When Penn Medicine introduced Penn E-lert — a state-of-the-art electronic remote monitoring system providing intensive care units with as an additional layer of expert medical support — in 2004, technology was not yet a major part of health care. Indeed, even the term “telemedicine” was only just entering the industry’s vocabulary.
But, over the ensuing years, Penn Medicine wisely continued to invest in bringing technology to the forefront of patient care. Then, last March, COVID-19 hit and brought with it unexpected consequences that needed immediate solutions. Multidiscplinary teams at Penn Medicine worked tirelessly to expand the basic telehealth structures the Health System had in place while also creating new innovations … and they did it at warp speed.
Today, technologies are integrated into and have helped to transform many processes of care at Penn Medicine at a new and greater scale, thanks to these accelerations brought on by the pandemic. Below are just a few examples, from expanding the reach of programs that help keep patients connected to care teams while they stay safely at home, to improving mental health care access to support health care personnel when it was most needed in an immensely challenging time.
Staying Connected with Texts: The New First Tier of Care
Almost a year into the COVID-19 pandemic, one of the great success stories of Penn Medicine’s care for patients who tested positive or had suspected cases of the disease is one that didn’t necessarily involve personal contact with a clinician — except for those who truly needed it.
More than 12,000 patients have enrolled in the program called COVID Watch. This text messaging tool monitors patients at home to help keep them safely out of the hospital.This is important because, for every COVID patient who is sick enough to require hospitalization, many others with mild symptoms — or no symptoms at all — can shelter in place at home, keeping them safe and protecting others. But “they were scared, afraid to come to the ED, which would be dangerous for everyone,” said David Asch, MD, MBA, executive director of the Center for Health Care Innovation. “We needed to reassure the ones who would do fine and escalate and expedite care of those who needed a higher level of care.
“The question wasn’t, do you or do you not have COVID?” he continued. “For us, the question was, given that you have COVID, do you need to be in the hospital?”
It proved extremely successful. The majority of patients who enrolled — 85 percent — were able to stay safely in their homes without requiring human contact, Asch said. Those who did were referred to the next steps of care. “This freed up clinicians to care for patients who did need it.”
Not only did most patients prefer this approach — not having to drive in for a visit — it proved efficient, said Anna Morgan, MD, of General Internal Medicine. “We can monitor 1,000 patients with a few nurses.”
Asch firmly believes that this type of high-contact, low-touch technology “is an idea that should live on beyond the pandemic,” he said, especially for managing common issues such as high blood pressure, high cholesterol and arthritis.
Think of how it’s used in other industries, such as booking a flight online. “You make a reservation but if you have points to use or you need a wheelchair, you need to call,” he said. “It’s the equivalent in health care. The first level is facilitated self-service, via a text messaging tool. “If that doesn’t work, care automatically progresses to the next level,” for example, a call from a nurse.
Under this model, “primary care is the new tertiary care, not the first stop,” he continued. “We’ll take you from primary care to CAR T cell therapy or transplant if you need it, but Penn Medicine can be there even before you need a primary care doctor,” he said.
“We moved the front door of Penn Medicine right into your home, to where you are. If you need to see a primary care doctor, that’s fine. But it’s behind door number three.”
Switchboard Transforms Virtual Visits
In several industries, digital transformation — the integration of digital technology into an organization, fundamentally changing the way it operates — has grown significantly over the past several years, said Srinath Adusumalli, MD, MSHP, assistant chief medical information officer for Connected Health, and clinical innovation manager with the Center for Health Care Innovation. But until COVID hit, the advances had not fully hit health care.
Today, Penn Medicine has a robust digital hub that makes thousands of virtual outpatient visits possible operate efficiently and smoothly in ways that were impossible just a year ago. A new platform called Switchboard is a big part of the reason.
The platform supports both patients and providers in virtual interactions. Providers have easy, one-click access to video visits and can easily access all the necessary patient information, on any device. It also offers a relatively new avenue of communication with patients: text messaging between patient and provider. “A clinician can directly text a patient ‘I’m running five minutes late. Please stay in exam room,’ to which the patient can quickly acknowledge: ‘ok.’” Adusumalli said. “It is difficult to use other methods like a phone call to communicate that quickly.”
Benefits for patients include a simple notification — text or email — noting the date and time of the virtual visit and name of the provider. Patients also receive simple but precise instructions on how to engage with telemedical care, which includes a link that goes directly into a virtual room. “This is a good example of technology use at Penn Medicine,” he said. “It fits needs of both patients and providers.”
Remarkably, Switchboard was built incredibly fast last spring, when ambulatory practices were suddenly shut down to prevent the spread of the pandemic. A multidisciplinary team from the Office of the CMIO, the Center for Health Care Innovation, EHR Transformation, and Information Systems, created the platform over the course of a single weekend.
The cultural transformation that took place has been equally essential to Switchboard’s success. “We can put out all the tools we want and no one may use them,” Adusumalli said. But people have taken Switchboard and dreamed up their own extensions as well. “We’ve added new ideas to improve work flow,” for example, a patient who has seen a provider and has some outstanding labs could automatically receive a text reminder: “You have outstanding labs. Please get them done.”
Switchboard can also now quickly measure patient experience. Previously, patients received a message with a link to a survey a few weeks after their visit, when it was more difficult to remember what happened at the visit. Borrowing an idea from Uber, Switchboard now activates a brief survey as soon as a patient has scheduled, just completed a visit, or completes another encounter-related event. “It’s just a few questions, to rate the experience from 1 to 5. If it’s not a 5, a text goes back: How we can improve?”
At its peak last spring, Switchboard supported 6,000 visits a day, slowly falling to around 2,500 as the initial surge decreased. But, “more recently, with the second surge, virtual visits climbed to 4,000.”
What’s the future of virtual visits at Penn Medicine? Adusumalli said add-on functionality will continue, particularly for inpatient support as Penn Medicine expands into the Mercy Hospital project and HUP East, its new inpatient facility scheduled to open this fall. But much depends on insurance reimbursement and federal regulations once the public health emergency state is rescinded.
While virtual visits cannot be used for all patient visits, from a clinical standpoint, “some degree of this type of care will persist. Patients like it and it’s needed.”
Targeting Mental Health: Support When It’s Needed
Across the country and the world, the COVID-19 pandemic has had a devastating impact on people’s mental as well as physical health, particularly those on the front lines who experience increased feelings of stress, anxiety, frustration, exhaustion… and just being overwhelmed. Early on Penn Medicine recognized the need to provide easy access to mental health resources.
Knowing the psychological effects would be long lasting, a multidisciplinary team — which included members of the Workforce Wellness Committee, the Center for Health Care Innovation, and faculty of Psychiatry — created COBALT. The digital platform supports employees’ mental health issues with a wide range of resources, including mental health and wellness content, live groups, and individual virtual support.
From the start the demand was overwhelming; COBALT had 10,000 visits in the first couple months. The scale of the need made it possible to scale up COBALT’s offerings quickly and establish the value of offering such a platform for anyone who might need this type of accessible mental health support.
Today, COBALT has significantly expanded. For example, the site now offers group sessions led by experts — such as Thea Gallagher, PhD, director of the Outpatient Clinic at the Center for Treatment and Study of Anxiety in Psychiatry — on timely topics, for example, election stress and responding to racial injustice. This allows employees to band together and support one another with a trained facilitator. And one-on-one providers expanded to include chaplains, nutritionists, resilience coaches and sleep experts. COBALT is also now used as a tool for team managers. So far over 100 of these customized sessions have been held.
While still offering these resources for employees for the foreseeable future, COBALT is also returning to its pre-COVID vision. Last month, the Penn Integrated Care program, which embeds mental health teams in primary care practices, started a pilot using the digital assessment, triage, and scheduling tool that has been built using COBALT. This will take the platform to the next step in evolving this pandemic-era innovation toward broader, lasting improvements in care — getting everyone the help they need as soon as they need it.