s use is limited to existing patients of Epic EMR customers; InTouch is used primarily for consults; swyMed is used by respondents primarily for mobile, first responder needs; Vidyo delivers video-conferencing tools,

which are typically combined with other VCP solutions. SnapMD is seen as a low-cost option, but some customers say the impact has been limited. Commentary from VSee customers suggests a similar experience,” KLAS researchers wrote in the report.

Many healthcare organizations are early on in their virtual care journeys, and their ability to achieve desired results depends on guidance from vendors. According to KLAS’ analysis, swyMed and InTouch receive the most praise for taking initiative in proactively guiding customers and also in quickly responding to support problems.

While respondents praise American Well’s platform scalability, some customers blame the vendor’s “exponentialgrowth for staffing shortages that have led to implementation holdups and backlogged service requests. Some SnapMD customers say hard-to-beat pricing comes with a support model that is spare in terms of providing tailored guidance, according to the KLAS report.

Most vendors offer two additional options that can help accelerate customers’ expansion and growth—supplemental services, including added-cost advisory and outsourced services, and tools that automate patient-facing tasks that traditionally require additional staff. I

KLAS found that few customers mentioned these options in top-of-mind conversations. “Respondents who spoke of their vendor’s supplemental services most often referred to marketing support or strategic planning services from vendors American Well, MDLIVE, or Zipnosis. Those who referred to task automation report patient-self-service capabilities around check-in, scheduling, surveys, and/or patient flow from InTouch Health (TruClinic), Epic, MDLIVE, or Zipnosis,” the KLAS researchers wrote.



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Study: Neonatal Telehealth Reduces Hospital Transfers, Saves Money

December 11, 2018
by Heather Landi, Associate Editor
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Neonatal video-assisted resuscitation reduces transfers from hospitals without newborn intensive care units and provides significant cost savings, according to study published in the November issue of Health Affairs.

The study authors, led by Jordan Albritton of Intermountain Healthcare, examined a newborn telehealth program implemented at eight Intermountain Healthcare community hospitals in November 2014–December 2015 and the impact on the transfer of newborns from those eight hospitals to level 3 newborn intensive care units.

Studies show that 10 percent of newborns require assistance breathing at birth, and 1 percent require extensive resuscitation. At Intermountain Healthcare, approximately 1–2 percent of all babies born in suburban and rural hospitals are transferred to newborn intensive care units (NICUs) for higher-level care, according to the study.

In response to the need to improve outcomes for complex newborn patients, an innovative telehealth program was established at Intermountain Healthcare in 2013 to provide synchronous, video-assisted resuscitation (VAR), bringing a neonatologist to the bedside. As a result, access to specialized neonatal services in rural and suburban settings is no longer limited to telephone calls or the arrival of a neonatal transport team, the study authors wrote.

While telehealth can facilitate video connections between neonatologists at tertiary care centers and providers at smaller hospitals, there is little empirical evidence about the benefits of telehealth programs for neonatal resuscitation, according to the study authors.

Although Intermountain Healthcare began using telehealth technologies in 2013, the current VAR program was implemented in the period November 2014–December 2015. Today, neonatologists from four level 3 NICUs provide VAR support for nineteen referring hospitals.

As part of the study, the researchers evaluated eight hospitals that contained either well-baby (level 1) or special care (level 2) nurseries staffed by physicians, advanced practice clinicians, nurses, respiratory therapists, and other health care professionals. T

The study found that video-assisted resuscitation was associated with a reduction of 0.70 transfers per facility-month and a 29.4 percent reduction in a newborn’s odds of being transferred. Annually, this resulted in 67.2 fewer transfers and an estimated cost savings of $1.2 million per year.

The study authors conclude that reducing transfers keeps families closer to home, increases community hospital revenue, and reduces risk associated with transfers.

“This program helps keep newborns in level 1 or 2 nurseries, which in turn allows families to stay closer to home, improves social support, and increases the revenue of community hospitals while reducing costs and risks associated with transfers,” the study authors wrote. “Payers should consider reimbursement for pediatric subspecialty telehealth consults for neonates in level 1 and 2 nurseries. Through improvements in care quality and cost savings, this service would likely pay for itself many times over.

However, the authors also note that lack of reimbursement for telehealth services limits widespread implementation.

“Policy changes are necessary to align payment incentives and promote the use of telehealth services,” the study authors wrote.

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