As the pandemic began to unfold in the U.S. earlier this year, healthcare organization leaders had to rapidly change operations in a variety of ways, with one of course being shifting a significant amount of care delivery to telehealth. At Watertown, Mass.-based Steward Medical Group, the largest physician-owned and operated health system in the U.S., a separate clinical IT challenge presented itself as well, just as the COVID-19 crisis was worsening back in the spring.
Prior to the onset of the pandemic, Steward was on its way to transitioning all of its practices to athenahealth’s electronic health record (EHR). So while the group felt prepared and able to optimize its clinical and financial performance during the crisis, it still needed to quickly stand up a telehealth program at the same time they were completing their transition to a standardized EHR platform for 433 ambulatory practices across 11 states, recalls Mark Scheyer, Steward Medical Group’s chief operating officer. In a recent interview with Healthcare Innovation, Scheyer discussed what that transition was like, the benefit of now having all practices on the same EHR platform, and how Steward has been able to optimize operational performance during the pandemic. Below are excerpts of that interview.
Can you describe what it was like to stand up a telehealth program while at the same time converting all your practices to a standardized EHR platform?
Looking back about eight months ago, we really didn’t have a telehealth program or platform that we were offering to our patients. Very quickly as the pandemic unfolded, Steward Medical Group had to quickly stand up a telehealth program at the same time we were in the process of transitioning over to a standardized EHR platform. Fortunately, the IT team had started moving towards a Microsoft Teams platform behind the scenes. That was something that they were building, which we quickly parlayed into standing up our telehealth program through the Microsoft Teams platform. We were able to create a Teams platform that was patient-facing, and we were able to stand up a telehealth program within about three business days, which I thought was incredible. And then on the ambulatory EHR side, we were already starting the process of converting over a number of practices across Arizona, Utah and Texas onto our standard EHR platform, which we ultimately completed in June. We were targeted to complete that in May, so without really moving our timelines too much we finished up that project [just a month later].
Can you speak to the value in having your entire enterprise on one EHR platform?
We have 433 practices across 11 states that we operate in, and we have about 1,400 providers under our umbrella. Having everyone on athenahealth has allowed us to have insight into what was happening from a volume perspective, up to the minute on what was happening across all of our practices, without actually having to go into every single department [individually]. So I can see at a high level, for example, that our ambulatory volumes dropped significantly, almost overnight. That [enabled] us to quickly pivot our daily operations to match the demand, or lack thereof, of services that were happening. In other words, it allowed us to move very quickly to basically facilitate improved staffing levels against the volume.
And it also gave us a lot more insight into exactly what percentage of our visits were telehealth versus in-office visits. As you can imagine, because the first wave really hit Massachusetts hard, practices [in that state] were the early adopters of telehealth versus places like Florida, Arizona, and Utah where they weren't even really contemplating using telehealth since they weren't hit as hard. Now, eight months later, the surge is actually happening in the states that weren’t hit as hard early on. Sure enough, I am starting to see an uptick in telehealth appointments that can be seen because we basically have taken all the appointment data out of athena, and we've pushed it into a data warehouse. Then we've connected Tableau [data visualization software] to the data warehouse so that I have visual representation of what's happening from a patient volume perspective, employment type perspective and service delivery mix perspective.
Since you weren’t using telehealth too much previously, how much skepticism/hesitation was there around telehealth early on in the pandemic?
Overwhelmingly, the response has been positive on the provider side. I think the biggest downside to telehealth right now is that the physical exam on the patient is not being performed. Not only is that a risk management issue, but it's also patient care issue. So if you're not palpating someone's neck to make sure that there's no evidence of some sort of tumor or growth, or if you're not actually listening to their heartbeat while sitting on the table, or if you're not actually checking out the way their spine moves during an orthopedic valuation, you are missing part of the care delivery piece. I want telehealth to [stick around] for the long-term, but it's not for every patient [or every issue]. There’s a significant amount of use cases for telehealth, but it doesn't replace the physical exam that needs to continue to happen between the provider and the patient.
In which other ways have you been able to optimize operational performance during the pandemic?
Flexing staffing to meet the volume demands is obviously really important from an operational and expense management perspective. I also think keeping staff safe during the pandemic has been a challenge; we quickly implemented and put in a number of safe and secure messaging signage. We put up a number of plastic barriers for the front-desk staff. We didn’t want patients sitting in the waiting room, so we have asked them to call the front desk so they basically would go from their car into the exam room without having to stop in the waiting room. We have also implemented a screening protocol to try to screen out as many patients who may be in a higher-risk category, and then we still do leverage telehealth to try to keep those patients safe and distanced.
What COVID-19 challenges exist today that might not have during the initial wave?
First and foremost, there has been more talk about pandemic fatigue lately. When this first started, we were all thinking that by the end of the year we will be in a better spot and this will be behind us. Eight months later, that does not seem to be the case. So I worry about the number of providers that we have who are in the hospital and treating these patients day in and day out. I think there needs to be [better] support around the providers to deal with some of those social-emotional challenges.
I've also been reading a lot about providers who have decided to close their practices because it's just becoming too hard to manage the patient's expectations, while ensuring that employees are safe during this difficult time. So obviously I'm always thinking about making sure that we're providing the staff with the necessary PPE that they need to deliver care. The supply chain has actually become more important than ever.
The last thing is sustainability. The way the healthcare system is set up, it's very much about reimbursing hospitals for procedures, and it's been moving in this direction for quite some time. Even though some healthcare systems like Steward have been innovative around quality and risk contracts, and accountable care organizations, the healthcare system still rewards places for procedures. The pandemic has shown that once the procedures take a dip, it really handicaps how much healthcare systems bring in from an income perspective. I am now hoping that long term, we can care for patients on a more holistic [level] and that the payment systems get a little bit more aligned around treating patients holistically.
So do you think that the pandemic has sort of served as an accelerant for value-based care?
Yeah, I hope so. A lot of the insurance companies are doing really well because they haven’t had to pay out much money for procedures. If you’re diversified on more of the capitation, or per-member-per- month type of risk contracts, you're going to get the income regardless of how many procedures you do. And you're going to benefit from a reduction in total medical expenditure as well. So I think this has opened doors to a lot of different opportunities, and telehealth is just the tip of the iceberg.
