Prior to COVID-19 hitting early this year, telemedicine at Baltimore-based Johns Hopkins Medicine was low in volume, representing less than 0.1% of total ambulatory care. Epic
During the peak of the pandemic, more than 50% of ambulatory care was delivered through telemedicine, reaching a peak of nearly 100,000 encounters in May 2020. This virtual care is delivered through an integrated video platform through the organization’s Epic EHR.
This rapid increase in telemedicine capabilities created unique challenges, including: 1) Scaling the existing platform to handle new, COVID-19-driven volume, 2) Improving patient access and technical support structures, and 3) The need to monitor larger numbers of patients and different vital signs remotely.
“In addition to the need to scale our video-visit capabilities, the pandemic highlighted a myriad of other new issues to be solved,” noted Dr. Brian Hasselfeld, a pediatrician and medical director for digital health and telemedicine in the office of Johns Hopkins Physicians. “In managing our own workforce, we identified the need to screen and monitor employees for concerning infectious symptoms daily.”
As post-acute discharge options became limited due to bed capacity and medical staff learned more about pulmonary complications of COVID-19, the organization needed ways to more safely discharge to their homes patients who had been admitted with COVID-19. Further, with new infectious risks and with limitations of personal protective equipment, there were new needs around video and remote monitoring of patients admitted in the hospital.
Earlier this year, the U.S. Federal Communications Commission awarded the Johns Hopkins Health System $1,000,000 for a remote intensive care unit, a medical kiosk, tablets and other connected devices, cameras, and other telehealth equipment.
This included patient-monitoring equipment to provide routine and complex care for patients with COVID-19, including a COVID-19 ambulatory response team and a regional public-private partnership to serve patients in the surrounding community, all using telehealth. Most of the vendor functionality is tied directly to Epic EHR integration.
“Our FCC application was focused on multiple areas, to address each of these problems,” Hasselfeld said. “As our video-visit volume expanded by up to 1,000 times in areas of our health system, basic IT infrastructure to improve video/audio performance was critical. This was work directly with our integrated video vendor inside of our Epic EHR, which also included improved IT support pathways.”
“As our video visit volume expanded by up to 1,000 times in areas of our health system, basic IT infrastructure to improve video/audio performance was critical. This was work directly with our integrated video vendor inside of our Epic EHR, which also included improved IT support pathways.”
Dr. Brian Hasselfeld, Johns Hopkins Medicine
“We engaged with a mobile digital application pushed directly to our employees via text reminders, with customized questions around symptoms and a dashboard backend to visualize trends,” he continued.
“In coordination with our home care group and pulmonology clinical teams, we expanded our home pulse-oximetry remote-monitoring capability and, in coordination with home care nursing teams and pulmonary provider teams, paired home pulse-oximetry data with virtual pulmonology follow-up for patients leaving the hospital after admissions for COVID-19 for safer care in the home.”
Inside the hospital, staff acquired a wide variety of IT equipment, ranging from mobile phones to tablets, to multifunctional camera kiosks, in order to ensure patients in a wide variety of inpatient venues could engage virtually with providers and outside friends and family, he added.
In critical care areas, which fluctuated and often expanded into previously noncritical care space in the hospitals, the organization began work with a software vendor for improved remote vital sign monitoring, he said.
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MEETING THE CHALLENGE
“The aforementioned solutions, which are multiple solutions addressing multiple new problems across the various care settings in Johns Hopkins Medicine, were used broadly,” Hasselfeld said. “Improved video-visit platforms touched all ambulatory providers and staff. Enhanced home monitoring engaged a multidisciplinary team ranging from discharge case managers/care coordinators, home care nursing, and pulmonology specialists.”
Improved inpatient video monitoring and data aggregation was leveraged by all types of providers and staff in the hospital setting, and also improved patient connectivity to family and friends during inpatient stays where visitor restrictions were in place due to the pandemic, he added. Each of these solutions was integrated into the Epic EHR infrastructure to limit workflow disruptions and maintain source-of-truth integrity for the medical record, he explained.
In the ambulatory space, Johns Hopkins Medicine has completed more than 400,000 virtual visits, touching nearly 200,000 unique patients.
“Our expanded home-monitoring platform enrolled 270 patients upon discharge from our hospitals, with approximately 20 nursing virtual touchpoints – calls, messages or clinical interventions – per enrolled patient, creating a safer environment after acute illness,” Hasselfeld reported. “With these intensive services, only around 2% of the patients in the home pulse oximetry program required readmission to date.”
Thousands of patients in the Johns Hopkins hospitals, he concluded, were monitored remotely or experienced virtual subspecialty consultation to keep patients safe from unnecessary infectious exposure when clinically appropriate.