S4E4: Smart Rooms & HF Readmissions (ft. John Voight, Memorial Hermann)

Dr. John Voight   2:12
You know, improving efficiencies around that documentation. If you have a virtual nurse doing the documentation of your admissions and discharges, you can you can create efficiencies because they become content experts at that. We're going to be, you know, the the smart technology has lots of capability. It has room sensors, RTLI.Class capability. It can it can track equipment when it enters the room or exits the room. It can help with fall prevention and reminding patients to get back in bed so that they don't get up and fall accidentally and we can aggregate that data.And find out how often did a patient try and get out of bed? How often did the the staff enter the room or exit the room? How often was a certain piece of equipment in the room? And I think those things are going to be valuable to us in how we actually deliver the care.And I didn't mention the admissions and discharges. It also gives us insight and to be able to determine or measure how efficient are we at getting those admissions and discharge documentations completed.And other things I think we get from that is we get real-time data such as vital sign trends, mobility status, other things, early warning systems that we can we can implement and tie to the smart room technology to enhance nursing workflows.

Jordan Cooper   3:40
I appreciate you going into detail there, John, on how you're implementing the virtual smart room. I want to dive in to a number of topics, but first we'll start with something you said, offload documentation requirements and allowing nurses to practice at the top of their license. I think that's something that many organizations are looking at.Not only for increasing revenue capture, but also for decreasing burnout. Can you speak about how this smart room implementation is offloading these documentation requirements? How is there ambient listening technology? What are you guys doing?

Dr. John Voight   4:03
Mhm.Yeah. So it's a great point and I'll focus on burnout and well-being specifically from a nursing lens. I think that while every organization wants to to become more efficient and cost conscious.I think that from a clinical perspective, we always focus on, you know, if we can keep the turnover down of nurses and keep them more engaged and and feeling more valued in their profession, then that's also a cost saving strategy and so.The the benefit is multimodal. I think that initially we're focusing on having a virtual nurse who will beam into the room on the camera and the monitor and talk to the patient and or the family member to do that somewhat lengthy admission process that normally takes a bedside nurse about.

Jordan Cooper   5:06
Mm.I.

Dr. John Voight   5:11
An average of 40 minutes to do an admission in the chart. And if we can, if we can designate that to someone else who actually improves at the efficiency and doesn't have the constant interruptions with other call bells going off or bed alarms going off or interruptions from providers who are asking questions.Phone calls, then that Virtual nurse has the attention of the patient and or family member for the duration of that admission process. So we can probably get it down to anywhere between 15 and 20 minutes. So there's some significant efficiencies gained from that process. There will still be other documentation that has to be done by the bedside.

Jordan Cooper   5:48
you.

Dr. John Voight   5:51
Nurse as they're providing care and there will be the addition of ambient technology added for nursing at some point in the future. The smart room technology gives us that capability as well. So we're not going to do it from the beginning, but at some point.Maybe it's a year from now. We'll add the ambient listening and and be able to capture the the documentation that's essential for the bedside nurse to do as well.

Jordan Cooper   6:17
So I know that this is Healthy Data podcast, but we can't forget that there's a human relationship between the patient and the provider. I'm wondering, are there, I mean, to what extent are in-person interactions between floor nurses and patients being replaced?With the video nurse and how is that affecting the relationship and the quality of care?

Dr. John Voight   6:44
Yeah, it's a great point. Yeah, it's a great point. And I would say that it actually enhances the time at the bedside while the video nurse, the virtual nurse is doing that, that admission and discharge, the paperwork component of it, the collection of that data.

Jordan Cooper   6:45
How are you tracking that?

Dr. John Voight   7:02
To enter into the record is not what is one of the favorite things that nurses like to do, right? They they never did it in the old days and and So what they really prefer to do is to be there to provide that comfort, the compassionate, connected care.

Jordan Cooper   7:10Right.8.

Dr. John Voight   7:19
To patients and families holding hands while also doing the technical aspects of nursing, right? Making sure that your medications are infusing correctly and making sure that patients don't have, you know, skin breakdown and and all the other complexities of nursing.

Jordan Cooper   7:22
Mhm.

Dr. John Voight   7:36
I I think that offloading that from the bedside nurse gives more time for the bedside nurse to be in the room and to be interacting with patients and families and providing real-time education and doing some of these other assessments that are more meaningful and valuable both to the patient and to the nurse.

Jordan Cooper   7:54
Just to understand the impact of FT E's per bed, prior to the virtual room, did you have two nurses assigned to the same patient? Cause it sounds like there's one nurse who's ensuring that the infusion is correct and there aren't decubitus ulcers underneath the patient and doing the compassionate care in person.And there's a second person on the other end of the video screen at the same time who's maybe doing the ADT stuff. So prior to the virtual room, were there also two nurses or was it on one? Like what's the financial impact there of having potentially two people at the same time?

Dr. John Voight   8:30
Yeah. So it's a great point. And this really goes to to the thought process around when you add smart room technology, do you just layer it on top of your existing care delivery model or do you have to transform your care delivery model?

Jordan Cooper   8:41
Mm-hmm.

Dr. John Voight   8:49
To produce a different outcome and we're going about it a little differently. We're taking the approach that we're going to redesign the care delivery model right now before we go live, we're operating under a primary nursing model, which means it's one RN who takes care of four to five patients at a time.

Jordan Cooper   8:50
Cortana.Mhm.

Dr. John Voight   9:09
And then we have a patient care tech on the floor that takes care of up to 12 patients at a time. So that patient care tech is a support role for nursing. They do the vital signs and the bathing and the ambulation to the bathroom and things like that. We're going to change that dynamic because we're going to change it from a four to one to A63.

Jordan Cooper   9:19
Mhm.Mhm.

Dr. John Voight   9:29
Model and that 63 model is 6 patients per RN with the addition of a virtual nurse and also decreasing that PCT model from a 12 to one to a six to one. So essentially you as a nurse will have a PCT that's assigned with you to be able to deliver that care at the bedside.Side and then the virtual nurse will be the addition to supplement and make sure that they're doing as much of that documentation as possible when you talk about the financial impact on the organization by changing that four to one model and going to a six to one.

Jordan Cooper   10:00
Mhm.

Dr. John Voight   10:04
And then increasing the tech coverage with the virtual nurse. It's not an additional cost, it's essentially the same cost.

Jordan Cooper   10:13
Interesting. All right. I appreciate you explaining the financial impact. I'd like to go back to data. We spoke about aggregating data. For example, you had KPIs about patients getting frequency of patients getting out of bed, staff entering and exiting the room, equipment in the room.What sort of mechanisms are you using, or what sort of challenges did you encounter in aggregating, normalizing, deduplicating this data and making it available, as you mentioned, in real time? Have you been able to set up a fire repo in a commercial cloud VCPU?You know, what sort of different data have you been able to do most of this within the EHR and enterprise data warehouse? How are you doing this aggregate data aggregation?

Dr. John Voight   10:56
Well, you know, we've implemented Epic, which is our, you know, it's a nationally accepted electronic health record and we have all kinds of dashboards and data reports in that system that are formulated and tabulated automatically based on on, you know, how they're set up.

Jordan Cooper   11:00
Yeah.And.

Dr. John Voight   11:13
Artisite has some reporting functionality as well. And then we also have Pilrom, which is made by Baxter for our bed data. So I think it's the, as I said, we haven't implemented our virtual smart rooms yet.

Jordan Cooper   11:31
Mhm.

Dr. John Voight   11:31
But that is part of the process is to look at how are we going to collate all of that data into meaningful, actionable reporting structures, whether that's dashboards or daily reports or whatever it might be, where we can look at it and say, OK, here's what we see with this data. What are we going to do next? How are we going to transform this?And and are we on the right track or do we need to regroup?

Jordan Cooper   11:51
Mhm.Yeah, sounds like many questions that are before you right now are the very questions before many of your peers and listeners to this podcast episode across the country. I'd like to pivot to two of the other topics that we're going to cover today.One is a community paramedic program pilot to reduce readmissions for heart failure. Would you please tell me a bit about that pilot?

Dr. John Voight   12:21
Absolutely. You know, one of the challenges that we have in a acute care is that our heart failure patients that are readmitted within 30 days, CMS has, you know, take back money for those patients.

Jordan Cooper   12:36
Mhm.

Dr. John Voight   12:36
The claw back so to speak and so if they come back within 30 days after discharge then we get penalized for that financially. So the the goal is to how is to think how do we keep these patients that tend to be chronically ill patients that.

Jordan Cooper   12:43
Mm-hmm.

Dr. John Voight   12:53
Can be non-compliant, you know, for the ones that tend to be readmitted. How do we manage the care of those patients? Because we've tried phone calls and we've tried all kinds of strategies to keep them out of the hospital with very little success.

Jordan Cooper   12:59
Mm-hmm.

Dr. John Voight   13:09
So we we decided last year that we were going to pilot a community paramedicine program and it's hospital-based, which is somewhat unique. And maybe to your point about data, one of the things that we wanted to insist on was that this was actually.Captured in our Epic platform. So we built out the documentation for the paramedics to be done in Epic instead of some EMS agency platform and we feel that that's super beneficial for us because.

Jordan Cooper   13:32
OK.Good.Mhm.

Dr. John Voight   13:48
We'll be able to tap into the data and see what we're actually doing. So when they're when they're doing this, they're pre-visits and they round in the hospital and they meet with the patients before they're discharged and they talk about what we're going to be doing over the next 30 days. We make sure that we help get their meds to the bedside so that they have their meds before they go home.And then that information is captured in the Compass Rose module in Epic, which is really for community care and and population health. And then when they go out to the house and they make a home visit.Which we know is a big driver of keeping patients out of the hospital. They document any of their interventions at the home in the outpatient module and the benefit of that is that that goes directly to into the record, so the primary care and.The cardiologists all get to see that information when they're making these home visits and how is their patient progressing outside of the hospital? And do they need to be seen sooner in the clinic or do they need to be brought back into the hospital or are they maintaining at home?

Jordan Cooper   14:46
U OK,

Dr. John Voight   14:56
Our paramedics are doing great because they actually have protocols that they can go out and they can assess the patient. And if the patient's not significantly exacerbated, if they've gained 4 lbs or whatever, they can give them some medication to manage them in the home setting. So we're preventing them from coming back into the hospital as much as possible.The goal is knowing that we're not going to keep all these patients out of the hospital, but if we can at least start addressing maybe a third of them or a little bit more, then we're making progress.

Jordan Cooper   15:16
Is this the?OK.So are you? I'm not sure how long has this has been going on and how you're calculating your return on investment, but it it seems like this is the kind of program that may be able to pay for itself. If you can offset the penalties from the public and private payers in your risk-based shared value delivery model, then I think.Those penalties may exceed the costs of the paramedic pilot program, therefore leaving the organization in the black within this particular use case. Is that has that borne out in with the over the course of the intervention?

Dr. John Voight   16:04
It's a great thought. Unfortunately, we get paid for the readmissions, right? But you know, if you if you figure you're going to get paid, but you're also going to have to pay a penalty on the back end, it's not a full payment. But at the same time, one of the things that we built as our KPI was to decrease the length of stay.

Jordan Cooper   16:09
Mhm.OK.

Dr. John Voight   16:24
Half a day for the CHF population, we've been able to do that already and some of the strategies we've taken to impact that is that we're working with our Ed partners to make sure when these mildly to moderately exacerbated heart failure patients come into the Ed.We admit them to the OBS unit for 24 hours, we tune them up and then we discharge them and and they know that the paramedic will go out there the next day to assess them and maintain a close eye on them. So by doing that we prevented the readmission into the hospital which is definitely contributing to.Cost savings.

Jordan Cooper   17:03
I see. And are there any challenges with facilitating? I guess the paramedics are working on iPads or some sort of digital input data, maybe a smartphone. Are there any challenges? You said you're leveraging the Compass Rose module and Epic.Are there any challenges to incorporating the data that is obtained in the patients homes by the paramedics into the EHR and making it available at the time of care when a patient returns to the emergency department?

Dr. John Voight   17:37
Yeah. No, there's no issue with it now. When we first started this back in September, there was no documentation in Epic. So we had to start from scratch and our Epic partners and our folks at at our system.ISD team really worked hard at helping us create it and and it was interesting because we talked about which is the best module to put it in. Is it Compass Rose population health? Is it is it the outpatient platform? We wanted to make sure that we captured those social determinants of health.And and the interventions that we were doing before we actually went out to the house and the appropriate tools so that our community partners could see those kind of interventions and and that's helped us because now we've got some of these patients that are tapping into the community health workers.They can go out and help them with other tasks at home to keep them out of the hospital. But we also wanted to make sure that the primary care physician and the cardiologist could see it on the outpatient side. So we we built two different, you know, structures within Epic to be able to accommodate that and right now we're working with our partners at ISD.To help us build a dashboard for that purpose. And so we've we've got I think maybe the second iteration of that dashboard that's been completed. Now we've got more things we're going to add to it, but I think it's important for us one of the things that we recognize to your point.We started this and I I would say the first quarter of data that we got was just the beginning of February. And one of the things we noticed is that we weren't having as significant of an impact as we wanted to with going out to the home or with reducing readmission. So when I went back and looked.

Jordan Cooper   19:16
Hmm.

Dr. John Voight   19:28
Notice that we had a lot of phone calls we were making and a few house visits. When I looked at the patients that actually had a house visit, only 6% of those patients came back in. So we pivoted and we said, OK, well, we need to stop all the phone calls and we need to get out to the house.

Jordan Cooper   19:44
Mhm.

Dr. John Voight   19:44
So we're curious to see what the new data is going to show us and the upcoming, you know, weeks. We anecdotally, we feel that we're making a difference and it's already paying off, but I want to see what the real data shows us in that regard with home visit increase.

Jordan Cooper   19:53
Mhm.Well, John, we're approaching the end of this podcast episode and I appreciate your last comment just there about looking to not to to create an intervention and then to evaluate it ex post facto with data in order to make decisions about how to proceed. I like how you pivoted from more calls and fewer visits to.More visits and fewer calls based on the data that you looked at. As we wrap up this episode, just to recap here, we've spoken about the smart rooms, about the dedicated nurse and offloading documentation to reduce burnout. Actually the offsite nurse was able to.To reduce by half the amount of time required for admission or discharge. We spoke about the community paramedicine program to reduce heart failure readmissions. I'd like to ask you to wrap up.What would you advise yourself a few years ago, before you engaged in either of these programs, knowing what you know now, how would you, what would you say to yourself to make this process go more smoothly?

Dr. John Voight   21:11
I think as leaders, as executives, I think it's imperative that that you're receptive to change. I think you have to be, you know, we never predicted three years ago or five years ago that we would have AI.And the rapid pace at which AI is now evolving, I mean daily literally and I don't think we ever could have predicted the kinds of capabilities that we have now or what's going to come in another five years and I would say that.

Jordan Cooper   21:35
Mhm.

Dr. John Voight   21:47
It's imperative that as executives, even old timers like me, that we recognize that times are changing and we shouldn't be fearful of those changes. We need to use those changes as much as we can to improve care.In the healthcare market to make sure that we're giving the best care we possibly can and to improve outcomes and if you embrace the changes and you embrace the technology and the opportunities that exist and certainly using the data to drive.Whether you're actually making the difference you anticipate you're making, I think you'll be, you'll be well positioned.

Jordan Cooper   22:21
Hmm.

Dr. John Voight   22:27
Absolutely. Thank you so much.Thank you.

Jordan Cooper stopped transcription