The ICU initiative positions AHN and Highmark Health to accelerate development of other virtual health endeavors.
In a quest to build a virtual ICU program for multiple hospitals in its 13-hospital health system, Allegheny Health Network (AHN), Pittsburgh-based Highmark Health not only boosted its capacity to care for critically ill patients, it also built the infrastructure for expansion of future virtual care initiatives.
At a time when telehealth and virtual care are top of mind, lessons AHN learned along the way provide a useful framework for other health systems exploring these endeavors.
About three years ago, leaders at Highmark Health began exploring development of a virtual ICU, often called eICUs by other hospital systems. Highmark, which refers to itself as a "blended health organization," functions as a payer, operating one of the county's largest Blue Cross and Blue Shield Blue affiliates, as well as a provider through AHN.
"The ability to institute a virtual ICU model was aligned with our mission and goals, which was to increase the capacity and capabilities of those community hospitals in an effort to manage patients close to home," says Anil Singh, MD, MPH, MMM, executive medical director, enterprise clinical organization-clinical solutions, design, and implementation, Highmark Health.
Before the concept was launched, community hospitals would send their critically ill patients to Allegheny General Hospital, creating a "bottleneck effect" trying to admit multiple patients into one hospital. "There were not enough beds, there was not enough staff, there were all sorts of issues," Singh says.
A shortage of intensivists compounded the problem. "I was struggling to find enough clinicians to help cover the units around our system," Singh says. "I always jokingly say that intensivists aren't falling from trees. They're a scarce commodity."
The virtual ICU "became an opportunity for us to manage a larger volume of patients at the same level and capabilities as our quaternary care hospital with the ability to do that at the highest quality with the same outcomes," he says. Initially, four outlying hospitals were involved in the initiative, with a total of 64 ICU beds.
1. Partner With an Experienced Player to Accelerate the Process
As AHN began its journey, "We zeroed in on Mercy Virtual early in the due diligence process as a potential partner to help us," says David Hall, MBA, vice president of strategic partnerships, Highmark Health.
Based in St. Louis and affiliated with Mercy health system, Mercy Virtual launched a "hospital without beds" in 2015. Today, in addition to serving 43 hospitals in its own health system, Mercy Virtual works in partnership with other hospitals, and its 300 clinicians deliver 24/7 virtual care services to 600,000 patients across seven states. Hall outlines three benefits the partnership provides:
- Technology: The technology involved in eICU operations requires products from multiple vendors. Mercy Virtual had already vetted the recommended technology stack, streamlining the process. "They understood how those technology pieces all come together in the EHR (electronic health record) system," Hall says. "So as we put in the monitors, Wi-Fi, video capability, and audio capability and integrated it into Epic, they brought that know-how together for us."
- Staffing: The partnership provided a way to immediately expand AHN's roster of clinicians. "They had about 140 clinicians that are both licensed in Pennsylvania and credentialed at the Allegheny Health Network who are essentially extensions of the AHN clinical team," Hall says. Depending on the needs of an AHN hospital, Mercy's clinician provides partial or fulltime virtual ICU coverage at all facilities. When an intensivist is not on the premises, advanced practice providers carry out orders from the remotely located physician.
- Training: Mercy Virtual provided training and support as each AHN hospital came online.
The Mercy Virtual team guided AHN through the strategy, build, implementation, and technology alignment, as well as the training and education. "They have been a true partner at all levels," Hall says. The first AHN virtual ICU debuted in January 2020 with three others rolling out over the next three months as the pandemic gained traction.
"We went through the build, all the strategy, the implementation, the technology alignment, everything that we did there, the training, the education, all of that occurred in 2019, we went live with the first virtual clinic for virtual ICU at the end of January 2020. We had no idea what was coming down the pike, honestly, with the COVID and the pandemic. So we rolled out the first four hospital [virtual] ICU programs in January, February, March, and April of 2020."
2. Expect Unanticipated Challenges Due to Outdated Technology
One issue that the team didn't expect to encounter was outdated technology and issues with broadband and Wi-Fi at some of the hospitals, particularly in rural areas, Hall says. "It's like going back in time from a technology standpoint," he says. "Getting Wi-Fi, connectivity, and everything else that you need in there, is a pretty good challenge in some of these remote areas." Weak Wi-Fi signals create issues with real-time data feeds from the bedside to the virtual command center.
"We've had to do significant increases in broadband capabilities and Wi-Fi strengths," Hall says. In addition, there were challenges with EHRs that were unfamiliar to the installation team.
"When you get away from the feel-good PowerPoints that define virtual technologies and digital health, and you get into the real world of executing these strategies, the blocking and tackling is pretty raw," Hall says. "We had to knock down walls take out windows to turn these environments into virtual environments that can be set up safely and appropriately to take care of patients."
3. Build Culture Change Into the Process
In addition to bringing new technological capabilities to each of the hospitals involved, the virtual ICUs have led to cultural change, Hall says. Some of the hospitals had been delivering care in the same way for decades. "This virtual program has created a capability in these community hospitals that they historically have never had," he says.
"Sicker people are staying there, and they're able to treat them appropriately," Hall says. "As you can imagine, when you transfer a patient out of a community setting, it hurts the economics of that system, but it also is incredibly disruptive to that patient and the family when they have to go an hour, two hours, three hours into the city for care."
One benefit of the virtual ICU model is that it enables hospitals to switch from reactive to proactive care, Singh says. This requires a shift in mindset. "You can intervene ahead of time and prevent bad things from happening."
The innovation also has enhanced staff morale and reduced turnover. "We've gotten an incredible response, particularly from nurses in terms of quality this has brought to their work lives—their ability to work at the top of their license," Hall says.
4. Track Key Performance Indicators
Highmark Health provided some key performance metrics comparing performance of virtual ICU beds in four hospitals from 2019 to 2020. However, Highmark notes that introduction of the virtual ICU program was staggered over the first four months of 2020, so the numbers don't present a completely accurate year-over-year comparison. In addition, 2020 presented some performance anomalies. Typical inpatient volumes were down during the pandemic while these sites also assumed significant COVID volumes.
- Discharges: Decreased by 3.6% year over year due to pandemic volume downturns
- Net Patient Revenues: Increased by 6.9%
- Transfers Out: Decreased by 16.6%
- Transfers In: Increased by 7.9%
- Case Mix Index: Increased by 10%
At the same time, quality and safety data was tracked to ensure the virtual units were delivering comparable metrics, Singh says. "The premise of all of this is if we can improve health outcomes, total cost of care will come down."
5. Use the Virtual ICU Framework to Scale Additional Virtual Initiatives
"As we think about the broader scope of where virtual care can go, the virtual ICU becomes a microcosm of how you can begin to expand it because you have that kind of scalability," Singh says. "You need fewer bodies from the clinical standpoint, but you're able to [serve] a larger number of patients. The reason why you're able to do that is because you're basically intervening on the patients that absolutely need you at that particular moment in time."
"It becomes a defining strategy for the enterprise," Hall says. "You create these standards of care across the region that is really differentiated for Highmark Health."
While AHN will use this foundation to explore other virtual initiatives, Highmark can "work with other local provider partners and AHN to execute similar strategies in local markets," Hall says.
To accelerate these plans, Highmark Health recently hired Laura Messineo, MHA, RN, as vice president of enterprise virtual health. Her scope of work will encompass prevention, wellness, ambulatory care, acute care, and post-acute care, as well as designing clinical workflows to deliver the same quality of care an individual receives through traditional in-person service.
"From a virtual perspective, we're really looking to transform the delivery of care," Messineo says.
“As we think about the broader scope of where virtual care can go, the virtual ICU becomes a microcosm of how you can begin to expand it because you have that kind of scalability. ”
Anil Singh, MD, MPH, MMM, executive medical director, enterprise clinical organization-clinical solutions, design, and implementation, Highmark Health.
Mandy Roth is the innovations editor at HealthLeaders.
Partnering with an experienced health system can jump start virtual health efforts.
Plan to deal with outdated technology at remote facilities, as well as cultural change.
Building an eICU framework can accelerate other virtual care initiatives.