Introduction
As coronavirus disease 2019 (COVID-19) escalated into a global pandemic, health system scrambled to prepare for surge conditions. Patient loads increased exponentially, and state governmental agencies advised hospitals to double their capacity while simultaneously reducing their non-COVID-19 patient populations. As an additional measure to free up bed capacity, nonemergent medical procedures were severely restricted. The pressure to prepare and the pressure to perform changed how health care was delivered during that time and, potentially, permanently.
I am the Senior Vice President of the Houston Methodist Physician Organization, which employs 800 physicians across 18 specialties in 170 clinics across a geography larger than the state of Connecticut. Our Houston Methodist Hospital system includes eight hospitals, an integrated academic institute, and Houston Methodist (HM) operates more than 2393 hospital beds and has approximately 25,000 employees. Some changes at Houston Methodist were consistent with preparations modeled around the world, but others offer case studies for the future. With the dedicated and coordinated efforts of our hospital employees, our academic and clinical staff, our government leaders, and our first responders, this pandemic will end. However, the effects on hospitals and how we deliver care in physician offices may forever be changed. In many ways, health care will never be the same—and that is a very good thing.
Virtual foundation
In the months leading up to COVID-19, Houston Methodist was celebrating a milestone of success as we had reached a pace of 1000 visits per month through our “on demand” virtual urgent care platform. HM physicians and advanced practice nurses were employed to be “at the ready” to treat specific common medical conditions through a mobile virtual interface. Our virtual urgent care platform was accessible in a number of online venues such as Walgreens and Zocdoc. We had seen a volume increase of 20% every month in patient visits, had outstanding patient satisfaction scores, and the platform was proving to offer a cost-effective way to treat common illness in the comfort of the patient’s own home. The data we collected from those seeking virtual urgent care showed that many individuals were using this form of care delivery to supplant primary care office visits or urgent care visit ( Fig. 1.1 ).
In our established physician practices, we were utilizing our EMR, EPIC, to deliver virtual care to our patients that needed specialty and primary care. Patient volume was low in this use case, as we were struggling to implement a new virtual care operational workflow in a traditional practice. There was not a “burning bridge” moment to spur our physicians to try virtual care. We found that often times, physicians would be very excited about the idea of virtual care and would want to pilot it in their clinics. However, when it came time to introduce the new workflow, the momentum of the traditional in-person style of visits would quickly suffocate any new process. In the end, adoption for virtual care in established physician practices was low. It was clear that although we had made tremendous strides in building the administrative and IT infrastructure to facilitate a virtual health platform, many physicians were skeptical or felt like the time for virtual care had not come—at least not yet.
It was clear that we were at the beginning of a very long journey. We had a clear strategic imperative to build new patient business, reduce facility overhead, be more consumer-centric, and maintain connectivity with our patient base by leveraging virtual medical care. In our most optimistic of moments, we would hope that we could get 50% physician adoption of virtual care in our established physician offices, and reach 2000 patient visits per month on our virtual urgent care platform in the next 3 years. We had no idea of the impending wave of adoption that would push our dreams of virtual care to the brink and serve as a foundation of stability that we would use as a base for our slow and steady recovery from the worst pandemic in 100 years.
COVID-19
Being located close to the Gulf of Mexico, Houston Methodist (HM) is used to dealing with significant weather events, such as hurricanes and tropical storms. We are used to dealing with disasters and their associated recoveries. We know how to set up incident command infrastructures and deliver care to our patients in time of significant need. Five years ago, HM navigated through hurricane Harvey, a 100-year hurricane that resulted in historic flooding of the Houston area. We learned significantly from these types of events about how to deal with natural disasters. These organizational skills of resiliency, necessary organizational infrastructure, along with our complete dedication to our core values of integrity, compassion, accountability, and excellence to help guide our decision-making would serve us well in the fight that was to come against COVID-19.
At the beginning of March 2020, COVID-19 was starting to impact operational decisions significantly in the Houston Methodist Physician Organization, and how we deliver care to our patients. We immediately fell into a similar routine, as if battling a hurricane. We opened our “incident command infrastructure” and proceeded to prioritize our efforts. We immediately took stock of our assets to come up with a compressive plan to see patients in a safe outpatient (OP) clinical environment. At that time, we were unsure how COVID-19 was transmitted, how to disinfect our clinics properly between patients, or what assurances we could give our staff that they could work in a safe environment. Operating clinical operations with this amount of uncertainty left us with little choice but to switch most scheduled OP clinic visits to virtual visits. This would require an incredible effort by our physicians, operational teams, and all support services. Within our organization, we see on average 40,000 visits per month and employ more than 800 physicians over 15 clinical specialties. To transition our traditional in-person clinical care model successfully to a virtual care delivery model, the following would have to be accomplished:
- 1.
Training —all physicians and staff would have to be trained on the in-place EPIC EMR technology that would facilitate virtual care.
- 2.
Patient education —patients would have to be notified of this change in their appointments. Support lines would need to be established to help patients through technological difficulties. Physicians and staff would need talking points to ease patients’ fears/concerns about being treated virtually.
- 3.
Technology enhancement —we would need additional software server space so our technology could work efficiently. In-place technology to facilitate virtual care was not scaled to accommodate the volumes we were preparing to deliver.
- 4.
Communication —the organization needed to be in-sync to deliver a consistent message regarding our switch to virtual care, so that we could maintain the confidence of the community that we served.
Training
The lessons learned in our pre-COVID-19 virtual care experiences became invaluable for us to spring into action. Prior to COVID-19, we only had a small population of physicians who were willing to accept, or even try, a virtual approach to care delivery. Common excuses given were: “No way you can effectively treat someone virtually,” “My patients don’t want this,” or “This is not how I was trained.” These responses to virtual care quickly subsided when left with an option of not treating patients or finding a way to make virtual care work for their patient population. We immediately seized on the change in momentum and within 24 h we were setting up webinars, in-person training presentations, and printing “tip sheets” explaining how to perform a virtual outpatient clinic visit. The reception from the physician community to the training and move to virtual was incredibly positive. Physicians were excited that we had found a way to treat their patients safely and were relieved that the virtual visit platform was intuitive and easy to learn. Everyone understood that this was a new process and there were inherent glitches in the system that would have to be worked out. Within 3 weeks, we had effectively converted 80% of our visits to a virtual setting, and we trained 900 physicians in under 2 weeks ( Fig. 1.2 ).
