Rice County District Hospital, a 25-bed critical access hospital in the heart of Kansas, is improving inpatient care and critical patient transfers with technology. Officials say the platform is a life-saver and a crucial cog to staying open.

When you're the only critical access hospital around for hundreds of miles, you'd better have the resources for treating patients in need of emergency care—or the means for quickly and effectively getting patients to the care they need.

At Rice County District Hospital in Lyons, Kansas, staff are using patient placement technology to coordinate care for both patients inside the 25-bed, level 4 hospital, and those needing to be transferred to another facility. The platform integrates local EMS and other transport services, such as helicopters and planes, with health systems hundreds of miles away who have the specialists necessary to treat a critically injured patient.

"It has been complex at times, and very stressful," says Bonnie Goans, RN, the hospital's trauma and emergency preparedness coordinator, who remembers instances where it has taken two weeks to get a patient to the right hospital. "The technology we have now is really helping to make things smoother and more efficient."

Bonnie Goans, RN, trauma and emergency preparedness director, Rice County District Hospital. Photo courtesy Rice County District Hospital.

With a population of about 3,500 in a county of only 9,500, Lyons sits right in the middle of Kansas and the Great Plains, an area that could be used as the dictionary definition of "rural." There's plenty of farmland and a few industries, including an ethanol plant. The hospital sees its fair share of farming and industrial injuries, vehicle and ATV accidents, and, like everywhere else, chronic diseases.

And it offers an ideal location to prove the value of innovative new technologies in improving healthcare access and outcomes in rural America.

Of the estimated 6,000 hospitals in the US, according to the American Hospital Association, almost 1,800, or about 30%, are in rural locations. More than 130 rural hospitals have closed over the past decade, and another 600 are at risk of closing.

Telehealth advocates have been pushing virtual technology as an avenue by which these small, remote hospitals can keep more patients in-house and improve access to services and specialists, and Goans says Rice County District Hospital has been using telehealth for a variety of services, including cardiac, pulmonary, and neurological care. But there's only so much a 25-bed hospital with a staff of about 150 can accommodate, and some patients need care that the hospital just doesn't have.

That's where technology comes in—and one's neighbors.

"That's the good thing about being in a small community," Goans says. "Everyone pitches in. Everyone helps when they can."

The hospital has one EMS crew on hand and one backup, as well as access to a few helicopters and fixed-wing aircraft. There's a level 3 trauma center 30 miles away, and a pair of level 1 hospitals in Wichita, roughly 80 miles away. But anything that takes three hours or more "is a no-go," Goans says, because it leaves the community short of resources in case of an emergency.

The old process of arranging transports focused on the telephone, and it basically meant that anyone with hands free would place calls to (a) find the necessary transport and (b) find the right location. Now the information is pulled out of the electronic health record and fed into a platform that scans available health systems for the right clinicians and an available bed, while making sure transportation is available.

"A lot of times in the past it was your doctor making the phone calls because the nurses were busy doing something," Goans recalls. "And there were lots of calls to make. You needed the right doctor at the right hospital, and you needed a room available, and you didn't stop until you had the room. Then it was a race to get the patient on the road" to get to that hospital before that room was taken.

'We were used to being accepted. And suddenly that went away.'

The catalyst for change was the pandemic. That, combined with a nationwide shortage of staff, created a crisis.

Suddenly every hospital was at or near capacity, and everyone was scrambling to find a bed. Hospitals across the state (and the nation) struggled not only to support and care for patients with the virus, but also to care for patients with other health concerns who had to be kept separate from infected patients, while also taking steps to shield doctors and nurses from COVID-19. One news report estimated that nearly 80 patients in Kansas alone died waiting for a hospital bed.

"We were used to being accepted" for a patient transfer, Goans says. "And suddenly that went away."

The pandemic pushed state officials to invest in technology and resources allowing health systems to coordinate care. The state's Department of Health and Environment and Department of Emergency Medicine signed and then extended a contract with digital health company Motient to create a network enabling more than 110 of the state's hospitals and correctional facilities to use the company's Mission Control platform to coordinate transfers.

"In terms of preventative healthcare and resource redeployment, the wealth of data that will come out of a statewide program like this will be invaluable in a few years," Alana Longwell, MD, the chief medical officer at Newman Regional Hospital, a 25-bed critical access hospital in Emporia, about 160 miles from Rice County District Hospital, said in a 2021 press release announcing the contract extension. "We started using the platform to find beds, and now we use it for more than 90% of our transfer patients. The platform lets us slice and dice our data around time-critical diagnoses to help us increase efficiency and improve our transport processes."

At Rice County District Hospital, Goans says the platform reduced the frustration level of staff almost instantly. Doctors are now able to spend more of their time with patients, while nurses handle all of the transportation details, while phone calls are only made to make sure everything is in place.

Goans says the platform allows the hospital to run more smoothly, managing inpatient resources as well as transfers, and gives administrators the data needed to stay on top of things. For a small hospital with razor-thin margins, battling a staff shortage that's affecting the entire country, those capabilities are key to ensuring the right staff are in the right place.

"This does help us to manage care better, and in some cases, keep more of our acute care patients," she says. "Our doctors are practicing at the top of their license now, rather than making phone calls … and we are identifying delays [and gaps] in care that can be corrected more quickly."

The platform also facilitates telehealth and other digital health services, opening the door to more care opportunities on-site and collaborations with larger hospitals and health systems. That's crucial for small hospitals like Rice County District Hospital that aren't going to be expanding any time soon and need to make do with what they currently have at their disposal.

"There will always be a need to transfer patients," Goans says. "That won’t go away." But they can make sure those transports are quick, efficient, and necessary.

Goans expects to use more telehealth and digital health tools in the future to improve care in the hospital and surrounding community. And she has her eye on some new technology as well.

"I'm just waiting for some drones now," she says.

By a near unanimous vote, the US House of Representatives has passed a bill expanding telehealth access and coverage for Medicare services until the end of 2024, while making those flexibilities permanent for FQHCs and RHCs. The bill now goes to the Senate.

Congress is halfway toward extending telehealth flexibilities enacted during the pandemic until the end of 2024.

The US House of Representatives this week passed the Advancing Telehealth Beyond COVID-19 Act of 2021 (HR 4040) by a 416-12 vote, sending the issue on to the Senate. The bill, introduced more than a year ago by US Rep Liz Cheney (R-Wyoming), expands the definition of "originating site" to allow more locations to use telehealth, eliminates facility fees for new sites, expands the list of healthcare providers able to use telehealth, adds audio-only telehealth to the definition of "telecommunications system," and makes permanent the ability of federally-qualified health centers (FHQCs) and rural health clinics (RHCs) to use telehealth under the Medicare program.

These flexibilities were put into place by the Centers for Medicare & Medicaid Services (CMS) at the onset of the COVID-19 crisis to help healthcare organizations expand access to and coverage of telehealth services, with the caveat that they be terminated at the end of the public health emergency (PHE). The bill's goal is to give providers a better idea of how long they have to use those flexibilities before they either end or Congress takes more action.

The bill's passage drew immediate praise from the American Telemedicine Association (ATA) and its lobbying group, ATA Action.

“Today, we took a significant step forward in providing much needed stability in access to care for millions of Americans, with the US House vote to extend key telehealth flexibilities implemented during the COVID-19 Public Health Emergency (PHE) until the end of 2024," Kyle Zebley, the ATA's vice president of public policy and executive director of ATA Action, said in a press release. "We cannot allow patients to lose access to telehealth post-pandemic, and this bill will provide stability through 2024, while giving Congress time to address how to make the policies permanent."

“Telehealth has long been a bipartisan healthcare issue and we now turn to the Senate to ensure this important piece of legislation makes it to President Biden’s desk so he can sign it into law,” he added.

The American Medical Association also weighed in on the issue.

“Increased Medicare-covered access to telehealth has been a lifeline to patients and physicians throughout the COVID-19 pandemic, and the American Medical Association (AMA) is pleased by today’s bipartisan vote in the House," AMA President Jack Resnick Jr., MD, said in a statement. "The COVID-19 public health emergency made plain that care via telehealth should be available to all Medicare patients, especially with their own physicians, regardless of where they live or how they access these services. From continuity of care, broadened access to care, and removing geographic and originating-site restrictions, our hope is that the flexibilities afforded during the public health emergency will be made permanent."

Passage of the bill is significant not only because of the margin of victory in the House – indicating strong bipartisan support for telehealth – but because Congress has taken action on the issue. Dozens, if not hundreds, of bills have been proposed in both the House and Senate these past few years aimed at expanding telehealth access and coverage, many seeking some or all of the flexibilities outlined in the Cheney bill, but very few have seen any votes.

Passage in the Senate is no done deal, even with the House's strong support. But Senator Joe Manchin's (D-West Virginia) recent shift to support the Inflation Reduction Act may hint at a willingness to move forward on other issues as well, including healthcare. And the bill does have the backing of the Biden Administration.

"It is important to continue the availability of expanded telehealth to meet the needs of Medicare beneficiaries and health care providers," the Executive Office wrote in a Statement of Administration Policy shortly before the House vote, noting that telehealth visits increased 63-fold in 2020, especially in rural areas and for behavioral health services. "As we emerge from the worst stages of the COVID-19 pandemic, H.R. 4040 will ensure that the Medicare program continually adapts to provide convenient, quality, accessible, and equitable healthcare."

The Senate can now vote on the House bill, vote on its own version of the bill, combine the two, or do nothing.

And while Senate passage of the bill is now top of mind, advocates will continue to push for permanent expansion for some or all of those flexibilities, arguing that telehealth has proven its value during the pandemic.

Amazon has announced plans to buy concierge care company One Medical for almost $4 billion, positioning the retail giant right in the middle of an ever-growing battleground for primary care.

Amazon is getting into the primary care business.

The retail giant has announced that it is acquiring One Medical, the concierge-styled primary care company with a telehealth platform and more than 125 brick-and-mortar locations scattered across the country. The deal, valued at roughly $3.9 billion, would be Amazon's third-largest acquisition, giving the company a physical footprint alongside Amazon Pharmacy and Amazon Care, a virtual care platform for businesses.

“We think healthcare is high on the list of experiences that need reinvention,” Neil Lindsay, Amazon's senior vice president of Amazon Health Services, said in a press release. “Booking an appointment, waiting weeks or even months to be seen, taking time off work, driving to a clinic, finding a parking spot, waiting in the waiting room then the exam room for what is too often a rushed few minutes with a doctor, then making another trip to a pharmacy – we see lots of opportunity to both improve the quality of the experience and give people back valuable time in their days.”

“There is an immense opportunity to make the health care experience more accessible, affordable, and even enjoyable for patients, providers, and payers," added One Medical CEO Amir Dan Rubin, who will continue as CEO.

The announcement fits with the idea that primary care is becoming a hotly contested battleground, featuring competition from traditional healthcare organizations as well as telehealth companies and payers with their own provider networks and retail behemoths like Amazon, Google, Walmart and Walgreens.

All are trying to lay the groundwork for on-demand primary care services, either in person or through virtual care channels. Amazon's strategy is to make that encounter as ubiquitous as buying something on its website.

Nathan Ray, a partner in the healthcare segment of national management and technology consultant West Monroe, said the deal makes Amazon a major player in the ever-shifting healthcare market.

"Amazon continues to make forward progress towards being a broad and dynamic healthcare entity with the acquisition of One Medical, their activity here and in recent past within many of the most actively evolving areas of healthcare has shown they have an evolving strategy towards developing their role in the healthcare marketplace and now entering primary care (and risk contracting) the true center of focus and change after incrementally building relevance in DME, pharmacy, virtual care and employer health," he said in an e-mail to HealthLeaders.

"Amazon and One Medical will have some great opportunities to continue to improve on today’s technology and in particular evolving digital intelligence and engagement technologies that drive intervention, clinician effectiveness, and action based on both historic and real-time data and analytics that underpin the ability to develop and scale successful care models," he added.

Ray noted further that the deal does have some concerns.

"This move tells us both that Amazon is aware of what they lack, but also that they really may not have a grand strategy as of yet but are continuing to find value buying (particularly on the downbeat of the market here) and developing both solutions and services within the healthcare space that give them options," he said.

"The biggest questions I have are when will we begin to see more of Amazon’s signature of technology enablement, easy access, low cost and service quality begin to reveal itself within healthcare through this acquisition, and how might Amazon’s skill with those design elements yield market advantage," he added. "Primary care is a highly dynamic space with payers, providers, and healthcare services and technology organizations all focused on many of the same population health and risk attribution tools and concerns and a slow war of care models, utilization, and financial performance playing out as significant capital has entered from both private and public markets over the last 3-5 years particularly motivated by growth coming from managed care, particularly Medicare Advantage."

The executive director of revenue cycle management at Banner Health details lessons learned from deploying revenue cycle automation.

The healthcare industry is constantly evolving in ways that revenue cycle leaders can't control. Changes in billing requirements, payment models, and patient access can cause struggles for organizations with poor processes.

Successful organizations must enhance their revenue cycles and create the bandwidth to address these challenges. This means the use of technology and AI to streamline revenue cycle processes is essential.

Jamie Davis, executive director of revenue cycle management at Banner Health, recently spoke with HealthLeaders about Banner's journey in implementing the use of AI and automating its revenue cycle management. It wasn't an easy process, but it was necessary to protect the organization against revenue leakage.

Davis has over 20 years in healthcare and is the liaison for Banner Health's revenue cycle performance and strategic alignment with its regional c-suite. She oversees the revenue cycle portfolio, including vendor management, revenue cycle roadmap, continuous improvement, and strategy.

Banner Health currently has 22 day-to-day bots helping with its revenue cycle management. These bots complete tasks like adding insurance information and updating medical records. "All the things that our human resources shouldn't waste their time doing," Davis said.

These bots manage roughly 90 million records for Banner Health, and from mid-2020 to 2021, Banner has saved about 1.73 million man-hours by deploying them, Davis explained. Banner Health also has machine learning in its refund and variance space to help with credit and debt balances.

When it comes to taking on such a large automation endeavor, partnerships are needed Davis says.

"Our automation is done completely in partnership with our IT group. They have their own robotic process automation center of excellence, but they've also started dabbling in some process mining in our health plan data. And we are working towards automating things like low balance accounts receivable management and denials," Davis says. 

"The automation of the denials, low balance accounts receivable management, and the variances is really fun and innovative. That's where it's really rolling into that intelligent automation space since it's using machine learning that is predicting and reacting," Davis says.

Don’t go big at first

While Banner Health is fully rolling with a plethora of streamlined and strategic automation throughout its revenue cycle, it wasn't always smooth sailing. This, Davis says, is where you need to make sure to take your time and don't expect to go big at first.

"In full transparency, we tried to run first, and then we fell. We realized we needed to slow down a little bit, which was a great lesson learned," Davis said. "I think anyone who is trying to be innovative has those horror stories where something worked out really well in the boardroom and not so much in real life."

At the time Davis started developing its automation, Banner Health already had its IT team working with its medical records team to manage records and move them with bots. From there, it made sense to the team to expand its automation. 

"The theory is, we want our technology to pay for itself. We thought a great way to do that is to add machine learning to implant charge capture and it will increase that revenue. And we were very strategic about it—so we thought," Davis said. "We deployed process engineers and documented the processes. We found all the variants and began to write Python code and machine learning. And it worked until it didn't work. What happened was that the processes that we had documented varied from facility to facility."

Banner Health has 30 hospitals, and the appropriate workflows weren't aligning. 

"So, we automated a dysfunctional workflow, and it ended up being more cumbersome to utilize the machine learning. It was a good learning experience—we did the fail-fast theory."

Moving forward

After stepping back, realigning its strategic planning, and partnering with IT, Banner's deployment process started to turn around.

"We ended up creating hierarchal scoring for all of the automation that we wanted to consider. On one side, we have the benefits: for example, net revenues, compliance, or full-time employee re-allocation. We would then weigh those scores and compare them to the complexity of the build: for example, how many process variants does it have? How many systems are in there?" Davis shared.

After gathering those scores, Banner would use a classic grid to determine automation that was low-effort, low-return, and high-effort, high-return. This hierarchical approach made all the difference for them.

"Once we did that, we applied a continuous improvement team member to have oversight and to help be that subject matter expert in the revenue cycle to make sure we aren't recreating core processes. And from there, our automation just went gangbusters," Davis said.

Banner had about five bots at the time, and in almost no time they had 15 bots. Now they are at 22, Davis says.

"And we have governance over all of it as well. So, just because we can automate something, doesn't mean we should."

Managing all of this automation has become easier too, Davis said. The team now brings all of the automation to the table, just like they would do for any other project, and explain it to governance oversight so they can agree that it's strategically aligned.

It's also important to make sure the automation doesn't tax resources that are taxed elsewhere and to make sure there is monitoring in place. 

"We have dashboarding that monitors what those bots are doing, when they stopped doing it, and when they start doing it the wrong way. Because, you know, just like humans, a bot needs to learn, be educated, and be monitored," Davis said.

Davis credits its first failed attempt at deploying automation to the success it has today.

"I really think this playbook that we created has been really successful because now we have our feet under us from a bot perspective, and we are running really quickly."