• Use Case Triage—identify top priorities, identify related projects to combine with

• Create Teams for Use Cases

• Work planning for Phone Screening Use Case

• Next Steps

  • Will discuss In person/phone screening Friday

  • Send out use case summaries to the group for the top 3

  • Follow up on resource opportunities

Proposed use cases:

Expanding In-Person Services Safely-- Onboarding and Mitigation Measures

Use Case Team: Jodi Wachs, Amar Das, Sharon Hibay,

Implementation partners: FQHC organizations?,

Workflow analysis

Users:

User requirements:

Clinic Dental and GenMed Plus has been under a stay at home order for the past few weeks and the state is beginning to reopen after COVID-19 cases have started to flatten. The clinic has had less than 10% of their normal volume of face-to-face visits for this entire time, which has had a catastrophic effect on their revenue although the improvements in telehealth reimbursement are slowly reducing the gap. Furthermore, the clinic has noticed there are some patients who are having worsening of their chronic medical conditions because they are not able to come to the clinic and are not getting access to meds, exercise and healthy food including a patient who ended up in the ED in heart failure after they couldn’t weigh themselves at home and another who was found to have a stroke related to uncontrolled hypertension after they ran out of meds (and missed their telehealth appointment). The clinic usually provides a large volume of dental services but have only been responding to emergencies and are furloughing some dental employees. They want to start bringing the regular services back online now that the community is adding other less essential services and ending stay at home. The team needs an approach to expand services and continue to screen appropriately patients planning to come into clinic as well as to reinforce training and education for staff and patients about appropriate mitigation for COVID-19 as they move through the clinic. May include changes to the physical clinic-- patients waiting in their car or directly bringing them into the clinic room for check-in, changes to scheduling and visit types-- triaging the activities which can still appropriately happen via telehealth, and changes to the hours and locations of service. May include some of the business case components as well as some other supply chain and telehealth screening components seen elsewhere.

Subcomponent 1: Clinical Decision Support for Phone Screening and Follow Up: Pre-visit Evaluation

Target outcome: Application (inside or outside EHR) that allows non-medical users to appropriately screen potential COVID-19 patients virtually (phone/video)

Community Health Center X has dramatically changed their practice because of the COVID-19 crisis, moving most of their visits to virtual, creating hours for a “COVID clinic” and a “non-COVID clinic”. Staff who have been diverted from their regular activities (dental assistants, for example) are being asked to staff phone screening and care management activities. The team identifies a need for guidance documentation and workflow for these phone visits to ensure the correct questions are asked and the responses are recorded, and that these data go into the record in a way that allows a case report form to be partially populated and to direct patients to the right clinic and resources and that this content is evidence-based and can be updated as research and recommendations change.

Population Health Dashboard to Track Patients with Exposure, Suspected COVID-19, Pending Tests and COVID-19 Positive Individuals-->Case Management Tools for Positive or Suspected Patients

Use Case Team: Susan Robinson, Lindsay Dietz, Chris Grasso,

Implementation partners: FQHC organizations?, population health management entities

Workflow analysis: Phone presentation, clinic testing sites, telehealth, case reporting, inpatient/outpatient transfers, home monitoring

Users: case managers, contact tracers, testing staff, patients, quality managers, population health leads, analytics team

User requirements:

Population Health and Case Management Use Case: Use Case Components

1. Identify Cases or Possible Cases- what data is needed, how to enter patients into the workflow - 4

Table 1. COVID-19 Risk Factors / Co-morbidities / Past Medical History

1. Request for visit (COVID-19 pandemic timeframe) with chief complaint or symptoms matching the following:

Table 2. COVID-19 Symptoms

Table 3. COVID-19 Severe Signs and Symptoms [Disposition A]

Exposure and Contact Tracing

“Have you had contact with someone who has or was told they may have COVID-19?”

“In the last month, have you or any close contact of yours worked in any health care setting or other essential industry like a grocery store or industrial plant?”

“Do you or anyone you have had close contact with recently stay in a nursing home, jail or prison, other institution or been homeless?”

Follow up contact exposure and tracing:

“Was the contact you had with this person using strict social distancing, meaning did you stay more than 6 feet away at all times or did you wear a mask during all of your contacts?”

If social distancing was followed in all the contacts, the patient should be considered negative.

Inputs into the PopHealth/Case Management system:

1. Phone or in person screening by the clinic

2. Patient comes in with symptoms

3. Hospital or external facility referral

4. Referred by health department as exposed to a positive patient

5. Telehealth visit or virtual message from patient

6. Routine surveillance

7. Anonymous notification from an exposure notification system

8. Referred as possibly exposed due to physical proximity to a positive patient?

Data Needed to Determine Status:

Symptoms: * research screening scoring-- speak to UPenn, ED/Inpatient team, consider how to deal with changing symptoms over time

• COVID-19 symptoms + (with scoring or severity?)

  • Fever

  • Cough

  • SOB

  • Other symptoms?

• No known symptoms

• Symptoms have resolved

Exposure:

• High risk settings (use the phone screening criteria to start)

• Known positive contact

• Anonymous exposure notification

• No known high risk settings or positive contacts

Diagnostic Testing Performed:

• Test specimen

• Test date

• Test product

• Test location

• Test result

  • Test pending

  • Test negative

  • Test positive

  • Inconclusive test

History of Positive Diagnostic Test?

Antibody Testing:

History of Positive Antibody Test?

Patient Identifiers and Contact Information:

• Name

• Address-- physical, facilities

Status:

• Patient needs evaluation from a medical professional

• Need for testing

• Patient tested positive

Issues for Follow Up:

• Deduplication-- failure to identify same patient across encounters

• Need for accurate contact information

1. Order and complete testing- order sets, CDS to suggest testing, instructions and referrals for tested patients, quarantine instructions - 2

2. Follow up test results and referrals – receipt of test results internal or external, other required follow up - 3

3. Case Reporting and Contact Tracing - eCR, paper reporting, contact identification, contact follow up - 2

4. Risk Calculation or Stratification - tools to evaluate risk and respond to high risk patients, need for social and medical services to keep patients healthy in quarantine - 2

5. Update Case Status--> Initiate Outpatient Case Monitoring of Positive or Probable Cases in Quarantine - 4

6. Inpatient/Outpatient handoffs - coordinate with ED/Inpatient group -

7. Convalescence - follow up testing, clinical research and plasma donation, identification of presumed low risk for future clinical activities - 1

Great Public Health Medical Center has arranged to start testing patients and employees for SARS-CoV-2 to assist with the public health crisis. They have had many patients who were suspected for COVID-19 and several who tested positive and either quarantined at home or were hospitalized and released. Two patients have died in the hospital so far. They are attempting to begin tracking both the patients who call in with suspected symptoms or exposures, testing those, and following up both on test results done on site and on those resulted from the public health department. They will perform contact tracing via phone as well and contact their own patients who a patient identifies as a contact if appropriate and send this data to the health department for both locations and individuals who are deemed at risk. The Medical Center needs a dashboard that allows them to assign follow up actions to the care team and schedule these as well as a method to follow up on pending tests.

Great Public Health Medical Center has set up a method to track patients positive for and suspected with COVID-19 and assess their needs. They need a method to provide case management and outpatient monitoring for these patients to know when they should come to the clinic or go to the hospital or go for repeat testing. The tool would help monitor vital signs like oxygen saturation if available and symptoms including a walk test and provide feedback to the team. The tool would allow case managers to get remote feedback from patients and call those who have issues or fail to check in remotely.

Subcomponent 1: Risk Calculator for Existing Patients and Follow-Up Risk Reduction Tool (NACHC)

Clinic GoodHealth sees a large proportion of Medicaid and Medicare patients with multiple chronic conditions and needs related to social determinants of health. They are seeking to go through their patients and determine who is at high risk for bad outcomes due to COVID-19 and provide specific patient outreach regarding remaining safe and reducing risk as well as following up on the management of their medications and symptoms and their need for additional services, such as access to food, picking up their medications or concerns about paying their rent. This risk calculator would utilize existing data from the record on clinical conditions and social determinants of health and request missing data where it is deemed critical. The calculator would populate the issues of concern or risk into a care plan template and either suggest follow up actions or allow the care team member to populate a plan for follow up. Data that populates this calculator would also be used for population-level analytics on the risk of the clinic population for negative COVID-19 outcomes and unmet needs related to social determinants of health.

• Link to the use case 2 for home care as an outcome

• SDOH typical stakeholders supporting social and community needs are currently overburdened or not operating at normal capacity (Hassanah)https://www.ajmc.com/newsroom/how-can-employers-address-social-determinants-of-health-exacerbated-by-covid19

• https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/assessing-risk-factors.html

Supply Chain and PPE/Medical Supplies and Therapy Tracking and Fulfillment

Clinic Low Infection has had challenges with access to personal protective equipment and other important infection control equipment due to supply chain shortages related to the COVID-19 crisis. The clinic has on multiple occasions been unable to order more than their typical amount of PPE and other equipment, and some of their shipments have been delayed up to a week or more. The clinic at the same time is seeing an increase in patients with Influenza-like illness and would like to do more COVID-19 testing including of their own staff but even more PPE is needed for this high risk activity. Other clinics in the area have closed because of a lack of PPE and this clinic is considering the same. The challenge of changing operations is already high and the lack of certainty about equipment is compounding this. They have access through their professional association some equipment but not others. Meanwhile Supplychain.com has been working with producers for several weeks to increase supply and they now have a large quantity of new equipment available over the next several weeks but are unsure how to prioritize the distribution of this material in the way that it makes the most impact. The clinic association agrees to take on the role of aggregating specific clinic needs and with the supply chain organizations, work to incorporate other data about projected trends in the infection in the community to prioritize current and future supplies for each organization in smaller shipments to maximize the ability of clinics to stay open safely.

• GHX has been doing a lot of work to do vetting non-traditional suppliers because traditional suppliers are maxed out in terms of capacity (Karen C)

  • C19HCC has been working on this use case-- could collaborate with this group (which is more focused on inpatient) https://www.ghx.com/covid-19/updates/managing-critical-supply-shortages/

• Jodi- will follow up with the Vizient team to investigate linkages

• This is an example of a state-level effort. North Carolina Government offers support to coordinate PPE. Here is a link to their key document: https://files.nc.gov/ncdhhs/documents/files/covid-19/Guidelines-for-Allocation-of-Personal-Protective-Equipment-PPE.pdf

• Link to the AHA/AHRMM work oni non-traditional suppliers  https://www.ahrmm.org/covid-19-resources-non-traditional-suppliers-offering-ppe-and-other-critical-supplies

• Where is my infusion pump? Harnessing network dynamics for improved hospital equipment fleet management

  Diego A Martinez, Jiarui Cai, Jimi B Oke, Andrew S Jarrell, Felipe Feijoo ...

  Journal of the American Medical Informatics Association, ocaa033, https://doi.org/10.1093/jamia/ocaa033

  Published: 26 April 2020

  • Abstract

  • Supplementary data

Testing CDS?-- retesting, antibody testing, tracing

TestOne Clinic has been offered the opportunity to offer and be reimbursed for COVID-19 testing. They have the choice of send-out, rapid and antibody testing or a combination of all three. They are permitted to take in outside patients not in their existing population and bill for these. They initially will have a limited capacity to test so they need to have some kind of criteria to determine who initially should get testing and which kind of test. They also need to track test results and notify patients. This will include overlap with the tracking and case management group. As they ramp up capacity they will want to modify the test criteria to include new patients but also will need guidance as to when to retest patients who are negative or positive.

Business and Operational Support Tools for Clinics

This would address the abrupt change in business needs for practices, specifically stand alone practices. Setting up telehealth, reallocating resources, possible pay adjustments and overall business capacity.

Mental Health Screening and Referral

Using Telehealth, apps, and HIT communication & outreach to proactively screen populations for pandemic-related PTSD, depression, anxiety, self-harm & suicidality. Screening content to include demographic (age, gender), clinical (MH history, medical comorbidities) & SDOH [race, ethnicity, financial insecurity (housing, heat, food, medications) data elements.

Related to COVID-19 infection or community restrictions, etc-- could include follow up for existing mental health patients and for ill patients and family members.

• StayHome.app - Developers at UW

Clinical Decision Support for Frontline Clinical, Corporate, and Government Organizations

Whether from Clinic DoGood, Company ShipIt, or Three-Letter Government Agency, frontline workers must interact, often in close proximity, to many individuals to perform critical services (whether clinical, delivery, or public safety) throughout a pandemic, like COVID-19.  As a result, they and their employers must carefully balance the risks of exposure with the performance of their duties.  To help them do so, we seek to create a digital clinical decision support (CDS) tool based on a combination of predictive analytics and wearables that could enable organizations to conduct real-time monitoring, large-scale screening, and possibly prognostic evaluation of their employees.  The CDS tool would draw upon a worker’s real-time wearable data as well as his/her health records to assess a person’s personal likelihood (not a population health estimate) of being uninfected, asymptomatic infected, and symptomatic infected.  And, if is asymptomatic infected, what is that person’s personal likelihood of becoming symptomatic.  (The health records needed may include data from a person’s laboratory testing or pharmacy benefits history.)  The models could be quickly built for using AI-driven software that is designed to create FDA-compliant Bayesian models for healthcare applications as soon as data from the first pandemic cases become available.  Population health efforts could benefit from the project too.  When aggregated, the individual personalized assessments can serve as the basis for segmenting populations into different risk cohorts.  Moreover, interrogation of the Bayesian models can help clinical researchers to better understand the relationships between biomarkers that can lead to certain viral outcomes.  The tool would be useful to monitor the health of frontline workers from Clinic DoGood, Company ShipIt, or Three-Letter Government Agency as well as help them better understand when social distancing protocols can be relaxed and more of their employees can return to work.

Themes:

Tools to Support Updated Guidance/ Education

Need to track changes to guidance, maintain the knowledge of which resources are out of date, provide support to staff on updates

Value of Incorporating Support for Patient-facing Solutions

For example, patient self-screening or symptom tracking, self-referral, telehealth outreach in non-real time