HEALTHTECH: How has automation in healthcare advanced in recent years? What can be done now that couldn't be done before?
ODISHO: Technologically, I think a few things that have made the potential for automation better are interoperability and data integration. The main thing that has changed is the acceptability of some of these tools, from providers, administrators and patients. The COVID-19 pandemic really launched us into more widespread adoption of telehealth. Patient comfort with using remote care management platforms and secure messaging has significantly improved. There has been more progress on implementing on back-end automations.
BARTH: I couldn’t agree more. Part of me wonders if the patient or families were always willing to adopt and it was really the healthcare system and the providers who were unwilling to adopt or adapt. Now, we’re on the same page and engaged. I think our patient populations are going to continue to push us to provide innovative care.
HEALTHTECH: How did your organization plan for this transformation? Who did you include at the start of your design process? Did any stakeholders need more convincing than others?
ODISHO: At UCSF, we’ve been doing video visits for years before the pandemic, and even when they weren’t being reimbursed, we as an institution were reimbursing the physicians for their time because we felt that it was important and we wanted to start building the capability and the tool sets around it. Up until 2020, our telehealth adoption was maybe 5 to 8 percent, which is more than many other places but still very small. But having that infrastructure and muscle memory in place allowed us to go from 8 to 90 percent over a weekend when the COVID-19 public health emergency was declared.
I think something similar happened for virtual and automated patient care. In 2018, we launched the Digital Patient Experience Workgroup. This brought in operational and technology leaders from all over the health system to start envisioning what virtual and automated care could be and start experimenting. We recently brought all of the different groups working on virtual care formally into our core IT team so that instead of having little islands of innovation spread across the organization, we can build the foundation to quickly move forward as a big organization.
As far as stakeholder engagement, critically, we need our clinic staff and nurse teams engaged because they’re usually on the front lines of any patient-facing tools. They’re the ones that hear from the patients. We have to make sure patients are involved in the design and implementation. Early in the design process, we engage with our existing patient family advisory councils for general feedback and advice. We then rapidly iterate and get feedback, first from a small cohort of patients with a specific condition. Then, as we stabilize the tool, we move toward a larger cohort, do additional user testing and interviews, and then finally go into general availability. Even at this point, we’re continually taking patient feedback and revising our program. It’s critical to have broad-based stakeholder engagement and buy-in.
BARTH: At Nemours, we had a well-established telehealth program that was being underutilized. The pandemic allowed us to ramp it up to a point where it overwhelmed the system to a certain extent, so we had to come up with other modalities to engage families. We used Amwell’s automated care platform (formerly called Conversa) and automatic texts to prepare families for their telehealth visits.
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HEALTHTECH: What has the clinician feedback been so far on all of your solutions?
BARTH: It’s just a different type of work. It’s all work, and somebody needs to manage that work, whether it's a clinician, a nurse or a physician assistant. They’re either getting phone calls, they’re getting messages or they’re working a dashboard. Everybody works a bit differently. Because of the tools that we’re using, we’re able to be more proactive instead of reactive. We’ve gotten positive feedback, but I think time will tell.
ODISHO: We really tried to integrate with existing provider workflows. We try to make providers more efficient where we can, but in situations where we will increase provider work, we want to make sure that's paired with improved patient care quality. If you’re increasing effort but improving quality and outcomes, you will get buy-in from providers.
We send alerts when patients are not doing well. We’re very aware of the burnout impact on physicians from managing alerts and inbound messages. We feed a lot of data back to providers, so we show them how many alerts are coming to them from these programs. But we also track what happens in the electronic health record after an alert comes through. If an alert comes through, and the provider marks it as done but doesn’t take any action, that may indicate that an alert wasn’t useful. Whereas if an alert comes through, and the provider orders a CT scan and labs and sends the patient a message, maybe that was clinically useful. So, we show that data to providers and say, “We sent this many alerts, and 35 percent of them resulted in additional action. How do you feel about that?” The providers can say there were too many alerts and that we need to adjust the threshold or that it’s about right for their practice. It’s an iterative process to make sure that we’re not having a negative impact on their workflow.
