May 13, 2020: Dr. Jake Lancaster, CMIO at Baptist Memorial Health joins us for today’s field report to talk about stepping up to meet the crisis and what things look like now that the institution is tentatively winding down. Just a few short months after Jake joined the team at Baptist, COVID struck, and he gives us an idea of the rapid changes in strategy that were required to ramp up and cope with the pandemic. Surprisingly, he describes a lower than expected case count. The team had initially planned for around ten times the numbers of COVID patients and are only now seeing an increase, and Jake brings up asymptomatic positive rates as a possible cause for this. We hear about the different situations on Baptist campuses in Tennessee, Arkansas, and Mississippi as the states start opening up and Jake weighs in on the preventative measures they are taking which are being branded as their COVID Care System. From there, we move to talk about the business of health care, and whether ER volumes will be returning to pre-COVID baselines any time soon. Jake shares his views about how the ratio between the severity of patient cases and their willingness to visit a hospital might play a role in this respect. Wrapping up, we ask Jake about the fall back plan at Baptist and he assures us that that the preventative measures they initially put in place won't go away any time soon!
Key Points From This Episode:
Field Report: Baptist Memorial Health
Episode 247: Transcript - May 13, 2020:
This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.
[0:00:04.8] BR: Welcome to This Week in Health where we amplify great thinking to propel healthcare forward.
My name is Bill Russell, healthcare CIO, coach and creator of This Week in Health IT, a set of podcast, videos and collaboration events, dedicated to developing the next generation of health leaders.
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Now, on to today's show.
[0:01:13.9] BR: Today’s conversation is with Dr. Jake Lancaster, CMIO for Baptist Memorial Healthcare out of Tennessee. Good afternoon, Jake, and welcome to the show.
[0:01:22.1] JL: Glad to be here, Bill.
[0:01:23.9] BR: Well, I'm looking forward to this conversation. Thanks for taking a few minutes. I know you guys are busy. You've been in this role for all of nine months. I guess, you got the, “Welcome to Baptist Memorial. Are you ready for a pandemic?” intro to the job?
[0:01:41.0] JL: Oh, yeah. Been here nine months, but it feels like about two years for sure.
[0:01:44.7] BR: Yeah, I would imagine. I mean, what was that like? I mean, you were in the role probably for about – before we started hearing about China, you were probably in the role for maybe three or four months. Then it really ramped up.
[0:01:57.5] JL: Yes. Definitely doing a lot a of different things now than what I was doing the first few months. I was really focused in those first few months on quality and safety initiatives and really improving the experience of the EMR with physicians. Yes, over the last two or three months, or two or three years, depending on you’re looking at it, it's been all COVID and trying to plan and prepare for the pandemic and do all we can to make sure that we're treating patients and taking care of our staff as safely as possible.
[0:02:27.5] BR: Yeah. We're going to get into some of that. Before we do, tell us a little bit about Baptist Memorial, because you're the third Baptist we've had on the show, so I want to make a distinction for people.
[0:02:36.9] JL: Yes. We are the Baptist Memorial Health Care Corporation that is based – our corporate office is based out of Memphis, but we have 22 hospitals, as well as many clinics across three states, so Tennessee, Arkansas and Mississippi. Our two largest facilities are in Memphis and then Jackson, Mississippi. We have several thousand employees, close to 4,000 providers that are tied to our health care system.
[0:03:05.9] BR: Fantastic. All right, so we're going to touch on the work leading up to the really, a pre-COVID era. Some of the things that may be going on today. Then I'd like to, if you allow me, start talking about coming out, because we saw some numbers this week that show a little bit of an uptick in terms of claims data, which would say that some of the OR capacity is starting to rise and those things. I'd like to finish there. Let's start with, how did you ramp up to handle the pandemic and what did you learn in the process?
[0:03:40.1] JL: Yeah. In the very beginning, the executive team, we're meeting about seven days a week, oftentimes two or three times a day in order to prepare for the pandemic. The initial phase, just like everybody else, we're focusing on screening, which just that seems so far from now, just the travel history, making sure all that was built out in our EMR, making sure that that came across well. I mean, which is not as relevant now, but that was a big deal this first couple of weeks, as well as standing up a reporting, standing up and making sure we had adequate PPE.
I mean, at that time we didn't have any idea of what the case volume was going to be like, so we were relying on a lot of those – the models that were out there, like CHIME, Panda and some of the others to try to predict what it was going to be like in our area. Really during that time, that was the first couple of weeks when everybody's hair was on fire. We started to show what the projection was and when it was supposed to hit in our area, that got people to step back a little bit and realize that this was going to be a marathon, not a sprint, which I think helped a lot.
Well, it helped and it hurt somewhat. When we started talking about this going on for several months as opposed to two weeks to a month that some had initially predicted that the worst was going to be, it freaked some people out for sure.
[0:05:10.7] BR: Yeah. The marathon aspect of this, we were talking earlier how people are just getting a little stir-crazy and things are happening. I was talking about what was going on at my area and you were talking about what's going on in your area. That’s what we really want to focus in on. What is going on in your area? Number of COVID patients maybe that you're treating? Are you starting to open back up? What's going on in the markets that you serve?
[0:05:38.4] JL: Yeah. Tennessee, Arkansas and Mississippi are all slightly different in how they have been impacted by COVID. Tennessee and Mississippi had been hit slightly harder than Arkansas and Memphis and Jackson, the bigger cities more so than the others. Jackson having slightly more than Memphis, we think because the proximity to New Orleans and Louisiana.
Over the past couple of weeks, you've probably seen on the news, where all three of the states really have had these reopening plans. We've been able to take our states open over the last one to two weeks with different states, having different timelines and different criteria for what's allowed. Even before the reopening plans, things were fairly stable. We didn't have a huge number of cases. System-wide, our total number of admitted patients has been a 100 across 22 hospitals, with probably 30 max admitted at any one hospital, with maybe about 20 med surg in 10 ICUs.
During our surge planning, we had prepared for probably 10 times that, close to 10 times that. Pretty far from what we thought our ultimate capacity was for COVID-19. Even before the states started reopening, like I said, it was leveling off, but actually our case counts had started to tick up largely because we think we were testing more. Around that time we started testing, every patient that was admitted to the hospital and the false – I'm not false positive, but our asymptomatic positive rate has been around 2% to 3%, which is it's low, but when you're testing hundreds and potentially a thousand patients, that's going to be a significant number.
We do have about 10 to 15 patients admitted across our system that are asymptomatic positives. That looks like our numbers are going up and they are technically, but that it may also be that we're just doing a lot more testing. The states reopened a couple of weeks ago, or a week and a half ago, we started testing everybody that was coming through the system. Now we have this scenario where our cases are slowly picking up, and so we don't know if that's due to the states reopening, or if that's due to more testing.
It's a little bit hard to understand where you are in the process. To me, the good news is our ICU patients with COVID has been relatively stable over the past several weeks. Those numbers aren't really going up in that same fashion as the rest of them. To me, it looks like it may be more due to asymptomatic positives. It’s certainly going to be interesting to watch up the next couple of weeks as we get more data.
[0:08:43.6] BR: Your hospitals are opening up. What kind of things are you putting in place? I mean, this is the thing that every health system across the country is dealing with right now is how do you create that safe environment? You don't want people coming in and getting COVID at the hospital. What's the new norm going to be like for me when I go to the hospital?
[0:09:03.5] JL: Everybody seems to have a different take on how to do this. What we have in place is called the COVID care system is what we’re calling it. I mentioned before, everybody that's coming to the hospital, everybody that's getting a surgery is getting tested for COVID. You're going to be putting two buckets. You’re either COVID positive, or COVID negative. Then based on that diagnosis, we're going to put you in either a COVID care zone in the hospital, or the COVID free zone. That's how we're laying it out. We obviously have full PPE for everybody that has been revised based on CDC's guidelines as they keep coming out.
Then at the same time, we've been toying with the idea of testing antibodies on all these patients as well. That was initially part of the COVID care system and still is technically, but we're really waiting on the final guidelines, final decision coming out of what those antibodies actually do for you. The thought was we would have so-called COVID competent patients and physicians, or care providers that had COVID antibodies, that could potentially be safer when treating these patients that were put in different zones of the hospital, depending on the risk level. Then the COVID naive patients and COVID naive providers that did not have antibodies at all.
Really, that is where we're steering. We have these long visio-diagrams of 30 slides about what to do in what situation as the patient enters this area, particular area, whether it's an outpatient clinic, or surgery, or going for cardiac rehab, or something like that. Depending on their testing status, depending on what the procedure is, dictates where and when that patient should go.
At the same time, we need to test the workforce, which has gotten a little complicated. Our employed physicians or employed staff were easier. We can test all of them. Require testing. We're starting to do that. That has been our second process after testing all patients. We started testing all really the frontline providers. Started with our two largest hospitals and expanding to the rest earlier this week.
We're testing all of them for the disease. Luckily, our rates for those have been really low. After testing about 2,000 clinicians, only one or two I think tested positive, which was much lower than we had expected, given our asymptomatic positive rate for patients. Now we're starting to look into how do we test our contracted employees? How do we test the independent physicians and our contracted staff? Those questions are a little bit trickier, because we really do have to get legally involved and wade through the contracts about what we can and cannot do and what can we require and what can't we require. That part is a little bit trickier than the employed staff, which is in place, that’s going well.
[0:12:18.0] BR: Well, how often are you going to do testing? I mean, that becomes the million dollar question, doesn't it?
[0:12:24.0] JL: Right. Everybody you ask has a different answer. We don't have a set answer yet. We are going to get a baseline, just test everybody and see what our roll numbers are and then make a decision based on that, because theoretically, you could retest every three days, every five days, every week. Some are saying every two weeks.
There's not a ton of science behind any of this right now. Luckily, with the new guidelines released by the CDC, you no longer have to do the straight nasopharyngeal test, that really long one that goes all the way to your skull. Now you can [inaudible 0:13:01.2] and something a little shorter. That staff have really appreciated that for sure and makes it a little bit easier for complying with testing. Once we get an idea of how many of our staff are actually positive, we will come up with a retesting plan. We have it tied to their employee record. Much like when your license is going to expire, we know when your test could potentially expire and we could call you back in for retesting.
[0:13:29.9] BR: Yeah, I talked to somebody who had the nasal swab done and they said it felt like they were touching my brain and actually – it's not comfortable.
[0:13:40.4] JL: Oh, no.
[0:13:41.7] BR: To say the least. All right, so let's talk about – Let's talk a little bit about the business – if you're okay, talk about the business of health care a little bit here. We did away with electric procedures and whatnot. It created a financial strain on the health system. About 250 health systems across the country have done furloughs and those kinds of things. There's something about getting this engine going again and there's an awful lot of people who are sitting at home waiting for we call them elective procedures, so people think, “Well, elective meaning, they're choosing to get them because they want to.” In reality, these are serious procedures for very uncomfortable situations. How quickly are we going to be able to ramp some of that stuff back up and get those ORs really functioning at that capacity in those clinics and other places?
[0:14:36.0] JL: Yeah. We have a little experience with this since we started resuming some elective procedures about a week and a half ago at all of our facilities, two weeks at some of our others, it depends on the state what you can do. Some states require that you can only do certain procedures and they lay that out. The ones that we presumed elective procedures, it's certainly not back up to our pre-COVID levels. In some cases, it's 60% to 80% of our volumes from prior, which is encouraging.
We're keeping a daily running dashboard of where we were last year at this time with each surgery and each procedure, all the way down to each physician. We can see what level they are, versus the prior year. It's interesting to see. When we get some feedback from patients about why they didn't want to resume or reschedule this procedure in summer are frankly scared. They've come to the hospital and they're fine with putting it off a little bit more. We have our physicians and others calling the patient's saying, “It's okay. It's safe to resume this. We have this COVID care system in place. Here's our plan to make sure you're safe, X, Y and Z.”
In a lot of cases, these patients have been waiting a long time. A lot of the cases, they were waiting a long time even before they were scheduled to begin with. We've had a lot come through, but then there's a few, maybe some that have comorbidities and are sicker than others that are looking to keep putting it off.
[0:16:11.4] BR: Yeah. Do you think there was some demand destruction? Do you think there's this group that is just not going to come in those couple of months? Are we going to be able to recapture that revenue, or are we just going to draw a line in the sand and say, “Okay, starting from here, we're going to try to get back to a 100%?”
[0:16:30.9] JL: Yeah, I don't know. There are groups that I don't know we're going to recapture. I'm not just talking about surgeries. I feel like the ones that actually need a procedure will come back at some point in the future. Now, the outpatient primary care visits, the ED visits that were always on the bubble of and did this person really need to come in for this? Some of that’s going to be captured via telemedicine, I think. Some of the worried well that wanted to just see a doctor about something, they're going to go through telemedicine. I have a feeling that some will probably just not be recaptured. Then telemedicine visits probably aren't going to end up in the end, paying as much as an inpatient visit will in the end.
[0:17:18.4] BR: Well, so let me ask you this. Do you think this will fundamentally change how the emergency department operates? Do you think we will see a lot of diversion over to telemedicine and just people think about the emergency department different moving forward?
[0:17:35.1] JL: To me, yes. I think the acuity in the ER is going to go up, because people are going to wait and put off coming for as long as possible. The patients that you used to see coming in at 2 a.m. with back pain they've had for three years, that's not going to be there for a while, I wouldn't think. I think that patient is going to be seen via telemedicine. There's all sorts of that chest pain, that maybe that's real, maybe it's cardiac, or maybe it's anxiety that maybe people are going to wait a little while longer, just to see if it goes away.
In some cases that we've seen across the country where that's led to heart attacks that have been missed and people dying at home, and so there's real worry about that. In the short-term, I think that ER volumes, which are down in our facilities 30% or something, or along those lines, aren't going to return to their prior COVID baselines in my opinion.
[0:18:34.6] BR: How has this juggled your projects and your priorities for projects coming out of this?
[0:18:40.8] JL: What projects? Over the last two or three weeks, we’ve started picking back up on some long-standing projects. We went through with our upgrade. We were the only system that actually did that. We were initially going to be seventh in-line for this Epic upgrade and we were the first system to take it live for the new version. Then we're starting to pick back up on the rest of our projects. That was the first major thing and then we're doing all these AI sepsis implementations, things of that nature that have recently started back up.
It's slow, but at the same time, our daily – I was meeting three times a day to talk about COVID-19 with four or five other meetings in between. Since we've gotten most of those processes ironed out and in place, a lot more free time during the day. We need to find other things to do and go back to the other things that were mission-critical. It's definitely gotten to a point where we can resume some of the other projects. Some of the trickier things like needing on-site support for certain things have maybe delayed it a little bit more.
[0:19:53.2] BR: Last question. Again, I really appreciate your time. Everyone's talking about a fall research of COVID patients. How are you planning for that? I mean, if you ramp up your hospitals, do you have a way to fall back and to increase capacity?
[0:20:09.0] JL: Yeah. I mean, we have our surge capacity plans that are in place. Like I said before, we had planned for close to nine to 10 times the numbers we're seeing now. We're going to keep watching this as we turn the data daily and keep watching to see what is happening in our state and local levels and we can go back to that contingency planning and that staffing plan if we need to.
I don't think we're going to stop tracking that anytime soon. What we have in place for our ventilators, our extra staff, our extra capacity is not going away. It'll still be there. The thing we'll have though is we have all these processes in place already. We have our PPE supply chain in place. We have our telemedicine solutions in place. We don't have to reinvent that. Tt's just going to be turning back on.
[0:21:03.2] BR: Fantastic. Jake, I appreciate you taking these questions. Next time I have you on, we're going to talk analytics, we're going to go into – we'll go into informatics, we'll go into all the fun HIT, things that I love to talk about. I appreciate you just as a system that's starting to step out of this, giving us a little precursor to what's going to go on across the country.
[0:21:26.0] JL: No, thank you and thank you for doing this show. This has been really helpful.
[0:21:28.6] BR: I appreciate it. Thanks again.
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