The New York City Real-Time Learning Lab Experience Around the COVID-19 Pandemic

July 20, 2020
The fact that New York City Health + Hospitals leaders were able to move forward on clinical informatics optimization in the middle of an enormous COVID-19 surge, and with modest resources, offers real hope

It was very heartening to read an article published by leaders from the New York City Health + Hospitals integrated public health system on July 16 published a fast-tracked article online in Health Affairs, in advance of its print publication.

Three leaders from the 11-hospital, 70-location published the article, entitled “Using Information Technology To Improve COVID-19 Care At New York City Health + Hospitals,” looking at a range of COVID-19-related challenges that they and their teams have addressed. The three leaders—R. James Salway, director of emergency management in the Office of Quality and Safety; David Silvestri, senior director of care transitions and access in the Office of Quality and Safety and the Office of Ambulatory Care; and Eric Wei, chief quality officer in the Office of Quality and Safety, are all helping to lead teams of managers and informaticists in the integrated health system.

In the article, the authors write that, “As the coronavirus disease 2019 (COVID-19) pandemic surged in New York City, the city’s public hospital system, New York City Health + Hospitals (NYC H+H), recognized that innovative technological solutions were needed to respond to the crisis. Our health system recently transitioned to a unified enterprise-wide electronic medical record (EMR) across all of our hospitals. This accelerated our ability to implement a series of technological solutions to the crisis,” the authors note. “We engaged in focused efforts to improve staff efficiency, including rapid Medical Screening Exams for low acuity patients, use of “Smart Notes,” and improved vital sign monitoring. We standardized patient work-up using specialty-specific order sets, created dashboards to give insight into enterprise-wide bed availability and facilitate transfers from the hardest-hit hospitals, and improved patient experience by using iPads to connect patients to loved ones. The technology bridged divides between different hospital systems city-wide to encourage sharing of data and improve patient care. By rapidly expanding use of information technology, NYC H+H responded to the COVID-19 surge and is now better positioned to work in a more integrated fashion in the future.”

As the authors noted in their article, “At the epicenter of New York City’s coronavirus disease 2019 (COVID-19) pandemic, New York City Health + Hospitals (NYC H+H), the nation’s largest municipal health care system, found itself forced to rely on information technology to expedite and expand its volume of work in caring for large numbers of socioeconomically marginalized New Yorkers, who were disproportionately impacted by COVID-19.1 Just two years prior to COVID-19, NYC H+H—a system serving over 1.1 million patients annually through 11 acute care hospitals, a long term care facility, a certified home care agency, and over 70 ambulatory clinics—had operated on multiple different medical records, scheduling, financial, and data storage platforms, impeding maximal coordination, efficiency, and rapid-cycle learning. On March 1 2020, the same day New York City reported its first case of COVID-19, the system turned on its unified medical record at its last remaining inpatient facility. The ways in which NYC H+H utilized its newly inaugurated medical record to direct and facilitate pandemic response were indispensable in supporting tens of thousands of New Yorkers over the peak period of crisis, from March 2020 to May 2020.”

Leaders from the New York City Health + Hospitals integrated public health system on July 16 published a fast-tracked article online in Health Affairs, in advance of its print publication.

R. James Salway, director of emergency management in the Office of Quality and Safety at New York City Health + Hospitals; David Silvestri, senior director of care transitions and access in the Office of Quality and Safety and the Office of Ambulatory Care and NYC Health + Hospitals; and Eric Wei, chief quality officer in the Office of Quality and Safety at NYC Health + Hospitals, on Wednesday published an article entitled “Using Information Technology To Improve COVID-19 Care At New York City Health + Hospitals.”

The article offers valuable insights into how the teams at the 11-hospital, 70-location New York City Health + Hospitals were able to quickly move forward and implement important advances, in the midst of an unprecedented public health and healthcare delivery crisis.

In the article, the authors write that, “As the coronavirus disease 2019 (COVID-19) pandemic surged in New York City, the city’s public hospital system, New York City Health + Hospitals (NYC H+H), recognized that innovative technological solutions were needed to respond to the crisis. Our health system recently transitioned to a unified enterprise-wide electronic medical record (EMR) across all of our hospitals. This accelerated our ability to implement a series of technological solutions to the crisis,” the authors note. “We engaged in focused efforts to improve staff efficiency, including rapid Medical Screening Exams for low acuity patients, use of “Smart Notes,” and improved vital sign monitoring. We standardized patient work-up using specialty-specific order sets, created dashboards to give insight into enterprise-wide bed availability and facilitate transfers from the hardest-hit hospitals, and improved patient experience by using iPads to connect patients to loved ones. The technology bridged divides between different hospital systems city-wide to encourage sharing of data and improve patient care. By rapidly expanding use of information technology, NYC H+H responded to the COVID-19 surge and is now better positioned to work in a more integrated fashion in the future.”

As the authors note, “At the epicenter of New York City’s coronavirus disease 2019 (COVID-19) pandemic, New York City Health + Hospitals (NYC H+H), the nation’s largest municipal health care system, found itself forced to rely on information technology to expedite and expand its volume of work in caring for large numbers of socioeconomically marginalized New Yorkers, who were disproportionately impacted by COVID-19.1 Just two years prior to COVID-19, NYC H+H—a system serving over 1.1 million patients annually through 11 acute care hospitals, a long term care facility, a certified home care agency, and over 70 ambulatory clinics—had operated on multiple different medical records, scheduling, financial, and data storage platforms, impeding maximal coordination, efficiency, and rapid-cycle learning. On March 1 2020, the same day New York City reported its first case of COVID-19, the system turned on its unified medical record at its last remaining inpatient facility. The ways in which NYC H+H utilized its newly inaugurated medical record to direct and facilitate pandemic response were indispensable in supporting tens of thousands of New Yorkers over the peak period of crisis, from March 2020 to May 2020.”

So what is it that the NYC H+H professionals did right? Well, from the evidence of the article, several important things. First, they moved very quickly. As they note, “As the number of COVID-19 patients in Emergency Department and ambulatory care settings at NYC H+H accelerated in the first days of the pandemic, the system deployed informatics tools to help rapidly evaluate and discharge low-acuity patients to free up resources for the moderately and severely ill. Note templates specific for COVID-19-related clinical presentations helped to quickly capture essential clinical data while reducing provider documentation burden by simplifying and automating as much of the note as possible. A semi-automated Medical Screening Exam (MSE) note was created by our IT team for use by providers in triage to allow them to quickly evaluate low-acuity patients. The chief complaint from triage, vital signs, medication history, and problem list were all automatically populated into the note. A limited physical exam that did not require physical contact was presented, as well, and the “SmartList” allowed the provider to select common symptoms such as cough, fever, and sore throat with a single click.”

In other words, the NYC H+H folks turbocharged the efficiency of their processes, and prioritized the processing of data and information absolutely crucial to caring for COVID-19 patients and moving forward in optimizing patient care delivery management.

Another key element has been the standardization of clinical workflows. As the NYC H+H leaders write, “If patients were presenting with severe enough symptoms to warrant further clinical testing, Emergency Department, Medicine, and Intensive Care Unit COVID Order Sets were established within the EMR to help guide providers with targeted ordering. These “order sets” included pre-selected labs, radiology studies, and nursing orders as well as other common orders such as oxygen delivery that the provider could include based on the needs of individual patients. These were standardized across the system with multi-specialty input to assure that they were in line with national best practices and updated at the speed necessary to match this rapidly changing crisis.”

What’s more, “In responding to the COVID-19 crisis, NYC H+H helped lead broader, citywide efforts to transform the sharing of clinical information across institutions to enhance the quality of care. At the start of the crisis, a group of hospitals that cared for the majority of patients in the New York metropolitan area agreed to remove barriers to health information exchange.”

All of these moves are precisely the kinds of change processes that the leaders of other hospitals, medical groups, and health systems will be needing to engage in in order to move the needle, at a moment when patient care organizations have been plunged into the thick of the COVID-19 pandemic. Optimizing efficiency is going to be incredibly important in the coming weeks and months, as will be the need to make clinicians’ experiences as flowing and accommodating as possible.

The good news here is that the NYC H+H leaders did this at the height (depth?) of the challenges facing them, as New York City was at the time an epicenter of COVID-19 infections, and clinicians there were beyond-stressed; and, being a public integrated health system, the NYC H+H leaders were able to accomplish this on tight budgets. Both of those factors should encourage the leaders of patient care organizations nationwide, as they move quickly, as needs require, to address enormous challenges in the moment, in the coming weeks and months. There is, as always, real hope.

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