For a new text-messaging tool called COVID Watch, the founding goal was simple, but important.
“We are going to have a lot of patients with coronavirus sheltering in place, and we need to give them the reassurance that Penn Medicine is watching over them,” said David Asch, MD, executive director of the Penn Medicine Center for Health Care Innovation, reflecting on the thought process behind the tool’s development beginning in early March.
No matter the circumstances, simplicity is foundational in all projects that come from Penn Medicine’s innovation team: humans respond best to what is easy for them to handle, according to research, much of it from Penn’s center. And in a time of pandemic, that takes on added importance.
So the center’s team developed a simple solution to affirm to patients, many of whom are likely experiencing the scariest illness of their lives, that they’re being cared for by Penn Medicine, even if it’s at a distance. Since the launch of ambulatory COVID-19 testing sites in West Philadelphia and Radnor in early March, growing numbers of patients have tested positive for the disease. But many don’t need to be admitted to the hospital. COVID Watch is designed to use automated text messaging to check in with the now-1,000 patients who are confirmed or likely to have COVID-19 but not sick enough to need hospitalization. That includes those who only have symptoms like a fever, dry cough, or fatigue.
“The image the public sees about the COVID-19 pandemic is one of all the hospitalized patients or patients on ventilators,” Asch said. “Those are indeed tragic images, but we should recognize that for every one patient on a ventilator there may be 100 more out in the community who are infected — any number of whom might get sick enough to need hospital care, and far more of whom could be fearful that they might. We developed this tool to watch over all those patients, and be there for them when they truly need us.”
A key to COVID Watch is that it runs on a staple of everyday American life that is already built into our routines, text messaging, which we do whether we’re healthy or sick. Twice-daily automated texts check in with each patient.
For the most part, only simple questions are needed: “How are you feeling compared to 12 hours ago?” and “Is it harder than usual for you to breathe?” Any answer indicating worsening conditions can be automatically flagged for a nurse on-staff to call in response and escalate to Penn Medicine’s OnDemand virtual visit service. Of those enrolled, only about two percent per day require further attention beyond the automated texts
“It’s always a challenge to distinguish those who are sick, but doing generally OK, from those who are really sick, and need our help,” said David Do, MD, clinical informatics manager and clinical assistant professor of Neurology, who has been central to the design and ongoing evaluation of COVID Watch. “With the coronavirus pandemic, that is a challenge we face.”
Although the coronavirus outbreak in the United States and across the world is unprecedented, the innovation team at Penn Medicine actually had a blueprint known to work well, an intervention that was effective for another illness that attacks the lungs: COPD (chronic obstructive pulmonary disease, also known as emphysema).
BreatheBetterTogether (BBT) is a program created by Vivek Ahya MD, vice chief of Clinical Affairs in Pulmonary, Allergy & Critical Care at HUP, and Michael Sims, MD, the clinical director of Penn Medicine’s COPD program. It originated in the Center for Health Care Innovation’s 2017 class of the Innovation Accelerator. It has proven effective in monitoring COPD patients’ breathing difficulties through its use of automated texts. To date, 244 patients have enrolled in the program.
“It’s already established for helping people who are at risk of respiratory failure,” Asch explained. “We decided to reshape and repurpose BreathBetterTogether because of all the symptoms of COVID-19 — the coughing, the aches, the fever — there’s just one that is fatal: hypoxemia, which patients experience as shortness of breath.”
With that in mind, around the second week of March, Asch brought up the idea to Mohan Balachandran, the chief operating officer of Way to Health, the automated, web-based platform that BreatheBetterTogether runs on, that was developed at Penn.
“We got together because we knew the outbreak was coming and we knew we needed to start talking about how to handle it,” Balachandran said.
While COVID Watch is based off BBT, Balachandran said it wasn’t just a simple relaunch of the same tool. While the team was able to leverage BBT’s baseline questions to get a better understanding of what COVID Watch should ask, the new team needed to come up with their own protocols.
For example, when patients with COPD who were monitored through BBT needed escalated care, that involved contact with a respiratory therapist and, sometimes, the dispatch of a nurse to the patient’s home for treatment. The program could also run with relatively few clinicians. But COVID Watch needed a much larger pool of clinicians to watch over patients and, to help maintain social distancing, the program needed to rely much more on telemedicine. When it looks like patients need more help, they are referred to Penn Medicine OnDemand — another program developed by the Innovation Center — for a video chat or phone call where staff assess their symptoms and direct them to the hospital, if need be.
“That’s a big difference between COVID Watch and all the symptom trackers you see around these days,” Asch added. “Those symptom trackers typically end with the advice to ‘call your doctor,’ which is not really that useful or at least is pretty obvious. In contrast, COVID Watch is fundamentally connected to a health care team, a team of Penn Medicine clinicians.”
That team of Penn Medicine clinicians offering care via both the COVID Watch remote monitoring tool and via telemedicine has grown rapidly in the past month. In anticipation of COVID-19, OnDemand expanded from roughly 12 staff members to more than 200. Krisda Chaiyachati, MD, the medical director of OnDemand, described it as “building an entire business in a week.” Anna Morgan, MD, an assistant professor of Internal Medicine who typically works at the Penn Medicine University City building, is a friend of Chaiyachati’s whom he recruited to be the medical director of COVID Watch. She echoed his sentiments about growth, though her program actually didn’t exist before the outbreak.
“I think what we’ve gotten done in two weeks would take six months to staff up in normal circumstances,” Morgan said. “It includes the technology piece of this, which has been very impressive, but it also includes the roll-out to various clinicians and service lines.”
COVID Watch is also taking on patients with the virus who are well enough to recover from home after they’ve been discharged from Penn Medicine emergency departments and hospitals. In addition to the automated texts that go out every morning and afternoon, COVID Watch has four nurses who answer calls from patients. At any time, patients can also just text the word “worse” for an immediate call with a COVID Watch nurse.
Additionally, there are several spin-offs and similar programs being used for specific populations, such as Pregnancy Watch, for expectant mothers with the virus—run by Adi Hirshberg, MD, and Sindhu Srinivas, MD, of the Department of Obstetrics and Gynecology. A different version of the program is being established for palliative care patients. The team also hopes to share the model with other health systems looking for a similar solution.
Another way the COVID Watch program keeps things simple and accessible: Penn Medicine clinicians can enroll their patients into COVID Watch directly from the electronic medical record — whether they are patients in primary care or specialty practices, or whether they were just seen in the emergency department. Susan Day, MD, a professor of Clinical Medicine and primary care physician at Penn, has made sure the program fits into the clinician workflow.
“The doctors and nurses work through the electronic health record,” Day said. “One reason this program is successful is that it meets clinicians where they already are.”